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HyperKalemia:

  1. DC all K+ and all drugs increasing K+
  2. STAT repeat K+
  3. 1 amp D50 + 10units IV insulin
  4. Albuterol 10mg nebulized over 20min (4 vials)
  5. 1 amp HCO3
  6. +/- 1 amp CaCl or Ca-Cluconate
  7. Kayexelate (If gut working) 15-60 grams PO or 30-50 grams retention enema, repeat q6hrs
  8. Hemodialysis if renal patient

HypoKalemia:

  • Each 20-30meq K+ will raise K+ by 0.1meq/L
  • IV rate not to exceed 10meq per hour
  • Try to correct Kto the low end of scale; (shoot for 3.7)
  • Do not give more than 60meq before rechecking

HypoMagnesemia:

  • 1-2 grams Magnesium Sulfate IVBP over 1-2 hrs

HypoCalcemia:

  • 1-2 grams CaCl or CaGluconate IVBP over 1-2 hrs

HypoPhosphatemia:

  • Neutra-PHos-K: 1 packet PO
  • Na-/K-Phos IV over 6 hrs (4.4mEq Na or K in 3mmol)

PO4:    1.6-2.1 mg/dL     give      0.15mmol/kg

            1.2-1.5         0.3

            0.8-1.1         0.45

            <0.8            0.6

Hiccups:

  • Thorazine 10mg IM q6-8 hrs prn

Antiemetic:

  • Zofran 4mg IV/PO q6hrs prn - check last EKG for QTc
  • Reglan 10mg PO qac /TID (5mg in elderly)
  • Phenergan 12.5-25mg PO/IV/IM q6 hrs prn
  • Compazine 5-10mg PO/IV/IM q6-8 hrs prn

Diarrhea:

  • Imodium 4mg PO, then 2mg PO after each loose stool thereafter, -Max 16mg/day

Laxatives:

  • Colace 100mg PO BID/QID prn
  • MOM 5-15 ml PO q6hrs prn
  • Tap Water Enema
  • Soap Suds Enema
  • Mag Citrate ½ to 1 bottle (Strong)
  • Glycerine Suppository
  • Dulcolax Suppository 5-10mg PO/PR QD (Strong)
  • Reglan 10mg PO qac /TID (5mg in elderly)

Indigestion:

  • Maalox Plus 10-20cc PO q4-6 hrs prn
  • Tums Extra Strength 1-2 tabs PO q4 hrs prn

Sleepers:

  • Melatonin 3mg PO QHS
  • Ambien 5-10mg PO qhs prn
  • Restoril 15-30mg PO qhs prn (Caution in elderly)
  • Benadryl 25-50mg PO qhs prn (Don’t use in BPH)
  • quetiapine 25mg PO qhs prn (check QTc)

EtOH:

  • Thiamine 100mg PO/IV + Folate 1mg PO/IV
  • MVI PO/IV, IVF: D5 after thiamine given
  • Ativan or Phenobarb (Never both)

DKA

  • Fluids:
    • Give 2 liters of NS over the first 2 hours
    • Then give ½NS at 200250ml/hr
    • when BS ~200250 change IVF to D5½NS
  • Insulin gtt:
    • Intital bolus 0.1 units/kg IV
    • IV rate 0.1 units/kg IV
  • If pt going to the floor, use the following parameters:
    • Decrease rate by 1 unit if BS decreases by 100
    • Decrease rate by 2 units if BS decreases by 200
    • Increase rate by 1 unit if BS decreases by 100
    • Increase rate by 2 units if BS decreases by 200
  • Accucheck q1hr
  • KCL Replacement:
    • Pts. Will require between 37meq KCL/kg during their treatment
  • DC Insulin gtt when serum ketones are clear

Blood Transfusions:

  • Always check Iron studies before blood transfusions!

Iron Studies:

  • TIBC, Ferritin, Serum Iron, % Iron Saturation

Cocaine Induced HTN:

  • Do not use Beta Blockers!!!
  • Clonidine 0.1mg PO q1hr (Max 0.6mg/day)
  • Hadralazine 10-20mg IV q4-6hrs
  • Vasotec 1.25-2.5mg IV q6hrs

Seizures:

  • If pt. not actively having seizures hold off on meds
    • Cannot get good results on EEG if pt is on meds
  • If pt. is actively having seizures:
  • Ativan
    • 2-4mg q5min while patient is having a seizure
  • Dilantin:
    • Loading dose: 15-25mg/kg (~1 to 1.5g)
    • Maintenance dose: 300mg/day TID
    • Check levels for toxicity
    • Look for ataxia and nystagmus

Status Epilepticus:

  • Phenobarbital:
    • Loading dose 300-800mg IV
    • 120-240mg q20min thereafter (Max total dose 2g)
    • Maintenance dose 50-100mg BID/TID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Anxiety:

  • Ativan 0.5-2mg IV/IM/PO q4-6 hrs prn
  • Valium 2-10mg PO BID/QID prn
  • Xanax 0.25-1mg PO BID/QID prn

Agitation

  • Haldol 1-5mg PO/IM/IV q4-8 hrs prn
  • Ativan 1-2mg PO/IV q2-6 hrs prn

Chest Pain:

  1. VS, O2 sat, O2 if needed
  2. STAT EKG, STAT PCXR
  3. Lytes, Cardiac Enxymes +/- ABG
  4. Chew 4 baby ASA
  5. NTG 0.4mg SL q5min x3
    1. NTG gtt if pain doesn’t resolve, titrate gtt for pain
  6. MI: Heparin wt-based protocol (Level 1 or 2)
      1. Level 1 with GIIIa/IIb
      2. Level 2 w/o GIIIa/IIb
    1. Loperssor 5mg IV q5min x3, then q6hrs
      1. Hold for HR<50 or SBP<100
    2. Coreg 3.125-6.25mg PO q6hrs
      1. Hold for HR<50 or SBP<100
      2. Use in patients with EF < 40%
    3. Morphine 1-2mg q2-4 hrs prn pain

SOB:

  1. O2 sat, give O2
  2. STAT ABG and PCXR
  3. Meds:
    1. DuoNeb 2.5mg-0.5mg/3ml INH q4-6hr
    2. Xopenex 0.63-1.25mg aerosol if pt. tachy
    3. Lasix for CHR (40-80mg IV)
  4. BiPAP 15/5
  5. Intubation if needed - call ICU

Low UOP:

  1. Flush foley or do straight cath
  2. Bolus IVF (if pt has good heart) 500-1000cc NS
  3. Lasix 20-80mg IV - call senior first
  4. Renal Dopamine (2-3mg/kg/hr)?

ET Tube:

  • Placement should be 3-5cm above the carina.  Always get CXR after intubation

NG Tube:

  • CXR for placement.  Make sure the NG tube is below the diaphragm.  Make sure the feeding tube is not in bronchus!

Pronouncing Death:

  • (Have Pastoral Care present for pt. & fam.)
  • No spontaneous breathing, no HR, no pulse via Doppler, no response to painful stimuli, pupils fixed and dilated.  Record findings in chart as well as time of death.  Notify attending and family.  Have the family leave the room while pronouncing.

Code Status:

  • Full Code:
    • Anything and everything.  Know your ACLS
  • DNR
    • Continue all treatment, but in the event of cardiac arrest do not perform chest compressions or cardiac defibrillation
  • DNR-DNI (Not Intubation)
    • Same as DNR, but do not intubate
  • DNR-CC
    • Comfort care only
  • Always document any conversation you have with family or the patient regarding code status.  If you don’t document it other physicians may not know what you have done.

Oxygen:

  • For each liter you add it raises FiO2 by 3%
  • Nasal Canula:
    • Max 6 Liters/min = Max FiO2 of 40%
  • Non-Rebreather Mask
    • Max 10 Liters/min = Max FiO2 of 60%
  • Non-Rebreather Mask with Reservoir
    • Max 15 Liters/min = Max FiO2 of 80%

BiPAP

  • Non-invasive mechanical ventilation
  • Initial settings of 15/5 usually works well

PE:

  • High intensity weight based heparin

Cough:

  • (Sugar-free) Guaifenesin 100mg/5ml
  • Guaifenesin + dextromethorphan 100mg-10mg/5ml
    • 10-20ml q4hrs

Hypotension:

  1. Fluids!!!
    1. If pt is on a vent give 1 liter @ a time
    2. If pt is CHF give 500cc @ a time
  2. Pressors: Have nursing titrate for Mean of SBP
    1. Dopamine: Max 20mcg/kg/hr
    2. Levophed: Max 40mcg/kg/hr
    3. Neosynephrine: Max 350mcg/kg/hr
    4. Vasopressin: Max 0.01unit/kg/hr

A-fib w/ RVR:

  • Cardizem gtt, titrate to keep HR < 110
  •  Oral conversion: [(gtt rate * 3) + 3] * 10 = oral dose

SVT:

  1. Adenosine 6mg IVP, may repeat w/ 12mg
    1. Max of 3 doses
  2. Lopressor IV 5mg q5min x3
    1. Hold for SBP < 100
  3. Cardizem: Bolus 0.25mg/kg IBW x2, then gtt
  4. Esmolol: Bolus 500mcg/kg over 1 min
    1. then 50mcg/kg for 4 min, if no response titrate drip up by 50mcg/kg/min to max of 200mcg/kg/min

Hyperglycemia: Insulin SS:

        0-70:          1 amp D50 (alt: OJ/Skim Milk), Recheck

        71-120:    0 units     121-150:  1 unit

        151-200:    2 units           201-250:  4 units

        251-300:    6 units           301-350:  8 units

        351-400:    10 units         400+:      Call HO

-Recheck BS in 4 hours!!! (Peak effect of Insulin-R)

Fever:

  • Tylenol 650-1000mg PO or 1 gram PR q6hrs
  • Fever > 102°F: (38.9°C)
    • Blood Cx x2, U/A w/ C&S, Sputum Cx + Gram stain
  • CXR
  • Cooling blanket if all else fails

HTN:

  1. Lopressor 5mg (2.5-10mg ) IV q6hrs
  2. Vasotec 1.25mg (0.625-2.5mg) IV q6hrs
  3. Hydralazine 10mg (10-20mg) IV q6hrs
  4. Clonidine 0.1mg (0.1-0.3) PO q1hr (Max 0.6mg)
  5. Catapress TTS #1 (#1-3) Change q72 hrs
  6. Labetalol 20mg IV, then 40-80mg q10min     (Max 300mg/day)
  7. Nifedipine 10mg SL q6hrs
  8. Drips:
    1. Nipride: start @ ½ - 1 mcg/kg/min (Max 500mcg/kg {Cyanide poisoning})
    2. Labetalol: start @ 1-2mg/min (Max 2.4g/day)
    3. Esmolol: Loading dose 500mcg/kg/min in 1 min,
    4. Then 50-200mcg/kg/min
    5. Cardene: start @ 5mg/hr

Central Line Placement:

  • Tip of central line should be just outside the right atrium.  It is ok if it is just inside the tricuspid valve, but if it is in the right ventricle if must be pulled back.
  • If placing a Left IJ - Make sure the central line passes the midline of the chest, if it does not, it may be in the aorta
  • If you have even a small amount of concern, make sure you have the nurse connect the line to a transducer to see if it has a waveform, look for arterial pressures
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