PMpsychiatry.mpaMy BrainMyBrainPersonalPersonalPsychPsychBrainBrain MedschoolMedschoo€ Palm GroupPalmGrouDavitaDavita@ÊJPs(qFacilities mulholland lounge 135 anatomy & histo 24 davis 5th floor 35-1 davis 2nd floor gym 3541ÊPs<ÿLaserdiscs in the UVA Library 3443-strange days 1201-hitchhikers 1164-blade runner 1338-abyss 1021-alien 3 0756-aliens 0873-alien 1150-road warrior 3267-mission tv 3651-prefontaine 3577-conair1-good movie 3494-james & peach 3463-breaking the waves 3340-trees lounge 3391-hackers 3538-star wars trilogy 3607-addicted to love 3216-girl 6 3218-pocahontus 3517 - la femme nikita 3268-stealing beauty 0548-a clck orange 3512 - ST 2 0241-2001:1 0620-postcards - edge 0427-singin in rain-2962 3570-5th element 3559-mib 3485-absolute power 3467-people v flint 3469-maguire 3402-godfather 2 3403- god 3 3355-courage under fire 3342-shes the one .davita 0955-my fair lady 3038-kids 3016-gene kelly 3729-alien r 3040-bridge of mad county boring 3480-marvin1 3361-spitfire1 3202-city hall 2576-ridgemont 2820-barefoot in the park -com 2562-benny& joon 2628-cool runnings 1257-groundhog day 4908-sx vhs 4880-golddiggers of 1935 3219 -toy 3179-powder 3076-beyond rangoon 2913-higher learning 3591-contact 2880-eat drink 2873-natural b k 2732-when a man 2699-nightmare before xmas 3146-brazil 2973-tron 3767-gattaca 3684-king creole 3696-boogie nights 3704-event horizen 3705-gi jane 3613-fiddler on roof 3611-air force one 3441-sling blade1 v9445-dune 3685-moonraker 3687-spy who loved 3653-full monty 3597-conspiracy 0275/0816-dr. StrangeloveÑPsÿÖCABG-coronary bypass JVD-jugular venous distention pre-eclampsia- hypertension edema can lead to stroke orthostatic hypotension >20/10 bp or > 10 bpm inc in HR atrial fibrillation = irregularly irregular rhythm stevens johnson syndrome = a severe form of erythema multiforme in which the lesions may involve the oral and ano-genital mucosae. It is also associated with malaise, prostration, headache, fever, joint pain. The Stevens-Johnson syndrome is a serious idiosyncratic dermatologic effect produced by many antiepileptics, including phenytoin, barbiturates, diltiazem, sulfonamides minoxidil, verapamil, zidovudine, tegretol, valproic acid, lamotrigine (speed of increase!) Mycosis fungoides =Qs¸Contacts er-dr.just Dermatology .dr parlette Dr steven robinson-harvard-son of brother of sam med-psych resident-dr. Markman Dr. Lesh - rel4u -anesthesia-OR follow alongQsuÿÖTo Read what happens after i die-sihms & sonsino - $9 jack riemer-collections of articles on death -confronting the angel of death final gifts-callanan & kelley 155.937 Peabody - the care ofthe patient The road less travelled - m. Scott peck how we die the star of redemption-franz rosenzwig the prophet-khalil gibraha Heinlein - the moon is a harsh mistress get a financial life internship blues-robert marion bleeding edge - kleinke chaos - gleick the PATTERN on the stone- hillis bova - twice 7, return to mars foundation's triumph bio of jackie kennedy before the beginning- martin rees 523.1? Rocks of ages - stephen jay gould back to the moon-homer hickman summer sisters - blum still me - reeve;Qs`ìProblems for medicine -fragmentation -spec. State v. Local -need unification -power by the # -need to be proactive not reactive -understand demographics & why -strategic partnerships/ alliances -economic\ patient issue-panderingtQs Artichoke dip 1 can artichoke 1 cup mayo 1 cup parm cheese 8 oz grated mozzarella pinch garlic salt bake 350 for 30 min;ÀŠFÿ”Movies to rent Alien r Avengers Deep Impact the Jackal - good zorro lost in space Negotiator - good Mecury rising Pleasantville pi rush hour waterboy the spanish prisoner the postman squeze starship troopers sphere wag the dog ulee gold wings of the dove winter guest man in the iron mask midnight in the garden of good&evil great expectations jackie brown ice storm amistad 1GÿeNeuropath tuturial Skull fractures - if lost conscious 1:4 have ICH.{commonly injure, lucid,decline to death} acute till 48hr, subacute 3d-3w, chronic longer & often etoh abuse temporal bone fracture - mma tear ACA, MCA = Sub arachnoid hematoma Basilar fracture -often see leeking CSF subdural hematoma-sickle shaped often w/ a membrane subdural hygroma-arachnoid tear with 1 way csf flow into space intracerebral hematoma diffuse axonal injury-shearing of the nerve fibers ischemic brain damage- most likely hippocampus & basal ganglia brain swelling - inc ICPressure, hard to txf 1rÿ2Talking Points People will be using them, so why not harness the potential opportunity. B/c the hardware will be the property of the individual, they will be inclined to use it for personal use as well, making it much more likely that they will be comfortable with the Pilot. This will provide an opportunity to follow the use of a PDA in several/all of the rotations, and therefore to determine the usefullness/needs for all rotations. Basic Questions? Software -great deal of software out there -check pilotgear.com -check pdamed.com (raphael) -?provide/supply a recommended base of applications for rotations Hardware -recommended min specs -potential organized group purchase to lower costs for the student --- for dr. Office visit preceptorship clerkships shareware software listl 1Mÿ*PalmPilot Interest Group Seth Robinson +x de Leon, Karen + Yoo, Jin Mark Anthony Lepsch x Joey Kim Rob Trundle Kenneth Edward Fasanella + Mark Kringlen x+ Steven Liu jeff ferguson + rob vaugn lee manning lisa mclemore+ rob ferguson + kim jones + wince Herman, Adam x(maybe) Lewelt, Aga x Damle, Sagar Prakalapakorn, Sipong x Toby Campbell x+ chris gorman x+ laura howard herb harmon tim villegas debra lee x merrideth leggat beth cowart julian sprague+ McGee, Hall tricia kao + jared tadje kroog, alex + tobin, alicia + 1NÿPPalmPilot Meeting Outline Welcome Who's this group for? What is the PalmPilot? What can you do with it -Address -datebook -to do list -memo -medical applications --drug ref --patient tracking --read info (dsm, etc) --NEJM and EBM --first year stuff like anatomy help Purpose of this Group -break up the work of figuring out what's good and what's not (show idea of pro's and con's etc) -discuss med issues and handhelds -collective group for hardware/software purchases -see where UVA could help and approach the appropriate people (software vs. hardware) -show webpage and links -show newsgroup -show emulator and sample of programs Have 4 mos Current Models (prices, etc) **Sign Up for attendance (include if have pilot, plan on getting, just interested) **Find out who would like to help out and break into teams™ 1Sÿ+Path - Hematopoiesis buffy coat = platelets + WBCs nl marrow = 30-70% hematopoietic cells active hematopoiesis in vertebra, ribs, sternum, skull, pelvis, scapula, and prox long bones M:E 3:1 = nl feedback regulation - by GF's (like erythropoietin{based on 02 levels in kidney}, G-CSF, CM-CSF) 5q- in myelodysplastic syndrome » pancytopenia w hypercellular marrow maturation = dec. size, loss of basophilia (rna), dec. mitosis, coarser chromatin 1. erythroblast - fine chromatin, nucleoli, basophilic cytoplasm 2. basophilic normoblast 3. polychromatic normoblast - inc. clumped chromatin, grey cytoplasm 4. orthochromatic normo - faint cytoplasm, nucleus is lost during this stage 5. reticulocyte - stain RNA with meth blue, measure new RBCs (should be 1%/day) 6. erythrocyte - biconcave 95% of RBCs in peripheral blood lifespan 120 days replace 1%/day (see above) 7-8 µ diameter erythroid hyperplasia = dec. M:E ratio, inc retic, inc. RBC precursors in the marrow Hgb A = a2ß2 Hgb A2 = a2d2 Hgb F = a2g2 RBC met = anaerobic glycolysis, & hexose -monoP shunt (prevent ox damage, if G6PD def. » ox damage and Heinz bodies from precipitated Hgb) methemoglobin reductase uses NADH to bring Fe3+ to Fe2+ for 02 transport inc 2,3 DPG = inc 02 release several enzymes can cause porphyrin not to be made, most common Sx = photosensitivity Crit = .37-.47 F, .42-.54 M L/L Hgb = 120-160 F, 140-180 M g/L RBC = 4.2-5.5. F, 4.5-6.3 M x 10^12/L MCV = ave size = crit/rbc 80-100 MCH = ave. wt. = Hgb/rbc 27-34 MCHC = 32-36£ 1TÿPath - Hemogloginopathies alpha genes (4 total) on 16 ß genes (2 total) on 11 thalassemia = dec. production of one globin chain >> imbalance of a:ß ratio dec. a = a thalessemia, etc. excess a = monomers excess ß (» hemolysis) = tetramers 4b= Hb H, 4g = Hb barts (in Babies) thalassemia = quantitative dec (microcytic, hypochromic) alpha = 80% gene del 1. silent carrier (a-/aa), 20-30% AA 2. a thal trait (a-/a- in AA or --/aa in SE asian) 3. Hb H dis (--/a-) - heinz bodies, microcytic hypochromic + target 4. Hydrops fetalis (--/--) = lethal ß = mostly point mutations (Med, SE asian, Africa) 1. ß-thal major - (-/-) starts 4 mos. age, severe anemia w/ ineffective erythropoiesis, unTx » frontal bossing (RBC made in frontal bones inc.), hepatosplenomegaly, death by 5 YO, inc. HbA2 tx = transfuse to Hb> 9, » iron overload (hemosiderosis 2nd to transfusions) tx with Fe chelation, life span ~ 30 yo also can do BM transplant 2. ß thal intermedia = milder (1) 3. ß thal minor = 20 % splenomegaly, most escape Dx, no tx, but DNA consult imp. Hemoglobinopathies = quality usually point mutations may inc. malaria survival? imp types= a) sickling trait = Hb AS (only sickle in severe hypoxia) Anemia = Hb SS (in AA) = change in b from glu»val sickling inc by acidosis, inc. T, inc BPG » dec. O2; also causes membrane distortions RBC survival = 15=20 days Worse anemia b/c aplastic events b/c of Parvo B19; need inc. folate, Fe; splenic trapping Increased risk of infection Acute Vaso-occlusive phenomena = pain, dactyliti, CVA, acute chest syn Hb SC = nl lifespan, ocular SFx, avascular necrosis of femoral head b) precipitation c) abnl 02 affinity d) methemoglobinemia (cyanosis) e) b thal b/c of dec mRNA stability Hb E = SE Asian¡ 1Vÿ€Path - Macrocytic anemia cobalamine(b12) and/or folate def. see oval macrocytes, Hyperseg PMN (>5), giant bands, pancytopenia Megaloblastic anemia - defective DNA synth. (no TTP b/c folate needed to make TTP from UTP) B12 req. IF from gastric parietal cells for absorption from ileum B12 binds transcobalamin II in plasma (made liver M-phage, endothelium) Pernicious Anemia = autoimmune dis with Abs to H/K ATPase » destroy parietal cells » no HCL, dec/no IF; usually individual is > 40 YO Folate = heat labile, etoh blocks hepatic release folate replacement can correct heme abnl of b12 def, but not neuro changes 1Yÿ¶Path - Microcytic Hypochromic Anemia Iron stored in RE cells in ferritin, circulate in body = size of stores, removed from circ by liver hemosiderin in m-phage heme iron (animals) better absorbed than non-heme (plants), taken up in the small intestine transferrin - 2 fe atoms, synth by liver, reg by liver iron content transferrin receptor on erythroblast binds 2 transferrins regulation is by rna binding protein IRP, high affinity when low iron, binds ferritin rna preventing translation (don't want to store it), and upreg t-receptor (want to grab it all). Opposite happens in high iron state in iron def, get Inc. TIBC, dec. serum iron iron def in M, postmenopausal F = blood loss (GI bleed?) Anemia of Chronic Dis b/c of dec RBC production Sideroblastic Anemia mito defect prevents incoporation of iron into Hgb >> ringed sideroblasts most b/c Rx, lead etc. hereditary (usually responds to B6 tx) or acquired (myelodysplastic syndrome) Hemochromatosis = inc. iron absorption, M 10x F, present 40-60, AR, bronze skin, CHF>>death, tx w/ phlebotomy(when inc. stores, not wait until dis) 10 yr = 30% w/ tx (DNA test family) 2nd Fe overload (hemosiderosis)± 1Uÿ½ Path - Hemolytic anemia hemolysis = premature RBC death compensated hemolysis = inc. prod. hemolytic anemia acquired immune mediated (Abs - DAT +) Mechanical (DAT -) misc. inherited hereditary spherocytosis b/c of dec spectrin w/ anemia, splenomegaly AD G6PD Deficiency ox damage » heinz body formation (denatured Hgb) extra & intra hemolysis x-linked extravascular = spherocytes (removal of portion of membrane forms the spherical shape) in liver or spleen » hypersplenism M-phages eat by Fc receptors grabbing Ab coated RBCs iron recycled, aa recycled, heme » bilirubin (unconjugated ^ w/ hemolysis b/c hepatic uptake is overwhelmed) intravascular = schistocytes RBC lysis in circulation (traum, Complement, toxins) free Hgb bound to haptoglobin (fast), cleared by liver, excess Hgb into kidney were met w/ hemosiderin into the urine ferriheme (ox free Hgb) » liver by hemopexin & albumin (carriers) Coombs test = antiglobulin test Direct wash RBCs + anti-human Ab » agglutination if RBCs coated w/ Ab Indirect Group O RBC + patient serum, wash, add anti-human Ab, + agglutination if Ab's directed against RBCs Warm Autoimmune Hemlytic Anemia extravascular hemolysis IgG w/ optimum T 37 » spherocyte formation (taken out in spleen) (+DAT, ^serum bilirubin) 50% have other dis (SLE, CLL, lymphoma) Sx= weakness, fever, ^HR, jaundice, splenomegaly Tx= steroids, if bad, splenectomy, immunosuppresion Cold Agglutinin intravascular hemolysis T=28-31 IgM binds in fingers/nose, then complement » MAC (intra) or c3b » extra phagocytosis monoclonal often w/ CLL/lymphoma etc. Sx= acrocyanosis, Raynaud's, +DAT monoclonal IgM Tx= avoid cold, folate, look for underlying dis Acute Postinfectious Cold Agg Induced Hemolysis - intravascular myco, pneumo, mono transient hemolysis can be severe + DAT, tx= keep patient warm Paroxysmal Cold Hemoglobinuria rare IgG ab that fixes Complement intravascular 1)idiopathic 2) viral 3)3rd syphilis Sx = Hgburia w/ cold exposure Test with chilled then warmed Indirect coombs Rx induced Hemolytic anemia a)Hapten = extravascular b)Immune complex mech = intraV can't use rx of same type again c)membrane mod d)AutoAb - extravascular Mechanical Hemolysis TTP (brain) & HUS(kidney) () most common both b/c platelets aggregate » RBC fragmentation Sx= hemolysis (schisto + ^LDH) thrombocytopenia PT & PTT nl neurologic deficits in TTP fever- minimal renal - HUS (^ BUN) Mech either endothelial damage or ^platelet aggregation factors Tx=med EMERGENCY, w/out Tx 100% death, use plasma Xchange, no platelet transfusions b/c make worse, relapse 40% in 10yrs Trauma - esp. Cardiac lesions, DAT - intravascular hemolysis¸ 1[ÿêPath - WBC basics neutopenia < 1.5 x 10^9/L inc infections < 1.0 agranulocytosis < 0.5 cyclic neutropenia (3-6 days/mos) left shift = premature release of myloid cells leukemoid rxn - underlying CAN causes Sx (no left shift) lymphocytosis in pertussis, toxo, mono, cmv, htlv1 hypersegmentation seen in megaloblastic anemia (right shift) Pelger-Huet anomaly AD, bi-lobed "pince-nez" cells, like bands except are PMNs Toxic granulation Dohle bodies - RER remnants&WÿžPath - Malignant Hematology chronic = proliferation of mature cell acute = prolif. of immature cells 1. Leukemia = diffuse BM infiltrate by a clonal process of hematopoeitic origin (early stages in BM) 2. Myeloproliferative disorders = CML (+ Phily chromosome) which becomes AML at end with "blast crisis" polycythemia vera (^RBCs), essential thrombocythemia(platelet) acute leukemia = blasts 3. Myelodysplastic disorders inc cellular elements in BM, but are dysplastic » acute leukemia or live 20+yrs 4. Lymphomas - from lyph nodes 5. Multiple myeloma and other Abs chloroma = clonal prolif. of myeloblasts or monoblasts outside of BM Acute Leukemia (BLASTs) - unTx = 6 mos from Dx » death in 90% nl marrow elements inhibited = hypoplastic acute leukemia etiology unknown except HTLV (20+ yr latency) EBV - associated w/ hodgkins,burkitt heredity environmental (rad, toxins, Rx » 2nd leukemia wi/ 5-10 yr lag) Poor Prognosis with: Rx/Rad induced certain cytogenetic abnl documented prior preleukemic phase + t cell markers Dec. metaphases in culture large tumor burdern high LDH cytogenetics 1 most imp. prognostic factor in acute leukemia abnl of chromosome 5 or 7 = bad M2 - t(8,21) CR/cure is high M3 - t(15,17) w/ DIC, CR/cure is high M4 - inv 16 CR/cure is high no chromosomal abnl, cure ~ 10-20% Tx = rad, chemo, BM transplant peroxidase = myeloid esterase = monoblast*QÿZPath - Chronic Myeloproliferative All acquired, clonal expansions w/ var. ability to » acute - CML M=F; ave 3-6 yr survival, age ~ 45 Sx = fatigue, wt loss, splenomegaly hypercellular BM, left shift Dec. Leuk alk phos, inc serum B12, hyperuricemia, + Ph' chromosome Bad prognosis w/ non-Ph', myelofibrosis, age > 60, low platelets Tx = palliative (ifnG, chemo), cure BMT Ph' = t(9,22) » fusion protein (bcr-abl) activates RAS oncogene » dec. cell adherence (loss of B-integrin) - Polycythemia vera prolif of RBCs (1 or Secondary) crit > 54M, 49F Sx = headache, splenomegaly Tx = Phlebotomy (crit < 45%), hydroxyurea (to dec. spleen size), % anagrelide (control thrombosis), ASA for digital ischemia - Myelofibrosis see extramedullay hematopoiesis, splenomegaly, nRBCs, reactive fibrosis b/c of TGF-B, PDGF if no Sx, then follow, if Sx RT or Splenectomy - Essential Thrombocyopenia Inc. platelet prod (>1mil), near nl life span, Sx from thrombosis/bleed (worsen w/ NSAIDs) Dx w. > 600K platelets, nl RBCs, +Fe, no Ph' Tx = hydroxyurea, anagrelide (87% response; for young), IFN-a .RÿŠPath - CLL Prolif of B, T, NK cell Can at times be difficult to separate from lymphomas/other CAN Chronic Lymphocytic L (CLL) -clonal, morphologically same as nl Lymphocyte age > 60, large range of survival Tx= w/ Sx or progression, Chemo/RT NOT prolong or cure, nucleoside Rx » good CR, BMT? Median Survival = 8 yrs Chronic Pro-Lymph L (PLL) -morph larger w/ more immature nucleus, lymphadenopathy uncommon, spleen MASSIVE, very ^ WBC #s Median survival = 3 yrs Hairy Cell (HCL) -clonal HAIRY CELL honeycomb BM Tx= 2Cda w/ CR = 85% T-Gamma lympocytosis -NK cell or CD8+ T, usually FcR + age >55, 1/3 RA +, inc. infections1XÿžPath - Malignant Lymphomas Lymphomas = nodes Reactive Lymphoid Hyperplasia -Follicular (RA, AIDs, Idiopathic) -Sinus (histiocytosis, lymphangiogram effect) -Diffuse (post-Vaccine, anti-convulsant Tx, viral) - Mixed (mono, toxo, cat scratch, TB) Malignant Lymphoma a) Non-hodgkins - prolif of B & T in either follicular or diffuse manner Cell size = small, large, mixed Nucleus = cleaved, not cleaved Growth = paracortical, nodular, diffuse Present = older, more debilitated, more advanced stage @ presentation, more peripheral REAL classification - Precursor B - Peripheral B - Precursor T - Peripheral T B 80%, T 20% B lymphoma = clonal Diffuse large B = MOST COMMON Pre B/T lymphoblastic = ALL/L myeloperoxidase (-) B CLL/prolymph leuk/small lymphoma = diffuse, 13q Mantle Cell Lymphoma = small, cleaved cells, diffuse/nodular t(11;14), overexpress cyclin D1, M 3X F, poor prognosis Follicle center lymphoma (B in germinal centers) i)small ii)mixed iii)Large t(14;18), not curable Marginal zone B - may be in MALT Diffuse large B = 60% cure Burkitt = lipid filled vacuole B cells, nodal starry-sky appearance t(8;14), agressive, usually children Anaplastic large cell = t(2,5) TyrKin b)Hodgkins = REED-STERNBERG cells (owl eye appearance), also popcorn cells. Usually regional nodal enlargement, contiguous nodes stage b = systemic sx stage a = no Sx e = extralymphatic involvment Stage 1 = single site Stage 2 = 2 + sites, same side of diaphragm Stage 3 = both sides of diaphragm Stage 4 = diffuse involvement i)Lymphocyte predominant - few RS cells, many popcorns, vague nodules ii) Nodular sclerosing - collagen fibrosis, F>M iii)Mixed cellularity - many RS, plasma, eos iv)Lymphocyte depleted - bizarre RS a:b = 2:1 Dx = painless nodal enlargement (Biopsy), systemic sx (fever, wt loss, etc) lymphoma = one cell type reactive = multiple cell types5EÿGMood, Organic, Anxiety, Thought, mood-bipolar(anhedonia) mania(moves), dysthemia, cyclothymia, double depression, ?delusional(seizure) not highly likely thought-nope organic-seizure, tumor, ms, anxiety-somatoform undifferentiated - like somatization but fewer sx-(hypochondriasis-but not delusional!!!), ocd?, munchausen(factitious -1 gain only) req self injury , malingering (2nd gain, 1 is dec anxiety) , somatization (more severe-subset - 4 pain sx - 2 GI Sx - 1 sex sx - 1 psuedoneuro sx) personality-histrionic, dependent psuedoseizure - nl EEG - conversion disorder:ZÿHPath - Multiple Myeloma, et. al. Clonal Proliferations of B Cells - solitary plasmacytoma - disseminated in BM of axial skeleton (MM) - Primary amyloidosis Monoclonal spike in serum not= MM (70% will be MGUS - monoclonal gammopathy of undetermined significance) Bence-Jones proteins = mono/dimers of light chains excreted in the urine (avoid IV contrast) Present w/ bone pain, anemia, renal dysfxn (myeloma kidney), inc. serum protein, neurologic (radiculopathy 2nd to vertebral collapse b/c of tumor), hyperviscosity (hemorrhage, headache, CHF, blurred vision), immunodef >> g(+) infection plasma cell leukemia > 2,000 cells Labs @ Dx = anemia, Inc. ESR, serum/urine M spike, osteolytic lesions Tx = plasmaphoresis & Chemo MM -plasmacytosis > 10% on BM -At least one of -serum M >3 or Bence-Jones + -discrete osteolytic lesions MGUS -opposite Smoldering MM = MM w/out osteolytic lesions Poor Prognosis = rapid response, amyloidosis Tx = prednisone, RT, Chemo, support; ave survival = 3 yrs response = 50% or ^ drop in monoclonal protein level Secondary acute nonlymphocytic leukemia = common complication Plasmacytoma - plasma cell tumor which may be intraosseous or extramedullary, Tx = RT, most >> MM Waldenstrom's Macroglobulinemia - B-cells, looks more like CLL (with hepatoplenomegaly & no lytic lesions) than MM, Tx w/ Sx Amyloidosis - B-pleated sheets, resistant to proteolysis, primary amyloidosis (ave. 1.5 yrs) vs. MM w/ amyloidosis vs. 2nd amyloidosis (b/c of inflam state) MGUS - median age 64 yrs, f/u 30% progress to MM, etc.HPÿ1Path - Blood Transfuse @ platelets 10,000 rbcs 25% (30 w/ cardio dis) hep C risk = 1/100K worse is ABO incompatiblity febrile non-hemolytic transfusion rxn >> stop transfusing, and check blood( WBC lysis in storage >>fever) allergic = itchy & hives (IV Benadryl), stop transfusion, check¢ÿ­Abdominal Pain Immediate Questions: (Determine whether the patient has an acute "surgical" [i.e., requiring surgery] abdomen) A. What are the patient's vital signs? Orthostatic blood pressure and pulse changes help ascertain the patient's volume status. Fever occurs in inflammatory conditions. Tachycardia and hypotension would suggest circulatory or septic shock from perforation, hemorrhage, or fluid loss into the intestinal lumen or peritoneal cavity B. Where is the pain located? When did the pain begin? Sudden onset suggests perforated ulcer, mesenteric occlusion, ruptured aneurysm or ruptured ectopic pregnancy. What is the quality of pain? Intestinal colic occurs as cramping abdominal pain interspersed with pain-free intervals C. Are there any associated symptoms? Vomiting may result from intestinal obstruction or could result from a visceral reflex caused by pain D. If the patient is a woman, what is her menstrual history? CHARACTERISTIC PHYSICAL FINDINGS IN THE ACUTE ABDOMEN -------------------------- Peritonitis: Generalized guarding, tenderness, rebound tenderness, hypoactive or absent bowel sounds Appendicitis: Right lower quadrant tenderness, guarding and rebound, discrete tenderness at McBurney's point, peak age 10-20 Acute cholecystitis: Right upper quadrant tenderness and guarding, positive Murphy's sign, may radiate to right scapula High Small Bowel obstruction: Severe vomiting, dehydration, no distention Low Small Bowel obstruction: Distention, hyperactive and high pitched bowel sounds, vomiting Bowel Infarction: Pain out of proportion to tenderness, rectal bleeding if venous infarction Ruptured aortic aneurism: Pulsatile tender mass, hypotension, back pain Pancreatitis: Steady, severe, LUQ and epigastric pain radiating to the back; pain less when sits forward; decreased BS; diffuse tenderness Plan: A. The abdominal films can help differentiate between: 1. Several diagnoses can cause a surgical abdomen, the most life-threatening considerations are perforated or ruptured viscus, intraabdominal hemorrhage, and necrosis of a viscus, (e.g., necrosis of an intraabdominal viscus due to intussusception, volvulus, strangulated hernia, or ischemic colitis). Other specific conditions that may not cause an acute "surgical" abdomen should be considered: pancreatitis, intraabdominal abscess, peptic ulcer disease or gastritis, pyelonephritis, renal stones, infectious gastroenteritis, ovarian cyst, tumor and salpingitis 2. Among the elderly and those on steroids, abdominal pain may be mild despite the presence of an acute abdomen. One should not underestimate the seriousness of mild abdominal pain in the elderly, especially if it is associated with acute confusion, fever, an elevated WBC or a metabolic acidemia B. Laboratory tests to consider are a CBC with a differential, amylase, liver function, urinalysis, and pregnancy test C. Flat and upright abdominal films. These films can be readily obtained and may provide important information. Observe for the following: gas pattern, evidence of bowel dilation, air-fluid levels, presence or absence of air in the rectum, pancreatic calcifications, biliary and renal calcifications, aortic calcifications, loss of psoas margin D. Observation. With the exception of those conditions that require urgent surgical exploration, most cases of abdominal pain can be initially managed with close observation, correction of any fluid or electrolyte disturbances, and judicious use of analgesics In general, any patient on a medical service developing acute abdominal pain should receive an evaluation by a general surgeon. In those cases in which mechanical obstruction is suspected or vomiting is present, nasogastric decompression should be initiated. Patients who appear in septic or circulatory shock should receive vigorous intravenous volume replacement, cultures, empiric antibiotics and be in an ICU setting £ÿÀAcute Arthritis Immediate Questions: 1. Is it really arthritis? When examining an individual with "joint" pain, you will ask yourself a series of questions. First, does the patient have arthritis, or some other form of musculoskeletal pain? There are four categories of etiologies for "joint" pain A. Arthritis: Hx - pain in the joint, or in the reference area of the joint; pain will increase with any joint movement; that is, all ranges of motion will cause pain PE - tenderness over "entire" joint, especially joint line; swelling of "entire" joint, either soft tissue or bony; joint effusion; limitation of and pain in range motion in all directions B. Periarticular: (e.g., tendinitis, bursitis, ligamentous) Hx - pain in or near the joint; usually localized to one aspect of the joint; pain with certain movements of the joint PE - localized tenderness and swelling, often along the outline of the involved structures; no joint effusion; usually normal passive range of motion, but decreased active range of motion when the involved structure is moved C. Nonarticular: (e.g., fibrositis, endocrine/metabolic, myalgia) Hx - pain unrelated to joint or joint movement; atypical pain pattern PE - usually normal articular exam; often with relatively normal physical exam D. Referred: (e.g., visceral, neurogenic, psychogenic) Hx - pain following a dermatome or peripheral nerve distribution; neurological symptoms; non-musculoskeletal symptoms PE - neurological abnormalities: strength, sensation, reflexes; non-musculoskeletal abnormalities Joint Aspiration: Joint tap is needed to determine the etiology of acute arthritis. An infection can destroy a joint, so treatment must be initiated rapidly. future link to See pages (?) for information on joint aspiration techniques Diagnostic Considerations for Acute Arthritis: Acute arthritis is a serious condition. Failure to recognize and treat an infection can lead to rapid joint destruction. The disorders that require prompt, specific treatment are infectious and crystal-induced arthritis. Pyogenic infections of the joints in adults are seen primarily in the debilitated, the elderly and those who are parenteral drug abusers. Among healthy adults with acute monarthritis, the probability of nongonococcal joint sepsis is estimated to be less than 10%. That is, other than GC arthritis, infections are infrequent. Findings that suggest gonococcal disease include a prodromal of myalgias, migratory arthralgias, fever, dermatitis or tenosynovitis. These associated findings occur in about 65% of patients Gram-positive organisms account for 80 to 90 percent of acute nongonococcal infectious arthritis, and staphylococci are responsible for the majority of those cases. Such infections especially occur in rheumatoid joints, those patients receivingcorticosteroids and individuals with a prosthetic joint Gout: Typically presents among men over age 45, (women usually do not have gout until postmenopausal). Acute gouty arthritis is typically an episodic, monarticular arthritis that develops rapidly to exquisite pain, heat, erythema and swelling. Severe first metatarsophalangeal arthritis (podagra) is common. The onset is abrupt and may follow trauma, surgery or no discernible stimulus. Fever (101 to 103deg.F) can be present Pseudogout: A microcrystalline synovitis induced by crystals of calcium pyrophosphate dihydrate and associated with calcification of hyaline and fibrocartilage (chondrocalcinosis). More properly, this disorder is named calcium pyrophosphate dihydrate (CPPD) crystal deposition disease. Unlike gout, the large joints are preferentially involved in CPPD crystal deposition disease, especially the knee, (found in over half the cases). Involvement of the shoulder, hip, wrist, elbow, and MCP joints also occurs. Generally, episodes of pseudogout are less intense and more protracted than those of gout. However, they also may mimic gout in intensity, duration and joint involvement ¤ÿ Acute Blindness Immediate Questions: ------------------------------- A. What is extent of visual loss? Monocular? Visual Field, hemianopsia (one-half visual field), homonymous (same half), bitemporal (pituitary tumor) or binasal (rare)? B. Prior symptoms? Eye pain? Differential Diagnosis of Acute Monocular Blindness: ------------------------------- A. Retinal detachment Often preceded by floaters or flashing lights; painless; detachment visible on funduscopic exam. Risks are extreme myopia and trauma. Emergency ophthalmologic consult is needed for urgent reattachment B. Central retinal vein occlusion No prodrome; painless. Funduscopic shows edema, hemorrhages and dilated veins. Associated with hypertension. Requires emergent ophthalmologic consult C. Central retinal artery occlusion Acute onset; painless; may be history other thrombo-embolic disease, atrial fibrillation or carotid disease. Funduscopic reveals pale disc and cherry red spot in the macula. Requires emergent ophthalmologic evaluation D. Acute (narrow angle) glaucoma E. Ischemic optic neuritis: Temporal arteritis Elderly white woman; may be history of headache; elevated ESR. Abrupt onset blindness. Begin empiric high dose steroids, if diagnosis is suspected F. Trauma G. Optic Neuritis Decreasing vision over several days; associated with multiple sclerosis H. Infiltrate or compression due to tumor or aneurysm Data to Document Eye Findings: ------------------------------- A. Inspection B. Extraocular muscle movement C. Pupil response direct and consensual D. Visual acuity and fields E. Funduscopic F. Obtain emergent ophthalmologic exam ¥ÿüAcute Dystonic Reaction Immediate Questions: A. What are the vital signs? B. What medications is the patient receiving? C. Is IV Benadryl (diphenhydramine) available on the floor? Diagnosis and Management: A. Dystonias are idiosyncratic drug reactions that involve acute involuntary muscle movements and spasms. Although any muscle group in the body can be involved, the commonest manifestations are torticollis, facial grimacing, and opisthotonos B. Because of their antidopaminergic properties, anti-psychotic agents often are associated with a variety of motor disorders. The use of drugs of this class, compazine for example, can cause an acute dystonic reaction C. Treatment is diphenhydramine 50 mg IM or IV, or benztropine 2 mg IM or IV; improvement generally occurs within seconds or within 15 to 30 minutes. These doses can be repeated in 30 minutes. Even if the agent is discontinued, oral treatment with either agent may be helpful for the next 3 to 21 days, since symptoms can recur ¦ÿkAdmission Orders Admit to (Service) (Attending/Resident/Intern Name) Diagnosis: Condition: (Stable/Guarded/Critical) Vitals: (Routine/Q shift/Q4 hours) Allergies: (NKDA) Nurses instructions: Diet: (Regular, 1800 ADA, 2gm or 4gm Na+) Activity: (BR w/ BRP, Ad lib) Lab: (CBC w/ d&p, A-8, SMA, PT/PTT, CXR, U/A, EKG, DXT's, Ca-Mg-PO4) Meds: (Drug, dose, frequency) PRN Meds: (MOM, Mylanta, Tylenol, Benzodiazepine) Additional Orders: IV orders: (Type at cc/hr or hr rate) DXT (AC and HS, Q4 hours, Q6 hours) Alcohol (DT) Precautions: • B12 1000ug IM now & in M • Vit. K 10mg IM now & qAM x3 • Folate 1mg PO qday x4 • MVI 1 PO qday • Thiamine 100mg IM qday x3 • Librium 25mg Po q6h PRN agitation • Lab: Mg, ETOH level, PT/PT Sliding Scale Regular Humulin: • <200 do nothing • 200-300 5u SQ • 300-400 10u SQ • > 400 call MD€ÿ˜Antifungal Drug Interactions Griseofulvin ----------------------------------- Level may be DECREASED by: • Barbiturates May INCREASE levels of: • Alcohol May DECREASE levels of: • Warfarin • OCPs • Cyclosporine Fluconazole ----------------------------------- Level may be INCREASED by: • HCTZ Level may be DECREASED by: • Rifampin May INCREASE levels of: • Warfarin • Oral hypoglycemics • Phenytoin • Cyclosporine • H1 antagonists (terfenadine, astemizone) May DECREASE levels of: • ?OCPs Ketoconazole ----------------------------------- Level may be DECREASED by: • Rifampin • Isoniazid • Phenytoin • H2 antagonists May INCREASE levels of: • Phenytoin • Warfarin • Cyclosporine • H1 antagonists • Oral hypoglycemics • Digoxin • ?Insulin • ?Corticosteroids • ?Chlordiazepoxide May DECREASE levels of: • Antipyrine • OCPs Itraconazole ----------------------------------- Level may be DECREASED by: • Rifampin • Isoniazid • Phenytoin • H2 antagonists • Phenobarbitone • Carbamazepine May INCREASE levels of: • Phenytoin • Warfarin • Cyclosporine • H1 antagonists • Oral hypoglycemics • Digoxin • ?Insulin • ?Corticosteroids • ?Chlordiazepoxide May DECREASE levels of: • Antipyrine • OCPs Terbinafine ----------------------------------- Level may be INCREASED by: • Cimetidine Level may be DECREASED by: • Rifampin • Phenobarbital ¨ ÿ½Asthma & Allergy in Pregnancy (From the National Asthma Education Program's Working Group on Asthma and Pregnancy) Inhaled Steroids ----------------------------------- Beclomethasone, 2-5 puffs bid to qid for asthma and/or 2 sprays in each nostril bid to control allergic rhinitis Oral Steroids ----------------------------------- Prednisone, burst courses of 40 mg/day in single or divided doses for 1 week and then taper for 1 week. If prolonged therapy is necessary, a single morning dose of prednisone on alternate days may help to minimize side effects Cromolyn sodium ----------------------------------- 2 puffs qid for asthma and/or 2 sprays in each nostril bid to qid to control allergic rhinitis Inhaled Beta Agonists ----------------------------------- Two puffs every 4 hours as needed Theophylline ----------------------------------- Oral sustained-release preparations to reach serum concentrations of 8-12 ug/mL Antihistamines ----------------------------------- Chlorpheniramine, 4 mg up to qid or 8-12 mg sustained release bid Tripelennamine 25-50 mg up to qid or 100 mg sustained release bid Decongestants ----------------------------------- Pseudoephedrine, 60 mg up to qid or 120 mg sustained release bid Oxymetazoline, intranasal spray or drops up to 5 days for rhinosinusitis Cough Medications ----------------------------------- Guaifenesin with or without dextromethorphan, 2 teaspoons qid‚ ÿBlood Unit Volumes • 1 unit of whole blood = 450 mL +/- 45 mL • 1 unit of PRBCs = 250-300 mL • 1 pack platelets = 50 mL • 1 unit leukocyte-poor RBCs = 200-250 mL • 1 unit washed RBCs = 300 mL • 1 unit "cryo" = 10 mL • 1 unit FFP = 150-250 mL • 1 unit single-donor plasma = 150-200 mL Source: Clinician's Pocket Reference, 7th Ed. (Table 10-1, p.160)ÿN Calories Used by Exercise Energy Costs, Cals/Min (for a 150-lb person, your mileage may vary) Aerobic Dancing, 7.8 Aerobics, 7.1 Aerobics (High Intensity), 8.6 Basketball (recreational), 7.5 Basketball, Full Court, 11.2 Biking (leisurely), 4.2 Biking (moderate), 7.0 Boating, 3.0 Bowling, 3.6 Calisthenics, 7.3 Canoeing, 4.8 Canoeing (2.5 mph), 2.9 Circuit weight training, 12.6 Cooking, 3.0 Cycling (10 mph), 7.0 Cycling (5.5 mph), 4.2 Cyclng (racing), 11.2 Dance Exercise (High Impact Aerobics), 10.9 Dance Exercise (Low Impact Aerobics), 9.2 Dancing (Ballroom), 3.5 Dancing (Rock), 4.0 Driving, 2.4 Fishing, 4.8 Football, 9.0 Football (touch, vigorous), 8.3 Frisbee, 3.6 Gardening, 5.0 Golf (2-some, carrying clubs), 5.4 Golf (power cart), 2.5 Golf (with handcart), 4.4 Hiking (leisurely), 5.2 Hiking w/20 lb pack, 4 mph, 7.7 Horseback riding, 4.8 House cleaning, 3.0 Ice Skating (9 mph), 6.4 Jogging, 8.4 Jogging (10 minute mile, 6 mph), 10.9 Lawn mowing w/pwr mower, 4.6 Light housework, cleaning, etc., 4.1 Lying down or sleeping, 1.5 Mountain Biking, 4.2 Office work, 1.8 Playing guitar, 3.6 Playing piano, 3.0 Playing with kids, 4.8 Raquetball, 9.2 Reading, 1.2 Rock Climbing, 13.1 Roller Skating (9 mph), 6.4 Rope Skipping (fast), 12.1 Rope Skipping (slow), 9.9 Running, 13.2 Running (12 min/mile) (5 mph), 9.5 Running (8 min/mile), 13.2 Running cross country, 10.7 Running in place, 9.5 Running up stairs, 17.9 Scrubbing Floors, 7.3 Sex (moderate), 1.6 Sex (vigorous), 3.5 Shopping, 3.0 Showering, 4.8 Sitting (reading or watching TV), 1.2 Sitting and writing, card playing, etc., 1.9 Sitting on the toilet, 1.2 Skating (ice and roller), 6.9 Skating, vigorous, 10.5 Skiing (cross country), 8.8 Skiing (cross country, 9 mph), 15.8 Skiing (water), 6.6 Skiing, downhill, 10.0 Sleeping, 1.1 Snow shoveling, heavy, 18.0 Snow shoveling, light, 10.4 Soccer, 9.0 Stairmaster / Stair Climbing, 7.1 Standing, 1.4 Standing (light activity), 2.4 Stationary Bike (10 mph), 7.4 Stationary Bike (20 mph), 15.5 Step Aerobics (10 inch bench), 8.9 Step Aerobics (4 inch bench), 5.7 Step Aerobics (6 inch bench), 6.9 Step Aerobics (8 inch bench), 7.9 Studying at desk, 2.1 Swimming, 9.5 Swimming (back stroke), 9.2 Swimming (breast stroke), 10.8 Swimming (crawl and moderate pace), 9.0 Swimming (crawl, 20 yards/min), 4.8 Swimming (crawl, 45 yards/min), 8.7 Swimming (fast crawl), 11.2 Swimming (side stroke), 7.9 Swimming (slow crawl), 10.3 Swimming (treading water), 4.1 Talking on the phone, 1.2 Tennis (recreational doubles), 5.2 Tennis (recreational singles), 7.5 Tennis (vigorous), 8.4 Volleyball (recreational), 4.1 Volleyball (vigorous), 6.0 Walking (13 min/mile, 4.5 mph), 5.4 Walking (15 min/mile), 5.2 Walking (17 min/mile, 3.5 mph), 5.2 Walking (30 min/mile, 2 mph), 3.3 Walking, strolling (less than 2mph), 2.4 Weight Training, 7.6 Weight training (muscular endurance), 6.9 Weight training (muscular strength), 5.2 Weight training (super circuit), 12.0 Weightlifting, 3.6 Writing, 1.2 X-country Skiing (5 mph), 11.5 Yoga, 4.8 «ÿf Central Lines Immediate Questions: (when line's not working) A. Does it fluxuate with respiration? A CVP should have a slowly undulating wave form that varies with the patient's respirations, if properly positioned in the chest B. Does it flush and can it be aspirated? C. When was the last chest x-ray? The tip should be in the superior vena cava Differential Diagnosis: A. Catheter in incorrect position B. Kinked catheter C. Other mechanical problems D. Infected catheter. Any question of sepsis originating in a central venous line requires expeditious evaluation. The best technique involves drawing cultures through the catheter, removing the line, and culturing the tip. And, often the IV team will have a protocol for declotting lines Plan: A. Unless the line is infected, it can be changed over a guide wire. All line manipulations should be performed using sterile technique with the patient in Trendelenburg (head-down) position to prevent air embolus B. A line thought to be clotted can often be declotted safely with a syringe. The catheter can be gently aspirated or flushed with a 1 cc tuberculin syringe Internal Jugular Insertion: A. Materials for central line placement are available in a kit, which you can obtain on the hospital unit B. IJ lines have less risk of pneumothorax and are preferred if hyperinflation or mechanical ventilation are present. Because direct pressure can be applied, the IJ line also is preferred if coagulopathy is present. For IJ lines use a 25 gauge needle and 1% lidocaine to raise a small skin wheal. Change to a 22 gauge needle to anesthetize the deeper layers, and then use gentle aspiration, with the same needle, to initially locate the internal jugular vein. Direct the needle through the skin wheal, directed toward the ipsilateral nipple and at a 30 degree angle to the frontal plane. If the vein is not entered, withdraw the needle slightly and redirect it 5 to 10 degrees more laterally Subclavian Insertion: A. Materials for central line placement are available in a kit, which you can obtain on the hospital unit B. Subclavian lines usually are more comfortable for the patient and easier to fix to the skin. However, it results in a pneumothorax in 1 to 2% of insertions C. Most commonly for subclavian lines, the patient is placed in Trendelenburg position, with a roll between the scapulae. This presumably makes the clavicles flatten and vein more prominent and simplifies puncture. The artery is above and behind the vein, so slow entry will allow going into the vein before the artery. The needle is passed below the clavicle and aimed toward the sternal notch, with the bevel upward. Turn the bevel to 3:00 when the vein is entered Other lines: Femoral lines are acceptable when there is no upper body alternative and when rapid access is needed during cardiopulmonary resuscitation ¬ÿChest X-Ray 1. Check exposure technique for lightness or darkness. 2. Verify left and right by looking at stomach bubble and heart shape. 3. Check for rotation: does the thoracic spine shadow align in the center of the sternum between the clavicles? 4. Make sure the x-ray is taken in full inspiration (10 posterior or 6 anterior ribs should be visible). 5. Is the film a portable, AP, or PA film? (The heart size cannot be accurately judged from an AP film.) 6. Check the soft tissues for foreign bodies or subcutaneous emphysema. 7. Check all visible bones and joints for osteoporosis, old fractures, metastatic lesions, rib notching, or presence of cervical ribs. 8. Look at diaphragm for tenting, free air, and position. 9. Check hilar and mediastinal areas for the following: size and shape of aorta, presence of hilar nodes, prominence of hilar blook vessels, elevation of vessels (left normally slightly higher). 10. Look at heart for size, shape, calcified valves, and enlarged atria. 11. Check costophrenic angles for fluid or pleural scarring. 12. Check pulmonary parenchyma for infiltrates, increased interstitial markings, masses, absence of normal margins, air bronchograms, or increased vascularity, and "silhouette" signs. 13. Look at lateral film for the following: confirmation and position of questionable masses or infiltrates, size of retrosternal air space, anteroposterior chest diameter, vertebral bodies for bony lesions or overlying infiltrates, posterior costophrenic angle for small effusion.§ÿb Common Peds Treatments Allergic Rhinitis (Antihistamines) -------------------------------------- • Rondec and Rondec-DM (drops in 30 cc with dropper) Age 1-3 Mo. -- Rondec drops -- 1/4 dropper full qid Age 3-6 Mo. -- Rondec drops -- 1/2 dropper full qid Age 6-9 Mo. -- Rondec drops -- 3/4 dropper full qid Age 9-18 Mo. -- Rondec drops -- 1 dropper full qid Age 18 Mo to 6 yr -- Rondec Syrup -- 2.5 cc qid Age 6 yr to Adult -- Rondec Syrup -- 5 cc Qid or one tab qid • Dimetapp, Triaminic, and Actifed OTC...Only for 6mo and older OM & other resp. infections -------------------------------------- • Ampicillin - 100mg/kg/d qid (2gm max) x10 days (125mg-250mg/5cc) • Amoxicillin - 40mg/kg/d tid (1.5gm max) X10 days (125mg-250mg/5cc) • Augmentin - 40mg/kg/d tid (1.5gm max) X10 days (125mg-250mg/5cc) • Bactrim - 1cc/kg/day bid for <40kg; >40kg use DS tab bid - Do not use in children under 2 months old! • Ceclor - 40mg/kg/d tid (1gm max) X10 days (125mg-250mg/5cc) • E.E.S. - For Mycoplasma or Bullous muringitis-See Staph below) • Pediazole - 50mg/kg/day Emycin qid X10 days (200mg/5cc) - Do not use in children under 2 months old! • Rocephin - 50mg/kg IM now (blood levels for 24 hrs) Strep Infections - Pharengitis & Impetigo -------------------------------------- • Under 30lb - Bicillin CR 300,000 units (.5cc) IM now • 30 to 45lb - Bicillin CR 450,000 units (.75cc) IM now • 45 to 60lb - Bicillin CR 600,000 units (1.0cc) IM now • 60 to 90lb - Bicillin CR 900,000 units (1.5cc) IM now • Over 90lb - Bicillin CR 1.2 million units (2cc) IM now • If PCN allergic, use E.E.S. 25 - 30 mg/kg/d Qid X10 days External Otitis -------------------------------------- • Cortisporin Otic Susp.- 3ggt qid X10days (10cc bottle w/ dropper) Staph Skin Infections -------------------------------------- • Dicloxicillin - 25-75mg/kg/day qid (62.5mg/5cc) • Erythromycin 40mg/kg/d qid (1gm max) X10 days (200mg/5cc 250 tab) Fungal Infections -------------------------------------- • T. Corporis - Lotrimin 1% cream tid X7days p resolution (30g tube) • T. Capitus - Griseofulvin microcrystalline 10mg/kg qd X 4wks or Griseofulvin ultramicrosize 7mg/kg qd X 4wks • Monilia - Micatin (OTC) or Nystatin cream tid - qid (30gm tube) • Thrush - Nystatin Oral Suspension 1cc to each cheek qid X 7days or Gentian Violet OTC on Qtip tid X3 days Pruritis -------------------------------------- • Benedryl - OTC or 5mg/kg/day div Q4-6 hr (12.5mg/5cc) • Atarax - 2mg/kg/day div qid (10mg/5cc 1pt bottles) Scabies -------------------------------------- • Lindane (Kwell) - Apply from neck down, leave on 8 - 12 hrs, then wash off completely. Do not use in pregnant women Pinworms -------------------------------------- • Vermox - 100mg tab once for all family members, may repeat in 2wks < 2yrs use Antiminth Syrup - 1cc/10lb once. Not in Pregnancy! Conjunctivitis -------------------------------------- • Garamycin Opthal Sol - 2ggt q4hrs X 7-10 days (5ml bottle) Asthma Medications -------------------------------------- • Ventolin Syrup (2mg/5cc) 0.1mg/Kg/dose q8 hours • Alupent Syrup (10mg/5cc) 1.3mg/kg/dose q8 hours • Slo-Phyllin Gyrocaps: 60, 125, 250mg • Slo-bid Gyrocaps: 50, 100, 200, 300mg • Theo-Dur Tabs: 100, 200, 300mg • Solumedrol 1-2mg/Kg loading then 1.6mg/Kg/day / q6 hours • Solucortef 4-8mg/Kg loading (250mg max) then 8mg/Kg/day / q6hrs ªÿÌCoumadin Initiation, 10mg Start Dose Day INR Dosage 1 10.0 mg 2 <1.5 7.5-10.0 mg 1.5-1.9 2.5 mg 2.0-2.5 1.0-2.5 mg >2.5 0.0 3 <1.5 5.0-10.0 mg 1.5-1.9 2.5-5.0 mg 2.0-2.5 0.0-2.5 mg 2.5-3.0 0.0-2.5 mg >3.0 0.0 4 <1.5 10.0 mg 1.5-1.9 5.0-7.5 mg 2.0-3.0 0.0-5.0 mg >3.0 0.0 5 <1.5 10.0 mg 1.5-1.9 7.5-10.0 mg 2.0-3.0 0.0-5.0 mg >3.0 0.0 6 <1.5 7.5-12.5 mg 1.5-1.9 5.0-10.0 mg 2.0-3.0 0.0-7.5 mg >3.0 0.0 Ref: Crowther MA. Warfarin: Less may be better. Ann Int Med 1997;127:332-3.®ÿÆCoumadin Initiation, 5mg Start Dose Day INR Dosage 1 5.0 mg 2 <1.5 5.0 mg 1.5-1.9 2.5 mg 2.0-2.5 1.0-2.5 mg >2.5 0.0 3 <1.5 5.0-10.0 mg 1.5-1.9 2.5-5.0 mg 2.0-2.5 0.0-2.5 mg 2.5-3.0 0.0-2.5 mg >3.0 0.0 4 <1.5 10.0 mg 1.5-1.9 5.0-7.5 mg 2.0-3.0 0.0-5.0 mg >3.0 0.0 5 <1.5 10.0 mg 1.5-1.9 7.5-10.0 mg 2.0-3.0 0.0-5.0 mg >3.0 0.0 6 <1.5 7.5-12.5 mg 1.5-1.9 5.0-10.0 mg 2.0-3.0 0.0-7.5 mg >3.0 0.0 Ref: Crowther MA. Warfarin: Less may be better. Ann Int Med 1997;127:332-3.¯"ÿœDr. Steve's Acid-Base Workup 1) Check ABG & Chem-7 2) Examine patient ;-) 3) Is ABG correct? [H+] = 24 * (pCO2 / HCO3-) [H+]: pH > 7.4 by 0.1 --> 40 * 0.8 pH < 7.4 by 0.1 --> 40 * 1.25 4) Identify 1° vs compensatory ^'s: check pH; check HCO3- A) Evaluate for mixed i) If A.G. > 20: 1° met. acidosis (regardless of pH or HCO3-) B) Calc. ^A.G. (A.G. - 12) -------- ^HCO3 (24 - HCO3-) 1-2 : Hi A.G. met. acidosis < 1 : Hi A.G. / non A.G. met. acidosis > 2 : Hi A.G. / met. alkalosis 5) Go to diff. dx. of each process ­#ÿ Drain Management Immediate Questions: A. What operative procedure did the patient have and what surgical sites are being drained? B. What type of drain was placed intraoperatively? Surgical drains are of two basic types: passive or active. Passive drainage is accomplished by gravity or capillary action. Drainage is further facilitated by transient increases in intra-abdominal pressure, as with coughing. Passive surgical drains include Penrose, Foley, Malecot, and Word catheters. Active drainage is accomplished by suction from a simple bulb device or a suction pump. These systems may be closed, like the Hemovac and Jackson-Pratt drains C. What is the nature of the drainage fluid? Examine the fluid for color, odor and volume. Also examine the tube for clots or other obstructing material Differential Diagnosis: A. Increased drainage - increased bloody drainage can be due to vessel leakage and may be caused by catheter erosion into a vessel. Document rate of bleeding every 30-60 minutes. Increased serous drainage may be from increased lymph drainage, particularly with increased activity. Drainage of urine may represent fistulas anywhere along the urinary tract B. Purulent drainage - this indicates infection C. Sudden cessation of drainage - tissue debris, especially in smaller catheters, is a principal source of catheter occlusion. Drains can be walled off from the general peritoneal cavity within about 6 hours. Intra-abdominal fluid can be collecting without drainage from the catheters. Therefore, regular examinations of the abdomen are necessary for early identification of intra-abdominal fluid collections D. Drain exit wound infection - erythema, induration and pain at the drain exit site are indicators of infection in the subcutaneous tract Misc. Drain Management: Usually drain management does not require emergent or urgent action with the exception of mediastinal tubes on the cardiac surgery service 1. Increased output. Almost always due to blood. Document rate of bleeding by accurately noting output every 30-60 minutes and following serial hematocrits. Measure coagulation parameters and correct as needed 2. Decreased output. A sudden decrease in output may be due to a clot in the tube and lead to an episode of cardiac tamponade °$ÿODrug Limitations in the Elderly Cimetidine (Tagamet) • 900 mg/day • Duration: 12 weeks Decongestants (Afrin, Neo-Synephrine, Sudafed) • Duration: 2 weeks Haloperidol (Haldol) • 3 mg/dose* HCTZ • 50 mg/dose Iron supplements • 325 mg/day Oral antibiotics • Duration: 4 weeks** Oxazepam (Serax) • 30 mg/dose Ranitidine (Zantac) • 300 mg/day • Duration: 12 weeks Thioridazine (Mellaril) • 30 mg/dose: Triazolam (Halcion) • 0.25 mg/dose * Note: Higher doses may be acceptable in patients with a known psychotic disorder. ** Exceptions: treatment of osteomyelitis, prostatitis, tuberculosis, endocardititis. Ref: 1994 Allen F. Shaughnessy, PharmD. Derived from: Beers MH, et al. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991;151:1825-32.©%ÿ4Drugs to Avoid in the Elderly Amitriptyline (Elavil) • Use less anticholinergic agent Antidepressant/antipsychotic combinations (Triavil) • If needed, prescribe individual agents Barbiturates (Seconal) • Safer agents available Chlorpropamide (Diabinese) • Accumulation can occur Cyclandelate (Cyclospasmol) • Doubtful effectiveness Dipyridamole (Persantine) • Doubtful effectiveness GI antispasmodics (Bentyl, Donnatal, Levsin, etc.) • Toxicity outweighs benefit Indomethacin (Indocin) • Safer agents available Isoxsuprine (Vasodilan) • Doubtful effectiveness Long-acting benzodiazepines (Valium, Dalmane, Librium) • Use short-acting agents Meprobamate (Miltown) • Except in those already addicted Methyldopa (Aldomet)* • Safer agents available Muscle relaxants (Flexeril, Norflex, Robaxin, Soma) • Toxicity outweighs benefit Pentazocine (Talwin) • Safer, more effective agents available Propoxyphene (Darvon, Darvocet-N 100) • Safer, more effective agents available Propranolol (Inderal)* • Other beta-blockers cause fewer CNS effects Reserpine* • Safer agents available Trimethobenzamide (Tigan) • Ineffective * Note: These agents may be acceptable in some instances. Although they cause CNS side effects frequently in the elderly, they have been proven to decrease morbidity and mortality in some circumstances. Ref: 1994 Allen F. Shaughnessy, PharmD. Derived from: Beers MH, etc al. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991;151:1825-32.¡'ÿEmergency Contraception Yuzpe Method: 0.1 mg of ethinyl estradiol and 1.0 mg of dl-norgestrel (or equivalent) taken within 72 hours after unprotected intercourse, and repeated in 12 hours. Ovral (Norgestrel 0.50 mg + Ethinyl estradiol 50 mcg), 2 (white) x 2 doses* Lo/Ovral (Norgestrel 0.30 mg + Ethinyl estradiol 30 mcg), 4 (white) x 2 doses* Levlen, Nordette (Levonorgestrel 0.15 mg + Ethinyl estradiol 30 mcg), 4 (light orange) x 2 doses* Tri-Levlen, Triphasil (Levonorgestrel 0.125 mg + Ethinyl estradiol 30 mcg), 4 (yellow) x 2 doses* * First dose within 72 hours of unprotected intercourse. Second dose 12 hours later. Patient may wish to time her first dose so as not to have to wake up during the night to take the second dose. Alternative Method: Ovrette (Norgestrel 0.075 mg), 20 tablets x 2 doses** ** First dose within 48 hours of unprotected intercourse. Second dose 12 hours later. NOTE: Norgestrel contains two isomers, only one of which (levonorgestrel) is bioactive. Thus, 0.50 mg norgestrel is equivalent to 0.25 mg levonorgestrel. When used for post-coital contraception, ECPs are 75% effective. Contraindications: pregnancy Nausea is most common SE (affects 50% of patients, half of which vomit). Antiemetics helpful: Meclizine HCl (Dramamine II, Bonine), 1-2 25 mg tabs taken 1 hour before first ECP dose; repeat in 24 hours if needed. Diphenhydramine HCl (Benadryl), 1-2 25 mg tabs taken 1 hour before first ECP dose; repeat prn q4-6h. Dimenhydrinate (Dramamine), 1-2 50 mg tabs or 4-8 tsp taken 30 min. to 1 hour before first ECP dose; repeat prn q4-6h. Cyclizine HCl (Marezine), 1 50 mg tab taken 30 min. before first ECP dose; repeat prn q4-6h. Other alternatives: dedicated ECP product (e.g., Preven) or insertion of ParaGard IUD. *ÿ9Foley Catheter Problems Immediate Questions: A. What has the urine output been? If the urine output has slowly tapered off, then the problem may be oliguria rather than a nonfunctioning Foley B. Is the urine grossly bloody and are there clots in the tubing or bag? C. Is the patient complaining of any pain? Bladder distention often causes severe lower abdominal pain Differential Diagnosis: A. Low urine output. If the catheter irrigates freely, evaluate for decreased urine output B. Obstructed or improperly positioned Foley catheter 1. Kinking of catheter or tubing 2. Clots and tissue fragments (especially if after a TURP) 3. Sediment/stones Management: A. Verify function. A rule of thumb is that a catheter that will not irrigate is in the urethra and not in the bladder. Start by irrigating the catheter with aseptic technique using a catheter-tipped 60 mL syringe and sterile normal saline. Catheter irrigation or replacement in any patient who has undergone bladder surgery must be done with extreme care B. Spasms. A patient with bladder spasms may complain of severe suprapubic pain, pain radiating to the perineum, or urine loss from around the catheter. Spasms are common after bladder surgery. Bladder spasms can be treated with oxybutynin (Ditropan), propantheline (Pro-Banthine) or belladonna and opium (B&O) suppositories C. Faulty balloon. There are several techniques to deflate a balloon that will not empty 1. Injecting 5-10 mL of mineral oil into the inflation port will cause the balloon of a latex catheter to rupture in 5-10 minutes 2. Threading a 16 French central venous catheter into the inflation channel (after the valve is removed) may bypass the obstruction 3. As a last resort, ultrasound-directed transvesical needle puncture of the balloon may be needed Ÿ-ÿ¢H. Pylori Treatment "As easy as 1-2-3": • 1 week of treatment • 2 times a day • 3 medications Omeprazole 20 mg bid Metronidazole 500 mg bid Clarithromycin 250 mg bid -or- Omeprazole 20 mg bid Amoxicillin 1000 mg bid Clarithromycin 500 mg bid PPI-based Triple Therapy: Recommended first line for the eradication of H. pylori associated with PUD by the 1997 Canadian H. pylori Concensus Conferencež.ÿŒHeart Murmurs Response of selected murmurs to physiologic intervention Systolic ------------------------------------ • Aortic stenosis Increased: Valsalva release Sudden squatting Passive leg raising Decreased: Handgrip Valsalva Standing • IHSS Increased: Valsalva strain Standing Decreased: Handgrip Squatting Leg elevation • Mitral Regurgitation Increased: Sudden squatting Isometric handgrip Decreased: Valsalva Standing • Pulmonic Stenosis Increased: Valsalva release Decreased: Expiration • Tricuspid Regurgitation Increased: Inspiration Passive leg raising Decreased: Expiration Diastolic ------------------------------------ • Aortic Regurgitation Increased: Sudden squatting Isometric handgrip • Mitral Stenosis Increased: Exercise Left lateral position Isometric handgrip Coughing • Tricuspid Stenosis Increased: Inspiration Passive leg raising Decreased: Expiration/ÿ5HgB A1C Average HbAlc Glucose (mg/dl) (%) ------------------------------------- 360 14 330 13 300 12 270 11 240 10 210 9 180 8 150 7 120 6 90 5 œ0ÿþHypercalcemia Immediate Questions: -------------------- A. Vital signs? Mental status? B. Underlying condition(s)? Differential Diagnosis: -------------------- A. Among outpatients, malignancy and primary hyperparathyroidism are leading diagnoses. Malignancy predominates as an etiology for hypercalcemia among hospitalized individuals B. Potential etiologies: 1. Malignancy: bone mets, ectopic PTH, osteoclast activating factor 2. Primary hyperparathyroidism 3. Myeloma 4. Vitamin D excess 5. Sarcoid / granulomatous disease 6. Milk alkali 7. Other: hyperthyroidism, thiazide diuretics, lithium, immobilization (especially children) Therapy: Patients usually are profoundly volume depleted and can require several liters of NS volume replacement. Volume replacement is the initial step in management. Lasix can be added to help increase a saline diuresis (>2500 ml urine/day) and calcium excretion but should only be used following volume replacement Agent Dose Comments -------------------- saline + furosemide 40-80 mg IV each 2 hours monitor hourly urine output (diuretic only if adequately hydrated) mithramycin 25 mcg/kg IV every response takes 24 hours; can 2-3 days cause bone marrow suppression pamidronate 60-80 mg IV over 6 to response in 3 to 4 days, which (mainstay of therapy) 24 hours lasts up to 7 to 14 days prednisone 40-60 mg per day antagonize actions vitamin D; decreases calcium absorption and increases calcium excretion; in most cases, effect lasts only for a few days ›1ÿ/Hyperkalemia Immediate Questions: A. What are the vital signs? B. Is the lab result correct? Consider pseudohyperkalemia, esp. if ECG shows no changes of hyperkalemia. There are a number of causes of factitious hyperkalemia, most common being the tourniquet method of drawing blood. Hemolysis of a blood sample is another source of error. Extreme leukocytosis (>70,000) or thrombocytosis (>1,000,000) can elevate the serum potassium. If there is a question, obtain a plasma potassium. C. What is the patient's urine output? D. What does the ECG show? The ECG is the most important test, (besides the potassium level). It provides more of a "bioassay" than the serum potassium. Changes seen with potassium increase include peaked T waves, flat P waves, prolonged PR interval and a widened QRS complex, progressing to a sine wave and arrest. E. Is the patient taking any medication that could raise the potassium level? Is the patient receiving potassium in an IV solution? If the patient is receiving spironolactone, triamterene, indomethacin and other NSAIDs; ACE-inhibitors, trimethoprim / sulfamethoxazole, pentamidine, succinylcholine; stop these medications immediately. Differential Diagnosis: A. Redistribution 1. Acidosis drives potassium out of the cells 2. Cellular breakdown a. Rhabdomyolysis b. Hemolysis c. Tumor lysis syndrome B. Increased total body potassium 1. Inadequate excretion a. Renal caused (acute or chronic renal failure) b. Mineralocorticoid deficiency or Addison's disease c. Drug-induced (potassium sparing diuretics [e.g., spironolactone] and ACE-inhibitors) 2. Excessive intake C. Pseudohyperkalemia 1. Hemolysis of the specimen 2. Prolonged period of tourniquets occlusion prior to blood draw 3. Thrombocytosis/leukocytosis Plan: The severity of hyperkalemia (as judged by the serum level and the ECG) dictates treatment. A. Repeat any abnormal value, taking care to avoid hemolysis, while assessing for increased WBC or platelets. B. Prevention of further hyperkalemia; discontinue any potassium administration and any contributing drugs. C. Calcium administration. Calcium counteracts membrane effects andprotects the heart. Calcium antagonizes the membrane effects of hyperkalemia and restores normal excitability within minutes. Administer one to two ampules of calcium gluconate, (10-20 mL of a 10% solution IV over 3-5 minutes), with the patient on a cardiac monitor. D. Potassium can be quickly shifted into cells by the administration of alkali or glucose plus insulin (one ampule D50 and 10 units regular insulin).Sodium bicarbonate (1 ampoule [44 mmol] of bicarbonate) may be administered intravenously over several minutes. E. Remove potassium from body. Kayexolate may be administered orally or as an enema. Remember that this will trade potassium for sodium and result in a sodium load. Normal saline diuresis can assist removal of potassium. ACUTE THERAPY OF HYPERKALEMIA • Condition: ECG changes of hyperkalemia Therapy: Calcium gluconate (10%) 10 ml IV over 3 minutes. Repeat in 5 minutes if needed. Follow with 10 units regualar insulin IV; the insulin may be by IV push, but must be followed with 1 ampule D50 IV push; alternatively, 10 unity regular insulin in 500cc D20 may be infused over 30 to 60 minutes. Comment: Lasts only 30 to 60 minutes. No bicarbonate after calcium. • Condition: After acute phase or if no ECG changes Therapy: Kayexalate: Oral dose of 30 to 60 grams in 50 ml sorbitol (20%). Rectal dose of 50 grams in 200 ml sorbitol (20%) as retention (30 to 45 minutes) enema. Comment: Oral dose preferred (enemas are only if patient cannot take po). • Condition: If renal failure Therapy: Hemodialysis as soon as possible. Kayexalate also will be effective, but not immediately.š2ÿxHypernatremia Immediate Questions: A. What is the patient's mental status? B. What have been intake, output and serial weights? Clinical Findings: A. Na+ serum is usually 150 mEq/L before symptoms manifest; a rapid rate of increase is more likely to result in problems B. Na+ 160 mEq/L: irritability, anorexia, ataxia, cramping C. Na+ 180 mEq/L: confusion, stupor, seizure Diagnostic Considerations: Extracellular Fluid Volume State Management: A. Assess the extracellular fluid volume B. "Hypernatremia with increased volume": Therapy is diuresis (e.g., furosemide), and replacement of the urine output with water (D5W) C. "Hypernatremia with " normal volume": Hypovolemia usually is not evident because of the large intracellular water reserve. Acute therapy is water (D5W) replacement, and evaluation for possible DI D. "Hypernatremia with decreased volume", (i.e., water loss Na+ loss): Estimate the degree of volume depletion by using: Water depletion approximately (0.6 X body weight ) X [measured serum sodium / 140] -1) * Correct volume with normal saline, and follow with half-normal saline * If initial serum Na+ >175, prevent cerebral edema by monitoring serum Na+ hourly until it reaches 155 mEq/L, allowing a decline of at most 2 mEq/L/hr * Replace one-half this volume over the first 24 hours, the remainder over the next 1-2 days ™3ÿìHypokalemia Immediate Questions: A. Is the patient symptomatic? Symptoms of hypokalemia include weakness, nausea, vomiting and abdominal tenderness. Severe hypokalemia can depress reflexes and cause weakness B. What medications is the patient taking? Loop diuretics and amphotericin causes potassium wasting by direct renal effects C. Is there a history of vomiting, nasogastric suction, diarrhea or renal problems (such as renal tubular acidosis)? Database: Because potassium is the principle intracellular cation, measured serum hypokalemia usually represents a significant loss of body potassium. Thus, serum levels of 3.0 meg/L (mmol/L) often reflects total deficits of 100-200 meq or more. Look for coexisting hypocalcemia and hypomagnesemia. Check ABG's, as acid-base disorders may coexist and obtain an ECG. Severe hypokalemia can cause blunting of reflexes, paresthesia and paralysis Plan: A. Aggressive potassium replacement should be performed only after adequate renal function has been documented B. Parenteral replacement should be considered for digoxin toxicity, significant arrhythmia, and severe hypokalemia (<3.0 mmol/L). Maximum concentrations of KCl used in peripheral veins generally should not exceed 10 meq/100 cc, due to the damaging effects of high concentrations on the veins C. For lesser degrees of hypokalemia that require parenteral replacement, 10 to 15 meq/h may be infused peripherally. The maximum infusion rate is 10 meq/hour. Check serum levels frequently (every 2-4 hours depending on clinical response) to avoid hyperkalemia. ICU monitoring is required if arrhythmias are present or for rapid infusions of KCl D. Oral replacement include liquids and tablets. Slow-release pills typically contain 8, 10 or 20 meq tablet. Thus, it will take several days to replete the potassium depletion. Replacement doses should be 40-120 meq qd in divided doses, depending on the patient's weight and level of hypokalemia. More than 20 meq in one dose can cause GI upset ˜4ÿšHypomagnesemia Immediate Questions: A. What are the patient's vital signs? Cardiac arrhythmias including atrial fibrillation, ventricular tachycardia and ventricular fibrillation can occur B. Is the patient tremulous? Tremor, tetany, muscle fasciculations, and seizures are all associated with magnesium deficiency. Determining the presence of these neurologic problems will help guide the urgency of treatment Differential Diagnosis: Hypomagnesemia can be caused by medications, especially diuretics, antibiotics (ticarcillin, amphotericin B), aminoglycosides, cisplatin, and cyclosporin, often cause hypomagnesemia. Alcoholism and reduced intake/ malabsorption also can cause hypomagnesemia Laboratory Data: Electrocardiograph findings may include prolongation of the PR, QT, and QRS intervals, as well as ST depression and T wave changes. Rhythm disturbances include supraventricular arrhythmias, as well as ventricular tachycardia and ventricular fibrillation Plan: A. Asymptomatic individuals can be treated with oral magnesium. Oral magnesium oxide (20 meq of magnesium per 400 mg tablet) can be administered as 1 or 2 tablets per day; oral administration is most appropriate for chronic maintenance therapy B. Magnesium sulfate 1 g (2 mL of a 50% solution of MgSO4) equals 98 mg of elemental magnesium. For moderate depletion, infuse 6 gms (12 ml of 50% MgSO4 = 6 gms) in 500 ml saline can be given IV over 3 hours, followed by 5 gm in 500 ml saline over the next 6 hours. The 50% solution must be diluted for IV use. For slightly less urgent situations, 1 g/h may be given q3-4h with close monitoring of deep tendon reflexes. As long as signs and symptoms of hypomagnesemia are improving, the infusion can then be slowed so that the patient receives approximately 10 g of magnesium sulfate in the first 24 hours C. Intramuscular magnesium sulfate. Give 1-2 g IM q4h for 5 doses during the first 24 hours —5ÿ4Hyponatremia Important Questions: A. Is the lab value real? Repeat any abnormal lab. Was it drawn above IV site? What's the glucose? What are lipids? B. What's the volume state, based both on the patient's history and current exam? What fluids have been administered? C. CNS sx? Are there any recent prior sodium levels to document the chronicity of the hyponatremia? The urgency of correction depends on the patient's symptoms and the acuteness of the hyponatremia's onset Differential Diagnosis: The initial differentiation is between true hyponatremia and laboratory artifact. True hyponatremia may be classified according to the volume status of the patient: hypovolemic, euvolemic or hypervolemic. Hypovolemic hyponatremia may be further classified by serum and urine chemistries DIFFERENTIAL DIAGNOSIS of SIADH ---------------------------- 1. Malignant neoplasia a. Carcinoma (bronchogenic, duodenal, pancreatic, ureteral, prostatic, bladder) b. Lymphoma and leukemia c. Thyoma, mesothelioma, and Ewing's sarcoma 2. CNS disorders a. Trauma, subarachnoid hemorrhage, subdural hematoma b. Infection (encephalitis, meningitis, brain abscess) c. Tumors d. Porphyria e. Stroke 3. Pulmonary disorders a. Tuberculosis b. Pneumonia c. Mechanical ventilators with positive pressure d. Lung abscess 4. Drugs (including vasopressin, chlorpropamide, thiazide diuretics, oxytocin, vincristine, haloperidol, nicotine, phenothiazines, tricyclic antidepressants) 5. Others a. "Idiopathic" SIADH b. Hypothyroidism HYPONATREMIA CLASSIFIED BASED ON SERUM OSMOLALITY, VOLUME STATE and URINE SODIUM ---------------------------- Calculated Na Deficit = 0.6 (Wt. in kg) (140 - Na) + (140) (Volume deficit in L) (mEq) Corrected Na for LIPID, PROTEIN and GLUCOSE: ---------------------------- % serum H2O = 99 - 1.03 (lipids in gm/L) - 0.73 (protein in gm/dl) corrected Na = measured Na x 93/% serum H2O change in Na = 0.016 (measured glucose - 100) corrected Na = 0.016 (measured glucose - 100) + measured Na –6ÿ£Hypophosphatemia Immediate Questions: A. Is the patient an alcoholic, recovering from DKA or refeeding orally or parenterally? B. Symptoms or signs of weakness? (Clinical findings may not be prominent, despite PO4 of less than 1.0 mg/dl) Treatment: A. IV replacement is used for levels less than 1.0 mg/dl (even without symptoms) B. Monitor K, Mg, Ca, as abnormalities of other cations often coexist •7ÿICU Values • Pulm. artery pressure: 30/14 (10-25, 5-15 mm. Hg) • Mean pulm cap wedge press.: 12 (5-13 mm) approx. = to left atrial pressure and LVEDP. Post MI best @ 14-18 mm. If exceeds @ 30 have pulmonary edema. If mitral valve OK this reflects LVEDP, which in turn reflects LVEDV and end diastolic fiber length (preload). For each mm of PEEP > 25 the PCWP will be increased by 1 mm over the true LVEDP/LAP. With low albumin CHF with lower PCWP. • LVEDP: 12 (5-12 mm) • PAD: Pressure in pulm artery, measured with balloon down. In ideal cases may approx. PCWP, pulm HTN dissociates PAD/PCWP. • CVP: 1-5 mm; reflects RVEDP/preload, approx. = RAP. If CVP > 15 no resp to incr fluid. • Cardiac index: normal 2.5-3.6 L/min/m2. Typical CO is 4-6 L/min. Hypoperfusion at 1.8-2.2, shock at < 1.8. • PVR: 800-1200 • Mitral valve parameters: • Norm 4.5-6.0 cm2 • < 2.5: incr. atrial pressures • < 1.5: over 25 mm LAP • < 1.0: sx and pulm edema • Typical cardiogenic shock: CI @ 1.8, BP @ 90, incr. PVR, oliguria, pulm vasc cong on CXR. If PCWP is low or normal give fluids and maintain PCWP @ 15-20 mm. • Venous Oxygen saturation and A-V O2 gradient: • This is a measure of the balance between total body O2 supply and demand. Use with CO values. • Mixed venous saturation: normal 70-80%, heart failure < 60%, shock < 40%.[18 ml/dl] • A-V O2 gradient: normal 3.5-5.0. In cardiogenic shock the A-V gradient widens. In early sepsis it narrows (incr. CO and microvascular shunting), in late sepsis it widens. ”>ÿiMagnesium Toxicity (consideration when treating preeclampsia) Immediate Questions: A. What dose of magnesium sulfate was the patient receiving? Most patients receive 1-2 MgSO4 IV every hour. This dose is regulated by following serum levels and changes in physical examination such as decreased patellar reflexes, which are suggestive of high serum magnesium levels. Magnesium sulfate used in patients with premature labor may require doses of up to 3g/h B. What was her last serum magnesium level? Clinically significant hypermagnesemia can begin to be seen at levels as low as 4 mEq/L. Most patients who are being maintained on magnesium sulfate for the prevention of eclampsia will be held at 4-6 mEq/L Management: 1. Magnesium Toxicity may be seen at levels as low as 4 meq/l. Most patients are maintained at 4-6 meq/l to prevent eclampsia. Respiratory depression can appear at magnesium levels of 8-10 meq/l, and cardiotoxicity, while not usually seen until levels exceed 10 meq/l, can occur at any serum magnesium level 2. Electrocardiogram Obtain a baseline study. Hypermagnesemia may manifest itself as a shortened Q-T interval up through complete heart block 3. Calcium gluconate Administer 1 g IV over approximately one minute, while waiting for serum magnesium and electrolyte values. If calcium administration improves the patient's status, then magnesium toxicity is most likely the correct diagnosis: magnesium is a calcium antagonist, and calcium should reverse its toxicity 4. Urine output Magnesium is secreted by the kidneys. Urine output should be maintained at a minimum of 30 mL/h “CÿÖMini Mental Status Exam Scores < 24 are associated with delirium, dementia or severe depression. In community dwelling persons > 65, 95% had a score of > 24. 1) What is the (year) (season) (date) (month)? (5 points). 2) Where are we (state) (county) (town) (hospital) (floor)? (5 points). 3) Name 3 objects: 1 second to say each. Then ask pt all 3 after being said. One point for each correct answr. (3 points). 4) Serial 7s. 1 point for each correct. Stop after five answers. OR, spell world backwards. (5 points.) 5) Ask for each of the 3 objects. One pt for each correct. (3 points) 6) Name a pencil and watch. (2 points) 7) Repeat: “No ifs, and, or buts.” (1 point) 8) Follow a 3-stage command: “Take the paper in your right hand, fold it in half, and put it on the floor.” ( 3 points) 9) Read and obey the following: “Close your eyes.” (1 point) 10) Write a sentence. (1 point) 11) Copy design (2 overlapping pentagons). (1 point)’DÿMom Talk 1) Baby's name 2) Mom's experience 3) Mom's help at home 4) Feeding (breast or bottle) 5) Car seat 6) Smoking 7) Umbilical cord care 8) Sleep positions (back or side) 9) Circumcision (yes or no) 10) Fever (see MD if >= 100.5 pr) 11) Follow-up (see MD in 2 wks)‘Hÿ*Newborn IVF 1st day: 80cc/kg/day D10W 2nd day: 100cc/kg/day D10W 0.2 NS 3rd day: 120cc/kg/day D10W 0.2 NS w/20meq KCl/L 4th day: 140-150cc/kg/day D10W 0.2 NS w/20meq KCl/L (HAL) Calories- Preemie: 120-140 cal/kg/day Term: 80-100 cal/kg/day 24 cal/30cc=0.8cal/cc 20 cal/30cl=0.66 cal/ccIÿÜNG Tube Management Immediate Questions: A. How long has the NG tube been in place? A tube that has just been placed may have bloody drainage from the trauma of insertion or as a result of recent gastric surgery B. What is the volume and description of the output? How much bloody drainage has there been? Is the patient having abdominal distress? Database: An abdominal radiograph is useful to identify the tube's location. Look for a large stomach bubble indicating poor gastric emptying. Check the position of the tube tip and verify that it is in the stomach Plan: A. Decreased output: 1. Verify position. This is based on xray confirmation. Flushing the tube with 40-60 cc of air and listening over the stomach results in a typical crackle or pop; however, this may also be heard with the tube in the distal esophagus or duodenum. Based on xray findings, you may want to advance or retract the tube, as needed 2. Verify function. Sump tubes should whistle continuously on low suction. Most tubes need to be flushed with saline (30 mL) every 3-4 hours to maintain patency 3. If the tube's position and function are not problems, then decreased output can indicate return of bowel function B. Increased output: 1. Poor gastric emptying (no obstruction) 2. Distal obstruction 3. Ileus C. Blood in the NG output: 1. Determine whether the cause of bleeding is serious enough to require specific aggressive therapy. Is there hypotension or hemodynamic instability? For either and signs of significant bleeding, place a large-bore IV and begin fluid and blood replacement. Bleeding may be due to trauma, all the causes of upper GI bleeding, and a coagulopathy 2. NG irrigation; H2 blockers or antacids LáPain Meds Therapeutic Equivalents (mg): PO Drug IM ------------------------------- 100 Codeine 60 15 MS 5 10 Oxycodone 7.5 Ž_ÿÅPreoperative Cardiac Risk Setting: Inpatient Population: Adult patients being evaluated before noncardiac surgery Add up the number of points that correspond to all of the items that apply to your patient (53 max): MI within past 6 mos = 10 S3 gallop or JVD = 11 > 5 PVCs/min at any time = 7 Clinically important aortic stenosis = 3 One or more of the following: • pO2 < 60 mmHg or pCO2 > 50 mmHg • K+ < 3.0 mmol/L or bicarb < 20 mmol/L • BUN > 50 mg/dL or creat > 3.0 mg/dL • Abnormal AST or signs of chronic liver dis. • Pt. bedridden from noncardiac dis. = 3 > 70 y/o = 5 Intraperitoneal, intrathoracic, or aortic operation = 3 Emergency operation = 4 Cross-reference your patient's total number of points with the appropriate patient group to find his/her probability of complications: Points (risk class) 0-5 6-12 13-25 >25 (I) (II) (III) (IV) Patient Group Minor 0.3% 1% 3% 19% surgery > 40 y/o 1.2% 4% 12% 48% and major noncard. surgery Known 3% 10% 30% 75% CAD, aortic surg., other hi-risk eÿ.Pulmonary Mnemonics SHITFACED: Causes of Interstitial Lung Disease • Sarcoid • Histiocytosis X • Idiopathic Pulmonary Fibrosis • Tumor (Lymphangitic) • Failure • Asbestosis (and other dusts) • Collagen Vascular Disease • Extrinsic Allergic Alveolitis (Farmer's lung) • Drug ABC's of Trauma • Aortic Transection • Bronchial fracture • Cord injury (Thoracic spine) • Diaphragmatic rupture • Esophageal tear • Flail chest • Gas (subtle pneumothorax) • Heart (Cardiac injury) • Iatrogenic (Misplaced monitoring & support catheters) PEARL: Causes of Unilateral Lung Disease • Pneumonia • Edema • Aspiration • Radiation • Lymphangtic Tumor FAT PAD: Cardiophrenic Angle Mass • Fat • Pericardial cyst • Adenopathy/Aneurysm • Diaphragmatic Hernia BIG HIPS: Honeycomb Lung • Bleomycin • Idiopathic • Granulomas • Histiocytosis X • Interstitial pneumonia • Pneumoconiosis • Sarcoid Late Night Sex: Interstitial Lung Disease & Hyperinflation • Lymphangiomyomatosis • Neurofibromatosis • Sarcoid • Emphysema • X, histiocytosisŒfÿ¨Ranson's Criteria Initial: • Age > 55 • WBC > 16,000 • Blood glucose > 200 • Serum LDH > 350 • AST > 250 During first 48 hours: • HCT falls > 10% • BUN increases > 8 mg/dL • Serum calcium < 8 mg/dL • Arterial pO2 < 60 mm Hg • Base deficit > 4 mEq/L • Fluid sequestration > 600 L Mortality: • If 0 - 2 signs, then 2% • If 3 - 4 signs, then 15% • If 5 - 6 signs, then 40% • If 7 - 8 signs, then 100% ‹kÿSensitivity & Specificity • TP = true positives • FP = false positives • TN = true negatives • FN = false negatives • Sn = sensitivity • Sp = specificity Has No Disease Disease Test Positive TP FP Test Negative FN TN • Sensitivity (true positive rate) = TP / ( TP + FN ) • Specificity (true negative rate) = TN / (TN + FP ) • Positive Predictive Value = TP / ( TP + FP ) • Negative Predictive Value = TN / ( TN + FN ) • Odds Ratio = TP * TN / FP * FN • Accuracy = (TN + TP ) / tot. no. of subjects • Likelihood Ratio for pos. test = Sn/(1-Sp) = [TP/(TP+FN)]/[FP/(FP+TN)] • Likelihood Ratio for neg. test = (1-Sn)/Sp = [FN/(TP+FN)]/[TN/(FP+TN)] • Sensitivity = ability of test to detect disease • Specificity = ability of test to rule out disease • Null hypothesis = assumption that the observed difference between two groups studied is due to chance • Type I error = rejecting the null hypothesis when it is true • Type II error = not rejecting the null hypothesis when it is false • p-value = probability that the difference occurred by chance (probability of a type I error) • Power = probability of detecting a real difference when one exists (1-probability of a type II error) • Cohort = prospective study of a group to determine outcome (no intervention); mainly used to calculate incidence, relative risk, and attributable risk • Cross-sectional = measures the association of a risk factor and disease in a group of subjects at a single point in time; mainly used to calculate prevalence, sensitivity, specificity, and odds ratio • Case-control = retrospective study of groups with and without disease to compare past exposure to a risk factor; mainly used to calculate odds ratio, cannot calculate prevalence or incidence Šlÿ¿Service Medicine On-Call Agitation: Ativan 0.5-2.0 mg IM/PO q6-8h Haldol 1-5 mg IM/PO q4-8h Constipation: Dulcolax 10 mg PO/PR PRN Colace 100 mg PO BID PRN Indigestion: Maalox Plus 30 cc PO Riopan 30 cc PO (R/O CP of cardiac origin) Nausea: Inapsine 1.25-2.5 mg IV q4h Phenergan 12.5 mg IV or 25 mg IM Insomnia: Ambien 5 mg PO qHS PRN, may repeat x1 (best choice) Benadryl 25-50 mg PO qHS PRN (don't use if BPH present) Restoril 15-30 mg PO qHS PRN (don't use in elderly) Hypokalemia: KCl PO or 10 meq KCl in 100 cc NS over 1 hour, max. dose 40 meq (don't fluid overload if CHF present) Hyperglycemia: Sliding scale insulin 200-250 --------> 2 units reg. 251-300 --------> 4 units reg. 301-350 --------> 6 units reg. 351-400 --------> 8 units reg. >400 ------------> 10 units, call HO Hypoglycemia: Orange juice or skim milk, recheck. If no change, give 1 amp. D50 Fever: Tylenol, blood cx. x2, U/A w/C&S, CXR, sputum cx. Chest Pain: EKG, VS, SL NTG, O2, +/- CXR SOB: O2, ABG, EKG, CSR, VS, SMA-7, H/H if anemia suspected Fall out of bed: Check for LOC, VS, obvious inj. (lacs, fx.), meds (anticoagulants, seizure meds), neuro exam. May suggest siderails up, posey, night light. Dobhoff Tube: Should be in stomach or duodenum (best placement). If in stomach, can give Reglan 10 mg IV and lay on left side for 30 min. then recheck KUB. ET Tube: Placement should be 1-2 cm above carina. Always check a CXR after intubation. Death Pronouncement: Check for response to painful stimuli, heart sounds, carotid pulse, spontaneous respiration, pupils fixed and dilated. Record findings and time of death. Notify attending and family. ?Autopsy if appropriate. Have family leave the room when pronouncing. Misc: If you order an ABG, always order an SMA-7. ‰nÿWSix P's of Nursing Home H&P PERSON - age, occupation, fun activities, where were they before N.H., place of birth, children, may need to ask family or social service PROBLEMS - diagnosis (old & new) PERFORMANCE - MMSE scores, ADL's (feeding, bathing, dressing, tansferring, walking, assistance) PRESSURES - fears, worries PHYSICAL - heart, lung, abd., ext., skin, breast (q month) PLAN - routine lab, change or D/C meds, NO prn restraints (Ativan is OK), fall assessments (probable on call duty) Admit labs: CBC, SMA-7, TSH, UA, drug levels, pre-albumin ( < 18 = poor nutrition)ˆqÿSutures Absorbable Sutures: • Plain gut (7-10 days) • Chromic gut (10-14 days) • Vicryl (14-21 days) • Coated Vicryl (14-21 days) • Monocryl (7-14 days) • PDS (1-3 mos) Nonabsorbable Sutures: • Silk • Stainless steel wire • Ethilon (nylon) • Nurolon (nylon) • Mersilene (polyester fiber) • Ethibond (coated polyester) • Prolene (polypropylene) Duration of Sutures: • Face: 5.0-6.0 vicryl and 6.0 nylon: 3-5 days with steristrips • Scalp: 7 days • Neck: 7-10 days • Upper extremity: 7-9 days • Trunk: 8-10 days • Lower extremities: 10-30 days (longer with smoking, obesity) Close slow-healing tissues (skin, fascia, tendons) with nonabsorbable sutures or a long-lasting absorbable suture. Close fast-healing tissues (stomach, colon, bladder) with absorbable sutures. Avoid multifilament sutures which may convert a contaminated wound into an infected one. Use monofilament sutures or absorbable sutures which resist harboring infection. Where cosmetic results are important, use the smallest inert monofilament suture materials (nylon, polypropylene). Avoid using skin sutures alone. Close subcuticularly whenever possible. Use sterile skin closure strips to secure close apposition of skin edges when circumstance permits. ‡vÿ Topical Corticosteroids Superpotent (I): -------------------------------------- Clobetasol propionate cream, 0.05% (Temovate) 45 g $41.00 (generic: 37.00­39.00) Clobetasol propionate ointment, 0.05% (Temovate) 45 g $41.00 (generic: 37.00­39.00) Augmented betamethasone dipropionate ointment 0.05% (Diprolene), 45 g $49.00 (generic: 41.50-43.00) Diflorasone diacetate ointment, 0.05% (Psorcon) 60 g $65.00 (generic: 40.00­57.00) High potency (II) -------------------------------------- Amcinonide ointment, 0.1% (Cyclocort) 60 g $38.50 Betamethasone dipropionate ointment (Diprosone), 0.05% 45 g $39.00 (generic: 7.50­20.00) Fluocinonide cream, 0.05% (Lidex) 60 g $42.00 (generic: 10.00­26.00) Fluocinonide ointment, 0.05% (Lidex) 60 g $42.00 (generic: 22.00­39.50) Fluocinonide solution, 0.05% (Lidex) 60 mL $40.50 (generic: 17.00­24.00) Desoximetasone cream, 0.25% (Topicort) 60 g $42.00 (generic: 23.00­31.50) Desoximetasone ointment, 0.25% (Topicort) 60 g $42.00 Halobetasol propionate cream, 0.05% (Ultravate) 50 g $51.00 Halobetasol propionate ointment, 0.05% (Ultravate) 50 g $51.00 Medium potency (III to V): -------------------------------------- Triamcinolone acetonide ointment (Aristocort A), 0.1% 60 g $27.50 (generic [80 g]: 4.00­6.50) Betamethasone dipropionate cream, 0.05% (Diprosone), 45 g $39.00 (generic: 9.00­13.00) Triamcinolone acetonide cream, 0.1% (Kenalog) 60 g $25.50 (generic [80 g]: 3.00­9.00) Triamcinolone acetonide ointment, 0.1% (Kenalog) 60 g $25.50 (generic [80 g]: 4.00­6.50) Fluocinolone acetonide ointment, 0.025% (Synalar) 60 g $33.50 (generic: 6.00­10.00) Hydrocortisone butyrate 0.1% cream (Locoid) 45 g $27.00 Hydrocortisone butyrate 0.1% ointment (Locoid) 45 g $27.00 Hydrocortisone butyrate solution, 0.1% (Locoid) 60 mL $39.00 Betamethasone valerate cream, 0.1% (Valisone) 45 g $29.00 (generic: 4.00­15.00) Hydrocortisone valerate cream, 0.2% (Westcort) 60 g $31.00 Hydrocortisone valerate ointment, 0.2 % (Westcort) 60 g $31.00 Mild potency (VI) -------------------------------------- Aclometasone diproprionate cream (Aclovate), 0.05% 60 g $28.00 Aclometasone diproprionate ointment (Aclovate), 0.05% 60 g $28.00 Triamcinolone acetonide cream, 0.1% (Aristocort) 60 g $21.00 (generic [80 g]: 3.00­9.00) Desonide ointment, 0.05% (DesOwen) 60 g $33.00 (generic: 25.50) Fluocinolone acetonide cream, 0.01 % 60 g $2.50­5.00 (generic only) Low potency (VII) -------------------------------------- Hydrocortisone cream, 2.5% (Hytone) 30 g $18.50 (generic: 5.00­10.00) Hydrocortisone ointment, 2.5% (Hytone) 30 g $20.00 (generic: 3.00­8.00) Hydrocortisone cream, 1 % (Hytone) 30 g $8.50 (generic: 1.50­8.50) Hydrocortisone ointment, 1% (Hytone) 30 g $10.00 (generic: 1.50­8.50)†zÿÁUseful Stuff G.I. Cocktail: • 30 cc Mylanta or Maalox • 5cc Donnatal • 5cc Viscous Lidocaine I.V. Fluids for Burns: • 2-4 ml x Kg x % BSA burned = fluid / 1st 24 hrs • Give 1st 1/2 in the 1st 8 hrs from burn. • Give rest over next 16 hours. Creatinine Clearance (measured): Cr(u) x Vol(u) / Time(min) / Serum Cr Calculate replacement Vol. of blood (Peds): [Vol Blood (Wt)(Change HCT)] / HCT of PRBC = [ 75 (Wt)(Change HCT)] / 65 …{ÿ9Ventilator Management Intubation criteria -------------------------------------- • pH <= 7.25 • More respiratory muscle fatigue & paradoxical respiration Extubation mechanics -------------------------------------- • Vc > 10-15 ml/kg • PIMAX < -25 • Shunt < 10-20% • [Vc * 30]/2 > Ve • PO2 >= 60 with FiO2 0.4-0.6 Ventilator settings -------------------------------------- Tidal volume: • Normal 12 ml/kg • COPD 8-10 ml/kg • ARDS 12-15 ml/kg Rate: • Norm 10-12 I:E • 1:2 or 1:1.5 Peak insp. flow: • Norm 40 L/min • Tachyp 70-90 • RDS 85-100 • COPD 40-60 L/min Modes: Usually start with SIMV or assist/control to start. (SIMV of 8 is about same as assist/control) PSV of 10 is equal to work of breathing through tube. Apply PSV gradually until RR 20 and TV 7ml/kg. PEEP: In RDS use if PaO2 <60 with FiO2 >90 FiO2: Rule of 7: To incr PaO2 by 1% need incr FiO2 by 7mm Hg Sedation -------------------------------------- • Valium 5 mg and MS 4mg then Pavulon 4mg; may repeat same with Pavulon 8 mg • IV Haldol (flush line with saline first). Wait 20 minutes between doses, double the dose q20m until effective (max 40 mg qh) • mild: 0.5-2.0 mg • moderate: 5.0-10.0 mg • severe: 10.0 mg plus • Pavulon: load with 0.05 to 0.1 mg/kg then give 0.02 to 0.05 q4h„|ÿ†Ventricular Hypertrophy Sokolow-Lyon Criteria for LVH ------------------------------------ S in V1 + R in V5 or V6 > 3.50 mV or R in V5 or V6 > 2.60 mV Sokolow-Lyon Criteria for RVH ------------------------------------ R in V1 + S in V5 or V6 >= 1.10 mV Cornell Voltage Criteria for LVH ------------------------------------ Females: R in aVL + S in V3 > 2.00 mV Males: R in aVL + S in V3 > 2.80 mV Romhilt-Estes Scoring System for LVH ------------------------------------ 1. R or S in any limb leads >= 0.20 mV or S in lead V1 or V2 or R in lead V5 or V6 >= 0.30 mV Score = 3 points 2. Left ventricular strain ST segment and T wave in opposite direction to QRS Score without digitalis = 3 points Score with digitalis = 1 point 3. Left atrial enlargement Terminal negativity of P wave in V1 is >= 0.10 mV in depth and >= 0.04 sec in duration Score = 3 points 4. Left axis deviation of >= -30 deg Score = 2 points 5. QRS duration of >= 0.09 sec Score = 1 point 6. Intrinsicoid deflection in V5 or V6 >= 0.05 sec Score = 1 point Total = 13 points LVH = 5 points Probable LVH = 4 points ƒ~ÿYWound Complications Immediate Questions: A. Is there a wound dehiscence, and if so, to what extent? Did any fluid leak from the wound? Always evaluate the wound yourself as soon as possible; see how much of the wound has opened and if there is an evisceration. An "open wound" is not a dehiscence unless the fascia opens B. Are there findings of an infection? Plan: A. Initial management. Determine by wound examination if there is an evisceration, fascial disruption without evisceration, or a superficial wound separation. In all cases, it is safe to make the patient NPO and start antibiotics to cover skin organisms, until a final plan is formulated B. Evisceration/fascial dehiscence. Cover the wound with saline soaked sterile gauze, then cover with a large sterile dressing. Notify the senior staff since evisceration requires operative repair C. Fascial dehiscence with evisceration. If the overlying skin and subcutaneous tissues are intact but there is clearly a fascial defect, it may be treated by operative repair or observation. Without treatment, a ventral hernia will develop D. Superficial wound separation. Healing by secondary intention is mandatory when there is an associated superficial wound infection, and is the safest management in any case E. Wound infection. Culture and antibiotics selected based on type of surgery. See the Stanford/Parkland guide for antibiotic choice, which varies with surgery type for: 1. surgery not involving GI or female GU tract 2. surgery involving GI tract (including oropharynx) and female GU tract 3. extremity, +/- sn sepsis Ç!ÿÈDermatology 1. Nystatin cream doesn't work on dermatophytes 2. Tinea crusis does NOT affect the scrotum, candidiasis DOES. 3. If repeated cellulitis, look for a portal of entry (often a sore on the foot between the 4th & 5th toe) 4. Heat is good for an abscess of the skin, but AVOID with cellulitis 5. Always mark the line of cellulitis. 6. If a rash is on just 1 hand, check both feet. 7. Grier's goo - Zinc Ox + Hydrocortizone + Nystatinð:ÿ°Ivan Levin A+ blood type-ivan O+ vera!!! dr. Lafave - pcp dr. Rappaport -card dr. Ries - pulm dr. Sanders - pulm dr. Summers - surg dr. Loew -card 847-677-9600 847-673. 2922-marty dr. Carl tommaso - 847-675-8990 r847-677-9600 to page dr-bruce burgleson - both cath docs rest redistribution thalium mr? Echo cordoron benji pager-847-333-1102 atrial flutter prob staph balloon pump, 4.5 years younger Sister elaine died in 1975 of pancreatic can ivan b. 1923 anna(chana ) goldstein & david levin parent david levin -milkman (w/ horse) for borden dairy anna d. Of pneumonia both died @ 72 fished together in wisc. & canada ivan's =zoology favorite subject (along with girls) went fishing on prom night family man in army - england & germany ww2 - radio man loved music - country, classic, shows, pop, jazz (alligators that squeek to protect them) out of army in '45 lived @ home & did a lot of manual jobs (including security) strong & wirery walked around track nancy meet ivan in 1970 through elaine nancy(29) met elaine @ a fastfoood restaurant in 1970 married 1971june 12 (eloped) civil marriage engaged - march 1 1971 honey moon was a weeken at The Fireside about 1969 went to a VA hospital in downtown chicago & found out about diabetes nancy went with elaine to the hospital and met ivan there after hospital, then saw him sleeping on the floor @ elaine's (staying there) & tickled him nancy = nechama heb name start bowling w/ davita for girlscouts one reason for retirement was a hernia in 20's played softball 3rd base pingpong tournements when younger bowl (ave 180 @ height - high 270?) & fish watched sports on tv liked local hs basketball (thooght better) had dog growing up (nonni & then nonni 2 - nicknamed two friend dale, jimmy & ivan from 6 yo ivan leroy (big bad leroy brown) life magazine read read the blotters - record of police good at math - very organized vera remembers having chinese food thurs before diabetes got bad 6 yrs ago ivan father david -grandfather israel mom anna -grandfather abraham goldstine nancy winkel dad Eli p. - grandfather jack & gmom anne mom julia - g.dad william shafran & vera  ŸAltered Mental State = AEIOU TIPSS A-Alcohol E-Encephalopathy I-Infection O-overdose U-uremia T-trauma I-insulin P-psychosis S-syncope S-seizures"yÿ*Urinary Incontinence = DIAPPERS (potential transient causes) D - delirium, dementia I - infection A - atrophic vaginitis, atrophic urethral mucosa P - pharmacy (sedative-hypnotics, diuretics, Ca channel blockers) P - psychologic E - endocrine R - restricted activity S - stool (impacted)]p«=ÿáLymerix -vaccine rotavirus - vaccine? vioxx - no sulfa problems celebrex - x react to sulfa ddx hives / itching ointment oil based - good for cracked skin jones fracture reflex sympathetic dystrophy - causes include soft tissue injury, fractures, post-op, post - mi, post cva TENS - transcutaneous electrical nerve stimulation can be used to tx rsd (stim GSA » pain block). Ineffective for low back pain. Contraindicated w/ pacemaker. capnocytophagia - gram (-) that occurs in spleen (-) patients bitten by a dog. IHSS - idiopathic hypertrophic subaortic stenosis- valsalva ˆ murmur - echo diagnostic, ekg usually abnl. diastolic murmurs are ALWAYS pathological! Never transfuse just one unit of bloodap« 3Books to Read - Davita Mother of pearl hannibalcp«oUSmart doc galax datemate bbuddy digger cityzen topsecret word 97 doc converterdp«^ÿ«PHLEBOTOMY 1. Explain procedure to patient. 2. Check patient identification. 3. Prepare supplies: - needle and syringe (or vacutainer) - alcohol swab - disposable gloves small pillow or folded towel (optional) sterile 2x2 gauze rubber tourniquet bandaid or tape (optional) appropriate blood sample containers patient I.D. labels completed lab requisition (specimen transmittal form) 4. Assess patient for: - bleeding risks - contraindicated venipuncture sites (proximity to artery or IV catheter, hematomas, AV shunt sites on dialysis patients, etc.) - anxiety/fear - need for assistance/restraints (esp. in pediatric patients) 5. Assist patient into position that is comfortable and safe for patient and you. 6. Wash hands. 7. Apply gloves. 8. Do preliminary inspection for venipuncture site. 9. Apply tourniquet 2-6 inches above proposed venipuncture site. 10. Assess tightness of tourniquet (palpate distal pulse below tourniquet). 11. Keep tourniquet on no longer than 1-2 minutes. 12. Ask adult patient to open/close fist several times and leave fist closed. 13. Inspect for prominent, straight vein without swelling or hematoma. 14. Palpate vein for rigidity, rolling, etc. 15. Decide on venipuncture site. 16. Apply alcohol to site. 17. Remove needle cover, keep needle sterile, and warn patient of "stick". 18. Hold needle at 15-30 degree angle with bevel up. 19. Slowly insert needle into vein. 20. Watch for blood return. 21. When blood returns, slowly pull back on syringe plunger to obtain desired amount of blood, keeping needle stabilized. 22. RELEASE TOURNIQUET. 23. Hold 2x2 gauze over needle insertion site and quickly pull needle out. 24. Apply pressure to site until bleeding stops. 25. Properly dispose of needle. 26. Transfer blood sample to appropriate collection containers. 27. Properly dispose of syringe and other supplies. 28. Apply appropriate patient I.D. labels to collection containers and seal in plastic bag. 29. Remove gloves and wash hands. 30. Attach proper lab requisition form to plastic bag containing blood samples. 31. Send specimens to lab. 32. Assist patient to comfortable position. 33. Recheck site for bleeding/hematoma.ep«Aÿ¯Mental Status Exam = ABC MAJIC TIPS Appearance & Attitude = dress & hygiene (paranoia, scars, visible tatoos, needle tracts, deformities), physical/emotional distress, appearance vs. Stated age (smoking, EtOH >> ^ age appearance), body habitus (thin/cacexia) attitude towards you (hostile, hypersexual), your response as well (anger, used), dark glasses in middle of night {mania} Behavior - body language, psycho-motor activity (agitation, retardation, nl), calm, eye contact,coopertivity, gait (spastic, wide-based, unsteady) compulsions Communication (speech)- propositional(verbal/auditory vs lexic graphic) vs prosodic, rate, vol, content Mood = subjective appraisel of patients emotional state “how are your spirits?” Use quotes Affect - quality (euthymic, dysphoric), intensity, range (changes=labile, blunted/flat, restricted), appropriateness , (in)congruent Judgement - stamped envelope, aware of consequences, motivated by consequences. Impaired / temp / Insight = awareness of condition (fair, good , bad) Cognition = mini-mental, designed for alzheimers not subcortical dementias like HIV. Information processing. Dependent on cooperation, IQ/Education (low education 24-26/30 nl, high 27/30 could be bad. Include ed. Record Level & what missed Thoughts -process (qnty, speed, L/L/G, LOA, FOI{mania}) tangentiality, circumstantiality, & content (phobias & obsessions, delusions (characterize - grandiose, paranoid, narcisistic, etc) Intellect - rough guess based on vocab (ave) Perceptions - illusions from sensory stim, hallulinations w/out stim (modality) {olfaltory [esp burning rubber] = temporal lobe epilepsy >> get EEG} Suicide = intent, plan, urgencygp«ÿ_Delirious = AFRAID, SPACE Atthention span shortened Fluctuations of behavior, mood, arousal Rapid Onset Autonomic changes Insomnia/Hypersomnia Disordered thoughts Sleep/Wake Disturbances Psychomotor (agitated/retarded) Autonomic Cognitive Emotional (labile) DDx + Withdrawal EtOH, Benzo (esp. alprazolam = zanax b/c short t1/2)hp« ÿ%Depressed = SIG E CAPS Sleep disturbed Interested in nothing Guilty Energy level is low Concentration poor Appetite disturbed Psychomotor Inc or Dec Suicidal Causes of Depression: Post-MI hyperthyroid hypothyroid Addison's Dis. Cushing Post-Stroke Seizures Tumors Huntinton's Parkinson's (50% have major dep.) Medicine Causes: Clonidine Hydralazine (HTN) Reserpine Guanethidine Steroids (including Prednisone, Cortisol) Propranolol Cimetidine Yohimbine (often found in herbals and will interact with SSRI's)ip«KÞOrganic Causes of Psychiatric Disease EVA HAD MITTENS Endocrive Vascular Alcohol/Drugs Hydrocephalus Autoimmune Degenerative Disease Metabolic Infections Toxins Trauma Endocrine Neoplastic Sleep Apneajp«aÿPsych Abbreviations FOI = flight of ideas LOA = looseness of associations HI/SI = homicidal ideation/suicidal i Circ/Tang = circumstantiality/tangentiality (N)SC = (Non)-service connected BP = Bipolar SZ or other variant = schizophrenia L/L/C = logical, linear, coherentnp«jÿ‹Schizophrenia = BAD HI Behavior disorganized Affective flattening Delusions Hallucination Incoherence Form = LOA, Overinclusiveness, neologisms (coining new words), blocking, clanging, echolalia, concreteness, alogia (poverty of speech quantity or content) Content = delusions of persecution, grandiosity, influence (patient control events through telepathy), reference (hidden meanings behind events directed to him), thought broadcastings (others hear his thoughts), thought insertion (thoughts placed in her mind) lack of insight - downward socioeconomic drift < 6 mos = schizophreniform < 1 mos = brief psychotic episode Types = Paranoid Disorganized Catatonic Undifferentiated Residual - minor features, maybe just withdrawn, isolated, odd Pre-psychotic personality = social withdrawal, social awkwardness, marked shyness, or possibly mild antisocial behavior.op«?µMania = GREAT SAD Grandiosity Racing thoughts Euphoria/expansive/irritable mood Activities, goal directed Talkative Sleep = dec need Activities, reckless Distractabilitypp«OÿPanic Disorder = PAnDA Panic Attackes ANticipatory Anxiety Depression (60%) Avoidance Choking Angina Tachycardia Abdominal distress (S2)weting, SOB (T2)rembling, tingling Reality Escape Out of control (F3)ear of dying,going crazy,fainting Intense within 10 Chillsqp«&wDysthymic Disorder = SAD HELP Sleep Appetite Depressed - 2 Hopelessness Energy Low esteem Poor concentrationrp«dÿEPTSD = DREAMS Distress Re-Experiencing #1 Event Avoidance #2 Month Sx of arousal #3 acute vs. Chronic (with delayed onset) keep back to wall, with plenty of guns & knives (easy admit for SI) Life Threatening Stress (exp. Or witness) malinger if inappropriate affect (true ptsd doesn't want to talk about)sp«+‰GAD = RECITES Restlessness Easily fatigued Concentration Irritability Tension (muscle) Excessive worry Sleep at least 6 mos.up«pÿ¹SOS Levels Restricted = must stay on the closed side, but have freedom within the closed side, may wear civilian clothes. SOS Level III = Patient checked on q15min, but may stay in his/her own room during free time. This is the level at which most new patients are admitted. This is labor intensive for the staff, and they appreciate the discontinuation of level as soon as it is safe. SOS Level II = Patient is in sight of a staff member at all times. Patient is req. to stay in the dayroom on the closed side. For patients w/ a strong SI/HI. SOS Level I = Staff member sits next to the patient. For acutely suicidal patients that might hurt themselves suddenly or unpredictably.vp«bÿœPsych Definitions: Akathisia - iniability to remain sitting, motor restlessness, muscular quivering apraxia = lack of making simple acts (amnestic, akinetic) constructional apraxia = inability to construct/copy designs blunted / flat affect = very little emotion, without warmth inappropriate affect = can be intense but inconsistent with thoughts or speech labile = shifts in affect over short period of time general paresis = partial or incomplete paralysis (often syphilitic in origin w/ progressive dementia, tremor, speech disturbances, muscle weakness, poss w/ delusions) Psuedobulbar phenomena = Emotional lability, Dysarthria, Dysphagiawp«)ÿPsych Hx Fam Hx - Look For Bipolar, Schizo , Depression, Suicide, Seizures, Strokes, parkinson, huntington if EtOH - legal?, dwi, a&b, are charges pending or cleared; pancreatitis, gi bleed, liver problems, head injury, withdrawal sx, DT, seizures, blackoutsyp«ÿäOdds & Ends Depakoate = platelets, lfts, pancreatitis, 250 tid » 500 bid delta thc (POT) - lipid soluble and UDS for 30 days vomiting causes hypokalemia - H/K exchange bullemia » tooth decay & need for dental consult benztropine not automatically needed with neuroleptics valproic acid therapeutil level for psych = 80-120 ; seizures = 50-100, lithium level = .6-1.2 carbamazapine = 4-12 New Patient Labs = Chem 7, CBC, TFT, LFT, UDS, Psych Tests?, RPR? zp«ÿ"Alcohol haIlulinations - tactile + more 48»-7 days use haldol to tx adrenergic hyperactivity - 24»72 hrs tonic clonic seizures - 48 - 72 hrs use short benzo - ativan need to know last drink DT - remember delerium 48-72 hrs use short benzo - ativan oxazepam TOM - up till stop in ICU{p«\ÿÌPersonality Disorders * Should appear before early adult * Typical of longterm fxn * Not exclusively during Axis I flare * Inflexible, maladaptive, persisting, sig fxn impairment Cluster A (odd or eccentric) * If occurs before first break psychosis state "Premorbid" Paranoid = distrust, suspicion, other's motives are interpreted as malevolent Schizoid = detachment from social relationships & restricted emotional expression Schizotypal = acute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behavior. Cluster B (dramatic, emotional, eratic) Antisocial = disregard for and violation of the rights of others Borderline = instability in interpersonal relationships, self-image, affects, marked impulsivity Histrionic = excessive emotionality and attention seeking Narcissistic = grandiosity, need for admiration, lack of empathy Cluster C (anxious, fearful) Avoidant = social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation Dependent = submissive and clinging behavior related to an excessive need to be taken care of Obsessive-Compulsive = preoccupation with orderliness, perfection, control ***NOS***|p«]IPharm books to use = Facts & Comparisons Drug Information Handbook }p«ÿäDefense Mechanisms High Adaptive Level anticipation affiliation altruism humor self-assertion self-observation sublimation suppression Mental Inhibitions Level displacement dissociation intellectualization isolation of affect reaction formation repression undoing Minor Image Distorting Level devaluation idealization omnipotence Disavowal Level denial projection Rationalization Major Image Distorting Level Autistic Fantasy Projective Identification Splitting of self image or other image Action Level Acting Out Apathetic Withdrawal Help-rejecting Complaining Passive Aggression Level of Defensive Dysregulation Delusional Projection Psychotic Denial Psychotic Distortionp«sÿ+TDO = Temporary Detaining Order In VA 3 Reasons 1) Suicide 2) Homicide 3) B/c of psych, can't take care of self Need Hearing within 48 hrs of weekday, 72 hrs on weekend, with Magistrate, Lawyer for patient, Independent Doc. Doc must explain necessity for commitment. Outcomes: 1) Release to d/c ASAP 2) Voluntary commitment by patient when asked by judge and patient agrees, must stay 72 hrs, then may notify staff of desire to leave, must stay 48 hrs past notification (or till re-TDO) 3) Involuntary commitment up to 180 days‚p«iÿ?Rx Anti-Depressants Tricyclics: = EKG q6mos, watch QT interval < 400 ms All are anticholinergic Dry Mouth Constipation Orthostatic Hypertension Conduction Abnormalities Blurred Vision Urinary Obstruction Delirium Nortriptyline and Desipramine are less anticholinergic Clomipramine = OCD Tx…p«9ÿ{INR = International Normalized Ratio = Patient PT/mean of PT normal range crank = methamphetamine, assoc w/ motorcycle/ gang use Glu kidney spill levels @ 3 mg/ml » 160-180 mg/dl Use Albuterol QID to dec. K+ (in hyperkalemia), also could use Kayexalate Metoclopramide can cause TD » AVOID Psyllium = bulk forming laxative, drink with H20, good for chronic diarrhea‡p«50%) Huntington's Parkinson's (lewey bodies in substantia nigra) Other (Lewey body dis {in cortex}) Treatable Vascular Normal Pressure Hydrocephalus Substance Induced Tumors Trauma - Subdural Infection Metabolic (ˆCa) Malnutrition (b12, folate) Other can be Double Dementia - multiple causation NPH = gait ataxia, incontinence, progressive dementia“p«@ÿÛMental Status, another method appearance - dishelved unkenpt intense eye contact (early sign) attitude - (cooperative) - reluctant- paranoia affect/mood - range ? Appropriate? anxiety level- activity - psychomotor ( akathesia / TD) thought process - stream of thinking (circ - tang) - dysarthria, foi loa thought content - SI/HI thought perception - hal/illusion/del. cognitive exam = AO & MMSE judgement/ insight reliable schizophrenia = DA –p«ÿClozapine = Clozaril CBC weekly for SIG Granulocytes below 1.5 = immediate STOP W/ NO RESTART Hx = 1960 in switzerland was 1° atypical, 1977 off US market, 1990 back on Adverse Fx = agranulocytosis seizures more common in 1° 6 weeks, if seizure, go down on dosage (use Valproic acid for seizures) sialorrhea = drooling » anti cholinergic SFx, dose related wt. gain, dec. GI system (slowed, constipation) long T1/2, sedation, go slow @ start, look for resolution of Sx, suppression of TD, dec. chronic H20 drinking —p«ÿ†Delirium Tremons - DT's ~72 hrs after reduced EtOH intake ~<5% hospitalized patients ~33% of Pts w/ withdrawal SZ Mortality Untreated = 15% Sx: Marked confusion, disorientation Marked Autonomic hyperactivity T > 100.5 HR > 110 HTN Dilated Pupils Vivid Hallucinations (A, V, T) Delusions Agitation MEDICAL EMERGENCY needing IV Benzo & cardiorespiratory monitor•p«8ÿãImmunizations Influenza = health care, group setting, immunosuppression, elderly @ 65 & up (yearly in sept/oct, trivalent ) beware if allergic to eggs pneumovax = same as above, 1x, 23 strains (? Booster, or ˆ valency) yeast tetanus/diptheria = every 10 yrs for all, need initial 3 shot series, dirty wound > 5 yrs give booster + antibiotic ppd (TB) = shelter, group home, prison, health care workers, IVDA, EtOH abuse every 1 yr; most looking for previous exposure & prophylaxis, not color, RAISED RING!!, then CXR if symptomatic 0.1 cc SQ forearm INH for 6 mos , check LFTs sgot (0, & monthly throughout, if risky repeat) , EtOH abuse contra, concern For rx Induced hepatitis, can cause polyneuritis (prophylaxis w/ b6) ¤p«JøObsessive - Compulsive Disorder Obsessions Compulsion -contamination - washing, cleaning -doubt - checking -aggressiveness - avoid objects of -disorder - ordering .- loes of something imp - hoarding©p«xÿoUrinary Catheterization 1. Purposes A. Monitor fluid status when urinary elimination is altered or impaired; consider whether the individual is at risk of dehydration/overhydration B. Preparation for surgery C. Irrigation of bladder D. Maintain patent urinary flow (secondary to obstruction) E. Relieve bladder distention F. Measure residual urine G. Maintain urinary continency for client with incompetent bladder H. Obtain a sterile urine specimen II. Types/Frequency A. Intermittent: - straight catheter - repeated as necessary ("in and out catheterization") B. Indwelling: - retention, "Foley", catheter - remains in place for an extended length of time III. Sizes A. Based on client's age and gender B. Based on client's medical condition C. Generally: 1. Men: 16 - 18 French 2. Women: 14 - 16 French (younger females = 12 French) 3 Children: 8 - 10 French IV. Complications/Concerns A. UTI - most common nosocomial infection B. Psychological implications C. Incontinence and inability to void post-catheterization D. Nonfunctioning balloon E. No urine (e.g., inadequate or inappropriate placement, dehydration) F. Leakage around catheter (check catheter for appropriate size) G. Dislodging - Accidental - Self - Improper placement Note:Proper catheter placement may be obtained by using the following guidelines with insertion. a. Female: Adult (2 - 3" + 2") Child (1" + 2") b. Male: Adult (7 - 9" + 2") Child (2 - 3" + 2") V. Preventive Measures A. Avoid instrumentation B. Remove as soon as possible C. Proper cleaning procedure pre/during/post catheter insertionªp«;ÿ®IV Accesses I. Purpose To provide appropriate and adequate access to the venous system in order to: - administer fluid to correct or prevent fluid and electrolyte disturbances - replace blood volume or blood components - provide nutritional support - administer medications II. Sites Peripheral - Digital - Metacarpal - Basilic - Cephalic - Antecubital Note: Lower extremity vessels are generally considered a last resort and placement of IVs in the legs, ankles and feet frequently requires a physician order. Central - IJ - EJ - SC - Femoral Note: Catheters may be single or multi-lumen; implanted; placed at the bedside or inserted in the OR III. Selecting a Vein Generally based on: - purpose of infusion - condition of veins & extrermity - duration of IV therapy - type of IV fluid or medication to be infused - medical condition, age, & size of client - one's level of experience with venipuncture IV. Selecting a Peripheral Cannula Generally: 24 Gauge (child or adult with small vessels) 20-22 Gauge (medical condition) 19-18 Gauge (surgery; blood infusion) 16 Gauge (trauma) V. Equipment for inserting peripheral IV Butterfly or Cannula Tourniquet 2 x 2s or other dressing supplies Betadine & alcohol wipes Gloves VI. Type of Aseptic Insertion Procedure Peripheral (medical and sterile technique) Central (sterile technique) VII. Maintenance Intermittent flushes NS Heparin (not used routinely at UVA) Continuous/intermittent infusions Manual Infusion pumps Site & line care (e.g., dressings, tube changes, bag changes) VIII. Discontinuation Consider whether patient: - has been heparinized - has a blood clotting disorder - has had a large vessel cannulated - has had a large bore catheter inserted IX. Complications Pain and discomfort Infiltration or phlebitis Bruising and hematoma formation Local or systemic infections Dislodging of access Clotting of cannula¨p«ÿ™CENTRAL LINES I I. TYPES OF CATHETERS A. Hickman B. Groshong C. Pice D. Port-a-Cath II. DRAWING BLOOD (Please refer to handout) GENERAL INFORMATION ABOUT CENTRAL LINE CATHETER SUPPORTIVE DATA 1 The catheters are central venous catheters designed to provide long-term vascular access for administration of intravenous therapy and for blood sampling. They may be single-lumen or multi-lumen. 2. Before the catheter is used post-operatively for the first time, a physician's progress note or order verifying correct placement and readiness for use should be on the chart. 3. The catheters are constructed of a delicate medical grade plastic. Sharp-edged instruments such as scissors and toothed clamps should never be used near the catheter. 5. When not in use, all catheters, with the exception of the Groshong, should be clamped on the clamping sleeve with the clamps provided. If the clamps are lost, a cannula clamp padded with tape or rubber tubing may be substituted. 5. Any disruption or disconnection of the catheter may result in air embolism. Symptoms of this emergency include: confusion, chest pain, dyspnea, cyanosis, tachycardia, hypotension, loss of consciousness, and sudden presence of a loud, continuous heart murmur. Emergency treatment for suspected air embolism consists of the following: a. Instruct patient to hold breath without inhaling first. b. Reclamp tubing and instruct patient to resume breathing normally. c. Place patient on left side. d. Notify physician immediately. e. Initiate resuscitation measures if necessary. 6. Catheter related sepsis or catheter site infection must be considered as a source of any fever or infection of unknown etiology in a patient who has a catheter. Notify the physician for any fever, and for tendemess/swelling/erythema/drainage at the catheter exit site or along the subcutaneous tunnel. Continued fever or signs of infection may necessitate removal of the catheter. 7. A common complication of catheters is the formation of small clots or fibrin sheaths covering the catheter tip and preventing infusion and/or withdrawal of fluid. 8. On rare occasions, a thrombus may form around the catheter or at the tip, obstructing blood flow in the vessel. Symptoms indicative of thrombosis include swelling and tenderness of the neck veins or upper extremity on the side where the catheter is placed. Anticoagulation therapy and/or removal of the catheter may be necessary. 9. Central line catheters must be removed only by a physician. Usually this is done at the bedside using local anesthesia, but in rare cases removal in the Operating Room may be necessary. 10. Sutures should be removed by a physician from Hickman and Groshong 7-14 days post-operatively. Sutures are not routinely removed in pediatric patients and neutropenic patients. PROCEDURE FOR ADULT CENTRAL LINE BLOOD DRAWING 1. Use Universal Precautions 2. The preferred sequence of filling of vacutainer tubes is: a. blood cultures b. blue top c. light green top d. lavender top e. gold top f. yellow top 3. If unexplained elevations in the PT or PTT are obtained, the tests should be repeated peripherally to establish accurate results. 4. Avoid drawing blood through a central line lumen being used for hyperalimentation. If unavoidable, flush the lumen vigorously with 20cc normal saline before drawing blood sample. 5. If difficulty is encountered when attempting to aspirate blood from the line, any of the following troubleshooting measures may be helpful: a. Have the patient cough or take slow, deep breaths. b. Reposition the patient on his/her side, or sifting up and leaning forward, or with his/her arms raised. c. Flush the catheter with 10cc normal saline. d. Request that the physician order an infusion of normal saline or other prescribed solution as a rate of 75cc per hour or greater for 6-8 hours, then repeat blood drawing attempt. ¦p«ÿ„ CENTRAL LINES II BLOOD DRAWING VACUTAINER METHOD: This method is entirely needleless and should be used unless the vacuum in the vacutainer tubes supplies insufficient negative pressure to withdraw blood. EQUIPMENT o Non-sterile latex gloves o Alcohol prep pads o Vacutainer holder with vacutainer adapter and needleless syringe cannula o Vacutainer tubes with patient labels attached o 2 - l0cc syringes filled with normal saline, with syringe cannula attached o Typenex band (if drawing type and screen) o Heparin flush 100u/mi as ordered (except for Groshong catheter) CONTENT: 1. Wash hands 2. Don gloves 3. Place all infusions running through any of the central line lumens on hold. Close clamps on all lumens except the lumen through which the blood sample will be drawn. 4. Holding the lumen to be used, swab injection cap with an alcohol pad. Repeat with another alcohol pad and allow to dry. If the lumen is put down or is contaminated in any way during the rest of the procedure, reprep with 2 alcohol pads before continuing. 5. Attach 1Occ saline filled syringe. Flush with saline and using the same syringe draw l0cc blood and discard. 6. Insert the needleless syringe cannula with vacutainer holder attached into catheter lumen. 7. Attach vacutainer tubes to obtain required blood sample. 8. Remove vacutainer apparatus from catheter lumen. 9. Flush catheter with 1Occ saline. 10.Resume all infusions or flush with 20 units of heparin if no running fluids. 11.Discard vacutainer apparatus in sharps box. SYRINGE METHOD: EQUIPMENT: · non-sterile latex gloves · alcohol prep pads · 2 - 1Occ syringes filled with normal saline, with syringe cannula attached · one empty syringe with syringe cannula attached (size of syringe determined by volume of blood required for samples) · heparin flushes (100 u