Specimen types

What tube is used for:

1. whole blood – purple, lavender, pink or light blue
2. serum – tiger top, SST
3. plasma – green top

What specimen is required for the following tests:

1. metals – whole blood - lavender
2. hormones – whole blood - lavender
3. CBC – whole blood - lavender
4. hormones – serum - SST
5. ferritin – serum - SST
6. cholesterol/ TG – serum - SST
7. albumin – serum - SST
8. creatinine – serum - SST
9. DHEA – serum - SST
10. thyroid hormones – serum - SST
11. INR – plasma – green
12. hemophilia – plasma – green
13. clotting factors – plasma – green

Which of the specimens can be described as:

1. Requires centrifuge for 20 minutes. Can be frozen for further testing. Blood
is allowed to clot. – serum
2. Allows separation of clotting factors. Uses green tube. – plasma
3. Uses heparin, EDTA, sodium citrate to bind Ca and prevent clotting. – whole
blood

Tubes and Tests

What tube is used for:

1. glucose – grey (“grey goose”)
2. INR – green (plasma)
3. food sensitivities – green (plasma)
4. electrolytes – green (plasma)
5. INR – lavender
6. PT, PPT – lavender
7. minerals – royal blue
8. nutritional chemistry – royal blue
9. toxic metals – royal blue
10. lead – brown
11. ESR – black
12. septicemia – yellow
13. blood type – yellow
14. DNA testing – yellow
 15. hormones – mottled
16. LV enzymes – mottled
17. whole blood hematology – pink

What tube can be described as:

1. Contains preservatives. Must be gently inverted. Tests for glucose. – grey
2. Contains preservatives - heparin. Must be gently inverted. Tests whole
blood – green
3. Contains EDTA or sodium citrate. Must be gently inverted. Must fill tube
for accurate test or will get low blood counts, low hematocrit, erroneous
RBC morphology. – purple/ lavender/ light blue
4. No anti-coagulants. Blood is allowed to clot. Tests must be done
immediately – red
5. Tests for minerals. Contains sodium heparin or sodium EDTA. – royal blue
6. Contains heparin. Tests for lead. – brown
7. Buffered with sodium citrate. Used for a non-specific test of inflammation
(ESR) – black
8. Sterile tube for septicemia. Contains growth medium. Must be drawn first.
May contain ACD (acid citric dextrose). Used for paternity suits. – yellow
9. Must be gently inverted. Centrifuged for 15-30 minutes. Can be frozen.
Used to test for liver enzymes (AST, ALT) – SST
10. Used to test for blood type at blood banks. Contains potassium-EDTA. Used
for whole blood hematology. – pink

What is the appropriate order of tube filling?:

1. yellow – STerile – STop
2. red (no anti-coagulants) – RED
3. light blue (must be FILLED) – LIGHT blue
4. green (heparin is less likely to alter EDTA) – GREEN
5. lavender (must be FILLED) – LIGHT lavender
6. SST/ red/grey, mottled – READY (mottled red)
7. grey – GO (grey)

STop RED Light Green Light Ready Go

Needle Gages

What gage is used for:

1. Blood donations – 18gage
2. Butterfly – 23 gage
3. Parenteral – 23 gage
4. Injections – 27gage
Tourniquet

What test is done without the tourniquet in place? – Ionized calcium

What is a possible consequence of leaving the tourniquet in place too long?

1. collapsed vein
2. hemoconcentration

Blood Draw Errors

What are the causes of collapsed veins?

1. tourniquet in place too long
2. dehydration
3. chemotherapy, drug addicts and frequent blood donors
4. elderly (d/t decreased collagen)
5. low BP
6. pull syringe back too quickly (more vacuum in small vein)

Potential Problems with Blood Draws

What problem is described as:

1. Small red spots under skin. Patient has clotting problem (hemophilia,
thrombocytopenia – female in 20s to 40s). Risk of excessive bleeding. –
petechiae
2. Patient is on anticoagulants for a clotting problem (Warfarin, Coumadin,
Heparin, Aspirin). Patient may be taking Plavix after a stroke. Patient may
be taking arthritis medications. Patient may be taking any herb with
salicylates (populus, salix, filipendula, betula). – excessive bleeding
3. Patient exhibits vacancy/ seizing. Patient has hypoglycemia and has
experienced seizures in the past. – seizure
4. When needling medial aspect of arm patient’s arm contracts and patient cries
out in pain. – hit a nerve

What is the appropriate sequence when dealing with a chemotherapy patient?

1. Blood draw
2. IV
3. use a butterfly – one poke, not two

What problem is described as:

1. large molecules coagulate together in tube – hemoconcentration
2. RBCs are broken in SST – hemolysis
What are the potential causes of HEMOCONCENTRATION:
1. tube is too small
2. tourniquet left on too long (also leads to collapsed veins)
3. too much massing or tapping of vein
4. fist too tight
5. repeated probing of vein
6. history of IV therapy/ sclerosed veins or occluded veins

What are the potential causes of HEMOLYSIS:

1. needle is too small
2. needle has burrs
3. tube shaken rapidly
4. skin is wet w/ alcohol
5. too much suction
6. pushing too hard on syringe when ejecting

What test results are altered by HEMOLYSIS:

1. decreased – RBC, MCV, MCH, ferritin, RBC-Mg, K, Fe, P
2. increased – protein, NH3, lactate deHase, ammonia

Who is at risk for HEMOLYSIS:

1. anemia – hemolytic and macrocytic (test – MCV) – RBCs are larger and
more fragile
2. vitamin E deficiency – vit E is protective to RBCs when squeezing thru
capillaries – SSX: dry skin, blood work
3. phospholipid deficiency

When should you be concerned about a Latex allergy?:

1. history of exposure to latex
2. history of allergies or asthma
3. allergy to Anacardaceae family – Rhus tox
4. allergy to kiwi, banana, avocado, chestnuts – cross reactivity
5. Vaseline – b/d latex
Alterations of Blood Values

What activity/ variable results in the following alterations of blood values:

1. Increases – LV enzymes, CRP, lactic acid, cortisol, protein, albumin, amino
acids, fatty acids, coagulation factors, ALP, electrolytes. Decreases – other
electrolytes. Increases or decreases DHEA depending on intensity – exercise
2. Transient increase in WBC, albumin, fibrinogen, glucose, insulin, cholesterol.
Decrease in iron – stress
3. Decrease in DHEA – age (and over-exercise)
4. Increase in TG and chol – age
5. Decrease in melatonin, cortisol, insulin, glucose, ACTH, TSH, T4,
aldosterone, plasma renin, iron. Increase in eosinophils – afternoon
6. Increase in TG, cholesterol, HDL, LV enzymes, proteins, lipids, calcium and
iron – standing
7. Increase in cholesterol, iron, protein, potassium, calcium, lactate, phosphorus
– tourniquet on too long/ fist pumped up too much
8. Increase in TGs – patient didn’t fast

Cleaning sites
When do you use:
1. Iodine – w/ immunocompromised individuals
2. Provodone – w/ immunocompromised or immunosuppressive therapy
3. chlorhexidine – used w/ indwelling picklines or catheters – minimum 2min to
clean

Crash Carts

When do you use:

1. Dextrose, saline or Ringer’s lactate – hypovolemia
2. Hydrocortisone cream – inflammation or hives
3. xylocaine cream – pain management
4. Epipen – cardiac arrest, bronchodilation, acute allergy
5. Benadryl (IV or IM) – chronic allergy
6. Calcium glucamate – magnesium overdose
7. Magnesium chloride (IV) – hypercalcemia

What is going wrong with these drugs?:

1. Patient has heart rate of >120bpm. Increased respiration, anxiety,
palpitations, arrhythmia, dizziness, vertigo, HA, chest pain, restlessness,
HTN, nausea, insomnia, urinary retention (BPH), increased O2 demand. –
Adverse effects of epinephrine/ EPIPEN
2. Patient is experiencing dry mucosa, fatigue, angioedema, bronchial spasm
and urinary retention – Adveres effects of BENADRYL
3. Drug has crystallized when left in the fridge. – Calcium glucamate
4. Patient is suddenly experiencing laryngospasm and convulsions. –
Magnesium chloride
What do I do for this patient?:
1. Patient is SOB, urticaria, bronchoconstriction (acute allergy) – epipen
2. Patient has long-term itchy eyes around cats (chronic allergy) – Benadryl
3. Patient experiences hives, itching, swelling, difficulty breathing, tachycardia,
palpitations after a new IV drip (allergic reaction) – Epipen and Benadryl
4. Patient has tetany, cramps, shakes, tingling of tip of tongue/fingers/lips/
feet (hypercalcemia) – Magnesium chloride
5. Patient is pale, irritable, agitated, increased HR, shaky, perspiring, has a
headache, is confused, and is experiencing visual changes (hypoglycemia) –
glucose (followed by protein)
6. Patient is experiencing shaking and cramping, but is mentally alert
(hypocalcemia) – IV magnesium (common in hypoparathyroidism)

What in this IV could be causing an allergic response?:

1. B1 – thiamine
2. Mg Sulfate (use MgCl instead)
3. preservatives
4. procaine (use lidocaine instead)
5. iodine

Who should NOT get these drugs?:

1. Epipen – arrhythmia, glaucoma
2. Benadryl – glaucoma, GI ulcer, hyperthyroid, urinary obstruction
3. Benadryl – ppl on CNS depressants (alcohol), anticholinergics,
mitronizidole, chlroporpramide, other antihistamines (Claritin, Allegra)

Complications of IV Therapy

What is the process described:

1. There is a hole present in the vein and the substance is able to leak out the
other side of the vein. Redness, swelling, edema and pain result. Bleed back
flow is absent. – Infiltration
2. Substance goes thru vein and into surrounding tissue. Very painful. Toxic
substances are able to seep thru veins (chemotherapeutic agents). Burning
pain, heat, swelling, blistering, necrosis, edema of the extremities result. –
Extravasation
3. Air is sucked into lines with the fluid. Patient experiences dyspnea,
wheezing, tachypnea, coughing, cyanosis, pulmonary edema, jugular
distension, HTN, substernal pain, neurological symptoms, anxiety, confusion,
syncope, seizure, general weakness, light headedness – Air Emboli
4. Part of the angiocath comes off and stays in vein. Patient experiences intense
sudden sharp pain, rapid pulse, weak and becomes cyanotic – Catheter
emboli
5. Trauma occurs to the endothelial layer. Blood backs up and limits blood flow
and IV. There is pain, heat and swelling at the site. Occurs more often in
legs/ feet – Thrombosis
 6. Trauma occurs to the entire vein. There is presence of a pathogen – staph or
strep. The vein feels hard, there is pain, heat, swelling, redness and
streaking. The IV flow decreases. – Phlebitis

How do I prevent these things from happening?:

1. Infiltration – pick a good vein, stabilize the IV – tape well to arm
2. Extravasation – pickline, slow drip or give by push, check regularly
3. Air emboli – check all connections
4. Catheter emboli – NEVER reinsert needle thru an inplace angiocath
5. Thrombosis – don’t use feet and ankles
6. Phlebitis – properly clean site, use non-irritating solutions, rotate sites

It happened anyways… now what do I do?:

1. Infiltration – take needle OUT, apply ice (heat if >30min), elevate area
2. Extravasation – take needle OUT, apply ice (heat if >30min), elevate area,
prednisone locally to reduce inflamm’n – refer if necrosis
3. Air Emboli – leave needle IN, trendelenberg position – head down, feet up,
left lateral decubitus, oxygen, monitor vitals – call EMS
4. Catheter emboli – put on tourniquet and lower body part – call EMS
5. Thrombosis – discontinue and find new site, apply ice if swelling
6. Phlebitis – discontinue IV, apply ice (then heat >30min)

Wait, what’s happening?:

1. Patient is experiencing local swelling, redness and pain at site of IV. They
have a fever, but later they have chills. – Local infection
What should I do?
1. antibiotics
2. culture (yellow tube) for organism

What else can go wrong??:

1. Patient has smooth mm contractions and venous spasms. Caused by painful
insertion of the needle, irritation or hyperosmolar solutions or by using a
large needle in a small vein. Another cause is pushing too fast. -
Venispasm
2. Patient is experiencing edema of the face or ankles. They have jugular
venous distension and a sense of oppression on the HT and LU. They have
pitting edema and a rise in venous pressure – Circulatory overload
3. Patient has trouble breathing, HA, chest pain, arrhythmia, hypoTN, shock.
Resulted from Magnesium (vasodilates – easier to push fast) being
administered too rapidly (Ca and/or Mg). – Speed Shock
4. Patient faints. – Syncope
How do I prevent these things from happening?
1. Venispasm – massage vein before insertion
2. Circulatory overload – monitor in/outs (infusion rate, urinary volume)
3. Speed shock – smaller needles, SLOW DOWN
4. Syncope – lie down

What can I do for these people?:

1. Venispasm – treat w/ Mg, heat – warm, wet towel over vein/ above site, calm
pxt
2. Circulatory overload – slow drip, check O2 levels, elevate head, apply heat,
diuretics (monitor K)
3. Speed shock – lie down, feet above head, O2, CPR if needed, leave canula
in

Tonicity – Damn Chemistry

What tonicity is this solution?:

1. Half normal saline – hyPOtonic (<250)
2. Saline – ISOtonic (250-375)
3. D5W – ISOtonic (250-375)
4. Ringers lactate – ISOtonic (250-375)
5. D5W + saline – hyPERtonic (>375)
6. D10W – hyPERtonic (>375)
7. D20W – hyPERtonic (>375)

What makes this tonicity so special?:

1. Hypotonic – low in electrolytes – when injected causes cell damage
2. Isotonic –
3. Hypertonic – most IV therapies, potentially irritating to vein wall,
contraindicated in renal failure and CHF – high in electrolytes and may l/t
swelling

Types of Injections

What would I use this injection for?

1. Intradermal (into skin) – TB test, allergy skin test, coccidiomycosis and
aspergillosis
2. Subcutaneous (under skin) – insulin, heparin, vaccines, Iscador
3. Intramuscular – B12, HepB vaccination
What kind of injection is described?:
1. Uses a 27 gage needle, ½ to 5/8”. Injected into the forearm or back (children).
A very low angle of entrance is used. There may be local pain or anaphylaxis
(adverse effect) – Intradermal
2. Uses a 20 gage needle, ¾”. Is not to be done over skin lesions, tattoos or local
infections. Needs to be a rapid injection. Has a slower absorption –
Subcutaneous
3. Uses a 22-27 gage needle, 1.5”. Injected into posterior deltoids or gluts.
Slower absorption. Two tracks used for iron injections. – Intramuscular
4. Uses a butterfly (odd gages) or an angiocath (even gages). ¾-1” long.
Avoid feet and legs. Use tourniquet and stabilize once in place. Hematoma
is likely consequence. – Intravenous

HCL therapy

Why would I use HCL therapy?:

1. increase WBCs
2. increase RBC oxygenation
3. increase lymphocyte counts and activity
4. increase CD4, 16, 56, 8
5. CANCER – prostate, pancreas, metastatic BrCA, esophagus, ST
6. Hepatitis C

What is a side effect of HCL therapy?

1. FEVER

When is HCL contraindicated?:

1. enclosed infection – abscess (pneumonia)
2. speeds rupture of appendix
3. meningitis in children
4. dental abscesses
5. may exacerbate autoimmune disease

What tests need to be done?:

1. WBC stimulation test – look for increased lymphocytes/ leukocytes
2. treat every 2-3 weeks

What is the dose of HCL?

1. inject 2mL slowly IV
2. then 10ml – once or twice weekly – diluted w/ normal saline to concentration
of 1:1000 or 1:1500 of dilute HCL

Fat soluble vitamins

What is the solution for the following vitamins?:

1. Vitamin A – saline, water, D5W
 2. Vitamin D – saline, water, D5W
3. Vitamin E – oil or water
4. Vitamin K – saline, D5W, Ringers lactate
5. Biotin - ?

What vitamin is described?:

1. As much as 1000IU/d. Found in liver, skin and eyes. Destroyed by sunlight
and heat. Potential irritation at site. – Vitamin A
2. RDA 400IU. Deficiency results in rickets, osteomalacia, osteoporosis. Need
to monitor calcium, RBC Mg, BUN, LV enzymes with high doses. May
falsely elevate serum chol, AST, ALT – Vitamin D
3. RDA 100IU. Damaged by light. Adheres to bag when in oil base. Vision
sense and gait changes in deficiency. May falsely elevate AST and ALT –
monitor LV enzymes. Used w/ sickle cell anemia and thalassemia –
Vitamin E
4. Given IM for acute hypoprothrombinemia. Given TPN to prevent same.
Given slowly – 5-10mg/ week for an adult, 2-5mg/ week for a child.
Deficiency results in bleeding/ coagulation problems. Must monitor
prothrombin time. Risk of death from anaphylaxis – Vitamin K
5. Deficiency leads to dry grey skin and pale tongue, anemia and alopecia.
Requires manganese as a cofactor. Involved in insulin synth and release.
Low in livers of children w/ SIDS – BIOTIN

Water soluble vitamins

What is the solution for the following vitamins?:

1. B3 – saline or sterile water
2. B5 – D5W, sterile water, Ringers lactate
3. Folic acid – saline, water, D5W, incompatible w/ calcium gluconate,
minerals and ascorbic acid
4. Chromium – saline or sterile water
5. Selenium – saline or sterile water
6. Manganese – saline or sterile water
7. Boron – saline or sterile water
8. iodine – saline or sterile water

What vitamin am I describing?:

1. Beriberi is deficiency. Neurologic confusion, loss of coordination, numbness
of hands and feet, memory loss. Risk of allergic reaction when IM. – B1 –
thiamine
2. Deficiency results in fatigue, mm weakness, blurred vision, anemia, alopecia,
chelosis. Vitamin is rapidly excreted. – B2, bioflavin
3. Safe in pregnancy. May cause flush (unless use niacinamide). Deficiency
leads to dementia, death, mm weakness, loss of coordination. Must monitor
LV enzymes (AST and ALT) – B3 – niacin
4. Stabilizes other B vitamins. Can NOT be given w/in one hour of succinal
choline or 12 hours of neostigmine. Used after abdominal surgeries. Involved
in conversion of choline to acetyl choline. Deficiency leads to adrenal
fatigue, constipation, ab pain, tachycardia, insomnia. NB for cortisol prod’n
– B5 – Dexpantinol
5. Deficiency is induced by OCP, antibiotics, sulfa drugs, isoniazine,
hydralazine, penicillimine. Deficiency can lead to seizures, glossitis, anemia,
anorexia, cheliosis, joint pains, seizures, profound weakness, stomatitis.
Cofactor is Magnesium. Enhances B12 absorption and HCl production.
Safe in pregnancy. UBG is falsely elevated w/ high doses – B6 – peridoxine
6. NOT given TPN or IV because it clogs tubes. Does NOT mix with calcium
gluconate, minerals or ascorbic acid. Absorption is blocked by sulfasalizine
and methotrexate. Deficiency results in numbness/ wkness of extremities,
restless leg and paronoia. Megaloblastic anemia on labs – FOLIC ACID
7. Used for shingles, fibromyalgia. Deficiency results in pernicious anemia,
numbness in feet, tremor, dementia, glossitis – B12
8. Sourced from corn, beet, tapioca. Treats scurvy. Involved in collagen
production – severe burns. May falsely elevate glucose in the urine of
diabetics. Influences coumadin in the blood. Deficiency results in defects in
hydroxylase enzymes. Crosses placenta. Need G6PD test before therapy.
Side effects may include KI stones, flushing, SC crisis, diarrhea,
macrocytic (B12/folate) anemia – VIT C
9. Used to treat hypokalemia, Mg intoxification, can irritate veins if pushed too
quickly. Cautioned with sarcoidosis, renal calculi, ventral fibrillation.
Crosses placenta. NB in blood coagulation, mm contraction, bone form’n.
Needs P and Mg for metabolism. Need to test serum calcium. Fe levels
may be altered. Plasma hydrocortisol levels may be transiently elevated.
Deficiency results in rickets, tooth decay, depression, brittle nails, delusions.
– CALCIUM
10. Crosses placenta. Toxic in high doses. Deficiency results in microcytic
anemia, hypochronic anemia – pale, palpitations, decreased cap refill,
fatigue, confusion, dysphagia, glossitis, brittle nails, depression, vertigo,
spoon nails, increased pulse rate. Oral preferred – IV ONLY if oral not
tolerated. Caution in hepatitits, alcoholics, severe LV impairment.
Absorption is affected by Ca, Cu, Zn, Mn (Cu and Zn compete). CI in non-
Fe deficient anemia, hemochromatosis, thalassemia, SCA, ALS, MS. –
IRON
11. Used for hypomagnesium seizures. Deficiency results in mm cramps, sinus
arrhythmia, tachycardia, constipation, hypothermia, insomnia,
dysmenorrhea. Crosses placenta. Needs B6 as cofactor. CI in heart block
and active labour. May result in a flush, hypoglycemia, bradycardia,
decreased HR. – MAGNESIUM
12. Deficiency leads to night blindness, poor wound healing, acne, anorexia
nervosa, alopecia, white spots on nails, poor memory. Concentrated in testes
and adrenals. Depleted by OCP. Competes w/ Fe, Cu. – ZINC
 13. Toxicity leads to Wilson’s disease – brown ring around iris. Deficiency leads
to kinky hair, fragile bones, hypochromic macrocytic anemia, alopecia,
hypercholesterolemia. Test for serum copper – COPPER
14. Enhances insulin sensitivity and increases insulin half life. Stored in
pancreas, brain, mm, KI, Sp, testes, LU. Ability to absorb decreases w/ age. –
CHROMIUM
15. NB in viral infections, skin cancer, cataracts, male sterility, asthma. Found
in serpentine soils – SELENIUM
16. Found with ammonia. Deficiency results in a difficulty in breaking down
sulfates. May develop asthmatic reaction, tachycardic HA, disorientation.
Deficiency involved in esophageal cancer. Found in volcanic soils.
Encourages excretion of Cu (Zn and Fe). Involved in xanthine oxidase and
aldehyde rxns. NB in alcohol metabolism. Decrease in dental caries. –
MOLYBDENUM
17. Role in bone health. Too MUCH leads to bone fracture. Role in glucose
metabolism, bones, teeth. – STRONTIUM
18. NB in ligaments, bones, glucose tolerance. Excreted by bile. Toxicity
mimics PARKINSONS. Mn and Zn may lower Fe abs’n. NB for tinnitus
and poor memory - MANGANESE
19. Controversial w/ BrCA (potential caution). Toxicity – NV, diarrhea,
dermatitis, lethargy. NB in plant fruiting. – BORON
20. Increases insulin sensitivity. Stored in LV, KI, SP, bone, testes. NB in
thyroid metabolism and RBC formation. High doses inhibit cholesterol
synthesis. Can increase BP in animals. – VANADIUM
21. Narrow therapeutic range. NEVER pushed. Always in a drip. Rapid onset.
Excreted by KI. Deficiency – mm cramping, U wave on ECG, polyurea,
polydypsia. Excess – fatigue, wkness, confusion w/ dyspnea, T wave,
depressed ST segment, prolonged QT interval, widened QRS, loss of P
wave, cardiac arrest  death. Hypercholesterolemia with deficiency.
May play a role in hyperhydrosis – POTASSIUM.
22. Deficiency or excess  GOITER. Deficiency – wt gain, decreased plantar
reflex, cold, dry skin/ hair, arrhythmia, infertility. Excess – heat intolerance.
NB for oxygen use and protein metab. Risk of anaphylaxis. S/E – acne -
IODINE

What vitamin should I use?:

1. Osteoporosis – Vit D
2. Vision problems – Vit E
3. Sickle cell anemia – Vit E
4. Thalassemia – Vit E
5. hypoprothrombinemia – Vit K
6. SIDS – Biotin
7. Diabetes – Biotin, zinc, chromium (600-1000mcg/d), vanadium
8. Alcoholic detox – B1- thiamine, molybdenum
9. Chelosis – B2, B5
10. Adrenal fatigue – B5
 11. Seizures – B6
12. Joint pains – B6
13. Megaloblastic anemia – Folic acid
14. Restless leg – folic acid
15. Shingles – B12
16. Fibromyalgia – B12
17. Severe burns – Vit C
18. Scurvy – Vit C
19. Osseous lesions – Vit D, Vit C
20. Chronic illnesses/ infections – Vit C
21. Cancer – Vit C
22. Skin cancer – Selenium
23. Esophageal cancer – Molybdenum
24. tinnitus – manganese
25. hyperhidrosis – potassium
26. hypercholesterolemia – potassium, vanadium
27. goiter - iodine

Which vitamins are unstable/ degraded by light?:

1. Vitamin A
2. Vitamin E
3. Vitamin B1 – Thiamine
4. Vitamin B2 – Riboflavin
5. Vitamin C

Which vitamins cross placenta?:

1. Calcium
2. Iron
3. Molybdenum

What kind of B12 should I use?

1. cyanocobalamine – used by hospitals – micturated out quickly
2. hydroxycobalamine – used by Dr.S – safer, longer shelf life – more
absorbable – labour’s disease (men who smoke)
3. methylcobalamine – best for neurologic diseases – MS, parkinsons, ALS,
circadian disorders, demyelination disorders

When should I use Sodium BiCarb?

1. metabolic acidosis
2. cardiopulmonary resuscitation
3. ASPIRIN OD

What happens when I use too much Sodium BiCarb?

1. metabolic alkalosis – decreased resp rate, edema, water retention, mm tetany
OZONE Therapy

What were the historical uses?:

1. gangrene in WWI
2. dental abscesses
3. bacterial, fungal and viral infections
4. hemostasis
5. disinfectant
6. burns
7. herpes zoster
8. water treatment after typhoid outbreaks
9. gout

What is the mechanism of action/ effects of Ozone?:

1. O3  H2O2  O2 + H2O
2. increases GSSH  GSH – quench free radicals from H2O2 prod’n
3. GSH requires Selenium
4. increases SOD and G6PD  cell lysis
5. increases respiratory burst
6. increases activity of neutrophils
7. increases cytokines (immunostim) – TNF, IL2, IL6, IL8, GM-CSF, NF KB
8. mixed data w/ platelets – increased PDGF (sometimes benefits shown)
9. euphoria results 1-4d after treatment
10. decreases uric acid and ascorbic acid – good for gout

When should you NOT use Ozone?

1. asthmatics
2. caution w/ AI, HIV, systemic inflammation – d/t increased NF KB
3. bad veins – NEED good veins – 18-19 gage needle
4. IM – painful!
5. inflammatory processes, porporias
6. SCA, thalassemia
7. appendicitis (chance of rupture)
8. idiopathic thrombocytopenia
9. hypersensitivity

What is the dose of Ozone?:

1. up to 40mcg/ml - if you go >100mcg/ml  lysis of RBCs

How do you administer Ozone?:

1. rectal insufflation – proctitis, Crohn’s, hepatitis, severe diarrhea (HIV+), GI
tumours (40mcg/ml – 100-700mls)
2. nasal/ oral cavity – sinus infections (3-5mcg/ml over 2-5 minutes)
3. vaginally – infection and cervical dysplasia
4. bladder – infection and CA
5. local – infections (dental abscesses)
What do WE use Ozone for?
1. gout
2. infections
3. cancers
4. hepatitis
5. viruses, bacteria
6. abscesses
7. polio
8. to increase O2 saturation in LU CA and smokers
9. thrombophlebitis
10. OK w/ pregnancy, anti-coagulants, normal mens’n

What is the procedure for Ozone administration?

1. 19 gage 1” needle
2. draw blood into glass container – add heparin to prevent clotting
3. gently stir
4. inject O3 into container
5. gently stir – turns PINK
6. put blood back in – need air inlet device, need filtration device to get clots
out
7. takes 35-40 minutes
8. use big needle so RBCs don’t break
9. ***similar to HCl – just use HCl – cheaper!

Hydrogen Peroxide (H2O2) Treatment

What are the historical uses?:

1. scarlet fever
2. diphtheria
3. pneumonia
4. cancer
5. acute and chronic disease
6. bactericidal
7. virucidal
8. fungicidal

What makes Hydrogen Peroxide so special?:

1. free radical
2. half life of 7/10 of a second!
3. IV – 3% - unstable – b/d to O2 and water
4. need to use glass and special tubing

When DON’T you use Hydrogen Peroxide?:

1. pregnancy
2. granulomatous disease or conditions
3. weak membranes – thalassemia, SCA
Side effects of Hydrogen Peroxide?:
1. if given rapidly – difficult breathing, chest discomfort, local irritant
2. Herxheimer reaction – d/t cell lysis  healing crisis

What is the procedure for administration of Hydrogen Peroxide?:

1. 25 gage 3/4” needle
2. glass container with D5W + Mg + Mn + B12 + B100 + H2O2
3. NO vitamin C added – would quench H2O2!
4. need air filter to draw glass into tubing
5. takes 1-2 hours
6. angiocath and needle are BIOHAZARD

UVC Therapy

What is the difference between the different UV rays?:

1. UVA – sun and tanning beds
2. UVB – burn
3. UVC – deadly

What are historical uses of UVC?:

1. botulism
2. ricin
3. rattlesnake, scorpion venoms
4. jaundice
5. cancer
6. septicemia w/ fever
7. peritonitis w/ fever
8. infections – strep, bacillis – viral/ bacterial
9. asthma
10. paralytic ileus

What happens to our bodies when we use UVC?:

1. improvement in RBCs
2. lowers fibrin
3. lowers blood viscosity
4. increases glucose tolerance
5. changes in cholesterol
6. modulates immune system

When shouldn’t you use UVC?:

1. with sulfa drugs – interferes w/ structural change that occurs w/ UVC
2. AI (very cautious)
3. pregnancy
4. blood dyscrazias
5. infections that are well contained (i.e. appendix before it bursts)
What is the procedure of UVC administration?:
1. Line inserted into vein
2. Blood drawn through machine w/ syringe
3. Irradiated for 10 seconds – done several times
4. blood looks green when goes over screen
5. 18 gage needle

COLCHICINE Therapy

What is the historic use of Colchicine?

1. gout
2. inflammatory processes

What is the mechanism of action of Colchicine?:

1. binds tubulin
2. inhibits microtubulin growth
3. blocks mitosis – CI pregnancy
4. inhibits some functions on PMNs
5. interferes w/ transcellular mvmt of collagen
6. reduces activity of hepatic collagen – causes fibrosis
7. active constituent – alkaloid – nitrogen based – white/ yellow in colour

What conditions are treated with Colchicine?:

1. Behcets disease – multisystem, chronic, relaxing vasculitis – any or all organs
– oral ulceration – affects GIT – reduces symptomology
2. Peronies disease – scar tissue – reduces pain, improves erectile fxn, reduces
formation of plaque/ scar tissue
3. Familial Mediterranean Fever – painful febrile attacks, joint pain, chest
pain, skin eruptions, amyloidosis – 1mg 1x/week for 2 weeks
4. Schnitzler Disease – chronic urticarial eruption w/ monoclonal IgM,
gamopathy, intermittent fever, joint pain, osteosclerosis, lymphadenopathy,
enlarged LV, SP, elevation of ESR
5. Psoriatic arthritis
6. Acute pseudogout
7. Acute hepatic porphoryias – reduces pain and takes pxt out of acute crisis
8. LV cirrhosis, scleroderma, necrotizing vasculitis, Pagets dz of bone, ITP

When should you NOT use Colchicine therapy?:

1. epilepsy
2. acute brain injury/ trauma
3. disruption of BBB – can develop tonic-clonic seizures – txt: diazepam
4. pregnancy
5. creatinine clearance – compromised KI function
6. hepatic and renal disease

What is the dose of Colchicine? 1-4mg Toxic dose? >4-6mg

What are the side effects of Colchicine?:
1. nausea and diarrhea
2. can extravasate if moves out of vein – causes painful burn
3. very inflammatory once moves out of vein
What are the toxic symptoms of Colchicine?:
1. thrombocytopenia
2. leucopenia
3. pancytopenia
4. agranulocytosis
5. aplastic anemia
6. renal failure
7. DIC
8. BM suppression (inhibiting mitosis)

What is the technique of administering Colchicine?:

1. 2 syringe technique – 1 has colchicine diluted w/ sterile water
2. second syringe has Mg, hydrocobalamine, sterile water
3. establish a butterfly
4. push ½ of Mg/B12 solution
5. transfer syringes – push colchicines – then switch and flush w/ Mg/B12
6. takes about 20minutes

CHELATION Therapy

What are the historic uses of EDTA?:

1. KI stones
2. Lead in auto battery factory workers
3. CAD, angina, plaques in coronary arteries, atherosclerosis
4. digitalis toxicity
5. reduce trace minerals
6. cancer
7. prevent rancidity of foods in tins

What is the protocol for EDTA use?:

1. sterile water/ D5W or NaCl is carrier – 3g for average adult (1g conventional
txt)
2. assess KI function w/ creatinine – CI if low (EDTA excreted in urine)
3. 2mg MgCl + 10-15g ascorbic acid + nabicarb + Bcomp + dexopanthothine
4. heparin may be useful
5. slow drip – 2.5-3 hours
6. need 500mL sterile water – make it isotonic – needs to be in 300ml/osmol
range
7. combined w/w/out dimercaprol
8. need to supplement w/ ZINC
What are side effects/ adverse effects of using EDTA?:
1. hypoglycemia, fatigue (sedative effects of Mg)
2. hypocalcemia
3. cardiac arrhythmias
4. N/V/D
5. fever
6. HA
7. urinary urgency
8. renal damage

What does EDTA chelate?:

1. lead
2. calcium, mercury, cadmium, aluminum (not great for aluminum)
3. (most cholesterol is calcium – effect on CV disease)
4. Co, Zn, Mn, Ca, Mg – essential nutrients

What does EDTA do?:

1. regulate NF KB – increases inflammation (leads to CA)
2. reduces hypercoagulability
3. 3 weeks – increases osteoclastic activity – subsequent 120 days – osteoblastic
activity increases
4. excreted in urine – half life of 30-60 minutes

DPTA
What does DPTA chelate?
1. Pu, Am, Fe, Zn, Cu

What makes DPTA special?:

1. need to supplement with ZINC
2. need lower doses than EDTA – SEs occur at lower doses

LIHOPO

What does LIHOPO chelate?

1. primarily Pu (plutonium) and Am (americium) – accident at chemical plant
2. also chelates iron

BAL

What does BAL chelate?

1. ARSENIC
2. Pb, Sb, Hg, Au(I)

What makes BAL special?:

1. excreted in urine and feces
2. metabolized to disulfides
When should you NOT use BAL?:
1. Caution w/ G6PD deficiency – fragile RBCs

What are the adverse effects of BAL?:

1. HTN, tachycardia
2. revolting odor  nausea
3. pain at site of administration
4. V
5. burning sensation of mouth, throat, eyes
6. lacrimation, hypersalivation

How do you know you’re dealing w/ Arsenic poisoning?:

1. delusions
2. restlessness, irritability
3. sleep disturbances
4. burning pains

DMSA/ Succimer

What does DMSA chelate?:

1. MERCURY
2. Pb, As, Hg, Sb, Bi, Au (I)

What makes DMSA special?:

1. given orally – T1/2 of 2hrs
2. primarily excreted in urine
3. stool and urine will smell like ROTTEN EGGS (sulfur)
4. Dose – 500mg TID – treat for 2-3 days then off for 2 weeks
5. crosses BBB

When don’t you give DMSA?:

1. G6PD deficiency

What are the adverse effects of DMSA?:

1. N/V/D/ gastroenteritis
2. skin rash
3. elevated LFTs
4. allergic response to sulfur

DMPS/ Dimaval

What does DMPS chelate?

1. mercury
2. Pb, As, Bi, Sb, Au
3. Essential ions – Cu, Fe
What makes DMPS special?:
1. similar adverse effects to DMSA
2. challenge – administer w/ saline
3. give w/ Vit C to enhance effects – collect urine for 24 hours

Deforoxamine

What does Deferoxamine chelate?:

1. IRON
2. Also: Al, Ga
3. used for phlebotomoy and lactoferrin

What makes Deferoxamine special?:

1. excreted in urine and bile

What are the adverse effects of Deferoxamine?:

1. allergic reaction
2. ocular toxicity – LT use
3. blurred vision
4. abdominal discomfort
5. leg cramps
6. tachycardia
7. hearing loss

Deferiprone
What does Deferiprone chelate?:
1. IRON – used in Thalassemia pxts
2. Al, Ga

What are adverse effects of Deferiprone?:

1. N
2. skin rash
3. monitor LV enzymes (ALT, AST, GGT)
4. agranulcytosis
5. arthralgia
6. ANA

D-Penicillamine
What does D-Penicillamine chelate?:
1. COPPER, Pb

What are adverse effects of D-Penicillamine?:

1. cutaneous lesions
2. acute sensitivity, GI upset
3. hypoguesia – loss of taste
What makes D-Penicillamine special?:
1. metabolized to disulfides
2. supplement w/ ZINC

Ditiocarb Sodium

What does Ditiocarb Sodium chelate?:

1. CADMIUM – UB, breast, prostate and endometrical CA
2. Zn

What makes Ditiocarb special?:

1. Cd is estrogenic
2. excreted in bile and urine
3. metabolized to disulphides
4. decreases zinc

What are the adverse effects of Ditiocarb Sodium?:

1. myelosuppressive
2. ulcerogenic in ST

Chelating Agents Toxic Ions excreted Essential Ions excreted

Deteroxamine Al, Ga Fe, Zn, Cu
D-Penicillamine Pb Cu, Zn
DMSA Pb, As, Hg, Au Cu
DMPS Pb, As, Hg, Au Cu
Deferiprone Al, Ga Fe, Zn, Cu
EDTA Pb Fe, Zn, Cu, Mn
DPTA Pu, Am Fe, Zn, Cu, Mn
BAL Pb, As, Hg, Au Cu
TRIEN Cu, Zn, Mn
DDTC Cd Cu, Zn, Mn