Floor Book

July 2013

Table of Contents

Adult Medicine ............................................................................................................................................ 3

Everything you need to know about billing for an admission H & P ............................................... 3 Admission & H.O. Orders TTU ............................................................................................................. 5 Helpful Tips and Orders ........................................................................................................................ 9 Diabetic Ketoacidosis .......................................................................................................................... 12

Diabetic Ketoacidosis .......................................................................................................................... 13

Hypertensive Emergency .................................................................................................................... 15 Sepsis .................................................................................................................................................... 16 Adult Pneumonia .................................................................................................................................. 18

STEMI .................................................................................................................................................... 20 Ischemic Stroke Management ............................................................................................................ 22 Fever of Unknown Origin .................................................................................................................... 24

OB/GYN ..................................................................................................................................................... 25 OB/GYN Tips and Orders ................................................................................................................... 25

PEDIATRICS............................................................................................................................................. 28 Pediatric Tips and Orders ................................................................................................................... 28 Pediatric Pneumonia Orders .............................................................................................................. 32 Criteria for admission of the child with Pneumonia ......................................................................... 33 Asthma in Pediatrics ............................................................................................................................ 34

Recommended Influenza Treatment Dosage .................................................................................. 37 Recommended Influenza Prophylaxis Dosage ................................................................................ 38 Inpatient Treatment of Bronchiolitis ................................................................................................... 39

Adult Medicine Everything you need to know about billing for an admission H & P You will make Allison, Dr. Young and Dr. Benton very happy if you will do these simple things:

Make sure you include something in family history and social history. For example:

Patients mother died of myocardial infarction at age 62. Patients father is alive and has COPD. Pt smokes 1 pack per day, denies use of alcohol and illegal drugs. For billing purposes, thats a perfect family and social history.

Include 10 systems on review of systems. For example:

Review of systems positive for cough, fever, hemoptysis, and leg swelling. All other review of systems negative including constitutional, eyes, ears nose and throat, respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, skin, neurological, psychiatric and lymphatic except as already mentioned. If you dictate that way, Allison will never bug you about missing $$ on billing because you messed up ROS.

Include 18 things in 10 systems in your dictation for physical exam.

Constitutional: Patient lying on bed in no apparent distress Eyes: Pupils equally round and reactive to light, no sclera icterus Ears nose and throat: Oral mucosa moist, tympanic membranes normal Respiratory: Lungs clear to auscultation bilaterally, no crackles or wheezes present Cardiovascular: Regular rate and rhythm with no rubs, gallops or murmurs. Peripheral pulses 2+ throughout. Gastrointestinal: Bowel sounds present in all 4 quadrants, patient has exquisite tenderness in right upper quadrant but no guarding or rebound tenderness. Murphys sign positive Genitourinary: No CVA tenderness (this is always a good one, unless of course its positive) Musculoskeletal: ROM intact all 4 extremities Skin: No rashes, ecchymoses or petechiae Neurological: Patient alert and oriented times 3, cranial nerves 2-12 grossly intact. DTRs 2+ throughout Psychiatric: Mood and affect normal Lymphatic: 2+ pitting edema bilateral lower extremities

Thats about 30 items in 11 systems, and is able to be coded at a much higher rate.

On assessment and plan, list each problem and talk about what you are doing for them. Billing is based on complexity.

1. Hip fracture. The patient has suffered an intertrochanteric fracture of the right femur. Dr. Parker has already seen the patient and is planning on performing surgery tomorrow. Will maintain patient NPO and provide maintenance IV fluids.

2. Pain control. In the ER, the patient has been given Dilaudid and it seems to be working well. We will continue her on this medication and make adjustments if necessary.

3. Cardiac risk assessment. The patient is 78 years old and does not have a history of coronary artery disease. We do not have a current echocardiogram. Based on the Goldman criteria, the patient only scores 5 points for age and 7 points for atrial fibrillation, although the patient is adequately rate controlled on metoprolol. This gives the patient 12 points, making her risk category 2 with a 3% risk for myocardial infarction, ventricular tachycardia or congestive heart failure, and a 1% risk of cardiac death. Even if the patient had severe aortic stenosis on echo, which is unlikely given her normal pulse pressure and the absence of a murmur, her risk would only change to class 3, giving her an 11% risk for cardiac complication and a 2% risk of cardiac death. Will maintain patient on metoprolol to help reduce the risk of cardiac complications, but switch to IV for now.

4. Diabetes. Patient takes metformin at home, but will have surgery so we will transition her to regular insulin q 6 hours with correction dose scale for now. We will obtain a hemoglobin A1c to evaluate the effectiveness of her current outpatient therapy.

5. UTI. Patient has positive leukocyte esterase and nitrites on urinalysis, as well as 11 WBCs. Patient had one dose of Levaquin in the ER, but given the extremely high resistance rates of our most common UTI bacteria to that particular antibiotic, I will give her Rocephin 1 gram IV daily.

6. Dementia. Patient appears stable in this regard, and we will monitor her during her stay and continue her Aricept. 7. Hypothyroidism. Will obtain a current TSH and continue her home dose of Synthroid for now. 8. GERD. Will continue patient on a daily PPI. 9. DVT prophylaxis. Surgery is planned for tomorrow morning, and we will provide appropriate DVT prophylaxis after

surgery. 10. Physical therapy. We will obtain a PT/OT evaluation and treatment. 11. Rehabilitation. Patient will need rehabilitation for strength building after surgery, so we will ask case management to begin

this process.

Talk about each problem, say a few sentences for the big issues and a short sentence for the small ones.

You will make your fellow residents very happy if you will do these simple things:

1. List all the patients doctors in the dictation. Its embarrassing when we call Dr. Cox to see a patient that already sees Dr. Soya, and it hacks Dr. Cox off when he comes out here and learns this from the patient. We just wasted his time, and he knows it.

2. Dictate quickly. The hospital and residency policy is to dictate within 24 hours. In reality, you will never regret it if you just get in the habit of dictating before you give the chart to the HUC for admission.

3. Address code status when its appropriate. Theres no point in asking a 35 year-old who only has pneumonia, but anyone with an irreversible condition should be asked. We dont expect this to happen, but if your heart stopped beating or you needed to have a tube down your throat and be on a machine to help you breathe, what would you want us to do? Would you want us to provide chest compressions, shocks and intubate you? Again, we dont expect that to happen, but what would you want if it did?

Admission & H.O. Orders TTU ADMIT to (attendings name) as (23H Obs or Inpatient) to (Tele/Med-Surg/ICU/SICU) DIAGNOSIS: CONDITION: VITALS: (Q shift, per protocol, Q15 min, Q 4 hours, neuro checks Q H x 24 H, then Q 4 if stable) Notify if temp >101 or SBP92%; foley to gravity; Accuchecks AC & HS/Q 6 H; seizure/aspiration/fall precautions; IS Q H while awake; SCDs to B/L LE; Neuro check Q H x 2, Q 2H x 2, Q 4 H x 2, then Q shift) DIET: (regular, carb-consistent, low salt, low fat, coumadin diet, clear/full liquid, NPO, meds with sips, 1500cc fluid restriction) ACTIVITY: (BR w/ BRP, Ad lib, BSC, up with assistance, ambulate TID) LABS: (CBC, CMP, BMP, PT/PTT, CXR (portable vs. PA & Lat), UA, EKG, ABG, amylase/lipase, Troponin/CE Q 8 x 3, Ca- Mag-

PO4; STAT vs. in AM; GGT for biliary) IV: (type @ cc/hr; reseal; none) ex. D5 NS @83cc/hr (?need bolus or K+ added) SPECIAL: old charts to floor, obtain other facility records MEDS: (drug, dose, route, frequency); Remember home meds PRN MEDS: Colace 100mg PO BID; Tylenol 325 (2) PO Q4-6 H PRN (if liver ok) CONSULTS: C&P Dr. (Name) for (service) re: (reason) (NOW vs. in AM)

Maintenance hourly IV fluid (4/2/1 rule) 4ml/kg for 1st 10kg; 2ml/kg for next 20kg 1ml/kg for each kg>30 Kids: Bolus 20:20:10cc/kg, Maintenance is D51/2 NS if over 10 kg D5 NS if under 10kg

PAIN: source? Need X-ray? Meds already ordered? PRN in place? ALLERGIES & LABS (check LFTs) Tylenol 325 (2) PO/PR Q4-6H PRN Pain Lortab 5-10mg PO Q4H PRN Pain Darvocet N100 1-2 q 4-6 prn pain Percocet 5-10/325mg PO Q4H PRN Pain Morphine 1-4mg IV Q 2-4H PRN Pain Demerol 25-50mg IV Q6H PRN Pain

(NOT IN RENAL PATIENTS) Phenergan 12.5-25mg IV Q 6H Toradol 15-30mg IV/IM Q 6H (watch SCr)

ABX: Rocephin 1-2g IV QD/ Fortaz 1g q8 / Ancef 1g IV q6hr Levaquin 500-750mg IV QD CC 20-49 750mg q48 Unasyn 1.5-3g IV q6 CC 15-29 q 12 CC 5-14 qd Zosyn 3.375 g IV q 6 CC 20-40 2.25 g IV q6 Vanco 1g IV q12(trough 30 min before 4rd) 15mg/kg follow levels AFIB with RVR: Cardizem 20mg bolus over 2 minutes, wait 10-15 minutes, rebolus with 25mg (if needed), then start drip per

protocol Agitation: ALWAYS EVAL PT FIRST! Look for cause vitals, Accucheck, pulse ox, drug reaction, etc. Ativan 0.5-2mg IM/IV/PO Q6-8H max 10mg/qd (may cause resp ) Haldol 2-5mg IM/PO Q4-8H (may cause BP drop) If dystonic rxn occurs, Diphenhydramine 20-50mg IM/IV. Geodon 20mg IM x 1 (esp if Haldol allergic; watch in long QT) Seroquel 12.5 mg Alcohol (DT) precautions: (see also Banana Bag) Use Ativan taper AND Ativan, Librium or Valium PRN Ativan 1-2mg IM/IV/PO Q6H PRN Librium 25mg PO Q6H PRN

Labs: Mg, EtOH level, CMP, GGT, alk phos, CBC, PT/PTT, UDS, albumin, AST/ALT B12 1000mcg IM NOW & in AM

Use the following OR banana bag: Thiamine 100mg IM QD x 3, MVI PO daily, Folate 1mg PO qd x4 Allergic RXN: Solumedrol 125mg IV, Benadryl 25-50mg Pepcid 20mg IV, EPI (if needed) Banana Bag (must order specifics below per L NS QD) 1mg folate, 2g MgSO4 (if Mg low), 100mg thiamine, 1 amp MVI

Ativan Taper 1mg Q4H x 24H 1mg Q6H x 24H 0.5mg Q4H x 24H 0.5mg Q6H x 24H 0.5mg Q24H then DC

BP Change: If and symptomatic: check if pt got BP med today, if on NSAIDs, or any increase in pain Consider clonidine 0.1mg PO, recheck in 1H; repeat if SBP >180 For IV meds, pt must be on tele: Enalapril 0.6 mg Iv q6 over 5 min Labetalol 20mg IV over 2 minutes x 1, or 100mg PO BID Lopressor 5mg IV; hydralazine 10-20mg IV If and symptomatic: do orthostatics, consider fluids, hold BP meds; if thinking sepsis get BCx and possibly move to ICU Chest Pain: ask for vitals (incl pulse ox), other signs/symptoms, order EKG and compare to old one, cardiac enzymes x 3 Q8H,

PCXR If suspect cardiac, OH BATMAN & call resident/attending NTG SL 0.4mg Q5min x 3; ASA 325mg chewed Lovenox 1mg/kg Q12H or heparin protocol Metoprolol 100mg PO BID (keep HR

Hyperkalemia hemolyzed specimen? How ? EKG changes? If rapid tx needed (symptomatic) & pt not going for dialysis: Calcium gluconate 10% 5ml IV (esp. if EKG changes) 10units regular insulin & 50ml D50 IV bolus Sodium bicarb 1 amp (44mEq = 50mEq Na+) Kayexalate with sorbitol 15-30g PO or NGT (60cc=15g) Recheck K+ 2-4H after the above is completed Alternatives (if needed): Lasix 40-80mg IV Albuterol nebs Bicarb drip (3vials in 1 L D5W) if needed Hypokalemia Check for EKG s u wave, flat T, ST s

0.1 in pH 0.4-0.6 K+ (how bicarb works!) Total body deficit: 150-400 mEq per 1.0 mEq change in serum K+ Correct underlying d/o: Mg, alkalosis, vol contraction, hyperald) PO (easier & quicker) KCL / Kdur 20-40mEq PO up to TID IV (limited rate) 40mEq in 250cc NS over 3 hr Use 10mEq for every 0.1 of K+ to increase Recheck K level 2 hours after last dose of replacement K+

Hypomagnesemia 2g MagSulfate in 100cc NS over 2H 1g MagSulfate in 50cc D5W over 1 hour Slo Mag 2 tabs PO QD or BID (MgCl is 64mg/tab) Mag Oxide 400mg PO bid X 2 days Hypophosphatemia Neutra-phos 2 packets tid x 1 day If 2 Kphos 20mmol in 500 cc NS over 4 or Sodium Phosphate 40 mmol in 1 L NS over 8 Fall: check vitals, pulse ox, accucheck, review meds, examine pt. Check for LOC, obvious injuries (lacs & fx), do neuro exam, additional symptoms (chest pain, SOB) *If tachypneic or tachycardic,

think PE Order appropriate studies, make fall precautions, ?night light, note in chart and complete incident report (does not go in chart) Fever: NO TYLENOL IN SURGERY PTs! Refer to surgery resident. Otherwise, Tylenol OK. Look for cause: UA, PCXR, BC x 2, etc. Safest Rx even in liver dz: 650mg PO/PR Q 4-6H PRN temp >101 If considering Motrin, check renal function and BP GI Cocktail: Donnatol 10cc, Maalox 10cc, viscous lidocaine 10cc Headache: R/O bad things first: subarachnoid bleed, temporal arteritis, migraine, acute angle glaucoma. Ibuprofen 400-800mg PO Q6H x 2 (watch renal func and BP) Tylenol 650-1000mg PO Q4-6H PRN Pain Indigestion: 1st R/O cardiac origin Maalox Plus 30cc PO Q6H PRN (caution in renal pts) May need ulcer prophylaxis with PPI or H2 blocker daily Insomnia: Caution in COPD pts; no sleepers in carotid pts Ambien 5mg PO QHS PRN, may repeat x 1 (best choice) Restoril 15-30mg PO QHS PRN (7.5mg in elderly) Benadryl 25-50mg PO QHS PRN (not in BPH pts) Vistaril 50-100mg PO QHS PRN Elderly: Lunesta 1mg PO qhs Delirium: Seroquel 25 mg po bid / Risperdal 0.5 mg bid*Any of above may be source of altered M

status* Infiltrated IV: D/C IV and site May use warm compresses PRN and elevate extremity KEO feeding tube: should be in duodenum; check CXR to verify placement; leave guide wire in until verified CXR Medication reversal: Narcan 0.2-2mg IV/SQ Q5min (opioids) Flumazenil 0.2mg IV Q30-60sec for max 5mg (BZD OD) Mental status change: Check vitals, pulse ox, accucheck, med list Examine patient! If suspect CVA, CT brain without contrast. ABG, CBC, CMP. Call resident/attending Nausea: Check NG tube function; Phenergan 12.5-25mg PO/IV/IM/PR Q4-6H PRN N/V (caution in elderly) Zofran 4mg IV/IM x 1 (can use Q 8H PRN N/V) (can cause possible bronchospasm) Reglan 10mg IV Q6H PRN N/V (not for use in Parkinsons pts, GI obstruction or seizure d/o) Compazine 5mg PO/PR Tigan 200mg IM/PR Q4H PRN N/V NG tube placement: Use 16-18 french; confirm with PCXR Neuro checks: Q1H x 2, Q2H x 2, Q4H x 2, then Q shift PCAs: if NPO and/or significant pain; 1st check allergies; PCA protocol sheet available at most nursing stations, or order as below: Morphine PCA: 1mg unit dose, 6min lockout, 20mg 4H max (may drop BP; caution in pancreatitis or choleycystitis) Demerol PCA: 5mg unit dose, 6min lockout, 100mg 4H max (not in renal or seizure pts) *PCAs need at least a maintenance IV rate of KVO (40ml/hr)*

PEG tube: if >2wks, should slide easily in/out and can irrigate if < 2wks, needs surgery Pronouncing DNR patient: wear gloves, check for verbal and noxious stimuli response, check pupils (should be non-responsive

and dilated), check for HS/BS/carotid and apical pulses, may use tissue paper to check corneal reflex. HO is responsible to document all physical findings, time and date of death, notification of attending and consultants (document in note) and to document who notified family. Time of death is when you examine pt, not when nursing calls and tells you theyve expired. Template for pronouncement below: (this will generally be the last note in the chart, and should be relatively formal in nature, so PRINT clearly and use a new progress note, and dont forget to sign and print your name)

Called by nursing to pronounce the death of Mr/Mrs _______. The patient was examined and did not respond to verbal or physical stimuli. The skin was cool and dry, the pupils were fixed and dilated. There was no heartbeat, respirations,blood pressure, or reflexes present. Mr/Mrs_______ is pronounced dead at _____AM/PM on MM/DD/YYYY at the age of ___. Family was/was not present. Primary physician and attendings were notified by the House Officer at ____AM/PM.

PT elevation: 1st hold Coumadin if bleeding, give FFP x 2 units or vitamin K 10mg PO/IV/SC/IM if stable, give vitamin K 10mg PO/IV/SC/IM PTT elevation: hold heparin for 4H (life is 1.5H), recheck PTT and follow protocol. Rectal pain: Americaine ointment QID Pericolace 2 PO now and QHS (softener and laxative) SOB: check vitals, pulse ox, ABG, EKG, PCXR, review H/H Consider HHN, increasing O2, hold fluids and give Lasix if suspect CHF. RT will help guide you! May need resident/att. Tele changes: GET EKG! Compare, look at pt, read chart. Symptoms? What type of change? Consider ACLS and call resident/attending Thrush: Nystatin oral susp 5cc swish & swallow QID Diflucan 100mg PO/IV QD Transfusion: T&C vs T&S Need 18-20 gauge needle Use leukocyte filter H&H 3 hours after last unit Hold maintenance fluids during transfusion Consider Lasix 20mg IV between units or after last unit Transfusion fever: check for transfusion rxn (IV site red, vitals, etc); may need to D/C transfusion; if fever only, consider Tylenol. Ulcer prophylaxis: Protonix 40mg PO/IV Daily Zantac 150mg PO BID Pepcid 20mg PO BID Vents: AC want 8-10cc/kg for tidal volume SIMV with pressure support and PEEP for weaning Want your I:E = 1:2-3 With increased RR want increased Q rate Co2 = rate TV Co2 = rate TV or Fio2 PEEP

Use good clinical judgment and evaluate all patients before starting any treatment. Review all dosages, side effects, and contraindications before prescribing any medications. Treat your patients, not your numbers. Take a deep breath, relax. Dont be afraid to ask for help. Trust the nurses.

Helpful Tips and Orders

Use good clinical judgment and evaluate all patients before starting any treatment. Review all dosages, side effects, and contraindications before prescribing any medications. Treat your patients, not your numbers. Take a deep breath, relax. Dont be afraid to ask for help. Trust the nurses.

ADMIT to (Peds, floor, ICU) per CMP (case mgmt protocol) for TTFM, under (attendings name) DIAGNOSIS: (Start with acute, then add chronic) CONDITION: (Stable, guarded, critical) VITALS: As per floor/ICU,( or Q shift, Q15 min, Q 4 hours, neuro checks Q Hr x 24 H, then Q 4 if stable) Notify if temp >101 or

SBP90%; foley to gravity; Accuchecks AC & HS/Q 6 H;

seizure/aspiration/fall precautions; SCDs to B/L LE; Neuro check Q H x 2, Q 2H x 2, Q 4 H x 2, then Q shift) DIET: (regular, 1800 cal ADA or Diabetic, low salt, low fat, Renal, coumadin diet, clear/full liquid, NPO, meds with sips, 1500cc fluid

restriction) ACTIVITY: (BR w/ BRP, Ad lib, BSC, up with assistance, ambulate TID) LABS: (CBC, CMP, BMP, PT/PTT, CXR (portable vs. PA & Lat), UA, EKG, ABG, amylase/lipase, Troponin/CE Q 8 x 3, Ca- Mag-

PO4; STAT vs. in AM; GGT for biliary) IV: (type @ cc/hr; reseal; none) ex. D5 NS @83cc/hr (?need bolus or K+ added) SPECIAL: old charts to floor, obtain other facility records, Add to Dr Consults list, PT/OT MEDS: (drug, dose, route, frequency); Remember home meds- See Med Rec Sheet

AFIB with RVR: Cardizem 20mg bolus over 2 min, wait 10-15 minutes, rebolus with 25mg (if needed), then start drip per protocol (ex- titrate to SBP 180 For IV meds, pt must be on tele: Enalapril 0.6 mg Iv q6 over 5 min ; Hydralazine 10-20mg IV Labetalol 20mg IV over 2 minutes x 1, or 100mg PO BID; Lopressor 5mg IV If and symptomatic: do orthostatics, consider fluids, hold BP meds; if thinking sepsis get BCx and possibly move to ICU Chest Pain: ask for vitals (incl pulse ox), other signs/symptoms; Order EKG and compare to old one If suspect cardiac, OH

BATMAN & call resident/attending Cardiac enzymes x 3 Q8H, with EKGs, PCXR NTG SL 0.4mg Q5min x 3; ASA 325mg chewed Morphine 2mg IV prn (hold for SBP

Decreased urine output: Check fluids/intake, Vitals (No BP, No PeePee), Palpate bladder, Consider bladder scan, Strait/foley cath, Check/flush foley if in place. Chart initial urine output.

If no output Prerenal vs renal: listen to lungs, look for edema. If CHF, try Lasix. If dry fluids (start slow; easy in, hard out) If renal check labs (BUN, Cr, K), check meds (ACEI, nephrotoxic drugs [aminoglycosides, etc]) Diarrhea: ?infectious: recent Abx c. diff screen x3; Check occult blood (x3), WBSs, C&S, O&P; Check lytes and replace fluids; no

Immodium until cause identified. DVT prophylaxis: Legs elevated, bed rest, measure calves Venous doppler B/L LE, then apply SCDs/Venodyne boots Lovenox 40mg SQ QD x 12D (Tx = 1mg/kg SQ BID or 1.5mg/kg qd), if CrCl400 call HO (give 15, 20 or 30 units) If still uncontrolled, may need to go to unit for insulin drip. Hypoglycemia is pt symptomatic? last dose meds/insulin? If A&O, give oral glucose (crackers or OJ) If obtunded, give 1 amp D50 Recheck in 15 minutes; may repeat if needed 8oz juice = 30g carbs; 2 graham crackers = 10g carbs (15g carbs BS 25-50mg/dL) Hyperkalemia hemolyzed specimen?(-in kids), How ? EKG changes? If rapid tx needed (symptomatic) & pt not going for dialysis: Ca gluconate 10% 5ml IV (esp. if EKG changes), 10 units reg insulin & 50ml D50 IV bolus Kayexalate 15-30g PO/NGT (60cc=15g), Na bicarb 1 amp (44mEq = 50mEq Na+) Recheck K+ 2-4H after the above is completed Alternatives (if needed): Lasix 40-80mg IV, Albuterol nebs, Bicarb drip (3vials in 1 L D5W) Hypokalemia Check for EKG s u wave, flat T, ST s; 0.1 in pH 0.4-0.6 K+ Correct underlying d/o: Mg, alkalosis, vol contraction, hyperald) PO (easier & quicker) KCL / Kdur 40mEq PO up to TID elixir or tabs (ck K in AM) IV (limited rate) 40mEq in 250cc NS over 4 hr (can give 10 mEq per hr) Total body deficit: 150-400 mEq per 1.0 mEq change in serum K+ Use 10mEq for every 0.1 of K+ to increase Recheck K level 2 hours after last dose of replacement K+ Hypomagnesemia 2g MagSulf in 100cc NS over 2H, 1g MagSulf in 50cc D5W over 1 hr Slo Mag 2 tabs PO QD or BID (MgCl is 64mg/tab), Mag Oxide 400mg PO bid X 2 days Hypophosphatemia Neutra-phos 2 packets tid x 1 day If 2 Kphos 20mmol in 500 cc NS over 4 or , Sodium Phosphate 40 mmol in 1 L NS over 8 IV fluid Maintenance (4/2/1 rule) 4ml/kg for 1st 10kg; 2ml/kg for 2nd 10kg; 1ml/kg for each kg>20 Kids: Bolus 20cc/kg, Maintenance is D51/2 NS if over 10 kg; D5 NS if under 10kg Fall: check vitals, pulse ox, accucheck, review meds, examine pt. Check for LOC, obvious injuries (lacs & fx), do neuro exam, additional symptoms (chest pain, SOB) *If tachypneic or tachycardic,

think PE Order appropriate studies, make fall precautions, put note in chart Fever: NO TYLENOL IN SURGERY PTs! Refer to surgery resident. Otherwise, Tylenol OK. Look for cause: UA, PCXR, BC x 2, etc. Safest Rx even in liver dz: 650mg PO/PR Q 4-6H PRN temp >101 If considering Motrin, check renal function and BP GI Cocktail: Donnatol 10cc, Maalox 10cc, viscous lidocaine 10cc Headache: R/O bad things: intracranial bleed, temporal arteritis, migraine, acute angle glaucoma. Ibuprofen 400-800mg PO Q6H x 2 (watch renal func and BP) Tylenol 650-1000mg PO Q4-6H PRN Pain Indigestion: 1st R/O cardiac origin Maalox Plus 30cc PO Q6H PRN (caution in renal pts) May need ulcer prophylaxis with PPI or H2 blocker daily Insomnia: Caution in COPD pts; no sleepers in carotid pts Ambien 5mg PO QHS PRN, may repeat x 1 (best choice), Vistaril 50-100mg PO QHS PRN Restoril 15-30mg PO PRN(7.5mg in elderly), Benadryl 25-50mg PO PRN (not in BPH pts) Elderly: Lunesta 1mg PO qhs; Delirium: Seroquel 25 mg po bid /Risperdal 0.5 mg bid *Any of above may be source of AMS* Medication reversal: Narcan 0.2-2mg IV/SQ Q5min (opioids) Flumazenil 0.2mg IV Q30-60sec for max 5mg (BZD OD)

NPO for sx give insulin dose and start D5 NS IVF

May need to sliding scale for larger patients

Mental status change: Check vitals, pulse ox, accucheck, med list Examine patient! If suspect CVA, CT brain without contrast. ABG, CBC, CMP. Call res/att Nausea: Ck NGT function; Phenergan 12.5-25mg PO/IV/IM/PR Q4-6H PRN N/V (caution elderly) Zofran 4mg IV/IM x 1 (can use Q 8H PRN N/V) (can cause possible bronchospasm) Reglan 10mg IV Q6H PRN N/V (not for use in Parkinsons pts, GI obstruction or seizure d/o) Compazine 5mg PO/PR Tigan 200mg IM/PR Q4H PRN N/V NG tube placement: Use 16-18 french; confirm with PCXR Neuro checks: Q1H x 2, Q2H x 2, Q4H x 2, then Q shift PAIN: source?, need X-ray?, meds already ordered?, PRN in place?

ALLERGIES & LABS (check LFTs) Tylenol 325 (2) PO/PR Q4-6H PRN Pain Lortab 5-10/500mg PO Q4H PRN Pain Percocet 5-10/325mg PO Q4H PRN Pain Darvocet N100 1-2 q 4-6 prn pain Morphine 1-4mg IV Q 2-4H PRN Pain Phenergan 12.5-25mg IV Q 6H Demerol 25-50mg IV Q6H PRN Pain Toradol 15-30mg IV/IM Q 6H (watch SCr) (NOT IN RENAL PATIENTS)

PCAs: if NPO and/or significant pain; 1st check allergies; PCAs need at least a maintenance IV rate of KVO (40ml/hr), PCA protocol sheet available at most nursing stations, or order as below:

Morphine PCA: 1mg basal rate, 1 mg unit dose, 6min lockout, 20mg 4H max (may drop BP; caution in pancreatitis or choleycystitis)

Demerol PCA: 5mg unit dose, 6min lockout, 100mg 4H max (not in renal or seizure pts) Pronouncing DNR patient: Wear gloves, check for verbal and noxious stimuli response, check pupils (should be non-responsive and dilated), check for HS/BS/carotid and apical pulses, use tissue paper to check corneal reflex. HO to document all physical findings, time and date of death, notification of attending and consultants (document in note) and to document who notified family. Time of death is when you examine pt, not when nursing calls and tells you theyve expired. Template for pronouncement below: (this will generally be the last note in the chart, and should be relatively formal, so PRINT clearly and use a new progress note, and sign and print your name)

Called by nursing to pronounce the death of Mr/Mrs _____. The patient was examined and did not respond to verbal or physical stimuli. The skin was cool and dry, the pupils were fixed and dilated. There was no heartbeat, respirations, blood pressure, or reflexes present. Mr/Mrs_____ is pronounced dead at _____AM/PM on MM/DD/YYYY at the age of ___. Cause of death is ______ secondary to _______. Family was/was not present. Primary physician and attendings were notified by the House Officer at ____AM/PM.

PT elevation: 1st hold Coumadin if bleeding, give FFP x 2 units or vitamin K 10mg PO/IV/SC/IM if stable, give vitamin K 10mg PO/IV/SC/IM PTT elevation: hold heparin for 4H (life is 1.5H), recheck PTT and follow protocol. Rectal pain: Americaine ointment QID Pericolace 2 PO now and QHS (softener and laxative) SOB: check vitals, pulse ox, ABG, EKG, PCXR, review H/H Consider HHN, increasing O2, hold fluids and give Lasix if suspect CHF. RT will help guide you! May need resident/att. Tele changes: GET EKG! Compare, look at pt, read chart. Symptoms? What type of change? Consider ACLS and call resident/attending Thrush: Nystatin oral susp 5cc swish & swallow QID Diflucan 100mg PO/IV QD Transfusion: T&C vs T&S; Need 18-20 gauge needle; Use leukocyte filter H&H 3 hours after last unit If CHF, hold fluids during transfusion; consider Lasix 20mg IV between units or after last unit Transfusion fever: check for transfusion rxn (IV site red, vitals, etc); may need to D/C transfusion; if fever only, consider Tylenol. Ulcer prophylaxis: If in ICU, or if has GERD Protonix 40mg PO/IV q24 (hosp contract); Zantac 150mg PO BID; Pepcid 20mg PO BID Vents: AC want 8-10cc/kg for tidal volume; SIMV with pressure support and PEEP for weaning Want your I:E = 1:2-3; With increased RR want increased Q rate Co2 = rate TV; Co2 = rate TV or Fio2 PEEP

Diabetic Ketoacidosis

Diagnosis: Glucose > 250 mg/dl, pH < 7.30, HC03

Diabetic Ketoacidosis

From Harrison's 18th Ed, TABLE 338-6. MANAGEMENT OF DIABETIC KETOACIDOSIS 1. Confirm diagnosis (plasma glucose, positive serum ketones, metabolic acidosis). 2. Admit to hospital; intensive-care setting may be necessary for frequent monitoring or if pH < 7.00 or unconscious. 3. Assess:

Serum electrolytes (K+, Na+, Mg2+, Cl-, bicarbonate, phosphate) Acid-base status (pH, HCO3-, PCO2, b-hydroxybutyrate) Renal function (creatinine, urine output)

4. Replace fluids: 2-3 L of 0.9% saline over first 1-3 h (10-15 mL/kg per hour); subsequently, 0.45% saline at 150-300 mL/h; change to 5% glucose and 0.45% saline at 100-200 mL/h when plasma glucose reaches 250 mg/dL (14 mmol/L).

5. Administer short-acting insulin: IV (0.1 units/kg) or IM (0.3 units/kg), then 0.1 units/kg per hour by continuous IV infusion; increase 2- to 3-fold if no response by 2-4 h. If initial serum potassium is < 3.3 mmol/L (3.3 meq/L), do not administer insulin until the potassium is corrected to > 3.3 mmol/L (3.3.meq/L).

6. Assess patient: What precipitated the episode (noncompliance, infection, trauma, infarction, cocaine)? Initiate appropriate workup for precipitating event (cultures, CXR, ECG).

7. Measure capillary glucose every 1-2 h; measure electrolytes (especially K+, bicarbonate, phosphate) and anion gap every 4 h for first 24 h.

8. Monitor blood pressure, pulse, resp., mental status, fluid intake and output every 1-4 h. 9. Replace K+: 10 mEq/h when K+ < 5.5 mEq/L, ECG normal, normal urine flow and creatinine; administer 40-80 mEq/h when K+

< 3.5 mEq/L or if bicarb is given. 10. Continue above until patient is stable, glucose goal is 150-250 mg/dL, and acidosis is resolved. Insulin infusion may be

decreased to 0.05-0.1 units/kg per hour. 11. Administer intermediate or long-acting insulin as soon as patient is eating. Allow for overlap in insulin infusion and

subcutaneous insulin injection.

Dr. Brantley's DKA drip orders: Glucose Insulin D10

Over 300 5 units/hr 0 mL/Hr 251-300 3 0 201-250 2 30 151-200 1.5 40 101-150 1 50 71-100 0.5 50 Below 70 0.5 70

DKA Glucose > 250 mg/dl PH < 7.30 HC03

Hypertensive Emergency Definition: marked increase in BP, generally SBP >180 or DBP 120, associated with end organ damage Labs: CBC, UA, CMP, EKG, Cardiac enzymes, Imaging, Echo Management: Admit to ICU. Continuous cardiac monitoring, assess volume and neurological status, urine output. Lower mean

arterial BP by 20-25% in 1 hour, DBP 10-15% (or ~110 mm Hg) over 30-60 min. After stabilization reduce BP to 160/110 over 2-6 hrs. Assess volume status. Gentle hydration with NS to restore fluid/Na.

DRUG IV DOSE and ONSET SPECIAL INDICATIONS/ CONSIDERATIONS

Nitroprusside

Initial: 0.3-0.5 mcg/kg/min; increase in increments of 0.5 mcg/kg/min, titrating to the desired hemodynamic effect or the appearance of headache or nausea; usual dose: 3 mcg/kg/min; rarely need >4 mcg/kg/min; max: 10 mcg/kg/min. Onset 1-2 min.

Arterial and venous vasodilator. Acute pulmonary edema (may use with NTG). Can be used in most HTN emergencies except MI and renal impairment.

Nitroglycerin Initial: 5 mcg/min. Doses of 5-100 mcg/min typically used.Onset 2-5 min

Venous >>arteriolar vasodilator. Not generally first line. Often used as adjunct, esp. in coronary ischemia or acute pulmonary edema

Labetalol

20 mg bolus, followed by boluses of 20-80 mg or an infusion of 0.5 to 2 mg/min titrated until effect. Avoid boluses of 1-2 mg/kg due to precipitous fall in BP. Max cumulative 24-h dose 300 mg. Onset 2-5 min

Non-selective and 1 blocker. DOC in hyperadrenergic activity, aortic dissection, acute myocardial ischemia (with NTG), aneurysm, acute ischemic stroke/intercerebral bleed, eclampsia/pre-eclampsia, hypertensive encephalopathy, post op HTN. Contraindicated in COPD, HF, or heart block

Enalaprilat 1.25 mg IV over 5 min Q 6 h, titrated by increments of 1.25 mg at 12- to 24-h intervals to a max of 5 mg Q 6 h. Onset 15-30 min

ACEI. DOC for HF. Reduce dose in azotemia. Contraindicated in MI, eclampsia, bilateral RAS

Esmolol 250 to 500 mcg/kg/min by infusion; may repeat bolus after 5 min or increase infusion to 300 mcg/min. Onset 1-2 min.

Ultra-short acting 1 blocker. DOC in acute myocardial ischemia (with NTG), aortic dissection, and peri/post operative HTN. Do not use in patients already on a -blocker, bradycardic, or decompensated HF.

Fenoldapam Initial: 0.1 mcg/kg/min, titrated by increments of 0.050.1 mcgg/kg/min to max of 1.6 mcgg/kg/min. Onset 2-5 min.

Dopamine agonist. May use in myocardial ischemia, acute pulmonary edema/diastolic dysfunction, acute ischemic stroke/intracerebral bleed, acute renal failure/microangiopathic anemia, HTN encephalopathy, sympathetic crisis. Caution in angina, glaucoma, and increased intracranial pressure. Contains sulfite.

Hydralazine 5 mg bolus then 510 mg IV every 2030 min PRN. Onset 5-15 min.

Vasodilation of arterioles (preload and afterload reducer). DOC in eclampsia. Contraindicated in HF, MI, aortic dissection. Generally avoided as primary therapy in HTN emergency due to prolonged and unpredictable effects.

Phentolamine

Sympathetic crisis: 5-20 mg IV bolus

Pralidoxime-induced HTN: 5 mg IV

Surgery for pheochromocytoma/HTN: 5 mg IV/IM given 12 h before procedure and repeated PRN Q 24 h. Onset 1-2 min.

-blocker. DOC in sympathetic crisis, catecholamine toxicity (i.e., pheochromocytoma), cocaine and amphetamine intox, clonidine withdrawal, MAO inhibitor interactions

Nicardipine 5 to 15 mg/hr IV. Onset 5-10 min. Dihydropyridine CCB. Most hypertensive emergencies except acute HF, caution with coronary ischemia

Clevidipine Initial: 1-2 mg/hr. Dose doubled at 90 sec. intervals. As BP approaches goal, dose may be increased by < double Q 5-10 min. Usual maintenance: 4-6 mg/hr; max: 21 mg/hr. Onset 1-2 min.

Ultra short acting dihydropyridine CCB. All hypertensive emergencies. Expensive. Adverse effect: A Fib

Seventh Report of the Joint National Committee on prevention, detection and treatment of high BP. Varon J. Treatment of acute severe hypertension. Drugs. 2008;68:283-297. Lexi-Comp Online. Accessed 10/03/2009.

Sepsis

Bacteremia Bacteria in blood no symptoms SIRS systemic inflammatory response syndrome

Fever, tachycardia, Tachypnea SIRS: Any 2 of these + suspected or known infection = Sepsis

1. WBC > 12 cells/ml, < 4000 cells/ml or > 10% bands 2. Temp > 100.4 or < 95 3. HR > 90 4. RR > 20 PaCo2 < 32 mm Hg

Septicemia- Source of infection With Bacteremia Septic Shock hypotension with septicemia Elderly may not have fever or white count Fluids

2 large bore IVs can give up to 4-5 liters if fluid deficit Central Line I J, Femoral, Subclavian Art Line

Pressers Dopamine 5 mcg/kg/min MAP >50

Not if Tachy Levophed 0.5-1 mcg/min

Ok if Tachy NeoSynephrine 100-180 mcg/min

Wont raise HR as much Periferal OK w/ [10mg/250ML] D5W

Vasopressin 0.04 unit/min ABX Broad Spectrum

Rocephin 1g IV q 12 Unasyn Zosyn 3.375 q IV q 6 Zithromax 500 mg IV qd Levaquin 750 mg IV qd Vancomycin with Sepsis 1gm IV q 12

GFR > 50 dose q 12 GFR < 50 dose qd

Xigris dont give with Lovenox already thinned blood ABX MRSA pneumonia

Vanc/Linezolid + FLQ/Aminoglycoside+Blactam/Aztreonam(pen allergy) Linezolid 600mg IV q12 + Levaquin 750 mg IV qd + Zosyn 3.375 q IV q 12 (Allergy PCN) Aztreonam 0.5-2g IV q 6-12

Pseudomonas + Ceftazidime(Fortaz) or Cefepime Ceftazidime 1-2 g IV q 12 Cefepime 0.5-2 q IV q 12

Labs: CBC, Chem 12, Mg, Phos, PT/PTT/INR, UA& CX, Blood Cx, Lactate, Cortisol, TSH, cardiac enzymes,

Venous gas need to maintain SVO2 > 70 tells oxygen to the tissues

Lovenox if coag panel ok INR, PT, PTT

Elevate BP - Solumedrol 125 mg GI bleeds or on vent Protonix Fever Tylenol, cooling blanket Hypothermia Warm saline, Bear Hugger

GOALS: - from C-Line CVP 8-12 SV02 > 70% MAP > 65 calculated Urine output 0.5 ml/kg/hr CRP, Lactic Acid

Random Cortisol 15-34 ug/dl --> HDCST Random Cortisom < 15 ug/dl glucocorticoid

replacement therapy Hydrocortisone 75 mg IV q 6

15-34 HDCST If < 9 --> GRT > 34 NO treatment

High-dose corticotropin stimulation test Mortality Base Cortisol ChangeTest 26% Good < 34 ug/dl >/= 9 67% Intermediate > 34 ug/dl >/= 9 82% Bad > 34 ug/dl 15 / CRP > 3 / HCO3< 24 Sedatives:

Versed 0.02-0.10 mg/kg/hr (titrate to effect) Versed 2mg * 4 --> Breakthrough (Haldol, Ativan) Ativan gtts MINDS Score Diprovan gtts 5mcg/kg/min (titrate to effect) Triglycerides LFTs

Adult Pneumonia

Where to Treat the Patient CURB-65: Confusion, Uremia, RR>30, BP =65 Score of 2: Severe pneumonia: hospitalize and consider ICU admission

Classify the Pneumonia 1. Hospital Acquired Pneumonia

Within 48 hours of hospital admission 2. Healthcare Associated Pneumonia

Resident of NH Wound care, IV therapy, or chemotherapy within last 30 days Hospitalization in acute care facility for at least 48 hours within the last 90 days Attendance of a hospital or hemodialysis center within 30 days

3. Ventilator Associated Pneumonia 48-72 hours after intubation

Empiric Treatment 1. Outpatient: macrolide or doxycycline 2. CAP Hospitalized: 3rd gen ceph + macrolide or respiratory FQ 3. HCAP or ICU:

a. (Anti-pseudomonal PCN or Ceph or Carbapenem) + [FQ or (gentamicing + Azithromycin)] + Vanc b. Vanc, Zosyn and Levaquin is a good example

4. Aspiration a. 3rd generation Ceph or FQ +/- Clindaymicin +/- Metronidazole

5. VAP: a. No MDR risk factors:

i. Ceftriaxone or Ampicillin-sulbactram or Levofloxacin b. MDR Risk factors:

i. One of the following: 1. Cefepime or Ceftazidime 2. Plus Imipenem or Meropenem 3. Pipercillin-taxobactam 4. Aztreonam

ii. Plus Cirpo or Levofloxacin orGentamycin or Tobramycin or Amikacin iii. Plus Vanc or Linezolid

Dosing

Community Acquired Pneumonia:

CAP - Antibiotic Dosage - IV Renal Dose Adjustments Rocephin 1 gm qd No adjustment needed Azithromycin 500 mg qd No adjustment needed

Hospital Acquired Pneumonia / HCAP / VAP: Risk Factors Hospital or Vent > 3 days, Nursing home, Hemodialysis, LTAC, SNU, Wound Care, Abx > 5 days, IV chemo, IV therapy

HAP - Antibiotic Dosage - IV Renal Dose Adjustments Anti-Pseudomonal Cephalosporin Cefepime 1-2 gm q 8-12 CrCl 30-60 give 1 gm q 12 *1 then 1 qm q 24

CrCl 11-29 give 1 gm q 12 *1 then 0.5 gm q 24 Ceftazidime 2 gm q 8 CrCl 31-50 give 1 gm IV load then 1 gm q 12

CrCl 16-30 give 1 gm IV load then 1 gm q 24 Carbepenems= 10% cross reactive PCN Imipenem (Primaxin) 500 mg q 6 or

1 gm q 8 CrCl 30-70 decrease dose by 50% CrCl 20-30 decrease dose by 63% CrCl 6-20 decrease dose by 75% then divide q 12

Meropenem 1 gm q 8 L racemic epinephrine CrCl 10-25 decrease dose by 50% q 12 CrCl < 10 decrease dose by 50% q 24

MRSA = Vanc / Linezolid Pseudomonas = B-Lactam + (FQ or Aminoglycoside)

1. B-Lactams = Cefepime, Ceftazidime / Doripenem, Imipenem, Meropenem / Zosyn, Timentin, Aztreonam 2. FQ = Cipro, Levofloxacin 3. Aminoglycosides = Gent > Tobra > Amikacin

Am J Respir Crit Care Med. 2005; 171: 388-416

Reasons Why Your Patient Is Not Getting Better Not dosing drugs appropriately (like Vanc) Resistant organisms MSRA, Pseudonomas Wrong diagnosis Consider fungal/viral, chemical pneumonitis, PE. CHF. ARDS, ILD, empyema, abscess, metastatic

infection, TB, Legionella Insufficient time might need up to 72 hours

MRSA Vancomycin (trough 15-20) 15mg/kg q 12 anuric 1 g q 7-10 days Linezolid (Zyvox) 600 mg q 12 No adjustment needed B-Lactam/B-Lactamase Inhibitor Piperacillin/tazobactam (Zosyn)

4.5 gm q 6 CrCl > 40 same 4.5 gm q 6 CrCl 20-40 3.375 gm q 6 CrCl < 20 2.25 gm q 6

PCN Allergy Aztreonam 0.5-2 g q 6-12 CrCl 10-30 same 1st dose the 50% usual dose CrCl < 10 same 1st dose the 25% usual dose

Quinolones Ciprofloxacin 400 mg q 8 CrCl 5-29 200-400 mg IV q 18-24 Levofloxacin 750 mg qd CrCl 20-49 750 mg q 48

CrCl 10-19 750 mg *1 then 500 mg q 48 Aminoglycosides Gent > Tobra > Amikacin Gentamicin (trough 60 q 24 CrCl 40-60 q 36 CrCl 20-40 q 48

Tobramycin (trough 0.5-2 mcg/ml) For once daily dosing Obtain random trough 6-14 after dose

7 mg/kg/day CrCl > 60 q 24 CrCl 40-60 q 36 CrCl 20-40 q 48

Amikacin (trough < 10mcg/ml) 15 mg/kg/day div q 8 Max dose 1.5 gm/day

Give initial dose then draw 2 [serum] Pt Creat* 9 = dose interval (creat 2*9= 18)

STEMI

Diagnostic Criteria: 2 mm of ST segment elevation the precordial leads for men and 1.5 mm for women (who tend to have less ST elevation) and greater than 1mm

in other leads. Over time, the ST segment gradually returns to baseline, the R wave amplitude becomes reduced, and the Q wave deepens. In addition, the T

wave becomes inverted. These changes generally occur within the first two weeks after the event, but may progress more rapidly, within several hours of presentation.

New left bundle branch block or true posterior MI is STEMI. Widened QRS (>3 small boxes) in Lead 1 is likely a bundle branch block.

Drugs/Doses: 162-325 mg chewable nonenteric coated ASA Lovenox: if pt

Thrombolytics: Alteplase appears superior to streptokinase Patients >67 kg: Total dose: 100 mg over 1.5 hours; infuse 15 mg over 1-2 minutes. Infuse 50

mg over 30 minutes. Infuse remaining 35 mg of alteplase over the next hour. Patients 67 kg: Infuse 15 mg I.V. bolus over 1-2 minutes, then infuse 0.75 mg/kg (not to exceed 50 mg) over next 30 minutes, followed by 0.5 mg/kg over next 60 min (not to exceed 35 mg).

Streptokinase, Tenectaplase, or Reteplase

The door-to-balloon time should be less than 90 minutes including transfer time if longer, thrombolytics are preferred unless there are contraindications.

Ischemic Stroke Management

Transient Ischemic Attack (TIA): In June 2009, the definition of a TIA was changed. The new AHA definition is a transient episode of neurological dysfunction

caused by focal brain, spinal cord or retinal ischemia, without acute infarction. No timeframe is defined; guidelines state that TIAs typically resolve in under 2 hours.

Workup for risk stratification and proper diagnosis: Neuroimaging within 24 hours, preferably MRI Noninvasive imaging of carotid and intracranial vessels

(Carotid and transcranial US, MRA or CTA head and neck) EKG ASAP; Echo and cardiac monitoring if vascular etiology not known Routine labs Hospitalize if TIA occurred within 72 hours and ABCD score 3 or higher

(1 each for > than age 60, initial bp 140/90, diabetes, duration 10-59 minutes, initial speech impairment without focal weakness; 2 each for initial focal weakness or duration 60 minutes or more. Two day risk of stroke 0% for score 0-1, 1.3% for 2-3, 4.1% for 4-5, 8.1% for 6-7.)

Guidelines for Initial Stroke Management: Stroke onset time is last time you know the patient was at baseline Intubate when airway is compromised Standard order sets recommended Do limited number of tests to speed diagnosis and treatment All pts: glucose level, non-contrast head CT or MRI, EKG, cardiac enzymes, Chem 7, Coags, O2 sat Depending on pt: Liver enzymes, UDS, EtOH level, hCG, ABGs (if you suspect hypoxia), CXR (if you suspect lung disease),

LP (if you suspect sub-arachnoid hemorrhage but head CT neg), EEG (if you suspect seizures ASA 325mg within 24-48 hours is recommended Clopidogrel/Plavix and/or GP 2B/3A blockers not recommended Cardiac monitoring for at least 24 hours after onset Over 60% have SBP >160; data concerning treating BP are conflicting. Panel consensus says that if you have to lower BP,

goal is only 15-25% on first day, and dont lower BP unless DBP >120 or SBP >220 (although theres no data that shows these levels are particularly dangerous). Drops of >20 mmHg are associated with poorer outcomes.

No specific time to start meds. If you must lower BP, labetalol is a reasonable choice: 10mg IV over 1-2 min, then ggt at 2-8 mg/min. Write to keep SBP is no less than and DBP is no less than

Initiation of existing anti-HTN meds at 24 hours is reasonable Do not treat until after CT seen Urgent anticoagulation is specifically not recommended DVT prophylaxis with SC Lovenox or heparin (SCDs if you cant anticoagulant) NPO until after swallow evaluation If cannot swallow, give NG, Dobhoff or PEG tube for feeds or hydration while working to restore swallow function (Timing not

given this is more a rehab issue than acute care) Correct hypoglycemia and hypovolemia Persistent hyperglycemia 1st24 hrs assoc with poorer outcomes goal is 50% of a hemisphere, MCA territory or of the cerebellum) have increased risks of brain edema and elevated

ICP consider early neurosurgery consult Fall precautions / Early mobilization (PT/OT) decreases subacute complications Foleys only when necessary / O2 if pt is hypoxic / Treat fevers and look for infection

Prevention of Recurrent Stroke/TIA: Control hypertension. Only 10/5 mmHg reduction has been shown to stroke risk. Close monitoring after discharge. Lifestyle

changes and medications should be used. The guideline states that no optimal medication regimen is known, but lists ACE inhibitors and diuretics as good options.

Control lipids and BP more rigorously in diabetics. ACEI and ARB are 1st line agents. Goal HbA1c is < 7%; good control has fewer microvascular complications. Pts with symptomatic atherosclerotic disease, target LDL is

Fever of Unknown Origin Most common Infectious causes:

o Extrapulmonary TB o Intra-abdominal abscess o Pelvic abscess o Subdiaphragmatic abscess o CMV o Subacute bacterial endocartitis

Most common non-Infectious causes: o Neoplasms: atrial myxoma, leukemia, liver mets, lymphoma, renal cell cancer, pancreatic cancer o Connective Tissue Diseases: adult Stills disease, temporal arteritis, polyarteritis nodosa, rheumatoid arthritis o Miscellaneous: drug fever, gout, recurrent PE/DVT, hematoma, familial Mediterranean fever

Diagnostic Approach: o Look for danger signs o A comprehensive history and physical is the key to establishing a diagnosis in a patient with FUO o Most patients with FUO have atypical presentations of common illnesses o Keys in the history:

Prior chronic infections Prior cancer, no matter how remote Prior surgery Travel history Any implants, including pacemakers, cosmetic implants, prosthetic valves, prosthetic joints

Diagnostic Approach: o Comprehensive history o Discontinue all non-essential medications o Repeated Physical Exams o CBC with peripheral smear, Chem-12, UA, ESR o Blood Cultures x3+ without Abx o ANA, Rheumatoid factor, HIV tests o CXR, Gallbladder US o CMV IgM Ab or viral detection o Heterophile Ab o TST (PPD) o CT Abdomen & Pelvis o Radionuclide scans o Venous dopplers lower extremities o Bone scan o Bone marrow biopsy o Liver biopsy

Clinical Pearls: o Alkaline phosphatase usually elevated in temporal arteritis, thyroiditis, renal cell carcinoma o Platelets >600,000 suggests cancer, bone marrow disease, TB, fungal infection o Peripheral smears for marrow invasion o Extravasated blood anywhere often causes FUO lasting for weeks o Up to 20% of FUO cases are CMV infection o Tumors have been documented to cause fever for up to 7 years o Consider Adult Stills Disease: Daily spiking fevers, transient rash, arthritis o Liver abscesses often have normal liver enzymes o Pain on raising the arms over the head is probably Takayasu arteritis

The key to diagnosing drug fever as the cause of FUO is stopping all non-essential medications. o What is the prognosis for FUO?

About half of cases without a Dx resolve over time For the other half, the largest case series showed a 3.2% mortality attributable to FUO with follow-up of 5+ years

Empiric Treatment not recommended

Exceptions: o Neutropenia, esp. in chemotherapy o AIDS o Preliminary data leads to a likely Dx (i.e., Travel history, vegetations on echo) o Suspect temporal arteritis

Norman, DC, et al. Fever of Unknown Origin in Older Persons. Infect Dis Clin N Am, 2007;21:937-945. Tolia J, et al. Fever of Unknown Origin: Historical and Physical Clues to Making the Diagnosis. Infect Dis Clin N Am, 2007;21:917-936. Mandell GL, ed. Fever of Unknown Origin. Mandell, Douglas, and Bennett's: Principles and Practice of Infectious Diseases, 6th Ed., Ch. 48. Churchill Livingstone, 2005.

(Available through PubMed.)

OB/GYN OB/GYN Tips and Orders CHORIOAMNIONITIS Signs - fetal tachycardia, Maternal tachycardia, maternal fever, uterine tenderness, purulent amniotic fluid Treatment culture cervix first

Ampicillin 2gms, Q6hrs IV + Gentamicin (1.5mg/kg) Q8hrs IV Allergic to penicillin - clindamycin 900mg Q8hrs

Unasym 3gms Q6hr IV Zosyn 3.375gms Q6hrs IV Imipenem cilastin 500mg Q6hr Meropenem 1gm Q12hr IV

Duration- continued till patient afebrile and asymptomatic ~24hrs FIRST TRIMESTER BLEEDING (Bleeding at < 12 wks ) Speculum exam to r/o cervical/vaginal lesions OB sono

Normal - IU Gest sac w/fetal pole, yolk sac, cardiac motion(Threatened Abortion) NO cervical dilation Management Observation, 50% goes to term

Abnormal- Missed Abortion- No Bleeding

Internal Cervical os closed Ring forceps will not enter in cervical canal Management - D&C

Inevitable abortion Bleeding Internal os open Ring Forceps enter os Management - Emergent D&C

Incomplete abortion Internal os open POC in uterus OB sono Management - Emergent D&C

Complete abortion Internal os open POC not in uterus OB sono Management - BHcg wkly till negative to r/o ectopic

Molar Pregnancy Increase BP and N/V Sono- Snowstorm Managament D&C and serial BHcg

Ectoscopic pregnancy

GBS POSITIVE TREATMENT Pen G 5 mU IV load then 2.5 mU q4 h until delivery PCN allergy check culture or consider

Clindamycin 900 mg IV q 8h until delivery or Vancomycin

GBS PROPHYLAXIS Vaginal + rectal GBS screening Cx at 35-37 weeks of all pregnant women (unless GBS bacteriuria during current pregnancy or previous infant with invasive GBS disease) Indications

Previous infant with invasive disease GBS bacteriuria during current pregnancy Positive GBS screening culture during current pregnancy (except planned Cesarian section) Unknown GBS status with: 18hrs, or intrapartum temp >380 C (100.40F)

GESTATIONAL HYPERTENSION BP >140/90 on >2 occasions at least 4hrs apart within 1 week period No proteinuria (

Dehydration- IVF replacement supplement w/ multivitamin Dimenhydrinate 50 mg (in 50 ml saline/20 min) q 4-6h IV ADD Metoclopramide 5-10 mg q8h IV or Prochlorperazine 2.5 -10 mg q3-4h IV or Promethazine 12.5 - 25 mg q 4 IV Thiamine 100 mg daily for 2-3 days (If vomited >3 wks) ADD Methylprednisolone 16 mg q8h IV/PO for 3 days, taper over 2 wks, If beneficial limit total duration of use to 6 wks, OR Ondansetron 8 mg over 15 min q12h IV

INDUCTION OF LABOR BISHOP SCORE 0 1 2 3 Cervical dilation closed 1-2 3-4 >5 Effacement 0-30 40-50 60-70 >80 Station -3 -2 -1.0 +1 , +2 Consistency firm medium soft - Position posterior midposition Anterior -

Add 1 point pre-eclampsia, each prior vaginal delivery Deduct 1 point- post dates, nulliparity, preterm, prolonged prom

Score- 0-4 45-95% failure 5-9 10% failure 10-13 0% failure

CERVIDIL - 10mg vaginal insert, kept for 12hrs OXYTOCIN - 1000ml LR + 20u pitocin Start at 2mu/min - increase by 2mu q 15min until 3-4contractions in 10 min period or, maximum of 40 mu/min is reached LATE PREGNANCY BLEEDING- (After >20 wks) Cervical- Erosions, polyp, carcinoma Vaginal- Varicosities, Lacerations Placental- Abruptio Placenta, Placenta previa,Vasa previa Vital signs /FHR/Fetal station, No digital Exam CBC, DIC Panel, Type &cross, Sono (placental Location), #16 IV, Catheter, Determine mom is stable or unstable

Mom Unstable(Tachy, Hypotensive)-IV fluid - Deliver Fetal Unstable(Brady, Tachy, Variable/late decels) -Deliver

Painful vs. Painless Painful (Abruptio Placenta, uterine rupture )

Abruptio placenta Normal placenta implantation, Most common 3rd tri bleeding Types - partial, marginal, complete (concealed) Management:

Both stable - Preterm not in labor - Observe Labor - Deliver

Either Unstable - Deliver Painless (placenta Previa, vasa previa) Placenta Previa-Low placental implantation

Types-Low-lying, partial, total Management- Both stable-

< 36 wks observe & term C-section Vag delivery if placental edge > 2 cm from internal os

Either Unstable - C-section Vasa Previa fetal vessel cross internal os

Classic Triad - AROM, painless bleeding, Fetal bradycardia MAGNESIUM RECOVERY - MGSO4 infusion for 24hrs o Vital signs B.P , O2 Sat, HR, RR o Urine output, lung examination, DTRs o Monitor every 2hrs o Management-Immediate C-section POST PARTUM FEVER

Unasyn 3gm i.v Q 6hr or Clindamycin 900mg i.v Q8hr + Gentamycin 1.5mg/kg i.v Q 8hrs

Till patient afebrile after 24hrs then discharge with no antibiotics Etiology :- Endometritis, Pneumonia, UTI, infection, DVT, Mastitis POSTPARTUM HEMORRHAGE > 500ml - vaginal delivery > 1000ml - C /section o Management ABC, IV fluids, urinary catheterization, CBC, type and screen o Bimanual uterine massage, evacuate retained products of conception o Repair of lacerations o Oxytocin 20-40 U in IL LR o Methergine 0.2mg IM q 2-4hrs (contraindicated in HTN) o Hermabate/ carboprost 0.25mg IM/intramyometrically q 15min up to total 2mg (contraindicated in heart, lung, liver ds) o Cytotex 1000mcg rectally or 200mcg oral with 400mcg s/e If bleeding continues surgical intervention D&C , B- Lynch, Oleary, uterine A legation, Hysterectomy

POST TERM PREGNANCY >42 weeks gestational age Confirm the gestational age IOL done at >41 week

PRE-ECLAMPSIA - SBP > 140/90 Mild - 1+ urine dip 24hr urine >300gms 160/105 Headache, flashing lights Urine dip 3+ 24hr urine protein 5gm; consider HEELP? MgSO4 4gm bolus followed by 2gm/hr Management - CBC (plt, anemia), chem 12 ( AST/ALT, Cr), UA (alb), Uric acid Serial BPs, LE edema, reflexes

PRETERM LABOR Gestational age > 20weeks < 37 weeks CTX- At least 3 in 30 min Serial exams show cervical change or single exam with dilation >=2 cm

Examination Fetal monitoring, tocodynamic monitoring SSE pooling, Nitrazine, Ferning GC/Chlamydial cultures, GBS, urine analysis, fetal fibronectin (if 3hrs >2hrs No epidural >2hrs >1hr

Check presentation, position and consider, AROM, Epsiotomy, vacuum, forceps or C/section PROM premature ROM (no labor) PPROM preterm PROM ( 18 hrs) Management: confirm gestational age, no SVE

SSE :- pooling , Nitrazine, Ferning Sonogram Fetal fibronectim 36wks - proceed to delivery by IOL - GBS prophylaxis by PCN G if indicated - Antibiotics for latency if indicated- Ampicillin, Gentamicin

SHOULDER DYSTOCIA Obstetric emergency. Most cases unpredicted, suspect if fetal head retracts back into perineum (turtle sign) due to reverse traction from the shoulders being impacted at the pelvic outlet. Management- HELPERR

1 Call for Help 2 Evaluate for episiotomy 3 Legs :hyperflexion and abduction of hips (McRoberts maneuver) 4 suprapubic Pressure (not fundal) with a rocking motion. 5 Enter vagina : Woodscrew- hand in posterior vagina and rotate posterior shoulder clockwise or anticlockwise until the anterior shoulder

emerges from behind the maternal symphysis. Rubin maneuver (fetal shoulder adduction): Push anterior or posterior shoulder towards fetal chest displacing shoulders from the anteroposterior diameter of chest

6 Remove posterior arm: Insert hand in vagina and identify posterior shoulder then follow along to Identify the arm and elbow, insert finger in antecubital fossa topull the arm and deliver the posterior shoulder.

7 Roll the pt on all fours (Gaskin maneuver) If all this fails try deliberate clavicular fracture, pushing back the fetal head to do a c/section or symphysiotomy.

URINARY TRACT INFECTION > 105 cfu/ml clean catch specimen, >102 cfu/ml- cath specimen -Macrobid 100mg P.O B.I.D x 7days

PEDIATRICS Pediatric Tips and Orders ABX: Treat UTI 5-7, OM 7-10, Pneumonia/Sinusitis 10 Rocephin IV 50-75mg/kg/d q 12h Amoxicillin (125,200,250,400)/5ml Neonate 1 yr 2.5 mg HHN q 4 1-2 wk then prn Disp 1 box Atrovent 500 mcg HHN q 2 Xopenex 0.31-0.63-1.25mg HHN q 4-6*2 wks then prn disp 1 (20) Flovent MDI 44 mcg -110 mcg 2 puffs bid w/aerochamber * 1mo Cromolyn 20 mg via HHN q 8 Candidiasis: Nystatin (100,000) units/ml Preterm: 0.5ml to each side of mouth QID Term: 1 ml to each side of mouth QID Child: 4-6ml swish & swallow QID Gentian violet 1 application to tongue stains cloths & skin Constipation: Glycerin: 4ml/7.5ml rectal solution/ suppository Neonate: 0.5ml/kg/dose rectal solution PR as enema QD-BID PRN or infant suppository PR QD PRN Child6y-adult: 5-15ml rectal soln PR as enema or 1 adult suppository PR QD-BID PRN Mineral Oil Liquid, oral: 180, 480ml Emulsion, oral: 480 ml Rectal liquid (fleet mineral oil): 133ml Child 5-11y: oral 5-15ml/24h div QD-TID PO Oral emulsion: 10-25ml/24h div QD-TID PO Rectal: 30-60ml as single dose Child >12y: oral 15-45ml/24h div QD-TID PO Oral emulsion: 30-75ml/24hr div QD-TID PO Rectal: 60-150ml as single dose Milk of Molasses enema Croup: Dexamethasone 5 mg IV q 6 Diaper rash:

1.) Zinc Oxide apply prn diaper change 2.) Questran 10% + Aquaphor 3.) Lantiseptic 4.) Flanders Buttocks 13.4% cream 4 oz 113 grams

DKA: VS q 1 * 4 then q 2 Feeds: Birth 1-mo 1-2 oz q 2-3 2mo 3 mo 3 oz q 3-4 3mo 4 mo 4 oz q 3-4 4mo 5 mo 5 oz q 3-4 6mo babyfood Gas: Infants Mylicon (NOT neonates) gasping syndrome 24 lbs or > 2y: 0.6ml PO PRN (max 7.2ml/24h)

GERD: Reglan 5mg/ml (0.2-0.4) mg/kg q6 and/or Zantac (ranitidine) 6 mg IV q 6 Hypoglycemia: BS < 40 D10 Day 1 65 ml/kg/d Day 2 80 ml/kg/d Day 3 100 ml/kg/d > Day 4 + 20 ml/kg/d

IRON: Ferrous Sulfate 3mg/Kg/day divided TID 75 mg (15mg) / 0.6 ml Ferrous Gluconate 3-6 mg elem. Iron/ Kg/day divided TID Elixir 300mg(34mg)/ 5ml

Maintenance hourly IV fluid (4/2/1 rule) 4ml/kg for 1st 10kg; 2ml/kg for next 20kg 1ml/kg for each kg>30 Example: 70kg person (4x10kg=40)+(2x20kg=40)+(1x40kg=40) = 120ml/hr maintenance rate

Meningitis: Empiric treatment based on age: Neonate: Ampicillin + Cefotaxime + Late-onset Nafcillin or Vanc+Cefotaxime 1mo -3 mo: Ampicillin + Cefotaxime or Ceftriaxone 3mo-5yr: Cefotaxime or Ceftriaxone >5yr: Cefotaxime or Ceftriaxone + Vanc for resistant S pneumonia Acyclovir dose: < 12yo 20 mg / Kg IV q 8 hr * 10 days; > 12 yo 5-10 mg / Kg IV q 8 hr * 10 days

Nausea/ Vomiting: Zofran 0.1 mg/kg per dose IV q 8 prn Newborn Sepsis: I:T ratio Bands to total (Bands + Segs) 0.2 or > = Sepsis CBC, chest X-ray, blood cx, CBG, O2 sat Amp + Cefotaxime TTN should resolve by 6 hrs of age Pain: Fentanyl 1 mcg/kg IV q 2

RSV: Racemic epinephrine 0.05 ml/kg/dose > 10 kg 0.5 ml in 3 ml of 3% saline via HHN q 2 < 10 kg 0.15-0.25-0.35 ml Alpha Interferon 10U/kg * 10 days Pedi Afrin 1 spay each nostril * 3 days

Sepsis: WBC > 15, CRP > 3, HC03 < 24 SIDS: around 45-50 wks Gestation 33-36wks, 1.37/1000; 37-40 wks, 0.69/1000

Steriods Prednisolone (15mg/5 cc) at 2mg/kg/d PO bid ___ teaspoons * 5 days Solumedrol 2mg/kg loading dose then 1mg/kg/d q 6 1oz = 30cc = 30 gm Urine Output: ((height*weight)/3600) Infants < 1 cc/kg/hr Children < 0.5 cc/kg/hr Older < 300 ml/m^2/24 Vitals: Respiratory Rate: Tachypnea: Heart rate: Neonat 45 < 2 mo 60 140 0-1 yr 35 2mo-1yr 50 130 1-3 yr 25 > 1 yr 40 80 4-6 yr 20 30 80 6+ 18 75

NICU Tips and orders Blood pressure: Rule of thumb MAP = current wks gestation Chronic Lung Disease Bronco Pulmonary Dysplasia:

1.) 0xygen Use 28 days post birth 2.) If needs Oxygen after the age of 36 wks

EKG: LAD Acyanotic AV canal defect Cyanotic Tricuspid atresia Feeds: Preterm: 80 cc/kg/day start feeds 10-20 ml/kg/day Advance to 150 ml/kg/day (TFV) Term: 60-70 cc/kg/day start feeds 20 ml/kg/day Advance to 150 ml/kg/day (TFV)

Total Fluid Volume (TFV) Day Of Life (DOL #1): 1. Calcium Gluconate IV 2. Protein (Trophamine) < 1250gm Start : 2gm/kg/day Max 4 gm/kg/day 3. Glucose D10 - NO electrolytes

Glucose Infusion Rate = 6-8 mg/kg/min < 1000 gm 100ml/kg/day

1000-1500 gm 80ml/kg/day > 1500 gm 60ml/kg/day

Urine output 0. 5-1 cc/kg/hr If Na need to Fluids If Na need to Fluids

Total Fluid Volume (TFV) Day Of Life (DOL #2): Add 20ml/kg/day for urine loss + 20cc/kg/day for Bili light

Ex. > 1500 gm 60ml/kg/day 80ml/kg/day 100ml/kg/day Total Parental Nutrition (TPN): 1st wk 60-80 cal/kg/day 2nd wk 80-100 cal/kg/day 3rd wk 100-120 cal/kg/day CLD 130 cal/kg/day

Lipids 9 cal per gm / 1 gm IV = 5ml Start: 1gm/kg/day Max 3 gm/kg/day

Formula 10-20 ml/kg/day 20 0. 67 cal = 1ml 22 0. 7 cal= 1 ml 24 0. 8 cal = 1 ml

Protein 4 cal per gm Start : 2gm/kg/day Max 4 gm/kg/day

Carbs(D10) 3. 4 cal per gm / D10 1cc=0. 34 cal Na (135-145) 2-4 meq/kg/day K (3. 5-6) 1-2 meq/kg/day

EX: Total Parental Nutrition (TPN): 3 kg child Lipids Start: 1gm/kg/day =1 gm IV=5ml

2. 2 cal per ml*(wt kg*5)15cc = 33 cal Formula Start: 10-20 ml/kg/day

(ml*wt kg) 30ml*0. 67 = 20.1 cal 20 0. 67 cal = 1ml 22 0. 7 cal= 1 ml 24 0. 8 cal = 1 ml

Protein Start : 2gm/kg/day 4 cal per gm*2gm*3 kg = 36 cal

Carbs D10 1cc=0. 34 cal D10 80cc*3 kg-lipids(15 )-feeds(30)-UVC(12) =

183*0. 34 cal = 62. 22 cal TFV = 183/24= D 10 @ 7. 63 cc/hr (Lip 33+Formula 20.1+Protein 36+Carbs 62. 22) /3 kg = 50.44 cal/kg/day

Total Fluid Volume (TFV) Day Of Life (DOL #3): Left Atrium (ANP) blood flow to kidney Diuresis 80% of fluid intake

Max urinary output 4-5 cc/kg/hr Glucose Infusion Rate: 6-8 mg/kg/min Glucose Infusion (mg/kg/min)= (0.167*[D]*rate cc/hr) / Wt in kg [D] = D10 or D 12. 5 Glucose > 50 Diuresis occurs 3rd day of life then can increase rate

Do not change electrolytes in first 24 hours of life Needs: < 32 weeks < 1500 gm need: Head Ultra Sound (HUS): DOL #7, 21, PCA 37 wks Eye Exam: (ROP) order 4-6 weeks after birth

1.) Zone 2.) Stage

1- Ridge 1 2 3 2- Dilation 3- Tortuous 4- Detached Worse (Z 1 S 4) Treat Threshold disease

Open Crib: 1800 g and air temp 30

Respiratory Distress and Persistent Pulmonary Hypertension: 28 wks 60% RDS PHN Persistent HTN of the lungs 32 wks 50% RDS 34 wks suck, swallow, apnea, surfactant develop 40 wks- NO retinopathy of prematurity Surfactant:

L:S 2:1 < 0. 5 % chance of immature lungs PG (+ ) < 0. 5 % chance of immature lungs BOTH 0% chance of RDS

Weight Gain: 18 grams per kg per day # - 7 days later# / 7 days/ weight

Pediatric Pneumonia Orders 1 week1 month: Amp+Gent or Amp+Cefotaxime or Amp+Gent+Cefotaxime if severe (may add Vanc or Linezolid if MRSA is

suspected) Ampicillin IV/IM 100-200mg/kg/day divided Q6h (Max 12g/day) Gentamicin IV 2.5mg/kg(IBW)/dose Q8h peak and trough after 3rd dose for therapeutic monitoring (goals peak 8-10,

trough 0.5-1) Cefotaxime IV 200mg/kg/day divided Q8h (Max 12g/day) Vancomycin IV 60mg/kg/day divided Q6h trough after 4th dose for therapeutic monitoring (goal 10-20) Linezolid IV 10mg/kg/dose Q8h **If Chlamydia is suspected Erythromycin PO/IV 12.5mg/kg/dose QID for 14 days

1-3 months: Azithro +/- Ceftriaxone Azithromycin IV 2.5mg/kg/dose Q12h Ceftriaxone IV 50-75mg/kg/day (Max 2g/day) add if pt. is febrile **If pt. has lobar pneumonia Ampicillin IV/IM 300-400mg/kg/day divided Q6h (Max 12g/day)

4 months - 5 years: Inpatient

Ampicillin IV/IM 100-200mg/kg/day divided Q6h (Max 12g/day) Inpatient ICU

Ceftriaxone IV 50-75mg/kg/day (Max2g/day) Azithromycin IV 5mg/kg/dose Q24h (Max 500mg/day) Vancomycin IV 60mg/kg/day divided Q6h trough after 4th dose for therapeutic monitoring (goal 10-20)

5-18 years: Ceftriaxone IV 50-75mg/kg/day (Max 2g/day) Azithromycin IV 10mg/kg/day divided Q12h (Max 500mg/day) Vancomycin IV 60mg/kg/day divided Q6h trough after 4th dose for therapeutic monitoring (goal 10-20)

Criteria for admission of the child with Pneumonia Hypoxemia (SatO270/ min for infants, RR >50/ min for older children; retractions; nasal flaring; difficulty

breathing; apnea; grunting Toxic appearance (more common in bacterial pneumonia and may suggest a more severe course) Underlying conditions that may predispose to a more serious course of pneumonia (cardiopulmonary disease, genetic

syndromes, neurocognitive disorders), may be worsened by pneumonia (metabolic disorder) or may adversely affect response to treatment (immunocompromised host)

Complications (effusion/empyema), CXR: consolidation, atelectasis Suspicion or confirmation that CAP is due to a pathogen with increased virulence, such as Staphylococcus aureus or group

A streptococcus Failure of outpatient therapy (worsening or no response in 48 to 72 hours).

Treatment of Pediatric Pneumonia

Age group Empiric Rx 1-6 mo Bacterial (not Chlam. Thrach, not S. aureus)

Ceftriaxone 50-100 mg/kg/day in 1 or 2 divided doses, OR Cefotaxime 150 mg/kg/day in 3 or 4 divided doses

> 6 mo Uncomplicated bacterial (not Mycopl, not S. aureus)

Ampicilline 150 to 200 mg/kg/day in 4 divided doses (MAX 12 g/day), OR Cefotaxime 150 mg/kg/day in 3 divided doses (MAX 8 g/day or 10 g/day divided in 4 doses for severe infection or substantial local penicillin resistance), OR Ceftriaxone 50 to 100 mg/kg per day in 1 or 2 divided doses (MAX 2 g/day or 4 g/day divided in 2 doses for severe infection or substantial local penicillin resistance)

M. pneumoniae Azithromycin 10 mg/kg/day for two days (MAX 500 mg/day); transition to oral therapy at 5 mg/kg per day as soon as clinically appropriate, OR Levofloxacin 16 to 20 mg/kg/day in 2 divided doses for children 6 months to 5 years; 8 to 10 mg/kg per day for children 5 to 16 years (MAX 750 mg)

Syndromes Empiric Rx Severe pneumonia Ceftriaxone 100 mg/kg/day in 2 divided doses (MAX 4 g/day), OR

Cefotaxime 150 mg/kg/day in 4 divided doses (MAX 10 g/day) PLUS Azithromycin 10 mg/kg/day for two days (MAX 500 mg/day); transition to oral therapy at 5 mg/kg per day as soon as clinically appropriate, OR Doxycycline 4 mg/kg/day in 2 divided doses (MAX 200 mg/day); transition to oral therapy as soon as clinically appropriate

Severe pneumonia requiring ICU admission

Vancomycin 60 mg/kg/day in 4 divided doses (MAX 4 g/day) PLUS either Ceftriaxone 100 mg/kg/day in 2 divided doses (MAX 4 g/day) or Cefotaxime 150 mg/kg/day in 4 divided doses (MAX 10 g/day) PLUS Azithromycin 10 mg/kg/day for two days (MAX 500 mg/day); transition to oral therapy at 5 mg/kg per day as soon as clinically appropriate PLUS (if indicated) Antiviral treatment for influenza

CAP due to aspiration Ampicillin-sulbactam 150 to 200 mg/kg/day in 4 divided doses (MAX 8 g/day of ampicillin component) OR, if MRSA is a consideration, Clindamycin 30 to 40 mg/kg/day in 3 or 4 divided doses (MAX 3.6 g/day)

Asthma in Pediatrics Step 1 Mild Intermittent SABA * PRN

Albuterol MDI (90 mcg) < 12 yo = 2-4 puffs q 20 min * 3

Albuterol Nebs ( based on Min Ventilation) 6 yo and have Medicaid - 110 mcg 1 puff bid - 220 mcg 1 puff qd

Step 3 Mild/Moderate persistent (Age < 5) Medium dose ICS (Flovent 176-352) (Age >5) Medium dose ICS or Low dose ICS + LABA

(176) Flovent MDI 44 mcg 2 puffs bid (220) Flovent MDI 110 mcg 1 puff bid before brushing

- refill monthly disp1 refill 6 w/ spacer aerochamber (180) Advair HFA 45/21 2 puff bid w/ aerochamber (200) Advair DPI 100/50 1 puff bid

Step 4 Mod persistent = Daily Medium dose ICS (Pulmicort 400-800)+ LABA

(640) Symbicort (Pulmicort/Formoterol) #120 - 160/4.5 2 puff bid before brushing refill monthly disp1 refill 6 w/ spacer aerochamber

Step 5 Mod/Severe High dose ICS (Pulmicort >800) or (Flovent > 400)+ LABA

(640) Symbicort (Pulmicort/Formoterol) #120 - 160/4.5 2 puff bid before brushing refill monthly disp1 refill 6 w/ spacer aerochamber

(500) Advair disk 250/50 1 puff bid

Step 6 Severe = Daily at rest High dose ICS (Pulmicort > 800) or (Flovent > 400)+ LABA + oral steroids (640) Symbicort (Pulmicort/Formoterol) #120

- 160/4.5 2 puff bid before brushing refill monthly disp1 refill 6 w/ spacer aerochamber + Orapred (prednisolone) 15mg/5ml = 2 mg/kg (max 80 mg qd)

- (500) Advair disk 250/50 1puff bid+ Orapred (prednisolone)15mg/5ml = 2 mg/kg (max 80 mg qd)

Frequency Severity Mild Symptoms only intermittently

URI triggered, Cold air Allergen triggered

Responds readily to PRN SABA

Moderate Symptoms almost daily, NOT at rest Night time sxs wkly, NOT nightly Symptoms restrict some activities

Requires systemic steroids

Severe Daily symptoms at rest Nightly Sxs Activity severely restricted by sxs

Requires Dr. visit, ER or hospital management

Kid 5-11 Pulmicort DPI * Flovent MDI** Flovent DPI** Low 180-400 mcg

100-200 GINA 88-176 mcg 100-200 GINA

100-200 mcg

Med 400-800 mcg 200-400 GINA

176-352 mcg 200-500 GINA

200-400 mcg

High > 800 mcg > 400 GINA

> 352 > 500 GINA

> 400

Adults Pulmicort Flovent

Low 600 mcg 220 mcg Med 1200 mcg 600 mcg High > 1200 mcg > 600 mcg

*Adrenal Suppression Pulmicort (Budesonide) Kids> 1200 mcg/day Adults > 2400 mcg/day

** Adrenal Suppression Flovent (Fluticasone) 400 mcg/day = 16% suppression

*** If above 500 mcg/day burst prior to surgery

Pari-LC + Plus Neb use w/ Pulmicort Respules Note: AeroChamber script: Pari non-vented face mask use with Pulmicort Give 2, they last 1 yr Small face mask < 6months Write dispence as written Med face mask 6mo-4yo Can get at 3 places:

TTFM pharmacy, Britcare National Home Health

Oral Steroids: Use Ideal Body Weight Orapred ODT 10/15/30 mg tabs (2mg/kg) at onset of asthma and qam * 5 days Orapred 15mg/5ml (2mg/kg) at onset of asthma and qam * 5 days Prednisone 20 mg tabs (2mg/kg) at onset of asthma and qam * 5 days

Decrease dose of ICS 25% q 3 months with control Consider dropping LABA before stepping down to low dose ICS Do not stop mod-high dose ICS suddenly

2007 NHLBI/NAEPP Asthma Action Guidelines

Inhaled Corticosteroids: Pulmicort Respules< 11 yo Low = 0.5mg / Med = 1mg/ Age 5-11 High dose = 2mg Pulmicort -Flexhaler (Budesonide DPI) = 90, 180,200mcg Flovent MDI #(Fluticasone) = 44, 110, 220 mcg Flovent DPI (Fluticasone) = 50, 100, 250 mcg Combinations (ICS/LABA): Symbicort (Pulmicort/Formoterol) #120

80/4.5 & 160/4.5 Advair HFA (Flovent/Salmeterol)

45/21 & 115/21 & 230/21 Advair Disk (Flovent/Salmeterol)

100/50 & 250/50 & 500/50

Antihistamine: Tavist syrup (Clemastine) 0.67/5ml 5 ml po bid Tavist Tabs (Clemastine)1.34mg & 2.68 mg ___mg po bid Loratidine 2-5 yo 5mg/5ml sig: 5 ml po qd Loratidine > 6 yo 10 mg 1 po qd Zyrtec (Cetirizine) 5mg/5ml 5ml po qhs disp 150ml Zyrtec (Cetirizine) > 6yo 5 or 10mg chewable/tablet 1 po qhs

H1 Blocker Mucous Membranes H2 Blocker Stomach and Skin: = 5-6 mg/kg/day

Zantac (Ranitidine) liquid 15mg/1ml __ mls by mouth bid Ranitidine tabs 75/150 mg 1 po bid max 300 mg qd

Leukotriene inhibitors Singular chewable 2-5 yo 4mg po qd 6-14 yo 5 mg po qd

Allergic Rhinitis: Flonase 2 squirts each nostril 1 time day Nasonex 2 squirts each nostril 1 time day Rhinocort aqua 2 squirts each nostril 1 time day Normal saline nasal spray 2 squirts each nostril prn Normal Saline nasal irrigation:

Add tsp plain table salt(no iodine) to 2 cups warm water. Irrigate each nostril with 1 cup of solution bid with cold qd when well

Eye drops: Naphcon-A 2 gtts each eye q 6 prn

1-866-patient =1-866-728-4368 Bridgestoaccess.gsk.com Mysymbicort.com FoodAllergy.org = Food allergy Action Plan

Spirometry Normals Patient Asthma Pre/Post drug change

FVC > 80% Pred +/- 12%

FEV1 > 80% Pred +/- 12%

FEV1/FVC > 80% pre-drug < 70 Obstructive

FEV 25-75 Small airways > 65% < 65% 25%

RV 15% post drug

RAW Reactive airways < 120 > 120 15% post drug

RV/TLC < 115 Long tail air trap

P INSPIRATORY Diaphragm > 60 P EXPRIATORY Muscles > 30 FEF MAX > 25%

Recommended Influenza Treatment Dosage TAMIFLU (oseltamivir phosphate) for people who have been exposed to Influenza A (H1N1). For more information, refer to http://www.cdc.gov/h1n1flu or www.fda.gov.

Pediatric Patients less than 1 year old* Body Weight (kg)

Dose by Age

Recommended Treatment Dose for 5 Days (Dose in volume is based on the concentration (12 mg/mL) of commerciallymanufactured TAMIFLU Oral Suspension)

Dosing for infants

< 3 months 12 mg (1 mL) twice daily

younger than 1 year

3-5 months 20 mg (1.6 mL) twice daily not based on weight

6-11 months

25 mg (2 mL) twice daily

Pediatric Patients 1 to 12 years old TAMIFLU Capsules may be opened and mixed with sweetened liquids such as regular or sugar-free chocolate syrup if suspension not available. Body Weight (kg)

Body Weight (lbs)

Age (years)

Dose for 5 Days

# Bottles of Oral Suspension Needed for the 5 Day Regimen

# of Capsules Needed for the 5 Day Regimen

15 33 1-2 30 mg twice daily

1 10 capsules (30 mg)

> 15-23 > 33-51 3-5 45 mg twice daily

2 10 capsules (45 mg)

> 23-40 > 51-88 6-9 60 mg twice daily

2 20 capsules (30 mg)

> 40 > 88 10-12 75 mg twice daily

3 10 capsules (75 mg)

Adults and Adolescents 13 years and older: 75 mg twice daily for 5 days. Treatment should begin as soon as possible after symptom onset.

Special Dosage Instructions: No dose adjustment is recommended for patients with mild or moderate hepatic impairment (Child-Pugh score 9). No dose adjustment is required for geriatric patients. Renal Impairment, Recommended Treatment Dosage: Dose adjustment is recommended for patients with Cr Cl 10-30 Treatment dose should be reduced to 75 mg once daily for 5 days. No recommended dosing regimens are available for patients undergoing routine hemodialysis and continuous peritoneal dialysis treatment with end-stage renal disease

Recommended Influenza Prophylaxis Dosage Pediatric Patients less than 1 year old Body Weight (kg)

Dose by Age

Recommended Prophylaxis Dose for 10 Days (Dose in volume is based on the concentration (12 mg/mL) of commercially manufactured TAMIFLU for Oral Suspension)

Dosing for infants

< 3 months

Not recommended unless situation judged critical

younger than 1 year

3-5 months

20 mg (1.6 mL) once daily not based on weight

6-11 months

25 mg (2 mL) once daily

Pediatric Patients 1 to 12 years old: Dosage following close contact with an infected individual is shown in the following table. Body Weight (kg)

Body Weight (lbs)

Age (years)

Dose for 10 Days

# Bottles of Oral Suspension Needed for the 10 Day Regimen

# of Capsules Needed for the 10 Day Regimen

15 33 1-2 30 mg once daily

1 10 capsules (30 mg)

> 15-23 > 33-51 3-5 45 mg once daily

2 10 capsules (45 mg)

> 23-40 > 51-88 6-9 60 mg once daily

2 20 capsules (30 mg)

> 40 > 88 10-12 75 mg once daily

3 10 capsules (75 mg)

Adults and Adolescents 13 years and older: 75 mg once daily for at least 10 days following close contact with an infected person. Therapy should begin as soon as possible after exposure. The recommended dose for prophylaxis during a community outbreak of influenza is 75 mg once daily. Safety and efficacy have been demonstrated for up to 6 weeks. The duration of protection lasts for as long as dosing is continued.

Prophylaxis in pediatric patients following close contact with an infected individual is recommended for 10 days. Prophylaxis in patients 1 to 12 years of age has not been evaluated for longer than 10 days duration. Therapy should begin soon as possible.

Special Dosage Instructions: No dose adjustment is recommended for patients with mild or moderate hepatic impairment (Child-Pugh score 9). Renal Impairment, Cr. Cl 10-30 Recommended Prophylaxis Dosage: dose can be reduced to 75 mg every other day or 30 mg every day.

Inpatient Treatment of Bronchiolitis This is the protocol we agreed on as a program, and we should follow it in most cases, for infants who are immunocompetent

and have no history of prematurity or underlying heart or lung disease.

When to admit:

Generally, admit for any of these: age

Evaluation of asymptomatic infants of any gestational age with the risk factor of chorioamnionitis

a. The diagnosis of chorioamnionitis is problematic and has important implications for the management of the newborn infant. Therefore pediatric providers are encouraged to consult with their obstetrical colleagues whenever the diagnosis is made.

b. Lumbar puncture is indicated in any infant with a positive blood culture or in whom sepsis is highly suspected on the basis of clinical signs, response to treatment or laboratory results

c. C. In term infants antibiotics should be discontinued by 48 hours. The infant may be discharged if the physical exam is normal.

Evaluation of asymptomatic infants > 37 weeks gestation with risk factors for sepsis (no chorioamnionitis)

a. Inadequate intrapartum treatment is defined as use of an antibiotic other than penicillin, ampicillin or cefazolin, or if the duration of antibiotics before delivery was < four hours in a GBS colonized woman or intrapartum antibiotic prophylaxis (IAP) not given.

b. Observation without testing in a term infant is acceptable if the frequency of observation is q 2-4 hours for 24 hours

c. Testing is an alternative when close observation is not possible

d. Discharge at 24 hours is acceptable if access to medical care is readily accessible, and a person who is able to comply fully with instructions for home observation will be present.

e. Lumbar puncture is indicated in any infant with a positive blood culture or in whom sepsis is highly suspected on the basis of clinical signs, response to treatment or lab results.

Evaluation of asymptomatic infants

KEY:

PROM: prolonged rupture of membranes

IAP: intrapartum antibiotic prophylaxis

WBC: white blood count

Diff :differential white blood count

CRP: C-reactive protein

I:T ratio: Band to total (Bands + Segs) ratio >0.2 suggestive of sepsis

Antibiotics:

(Please review neofax or Harriet Lane for specific weight and duration dosing per infant)

Gentamicin 4mg/kg IV q 24 hours and Ampicillin 100 mg/kg IV q 12 hours

Or

Cefotaxime 100-200 mg/kg/day divided q 6-8 hours and Ampicillin 100 mg/kg IV q 12 hours

(May need vancomycin if suspect MRSA)

Late onset sepsis: Occurring at 8 to 90 days of life. Caused mostly by GBS and gram negative species such as E. coli and Klebsiella species.

Workup: CBC with manual diff, CRP, UA, urine culture, blood culture, chest x-ray, lumbar puncture, glucose

Neonatal hyperbilirubinemia Physiologic hyperbilirubinemia:

Rises to greater 2 mg/dL in the first week of life. Peak of 6 to 8 mg/dL by day of life 3-5 and then falls. Nonphysiologic hyperbilirubinemia:

Onset before 24 hours of age Rise in serum bilirubin levels of >0.5 mg/dL/hour Sign of illness (vomiting, lethargy, poor feeding, weight loss, apnea, tachypnea, temp instability) Jaundice persisting after 8 days in a term infant or after 14 days in a premature infant.

Ask about: Maternal blood type Baby blood type, Coombs test (if positive identify antibody :Rh, ABO, KELL) Direct bilirubin (if high consider liver causes, if low check hematocrit and possible retic count.)

NICU Calorie Counts

20 cal/oz and 30 mL/oz

Formulas and Breastfeeding 20cal/oz = 0.67 cal/mL 22 cal/oz = 0.73 cal/mL 24 cal/oz = 0.8 cal/mL

Dextrose D5W = 0.17 cal/mL D7.5W =0.26 cal/mL D10W = 0.34 cal/mL D12 W = 0.41 cal/mL D12.5W = 0.43 cal/mL D14w =0.48 cal/mL

To calculate the calorie content in a dextrose solution, divide the percent solution by 100, and then multiply by 3.4. 3.4 is how may calories are in 1 gram of dextrose. Ex: Baby is D8WTo calculate how many calories per mL: 8 grams is 100 mL of SW= 8/100 =0.08 X 3.4 = 0.27 cal/mL.

TPN and Lipids 20% lipids = 2 cal/mL *For TPN, look on the sticker attached to the TPN order sheet to verify how many calories per mL.

Other MCT oil = 7.7 cal/mL ProMod = 7 cal/mL Rice cereal = 5 cal/mL Flaxseed oil = 8.7 cal/mL Corn oil = 8 cal/mL

*Goal of Total fluid volume (TFV) is 150 cc/kg/day, start at 65 cc/kg day. *Must calculate separate calories/kg/day from formula/breast milk/ IVF/ and TPN.