CARDIO DIAGNOSIS

I & AVL, V5, V6 Lateral Etiology :congenital, infectious, hypertensive,

II, III, AVF Inferior ischemic
ECG Anatomic: chambers, hypertrophy, dilated,
R-R : HR, 1500/small squares V1, V2 Septal
Valves, stenotic, regurgitant, Pericardium
P-R : 120 – 200 ms V3 & V4 Anterior Physiologic: arrhythmia, CHF
QRS : < 100 ms CBBB = >120ms Functional
QT : < 0.44 s ( 0.35- 0.45) IBBB = 100 to 120ms I – no limitation of activity, no sx
QTc : QT/ √R-R 1 AV = PR > 0.20 II – sl limitation, ordinary activity w/ Sx
Axis : - 30 to 110 deg 2 AV = incr/sudden drop beat III – Marked limitation, < ord act w/ sx
P wave : <3mm, width <0.11 secs sustained VT: > 30 secs IV – sx at rest
POSITIVE : I, II,aVF, V4-6 RBBB : wide QRS & predominantly positve
Biphasic: III, AVL, V1-V3 V1 , deep S in V6, rSR in V1& V2 A B C D
NEG: AVR LBBB: rsR –I, aVL, V5-V6 , wide qrs, High Structural Struc Refractory
QRS : <25mm <0.10 secs predominantly neg in V1 risk w/o Heart Heart HF
RAH = >2.4 mm amplitude P wave Ant Hemiblock – LAD, IBBB, Q1S3 struc Disease Dse requiring
Post HB – RAD, S1Q3 heart w/o sx of with sx intervention
LAH = > 120 ms P wave dse, sx CHF of HF
*DON’Ts: Normal sinus rhythm
LVH = SV1 + (RV5or V6) = > 35 of CHF
LVH by voltage (√ Inc QRS voltage)
RVH = Large R wave V1 Poor R wave progression
Px with
Ischemia – T wave inversion HPN, prev MI,
Old infarct – Q waves, 1mm wide or 1/3 R DM, LV
CO = HR x SV CAD systolic
Q wave: 1/3 (25%) ht of adj R wave and
MAP = Systolic BP + 2 Diastolic BP dysfuncti
greater than .04 secs duration 3 (n.v. 70-100 mmHg) on
Acute MI- ST elevn 1mm limb, 2 mm chest JVP: a = atrial contraction
V1, V2 – post (depression) C = isovolumetric sys, bulging tricuspid Asx
*post MI: tall R wave, ST dep upright T V = inc blood volume during systole valvular
x = atrial relaxation dse

CP CLEARANCE GOLDMAN CLASSIFICATION RECOMMENDED DIETS

√ CXR, CBC, ECG Class I 0-5 Low 1-2 % Hyperuricemic -Low purine diet
1. Rule out CAD Dyslipidemic –(TLC diet) Saturated fat<7%
2. Type of surgery Class II 6-12 Intermd 5-7% of calories, Cholesterol <200mg/day, High
3. Co-morbids soluble fiber (10-25g/day), and plant
4. Functional Capacity (mets) Class III 13-25 Intermd 16%
stanol/sterol 2 g/day
PROCEDURE STRATIFICATION Class IV > 26 High 56 % Peptic Ulcer -Bland diet
HIGH : ( risk > 5% ) : Emergency procedures,
ARF / CRF -Protein < 6mg/kg, Na 2mg/kg,
Aortic or other major vascular, Peripheral HISTORY
vascular, Prolonger surgery with large fluid shifts K 2mg/kg/d, phosphorus <800mg/kg/d
Age > 70 : 5 PTS Hepatic Enceph -high branched chain
INTERMEDIATE ( risk < 5 % ) : CEA, Head and
neck surgery, Intraperitoneal and intrathoracic,
MI in 6 mos, UA in 3 mos, chronic AF: 10 amino acid, low aromatic amino acid diet
PE
Orthopedic surgery, Prostate surgery Diarrhea -Low fiber diet, low fat diet; no
LOW (risk 1%) : cataract, arthroscopy,endoscopy, S3 gallop, JVD, decomp CHF : 11 dairy products
TURP, superficial procedures Severe AS/MS :3 Hepatitis-Regular, high calorie, high protein
ECG
DM – Total kcal (60-15-25) [50-20-30 if<
COMORBIDS Rhythm other than sinus or PAC :7
1500kcal) divided into 3 meals, 2 snacks and
LOW- HPN, AGE, CKD, DM >5 PVCS/min documented :7
MOD- arrhythmia, stable angina GEN STATUS 1 fruit exchange per meal. No simple
HIGH-VT/SVT, UA, CHF P02<60. PCO2>50, K<3.0, HCO3<20, BUN >50, sugars.
Cr>3.0, inc ALT, chronic liver, bedridden : 3 IBW = (Height in cm) – 100 (M)
FUNCTIONAL CAPACITY OPERATION
(Height in cm x 2.54) – 100 – 10% (F)
< 3 mets : washing, dressing,light house keeping Intraperitoneal, intrathoracic, aortic OR :3
3-5mets : cleaning windows, carry 15-30lbs, Emergency OR :4 Total Calories / Day = IBW (kgs) x Act
dancing, level waling 3-4 mph
Activity Level Male Female
5-7 mets : swimming, bike, walking 4.5-5mph
In bed but mobile 35 30
7-9 mets : can carry 60-90lbs,level jogging 5 mph
Light 40 35
> 9 mets : carrying loads upstairs <90lbs, quick
Moderate 45 40
climbing of stairs, heavy labor, walking uphill
Diabetic 25 25
OSTERIZED FEEDING What IV Fluid to Give
 Intubated, comatose, GCS 3 patients, Diabetic patient :PNSS, PLR (do not give

HCO3
Patients who need NGT feeding. Dextrose containing IV fluids)

28
 Same computation for the total Cardiac Patient :D5W, D5MM, D5MR
number of calories / day Bun Patients : Lactated Ringer’s
 Specify mixture concentration: Diarrhea : Lactated Ringer’s, D5MR

Ca

3
1 calorie / cc (1500 calories = 1500 ml) Hypernatremic(Na 150) :D5W or ½ PNSS
1.5 calories / cc (1500 calories = 1000 ml) Hyponatremic: PNSS, D5NSS

13

30
2 calories / cc (1500 calories = 750 ml)

5
BLOOD TRANSFUSION
√ E.g. Start OF as follows: 1600 calories (1.5 √ E.g. Use PNSS 500 cc x 20 cc/hr as side
drip
cal/cc) divided into 6 equal feedings, every

154

109

154
Always use a large bore needle / Abocath /

40

98

40
Cl
4 hours feeding (266 ml of osterized Venflon Gauge 20 (do not use gause 23 or 25 –
feeding will be given) may cause hemolysis)
•I unit – 450 cc of blood: FWB / PRBC
•I unit of PRBC – raises your hemoglobin

154

130

140

154
IV FLUID
Na

40

40
concentration by 1 mg/dl
 24 hours 40 cc/hr 1 L/day
 16 hours 60 cc/hr 1.16 L/day Pre-BT drugs:
 12 hours 80 cc/hr 2 L/day Paracetamol 500 mg IV
 10 hours 100 cc/hr 2.16 L/day Diphenhydramine 50 mg IV give 30
100
Glu

50

50

50

50
 8 hours 120 cc/hr 3 L/day minutes prior to blood transfusion
 6 hours 150 cc/hr 3.28 L/day Post BT:

D5NMK
D5NSS
IV Soln

D5MM After 3 PRBC, give Ca gluc; 6-hr CBC

D5MR
D10W

PNSS

D5LR
D5W

SIDE DRIPS LEVOPHED (NORADRENALINE): GLYCERYL TRINITRATE

Side drips (with medicines): D5W 500 cc /
100 cc or PNSS
(flow rate) ugtts/min = drip mcg x weight
F noradrenaline
F = solute mg/solvent ml x 1000mcg
60 min/hr
DOPAMINE DRIP:
D5W 250ml + 200 mg/amp
Drip: 2.5-10 mcg/kg/min
√ E.g. Start Dopamine drip: Dopamine
250mg/amp + D5W 250 ml to run at 26ml/hr
titrate by 2 to achieve SBP __
2ug/kg/min(drip mcg) : dilate renal and mesenteric
bv and sodium retention
5-10 - myocardial B1 receptor
>10 - alpha adrenergic receptor
DOBUTAMINE DRIP:
D5W 250ml + 250 mg/amp
Drip: 2.5-20 mcg/kg/min
2.5-10ug/kg/min- inotropic,
10-20 ug/kg/min- vasodilation
D5w250ml + 2 mg/2ml amp Noradrenaline (PERLINGANIT):
at 15-60 ugtts/min D5W 90ml + Perlinganit 10 mg/vial in a
Concentration: 8 mcg/ml soluset
Drip of 15-60 ugtts/min is equiv to 2-8 mcg/hr Drip of 10-50 ugtts/min is equivalent to 1-5mg/hr
Report in ng (mcg x 1000) D5W 90ml + 2 vials Perlinganit 20 mg/vial in
a soluset
NICARDIPINE DRIP: Drip of 5-25 ugtts/min is equivalent to 1-5mg/hr
*IV infusion site must be changed q12 should a
peripheral line be used HYDRALAZINE (APRESOLINE):
D5W 90 ml + 10mg Nicardipine in soluset D5W 250 ml + Apresoline 2 amps (20
10mg = x mg mg/amp) at 5-30 ugtts/min (up to 60
90 ml y cc ugtts/min)
Concentration: 0.1mg/ml Maximum daily dose: 3.5mg/kg per 24 hr
Drip of 10-50ugtts/min is equivalent to 1-5mg/hr.
Therapeutic : 3mg/hr; Max: 15 mg/hr AMIODARONE:
D5W 250 ml + Nicardipine 20 mg Loading: √ Load 150 mg Amiodarine + 100
Concentration: 0.08mg/ml mL PNSS to run for 10-15 minutes in SIVP
Drip of 15-67 ugtts/min is equivalent to 1-5mg/hr Maintenance: √10-20 mg/kg/day ( 600mg +
100 ml PNSS x 24 hours) usually for 48
ISOSORBIDE DINITRATE (ISOKET): hours, overlap with oral amiodarone
D5W 90ml + isoket10mg in soluset
Drip of 10-50ugtts is equivalent to 1-5mg/hr PENTOXYPHYLLINE:
D5W 90 ml + Isoket 20 mg in soluset (CHF) 300 mg + D5W 100 ml x 12 hours x 6 doses
Drip of 5-25ugtts is equivalent to 1-5mg/hr (dr. Ramos x 8 hours x 8 doses)
OXYGEN
FiO2 = LMP x 4 + 20 (via nasal cannula)
1 LPM : 24 FIO2
2 LPM : 28 FIO2
3 LPM: 32 FiO2
4 LPM: 36 FIO2
5 LPM: 40 FIO2 * max NC
Venturi Mask(MVM) – Start 30% Max 50%
In-line neb – >60%
*MI & Anemic px – always start O2 Hgb 7 or 8
MECHANICAL VENTILATOR
Mode : AC (Assist Control Mode ), SIMV /
IMV ,Pressure Support ,CPAP (Continuous
Positive Airway Pressure)
FiO2 (initial – 100%)
Tidal Volume = Weight (kg) x (6-8)
RR 24 (depends on actual RR of patient)
45-year-old male, Weight 70 kg
√ E.g. Intubate patient now and hook to
mechanical ventilator with the following
settings: AC Mode : FiO2 100% , TV 6-
8ml/kg , RR 24 . Request for Chest X-ray
(portable) now Request for ABGs 30
minutes post-intubation
CHF: FRAMMINGHAM CRITERIA RF: JONES CRITERIA
(1maj+2min) (2maj or 1 maj +2min and evidences)
Major: PND, Acute pulmo edema, Neck Major: Carditis, Arthritis, Sydenhams
vein distension, Cardiomegaly, Rales, Inc chorea, Erythema marginatum, Subq
venous tone, Abdominojugular reflux, S3 nodules
gallop, wt loss > 4.5/5 day tx Minor: Fever, Arthralgia, IncCRP/ESR
Minor: Dyspnea, Edema, Night cough, + Recent strep infection, elev ASO
Tachycardia, Hepatomegaly, Pleural eff,
Vital capacity reduced to 1/3 from normal CORONARY HEART DISEASE
CHD Risk Equivalent
IE: DUKE’S CRITERIA  Clinical CHD
(2maj, 1 maj+3min, 5 min)  Symptomatic carotid artery disease
Major: Positive Bld culture, (typical org x 2  Peripheral arterial disease
sites; Persistently + q12 apart, or all of 3 or ¾ with
first and last at least 1 hr apart; Single + Coxiella
 Abdominal aortic aneurysm
burnetti or phase I IgG> 1:800). Positive 2d  Diabetes
echo for oscillating intracardiac mass/ abscess/
new partial dehiscence of prosthetic valve or CHOLESTEROL TARGETS (ATPIII)
New Valvular Regurg LDL <100 Optimal
Minor: Fever, Immunologic, Vascular, 100-129 Near optimal
Echo, Predisposition or IV use, 130-159 Borderline high
Microbiologic 160-189 High
*Acute IE: get 3 sets culture first before antibiotics ≥190 Very High
(empiric); Cultures repeated until sterile; Total <200 Desirable
rechecked if recrudescent fever and at 4-6 weeks
200-239 Borderline high
of therapy to document cure
*If febrile for 7 days despite antibiotics, check for ≥ 240 High
paravalvular or extracardiac abscess.

HDL <40 M < 50 F Low ODHS STATINS

if>45%
Fluva-

20 mg
40 mg

≥ 60 High *The CURVES study: Atorvastatin was more

effective in reducing LDL and total cholesterol in
20
40
80

TG <150 Normal
patients with hypercholesterolemia, without
150-199 Borderline high increasing adverse events. No difference in
Prava-

200-499 High mortality/morbidity reduction.

OD

≥ 500 Very high *Recheck lipid levels after initiation or dose

10
20
40
80

40

change in 1–3 months, then every 6–12 months

Conversion afterwards.
20 mg if
>20%

Chole Mg% 0.02586 Mmol/l

10-20
Lova-

dinner

FIBRATES (↑HDL ↓TG) PPAR-α receptor agonists

After

TG Mg% 0.01129 Mmol/l

10
20
40
80

* CI in severe renal/liver disease, dyspepsia,

gallstones, myopathy
Major Risk Factors that modify LDL goals:
Simva-

40 mg if

Gemfibrozil (Lopid 900mg 30 mins before

ODHS
20 mg

>45%

 Cigarette smoking meals – empty stomach; Max: 1200mg in 2

10
20
40
80

 BP 140/90 or on anti HTN meds

5

divided doses preBF and preDinner)

 Low HDL chol <40 mg/dl Fenofibrate (Lofibra 200mg/cap OD w/ meals
o High HDL (negative risk factor)
40 mg if
Atorva-

>25%
10-20

 Family hx premature CHD (1st degree BODY MASS INDEX (FOR ASIANS)
OD
10
20
40
80

male <55 (<45 Harrisons), female <65 Underweight 18.5

(<55) Healthy weight (Normal) 18.5 – 22.9
Rosuva-

LDL>190
20 mg if

 Age M ≥45, F ≥ 55 Overweight 23 – 24.9

10-20

5 mg
5-10

Obese Class I 25 – 29.99

OD
20
40

Obese Class II > 30

5

10-year CHD Risk: Increased LDL +

CHD Risk equiv >20% risk LDL goal: <100 Morbidly Obese > 40
Start at
%LDL ↓

Timing

2 risk factors <10-20% <130

Pred body wt =
10-20
20-30
30-40
40-45
46-50
50-55
56-60

0-1 risk factors <10% <160

M: 40 + 5.42 (Ht in cm – 60)
F: 45.5 + 5.42 (Ht in cm – 60)
 ACUTE CORONARY SYNDROME UNSTABLE ANGINA/NSTEMI

progressive angina in
MI Acute: Hours – 7 days HIGH RISK

past 2 weeks with

likelihood of CAD
moderate or high
Healing: 7 – 28 days Early invasive: CoroAngio + CABG/PCI

LOW

New onset or
Healed: ≥ 29 days INTERMEDIATE
LOW RISK

normal
Marker Rise Peak Duration Early conservative: ± CoroAngio
CK TOT 4-8 hrs 24 hrs 48-72 (if positive stress test, recurrent ischemia)
CK-MB 3-12 24 2-3 d
STEMI

relieved with rest or SL NTG

resolved with moderate/high
Prior MI, PVD, CVD, CABG,
TROP 3-12 24 7-10

INTER (at least 1)

T wave inversions > 0.02

ST elevation ≥2 chest, ≥ limb, 2 contiguous

mV; pathologic Q waves

Rest pain >20 mins now
MYO 2 24

Rest pain <20 mins or

Reperfusion Therapy: (within 12hrs CP)

likelihood of CAD;
GOLDEN HOUR: 1st 60 minutes (<50%
Emergent ER MANAGEMENT:
mortality), Total ischemic time 120 minutes
Serial ECG, Biomarkers, Vitals, pulse ox,

Borderline
Age > 70
ASA use
Cardiac monitor, CBC, PT/PTT, Na, K, 1. Fibrinolysis (50% success rate)
BUN, Crea, AST/ALT DN time 30 min (Benefit: most 1-3hrs, with
3-6 hrs, some 12 hrs CP)
1. ASA 160-325 mg (2-4 tablets) chewed Alteplase- rTPA 15mg IV bolus then

ST changes >0.05mV; new

Pulm edema, new onset or
0.75 mg/kg IV infusion in 50cc PNSS

hypotension; brady/tachy;
and swallowed now HIGH (at least 1)
(max 50 mg) over 30 minutes, then 0.5

BBB; sustained Vtach

worse MR; S3 or new
2. Nitrates: ISDN 5 mg tab SL q 5 min x 3;

onset or worse rales;

Rest pain >30 mins
NTG 0.4mg tab SL q5 x 3; Isoket mg/kg in 50cc PNSS (max 35mg) by IV
infusion over 60 minutes

↑TropI, CKMB
/Perlinganit 15 mcg/min titrate q15min
Reteplase-rPA 10 units in 10ml sterile
ONGOING
3. Oxygen: give for O2sats<90 for first 6-12

Age >75
hrs after infarction; then reassess if N water IV bolus over 2 min q 30 x 2
maintain only for 4-6 hrs doses. Flush alternately.
4. B-Blocker: Metoprolol 50 mg tab ½ -1 Tenecteplase- TNK-tPA 0.5 mg/kg IV
bolus over 5 seconds single dose (Mix 50-

Mark
tab q 6-12hrs; (CI: HR<60, SBP<100, hypokal,

ECG
Clin
PE
Hx

PR>0.24s, rales>10cm from diaphragm, HF) mg vial in 10 mL sterile water (5 mg/mL).

5. ACE-I: Captopril 6.25 mg BID (1/4 25mg/tab) Streptokinase 1.5 M u in 100cc PNSS CONTRAINDICATIONS TO FIBRINOLYSIS
*anterior MI, prior MI, EF<40% IV infusion over 1 hour Absolute contraindications
6. Statin: Initial dose Rosu 5, Ator 10, Sim 20 Premeds (30 mins prior) for Streptokinase:  Prior intracranial hemorrhage (ICH)
7. Anticoag: UF Heparin 60 u/kg initial bolus Diphenhydramine  Known structural cerebral vascular lesion
(max 5000u) then 12 u/kg/hr infusion (max Hydrocortisone
DON’T use Streptokinase if given for past 5  Known malignant intracranial neoplasm
1000u/hr) up to 48 hrs days to 2 years!  Ischemic stroke within 3 months
*PTT 1.5-2x control  Suspected aortic dissection
√ Drip: Heparin 10,000u in 100cc PNSS 2. Percutaneous Coronary Intervention
DB time 90min  Active bleeding (excluding menses)
(=100u/cc) : __ cc/hr rate  Significant head or facial trauma w/in 3
*if with CI to fibrinolysis, sx >2-3 hrs,
Raschke Weight-Based Normogram cardiogenic shock, diagnosis in doubt mo
aPTT X ctrl bolus drip
3. Coronary Artery Bypass Graft Relative contraindications
< 35 <1.2 80u/kg +4u/kg/hr
 L main disease  History of chronic, severe, uncontrolled
35-45 1.2-1.5 40u/kg +2
 2 vessel/3vessel involving prox LAD & HTN
46-70 1.5-2.3 -
LV dysfunction  Severe hypertension on presentation
71-90 2.3-3 -2
 DM with multivessel disease & LV dys (SBP >180 mm Hg or DBP >110 mm Hg)
Stop1hr
Risks: Mortality 1-3%, Periop MI 5-10%,  Traumatic or prolonged (>10 min) CPR
> 90 >3 then
Vein graft failure in 1 yr 10-20% or major surgery less than 3 weeks
↓3u/kg/hr
Grafts:Internal mammary 90% patency in  Recent (within 2-4 wk) internal bleeding
10 years, Saphenous vein 40-50%  Noncompressible vascular punctures
Enoxaparin 1mg/kg q12 SC for 2-8 days
(Clexane 20mg/0.2ml, 40mg/0.4ml,
*At 10 years ffup, 50% late vein failure or  Pregnancy
progression of CAD  Active peptic ulcer
60mg/0.6ml) *withheld on morning of cardiac
cath procedure TIM Grade  Current use of anticoagulant (eg,
0 complete occlusion warfarin) that has produced an elevated
1 (+)penetration (-)perfusion distal international normalized ratio (INR) >1.7
CONTRAINDICATED in Acute MI: 2 (+)perfusion, flow delayed
Glucocorticoids, NSAIDs, Nifedipine or prothrombin time (PT) >15 seconds
3 full perfusion, normal flow
INDICATION FOR CORO ANGIOGRAPHY SECONDARY PREVENTION post STEMI 5. Nonpharmacologic
Angina refractory to med tx 1. ASA 80 mg OD  Smoking cessation
Markedly (+) exercise test, suggestive of L *Bare metal stent 160-320mg x 1 mo  Weight loss (BMI Target 18.5-24.9,
main or 3vessel disease Sirolimus eluting: x 3 mo Weight loss initial goal 10%
Recurrent angina or (+) stress test after MI Paclitaxel eluting: x 6 mo  Exercise (goal 30-60 minutes physical
Assess coronary artery spasm ± Clopidogrel 75 mg OD activity minimum of 3-4 days/week)
Evaluate perplexing chest pain in whom non OR Warfarin/Coumadin 1,2.5, 5mg/tab EXERCISE TESTING:
invasive tests are not diagnostic
(target 2-3 INR), maintenance 2-10 mg Submaximal 4-6 days postMI
√ Femoral artery – aorta – coronaries daily study
Complications: *In patients with AFib, at least 3-4 wks Symptom 10-14 days post MI
During: arrhythmia, asystole, MI, allergic after sinus rhythm; limited
After: hematoma, bleeding, ↓ renal fxn *Large Ant MI; LV aneurysm; Mural Maximal 3-6 weeks post MI
study
thrombus x 3-6 mos
KILLIP Class Hosp Mortality  Annual influenza vaccination
I no pulmo congestion 0-5% 2. ACE-I/ARB *monitor K  BP goals: ≤140/90; ≤130/80 if CKD/DM
II mod HF, bibasal rales 10-20%
3. Betablocker  HbA1c goal: <7%
S3 gallop, Rsided HF
Metoprolol 100 mg BID
III severe HF, rales>50%, 35-45%
Atenolol 100 mg OD COMPLICATIONS OF MI
pulmo edema
Timolol 10 mg BID Arrhythmia (Vtach, Vfib) – 1st 24 hours
IV shock 85-95%
Propranolol 80 mg TID Ventricular free wall rupture – most common
4. Statin out patient complication – 3-5 days
Activity after MI
Targets:LDL <70, Chol<200, TG<100, Ventricular aneurysm (dyskinesis) – 3-5 d
1st12 hrs: complete bed rest no BRP
Day1: upright, dangle feet over side of bed and HDL>40 Most common cause of death: Cardiogenic
sitting, if without complications *If TG 200-499, non HDL chol should be shock (Risk Factors: Age>70, SBP<120,
Day2-3: ambulating <130 or <100 Tachy>110, Brady<60, Inc time since
Day 3: ↑ ambulation (Goal 158m TID) onset of STEMI)

ESOMEPRAZOLE: METABOLIC SYNDROME Life expectance of generator related to:

PNSS 80cc + 80 mg Esomeprazole to run (any 3) Voltage output required for capture,
for 10 cc/hr Abdominal obesity >40” M >35” F Requirement for incessant or intermittent
High TG ≥150 pacing, Number of cardiac chambers paced
IBANDRONATE: Low HDL <40 M <50 F *LITHIUM batteries.
D5W 500cc + 6 mg Ibandronate to run for 1- BP ≥ 130/85 *Simple ventricular demand pacemakers
2 hours every 3-4 weeks Fasting glucose ≥ 100 mg/dl can exceed 10 years

PACEMAKERS PACING CODE

1. Temporary Pacing – Transvenous V Ventricular
insertion of electrode catheter into RV Chambers
A Atrial
apex and attached to external generator paced
D Dual
Complications: small risk for cardiac
perforation, infection at insertion site,
V Ventricular
Chamber
thromboembolism (inc risk if pacing wire left in A Atrial
in which
place >48 hours) D Dual
electrical
2. Permanent Pacing –Transvenous activity When discharge not
insertion through subclavian or cephalic sensed O dependent on sensed
vein into R atrial appendage (atrial electrical activity
pacing) and RV apex (ventricular Response O No response
pacing), leads attached to pulse to a I Inhibition of pacing fxn
generator, inserted into a subcutaneous sensed T Trigger of pacing fxn
pocket below the clavicle signal D Dual
*Epicardial lead placement if: transvenous
access cannot be obtained, chest already
open, adeq endocardial lead placement cannot
be achieved.
CLASS I Indications for PPI:
ACQUIRED AV BLOCK IN ADULTS
 3-degree and advanced 2degree AV
block at any anatomic level, with any:
o Bradycardia with symptoms (incl. HF)
presumed to be due to AV block.
o Arrhythmias and other medical conditions
that require drugs that result in symp brady
o Documented periods of asystole ≥ 3 sec or
any escape rate < 40 bpm in awake,
symptom-free patients
o After catheter ablation of the AV junction.
o Postoperative AV block that is not expected
to resolve.after cardiac surgery
o Neuromuscular diseases with AV block,
±symptoms, because there may be
unpredictable progression of AV
conduction disease
 Second-degree AV block, with
symptomatic bradycardia.
CHRONIC BI/TRIFASCICULAR BLOCK
 Intermittent third-degree AV block.
 Type II second-degree AV block
 Alternating BBB
 Sustained pause-dependent VT, ±
prolonged QT, in w/c the efficacy of
pacing is thoroughly documented
HOCM / IDIOPATHIC DCM
(Class I indications for sinus node
dysfunction or AV block as previously
described)
CARDIAC TRANSPLANTATION
 Symptomatic bradyarrhythmias/
chronotropic incompetence not expected
to resolve and other Class I indications
for permanent pacing.
CLASS I indications for implantable
cardioverter-defibrillator therapy
 Cardiac arrest due to VF or VT not due
to a transient or reversible cause.
 Spontaneous sustained VT in
association with structural heart disease.
 Syncope of undetermined origin with
clinically relevant, hemodynamically
significant sustained VT or VF induced at
electrophysiological study when drug
therapy is ineffective, not tolerated, or
not preferred.
AFTER ACUTE MI
 Persistent 2 AV block in the His-Purkinje
system with bilateral BBB or 3AV block
within or below the His-Purkinje system
after AMI
 Transient advanced (2/3 infranodal AV
block and associated BBB. If the site of
block is uncertain, an electro-
physiological study may be necessary.
 Persistent and symptomatic 2/3 AV B
SINUS NODE DYSFUNCTION
 Sinus node dysfunction with documented
symptomatic bradycardia, including
frequent sinus pauses that produce
symptoms. In some patients, bradycardia
is iatrogenic and will occur as a
consequence of essential long-term drug
therapy of a type and dose for which
there are no acceptable alternatives.
 Symptomatic chronotropic incompetence
TACHYARRYHTMIAS
None. (Ablation and/or drugs are effective
therapies for SVT, and it is unlikely that pacing
therapy will be required.)
 Nonsustained VT in patients with
coronary disease, prior MI, LV
dysfunction, and inducible VF or
sustained VT at electrophysiological
study that is not suppressible by a Class
I antiarrhythmic drug.
 Spontaneous sustained VT in patients
who do not have structural heart disease
that is not amenable to other treatments
SHIFT TRIAL (Ivabradine as rate
controller in CHF)
Ivabradine: specific inhibition of If current in
the SA node; pure heart rate lowering agent
in patients with sinus rhythm (no effect on
BP), for patients with CHF and systolic
dysfunction (NNT=20)
*Magnitude of benefit depends on initial HR
base (average 15bpm from base of 80bpm)
*Add on to px on maximal dose B blocker
*↓HR will lead to improvement in EF over
time (Tachycardia-induced CMP)
√ For HR>70: 5mg BID on day1, reassess
on D14. If HR>70, ↑dose 7.5mg BID. If
symptomatic brady or <50, ↓ 2.5mg BID
HYPERSENSITIVE CAROTID SINUS AND
NEUROCARDIOGENIC SYNCOPE
 Recurrent syncope caused by carotid
sinus stimulation; minimal carotid sinus
pressure induces ventricular asystole of
more than 3-second duration in the
absence of any medication that
depresses the sinus node or AV
conduction.
CHILDREN, ADOLESCENTS, AND PATIENTS
WITH CONGENITAL HEART DISEASE
 Advanced 2/3 AV block associated with
symptomatic bradycardia, ventricular
dysfunction, or low cardiac output.
 Sinus node dysfunction with correlation
of ssx during age-inappropriate brady
 Postoperative advanced 2/3-degree AV
block that isn’t expected to resolve or
persists at least 7 d after cardiac Sx
 Congenital 3 AV block w/ a wide QRS
escape rhythm, complex ventricular
ectopy, or ventricular dysfunction.
 Congenital 3 AV block in the infant w/ a
ventricular rate < 50-55 bpm or w/ CHD
and a ventricular rate <70
HYPERTENSIVE URGENCY
Sublingual:
Captopril (Capoten) 25 mg ½ to 1 tab SL or
PO q30 PRN
Clonidine (Catapres) 75-150 mcg tab SL or
PO q1 (max: 700mcg)
Nifedipine (Calcibloc) 5-10 mg SL or PO
(bite and swallow punctured capsule), q30
PRN, then 5-10 mg PO or SL q6-8hrs
SUPRAVENTRICULAR TACHYCARDIA
Vagal Maneuvers
Adenosine (Cardiovert) 6mg/2ml vial 3 mg
(1ml) rapid IV bolus (over 2 seconds)
*If first dose fails within 1-2 minutes, give
6mg (2ml) rapid IV bolus
*If second dose fails within 1-2 minutes,
give 12mg rapid IV bolus
CI: COPD, BA. Caution: mild hypotension
Verapamil (Isoptin) 5mg/2ml amp, 5-10 mg
IV over 2-3 minutes, wait 30 minutes
before next dose
Ffup with: Verapamil (Isoptin 40mg, 80mg
tab),40 mg PO q6, taken with food
PVCs / VENTRICULAR TACHYCARDIA DFiO2 = FiO2 (700) – actual pO2 + DpO2 PULMO
Criteria for admission and treatment of PVC: 700
Symptomatic
Desired pO2 = 140 – Age in pxs > 60 y/o BRONCHIAL ASTHMA
Organic heart dse, post MI
if px < 60 y/o = 104 – (0.43 x age ) Parameters Cont Partial uncont
Low EF ≤40%
Couplets, salvos, R on T phenomenon DFIO2: AaO2 + (PCO2 x 1.25) + DPO2 2 or
700 Daytime sxs less/ >2x/wk
Secondary etiologies: CAD, thyroid dse, wk
acidosis, alkalosis, hypercapnea, hypoxia, ≥3
Criteria for Weaning: Act limit none features
hyperkalemia, hypokalemia, digitalis any
No anxiety / diaphoresis nocturnal none of partly
excess, MVP, CMP or conn tissue disorder
Stable oxygenation O2 sat > 90 controlled
Need for 2 or
Support: NO Vasopressors, SBP >90, <180 >2x/wk in a wk
rescue less
Oxygen
Control anxiety, may use sedatives
RR < 35 bpm for 5min, <80%
HR < 140, or <20% change from baseline Lung fxn N
Diet: avoid alcohol, caffeine, coffee, softdrinks, tea pred
Correct electrolytes Asthma 1 in any
Nitrates for CAD SVT = Actual TV (15 s) none ≥ 1/yr
exacerbation wk
Therapeutics: (if other factors already corrected) RR (15s)
Pred PEFR (l/min) = (ht in cm x 5) - 400
Beta-blocker RSB = RR (min)
Lidocaine (Xepacaine 20mg/ml x 50ml vial) SVT RELIEVERS - inhaled
1-1.5 mg/kg IV, repeated after 3-5 min. <105: Extubate Salbutamol 100mcg/inh, 1-2 inh PRN
Total dose: 3 mg/kg Procaterol (Meptin AIr) 10 mcg/inh, 1-2
Amiodarone Oxygenation Ratio: puffs per dose PRN
Emergency: PaO2/FiO2 = Normal 400-500 Ipratropium bromide (Atrovent) 0.5mg/2ml
Lidocaine HCl 300 mg IM (at the deltoid ALI < 300 vial 1 vial TID-QID
muscle), repeated after 60-90 min if needed Subs Pulm Dys < 200 Ipratropium 20 mcg+ Salbutamol 120mcg
ARDS ≤ 200 (Combivent MDI) 1-2 puffs TID-QID, max12/d

RELIEVERS –oral/systemic CURB 65: Admit Patients: Confusion, Urea HIGH (ICU): S aureus, Pseudo
Salbutamol (Ventolin) 2 mg/tab, 2 tabs TID- > 7 mmol/L, RR > 30, BP </= 90/60, 65 Ceftazidime 1-2g q8 IV
QID up to 4 tabs TID-QID years old Piperacillin-Tazobactam 2.25g q6-8 IV
Terbutaline sulfate (Bricanyl) 2.5mg/tab * If 2-3 are present, admit if >3, to ICU Meropenem 500mg q8 IV
BID-TID, or 5 mg/ER tab BID, or 0.3mg/ml Cefepime 1-2g q12 IV
syrup 10-15 ml BID-TID. ANTIBIOTICS + Azithromycin IV, or Levofloxacin 500
Procaterol (Meptin) 25mcgtab BID or 50 LOW: S pneumo, H inf, M pneumo, C pneumo, M mg IV OD x 3 d then 500 mg tab PO x 4 d
mcg tab ODHS catarrhalis ± Risk for Pseudo: Ciprofloxacin 200mg IV
Amoxicillin 500mg cap TID q12 IV x 3 days then 500mg tab PO x 4 d ,
Combined RELIEVER+CONTROLLER Co-trimoxazole tab BID PO Or Amikacin 500 mg IV q12
Formoterol 4.5mcg + Budesonide 80mcg Roxithromycin 150 mg tab BID x 7 d
(Symbicort) 2 inh/day or 1 inh BID; Max:6 Clarithromycin 500 mg tab BID x 7 d ASPIRATION PNEUMONIA: inf lobe post basal
inh /day. As reliever, 1 inh PRN Azithromycin 500 mg tab OD x 3 d or 2g SD segment (supine), superior lobe posterior segment
(R decub), superior lobe inf lingular (L decub)
*[Symbicort also in 4.5+160, 9+320) Stable comorb:
CAP
Salmeterol 50 mcg + Fluticasone Co-amoxiclav 375-625 mg tab TID x 7 d
Clindamycin 300-600mg q6-8 IV
propionate 250mcg (Seretide Diskus 250) 1 Cefuroxime 250-500 mg tab BID x 7 d
Penicillin G 1-2 M units q4 IV
inhalation BID MOD: above+ enteric gram neg bacilli, anaerobic, HAP
Legionella Piper-Tazo 2.25g q 6-8 IV or Clinda IV
COMMUNITY ACQUIRED PNEUMONIA Cefuroxime 750 mg q8 IV + Tobramycin 80 mg q8 IV
MOD SEVERE Ampicillin-Sulbactam 750 mg-1.5 g q8 IV
RR>30 HR>125 T<30.>40. PaO2<60 Co-amoxiclav 600 mg -1.2 g q8 IV Switching IV to oral Antibiotics
Uncont comobid, extrapulm PCO2>50 + Azithromycin 500 mg IV OD very slow (duration: 10-14d: *abscess 4-6-8w)
sepsis, sus. aspiration, infusion to run for 45-60 minutes  WBC is normal
BP<90/60
 2 normal temp (16h apart), afebrile>24h
multilobar, pleural eff, Altered Or alone:Levofloxacin 500mg tab OD x 5-7d
 Improvement in cough and DOB, N RR
abscess, progression>50% in sens, dec  Etiol agent not high risk
a day UO  No unstable comorb; No reason for contd hosp
HOSPITAL ACQUIRED PNEUMONIA PLEURAL EFFUSION HR 100 bpm 1.5
>48h of admission, within 5 days from Light’s Criteria (Exudative classification) Immoobilization w/in 4 w 1.5
discharge, N xray on admission PF CHON/serum CHON > 0.5 Prev DVT/PE 1.5
*recent antibiotic use, new progressive infil, PF LDH/ serum LDH > 0.6 Hemoptysis 1.0
at least 2 of the ff: fever >37.8, wbc PF LDH > 2/3 of upper limit of serum LDH Malignancy 1.0
>10,000, purulent sputum *If clinically PF is transudative, measure If < 4, PE not likely.
Alb. If diff bet serum and pleural ALB >3.1 Well’s Rule + Negative D Dimer = 0.5%
RISK FACTORS FOR MDR HAP/VAP g/dL (transudative) probability of PE.
• Antimicrobial therapy in preceding 90 d *If TG > 1.2 mml/l (110mg/dl) = chylothorax
• Current hospitalization of 5 d or more *CXR: Westermark sign (oligemia),
• High frequency of antibiotic resistance
*If HCT > 50% of the peripheral blood = Hampton’s (wedge shape), Palla’s
in the community or in the specific Hemothorax (enlarged r desc pul artery), Knuckle sign
hospital unit
(Thoracentesis) >10mm fluid on lateral (abrupt tapering of vessel)
• Presence of risk factors for HCAP: *ECG: S 1 Q3 T 3
Hospitalization for 2 d or more in decubitus on affected side.
the preceding 90 d #1 Count, chem. #2 micro, #3 cytology Anticoagulation
Residence in a nursing home or (CT insertion): Empyema thoracis Clexane: 1mg/kg SC OD (prophylactic)
extended care facility  Loc. PF 1 mg/ kg SC BID (therapeutic)
Home infusion therapy (including  pH < 7.2 Heparin: 80 units/kg load, 18 u/kg/hr drip
antibiotics)
Chronic dialysis within 30 d
 + glu < 3.3mmol/L or <60mg/dl Warfarin: to overlap with heparin (3-5 days
Home wound care  + GS before effect)
Family member with multidrug-  + grossly purulent Dosing: 2.5, 5, 7.5, 10 mg
resistant pathogen SD: 1, 2.5, 5 mg
• Immunosuppressive disease and/or tx PULMONARY EMBOLISM Target INR: 2.5 (2.0-3.0)
Early-onset HAPand VAP: first 4 days of (WELL’s diagnostic criteria) Ex: Px on 2.5mg Coumadin, INR 1.8
hospitalization,better prognosis, antibiotic- Clinical SSX of DVT 3.0 2.5 mg = x = 3.47 = 3.5
sensitive; Late-onset HAP and VAP: 5 Alt Dx less likely PE 3.0 1.8 2.5
days or more, MDR, ↑M&M -- add 1mg to 2.5mg = 3.5mg

PULMONARY TUBERCULOSIS CHRONIC OBSTRUCTIVE PULMONARY NEPHRO

Cat New smear 2 4 HR DISEASE
1 +, new smear HRZE FEV`1/FVC FEV1 CrCl = (140 – AGE ) (wt) x (0.85 F)
-, w ext MILD <70% ≥ 80 % 72 x S crea (mg/dl)
parencymal MOD irreversible 50-80 %
invol, severe SEVERE 30-50 % 1 Kidney Damage w/ >/= 90
forms of VERY <30% or N or ↑ GFR GFR
extrapulm TB SEVERE >50%+Resp 2 Mild dec GFR 60-90
CAT Relapse,tx 2 5 Failure 3 Mod dec GFR 30-59
2 failure, RAD HRZES HRE *smoking cessation, O2 4 Sev dec GFR 15-29
/ 1 supplementation, volume reduction 5 Kidney failure <15
HRZE surgery
CAT New smr – 2 4 HR *Vaccination: Influenza, Pneumococcal; Acute Renal Failure
3 other than cat HRZE Rehab min 6 weeks (exercise training, Fluid Management:
1, less severe nutrition counseling, education) Normal Volume: FI = UO + 300-500 ml/d
form of TB Na intake = 2gm/day
Volume overload: Fluid intake < UO
INH 5 mkd (4-6) max daily 400mg Na intake = <2gm/day
RIF 10 mkd (8-12) 600 Furo 40-100 mg IV push
EMB 15 mkd (15-20) 1200 Volume depletion: restore with NSS
STR 15 mkd (10-15) 1000
Electrolytes:
PZN 25 mkd (20-25) 2000
Hyperhalemia
Hypocalcemia: CaCo3 or NaHCO3
*Bone, joint, meningitis, military = 9-12
Hyperuricemia: no tx unless with gout
months treatment
Avoid Mg containing antacids
 PRE RENAL POST HYPOKALEMIA 6. Na polystyrene: cation exchangein the GIT
RENAL RENAL - 1 gm binds 1mmol of K and 2 relases 2-3mmol of
FE Na <1 >1
K correction in 24hrs (meqs) Na , last for 4-6 hrs, avoid giving in post op patient
Urine Na <10 >20 = (4 – actual K) x 100 + 40 -25-50g mixed with 100ml of 20% sorbitol
(mmol/L) 2 7. DIALYSIS – for renal railure
Plasma >20 10-20 <10 30cc Oral KCl 40 meqs
BUN/Crea Durule 10 meqs HYPONATREMIA
Renal Failure <1 >1 *max: as drip peripheral line 10 meqs/hr; in *Correct NO more than 0.5-1.0mmol/hr ,
Index* central line 20 meqs/hr correct not more than 10-12mmol/l/ 24h
*RFI = U(Na) x P(Cr) Hypovolemia: Use 0.9 NaCl
U(Cr) HYPERKALEMIA
Stop BB, ACE-I, NSAID Target Na: 125-135
FENa (%) = U (Na) x P (Cr) x 100 1. Diuretics : Furosemide 40-80 mg IV stat Na deficit = TBW x wt kg x (desired-actual)
P (Na) x U (Cr) 2. Calcium gluc: dec memb excitability *Give 50% over 8 hours then in next 16 h
√10 ml 1 amp in 10% SIVP 2-5 mins if with
Chronic Renal Failure ECG changes; rpt after 10mins if no Euvolemia:
Fluid restriction improvement PNSS 1L x 10 hours + 20 meq/KCl
Acidosis: Na HCO3 grain 1 tab TID 3. Glucose-insulin High salt diet 8 gm/d
HCO3 Target: 24 umol/L 50 ml of 50%D + 10 U insulin in 2-5 mins Furosemide 20-40 mg IV OD
BP: 110-130 mmHg √Mix D50-50ml + 10u HumulinR slow IV stat
Hyperphosphatemia:CaCO3 1 tab TID Edematous, hypotonic hyponat:
then q6 x 3 doses; or 500ml of 10% Restrict water loss
PhosTarget: 4.5-6.0 mg/dl dextrose + 10units insulin over 30-60mins (if Salt restriction 2 gm/d
Anemia: EPO 50-150 u/kg sc 1-3x/wk vol overload is not a problem) Consider dieresis, Vasopressin antagonist
Hgb Target: 11-12 g/dl, 33%-36% 4. NaHCO3: shift K into cells, fastest way to
Hypertonic Hyponatremia:
dec K, reserved for severe Hyper K
√1 amp dil in 100cc D5W SIVP > 10 mins Corrected Na =: RBS - 100 x 0.016 + Actual
5.Beta agonist: c ell uptake, Onset 15-30 mins *Na increase should be 1-2 mmol/L

HYPERNATREMIA 1 g MgSO4 0.1 mmol/L; Target: 0.7-1.0 mmol ACID-BASE

Water def = (plasma Na – 140) x TBW x kg or 1.7 to 2.2 mg/dL
Bicarbonate Deficit =
140 (Body Wt in Kg ) (0.4) x (Desired – actual)
*WATER DEFICIT should be corrected at Symptomatic, Mg < 1 mg/dl ,
Day 1 : give MgSO4 6 gms in 1L IVF over 4 *give only half of computed
48-72h , 0.5 mmol/hr and no more than 12
mmol/L over 1st 24h. hrs, then 6g grams per 1L x12h x 2 doses Compensatory response
Safest route via mouth, NGT DAY 2-5 : Give (6 gms) over 24h daily Metab acid 1.2
D5W or ½ NSS *Preparations: 2.5grams (250mg/ml ) per Meta balk 0.7
10cc amp Resp acid 0.1 (Chronic 0.35)
HYPOCALCEMIA May give bolus (under cardiac monitoring): Resp alk 0.2 (Chronic 0.5)
1-2 grams MgSO4 over 15 mins
Corrected Ca (mg/dl): *COPD: chronic + acute resp acid (permissive
= measured Ca (mg/dl) + 0.8 (4 – alb g/dl) Asymptomatic Mg 1.1-1.4mg/dl, give oral hypercapnea PCO2 ≤55)
Mg, Milk of Magnesia (13-15meq/5ml), 5 ml Delta Bicarb = 5.25 + (actual – 55) x 0.1
√Ca gluc 10% soln 10 ml/amp; 1-2 amp
SIVP with cardiac monitoring then PO OD-QID Delta-Delta
incorporate 1 amp Calcium gluconate to AG:HCO3 (> HAGMA+Meta balk; = pure
present IVF HYPERMAGNESEMIA HAGMA; < HAGMA+NAGMA)
Discontinue Mg containing antacids Cl: HCO3 (> NAGMA+Meta balk; = pure
Chronic tx: CaCO3 500 mg 1 tab BID-TID
1. In px w/o CRF: Saline diuresis w/NSS at NAGMA; < NAGMA+HAGMA)
Calcitriol 0.25 mcg OD-BID (0.51.0
100-200cc/hr to promote Mg excretion
mcg/day), treat hypomagnesemia AG = Na – Cl + HCO3
2. Symp pxs w inc Mg levels
a. Calcium gluconate 10% soln: 1-2 amps RTA 1 RTA 2 RTA4
HYPOMAGNESEMIA Normal AG Yes Yes Yes
IV in 10-15mins.
inc Mg containing foods- seed, nuts, peas, acidosis
b. Furosemide 20-40mg IV q8
beans; monitor DTR , lethargy, tetany, Min. Urine pH > 5.5 < 5.5 <5.5
c.Stat hemodialysis for Mg > 9.0 mg/dl
weakness , cramps, anorexia , nausea, Potassium Low Low High
vomiting Stones Yes No No
 GASTRO ENDO ENDO
H. PYLORI TREATMENT HYPOGLYCEMIA HYPOGLYCEMIA
Bismuth subsalicylate 2 tab QID (100 – CBG) 0.4 = cc D50W (100 – CBG) 0.4 = cc D50W
Metronidazole, 250 mg QID
HYPERGLYCEMIA HYPERGLYCEMIA
Tetracyclne, 500 mg QID
(CBG – 100) / 30 = # of U of HR (CBG – 100) / 30 = # of U of HR
Ranitidine, 400 mg BID Check CBG after 1 hour Check CBG after 1 hour
Tetracycline 500mg BID
Clarithromycin/Metro, 500mg BID Insulin reqt = wt x 0.5-0.7 units/kg (2/3, 1/3) Insulin reqt = wt x 0.5-0.7 units/kg (2/3, 1/3)
Factor : 0.1-1 if N wt : 0.3-0.4 Factor : 0.1-1 if N wt : 0.3-0.4
Omeprazole, 20mg BID if malnut : 0.1-0.2 if malnut : 0.1-0.2
Clarith + Metron / Amox if obese 0.6-1 if obese 0.6-1
OBMT * IBW: ht in m2 x top normal BMI * IBW: ht in m2 x top normal BMI

CHILDS PUGH CLASSIFICATION DIABETES MELLITUS INSULIN

1 2 3 TARGETS: Short acting
HbA1c = <7% LISPRO 3-4H
Bilirubin < 2.0 2.0-3.0 >3.0
Preprandial plasma glucose = 90-130 mg/d INSULIN ASPART 3-4H
(mg%) REG INSULIN 3-6H
Post prandial plasma glu = <180 mg/dl (peak 100-
Albumin >3.5 3.0-3.5 >3.5 140mg%) Intermediate
PT 0-4 4-6 >6 *Critically ill: Blood glu shld be close to 110 NPH 10-16H
Ascites none Easily Poorly mg/dl and generally <140 mg LENTE 12-15H
controlled control BP = 130/80 mmHg Long
LDL = <100 mg/dl ULTRALENTE 18-20H
Enceph none minimal adv
TG = <150 mg/dl GLARGINE 24H
A = 5-6 100% 1 yr surv 85% 2 year surv HDL = >40 mg/dl
B = 7-9 80% 60% Usual: 2/3 of total insulin dose in am, 1/3 pm
IBW :Women: 100 lbs for first 5lb + 5lb/inch 2/3 am : 2/3 intermediate + ½ short
C ≥ 10 45% 35% Men: 106 lb for first 5 lb + 5lb/inch 1/3pm bef evening meal: ½ interm + ½ short

DIABETES MELLITUS TX : DKA *Harrisons : ORAL OHA

TARGETS: 1. IVF 2-3 L of 0.9 NSS over 1st 3 hrs ( 5- 1. Secretagoues: SU – target fasting and
HbA1c = <7% 10ml.kg/h), then 0.45% at 150-300ml/h, postprandial glucose, 2nd gen preferred
Preprandial plasma glucose = 90-130 mg/d then change to 5% glucose and 0.45% NSS
Post prandial plasma glu = <180 mg/dl (peak 100- 2. Biguanides ( Metformin) - target FBS ,
140mg%)
at 100-200ml/h when glucose reach not used in >1.5 mg/dl Crea in men, > 1.4
*Critically ill: Blood glu shld be close to 110 250mg/dl (14mmol/L) . mg/dl in women, CHF, Liver dis, severe
mg/dl and generally <140 mg 2. Regular insulin : IV 0.1u/kg or IM 0.4u/kg, hypoxia, TOXICITY : lactic acidosis
BP = 130/80 mmHg then 0.1 u/kg per hr continuous IV. ↑ if no
LDL = <100 mg/dl
3. Alpha-glucosidase: target postprandial
TG = <150 mg/dl
response by 2-4h. If K < 3.3, correct K first 4. Thiazolidinediones : CI liver dis and CHF
HDL = >40 mg/dl 3. CBG q 1 and Electrolytes Q4 x 24h Monotherapy:- FBS < 140, 2 hr PPBS < 180
IBW :Women: 100 lbs for first 5lb + 5lb/inch
Men: 106 lb for first 5 lb + 5lb/inch 4. Replace K w/ 10 meq/h if K < 5.5 , Combi therapy- FBS > 140, 2 hr PPBS > 180
40-80 meg/h if K <3.5 or if HCO3 is given. SU, + Met,/ TZD
Met, + SU / TZD
DKA HHS 5. *Glucose goal is 150-250mg/dl and +Insulin Regimens
Glucose 250-600 600-1200 acidosis resolved, insulin ↓ to 0.05-0.1 To augment B-cell function: waning b cell
mmol/L mmol/L u/kg/hr fxn increases gluconeogenesis at night
Na 125-135 135-145 6. Shift insulin to long acting or intermediate leading to inc FBS
Osmolality 300-320 330-380 acting  HS insulin + daytime SU
Ketones +++++ +/-  Gliclazide 80 TID + HN 10 u SC
7. HCO3 replacement if ph 6.9–7.0 after  GLimeperide 2 mg OD + Lantus 10u
HCO3 <15 meq Normal to
sl inc initial hydration:√ NaHCO3 50mmol/L  Single dose insulin + OHA
(meq/L) in 200ml of 0.45% saline over 1 hr;  Single dose insulin
Anion gap Inc Normal to
sl inc if ph <6.9 , √ 100mmol/L NaHCO3 in 400ml To replace B cell function
of 0.45% NSS in 2 hrs.  Split dose (2/3 and 1/3) 20 min before dinner
 Mixed split
 Basal plus
HYPERTHYROIDISM Temperature
CVS dysfunction SEPSIS
37.2- 37.7 5
Antithyroid 37.8- 38.2 10
99-109 bpm 5
PTU 50-150 mg q8: Therapeutic dose: 300- 110-119 bpm 10
38.3- 38.8 15
120-129 bpm 15
600 mg/day Max dose : 1200 mg/day 38.9 – 39.3 20
130 – 139 bpm 20 SIRS 2 or more:
39.4 – 39.9 25 Fever (> 38, < 36) RR >24 HR > 90 WBC
Methimazole 10-20 mg q8-12 hrs , Max >/= 40 30
>/= 140 25
dose: 60 mg/day <4,000 > 12,000 or 10% bands
Carbimazole 10-20 mg q 8-12 h, Max Sepsis SIRS + focus of infection
STORM TX:
dose: 60 mg/day PTU 600mg loading dose and 200mg- Severe Sepsis:
Beta blockers  SBP < 90, MAP < 70
300mg q6 PO/NGT/PR
Propranolol 10-40 mg TID-QID  < 0.5 ml/kg/hr
After PTU ,give stable iodide, KI 5 gtts q6 ,  PaO2/FiO2 = 250
Atenolol 50-100 mg OD Give Propanolol 40-60mg PO q4 / 2gm IV
Verapamil  PC < 80,000
q4, or Verapamil 40-80 mg TID  Metabolic acidosis
*Follow-up every 4-6 weeks, maintained for (AcuteAF) Digoxin 0.25 – 0.5 mg IV
18 to 24 mos
HYPOTHYROIDISM
STORM Levothyroxine Na 25, 50, 100, 150 ug tab HEMA
CHF
Mild (Pedal Edema) 5
Replacement dose: 1.5 - 2.2 ug/Kg IBW
CNS effects
Moderate (Bibasal  Middle age px, with IHD, COPD start Grading of Severity of DHF/DSS
Mild (Agitation) 10
Moderate (Delirium,
rales) 10 with 25 mcg DHF Grade 1
psychosis) 20
Severe (Pulmonary
 Elderly with IHD, 12.5-25 ug then inc by Fever accompanied by non-specific constitutional
edema) 15 signs and symptoms such as anorexia, vomiting,
Severe (Seizure,coma)30
A fib 10 25 ug/4-6wks
abdominal pain; the only hemorrhagic
Hx 10 *Dose adjustment by 12.5-25 ug about 2 manifestation is a (+) tourniquet test and/or easy
Hepatic dysfxn
>45 = thyroid storm mos after treatment. Once stable, measure bruising
Absent 0
25-44 = highly every 2-3 yrs
Moderate (Diarrhea,
suggestive
N/V, Abd pain) 10
<25 = unlikely
Severe (Jaundice) 20

DHF Grade 2 MCV (fl) = HCT/ circulating RBC

Spontaneous bleeding in addition to
manifestations of grade 1 patients usually in the MCH (pg) = Hb / circulating RBC
form of skin or other hemorrhages MCHC = Hb/Hct
(mucocutaneous), GIT
Fe Needed
DHF Grade 3 (DSS) = BW (kg) x 2.3 x (15-px hb) + 500 or 1000
Circulatory failure manifested by rapid,weak pulse
and narrowing of pulse pressure or hypotension,
ANC = WBC x (segmenters + bands)
with the presence of cold clammy skin and % Sat of Fe = Serum Fe (mg/dl) TIBC x 100
restlessness
Corrected Rt ct: % RC x (Hct/45%)
*Only if hct is abnormal
DHF Grade 4 (DSS)
Profound shock with undetectable blood pressure RI = Corrected rt ct
or pulse Maturation time
CRI <1% hypoproliferation
MICROCYTIC ANEMIAS > 2% hemolysis
IDA INFLAM THALASS MATURATION TIME HEMATOCRIT
45 1
Serum <30 < 50 N to high
35 1.5
Iron
25 2
TIBC >360 <300 N 15 2.5
Ferritin <15 30-200 50-300
hGB N N ABN 1 U prbc = inc 1 g/dl, 3 % hct
PATTERN 1 plt bag = inc 5-10k; 1 unit/10 kg
SMEAR Micro/ N/micro/ Micro/ Plt CCI: =
hypo hypo Hypo w/ post transfusion ct – pretransfusion ct x BSA
tageting #no of plt tx x 10
FFP = 1 ml = 1 IU of coag factor; 15-20ml/kg
Cryoprep= 80 IU F8,100-350mg Fibrinogen/10-15ml