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Surviving Floor Call 1. Buy MedCalc app ELECTROLYTE REPLACEMENT Potassium: 10 m

Surviving Floor Call 1. Buy MedCalc app ELECTROLYTE REPLACEMENT Potassium: 10 meq will raise K by 0.1 Cannot absorb more than 40-50 meq orally at one time Max peripheral infusion is 10 meq/hr Max central line infusion is 20 meq/hr Oral replacement > IV replacement Check and replace Mg! Phosphorus: Oral replacement IV replacement – Kphos 30 mmol has ~ 40 meq K Hypophosphatemia: Leads to weakness, bone pain, altered mental status. Caused by chronic alcoholism, refeeding syndrome, TPN Sodium: Hyponatremia: Determine volume status Hypovolemic (dehydration, vomiting, diarrhea, → 0.9 NS Euvolemic → water restriction, Demeclocyline, tolvaptan (ADH antagonist) Urine Na ↑ (>20), urine osmo ↑ (>200), serum osmo ↓ Hypervolemic → Diuretics Correct serum Na by 8-12 in 24 hours and 18 in 48 hours (<0.5 meq/hr). You generally only need to raise the serum sodium by about 5 to see symptomatic improvement Use 3% NS if symptomatic hyponatremia. Must be in the ICU with central line to use this Check urine sodium, urine osmolarity, serum osmolarity = 2x(Na+(BUN/2.8) + (blood sugar/18)) Corrected Na (for ↑ glucose) = Na + (Glucose -5/3.5) FYI: 0.9 NS = 153 meq Na FYI: 3% saline = 513 meq Magnesium: 1 mg IV raises Mg by 0.1 800 mg PO BID raises Mg by 0.4 Calcium: Calcium chloride is 3x as bioavailable as calcium gluconate for replacement in hypocalcemia Hypercalcemia Correct calcium (for ↓ albumin) = Ca + (0.8x (4-alb)) Due to increased resorption from bone, increased GI uptake or decreased renal excretion (HCTZ), malignancy, hyperparathyroidism (↑ serum Ca, ↓ serum Phos), Paget’s, milk-alkali, sarcoidosis Stones, bones, groans and psychiatric overtones Treatment: IVF, Lasix, bisphosphonates, Calcitonin DIURETICS: “BUN + Age = lasix dose” Creatinine x2 = total daily lasix dose 1 mg Bumex IV = 20 mg Lasix IV = 40 mg Lasix PO IV Lasix bolus = IV lasix infusion efficacy Diuretics → contraction alkalosis (↓ Na, K, Cl, bicarb) ANION GAP METABOLIC ACIDOSIS (MUDPILES) Methanol (elevated osmol gap): Can cause vision loss. Treat with fomepizole or ethanol or hemodialysis Uremia DKA (or alcoholic ketoacidosis which develops after the person stops drinking so serum alcohol will be negative) Paraldehyde INH Lactic Acidosis Ethylene glycol/isopropyl alcohol (elevated osmol gap, presence of calcium oxalate crystals in urine). Treat with fomepizole or ethanol Salicylates NON-ANION GAP METABOLIC ACIDOSIS (Hard-up) May treat with bicarb Hyperalimentation (TPN) Acetazolamide Renal Tubular Acidosis (RTA) RTA type I (distal tubule) inability of distal tubule to secrete acid. Urine pH < 5.3, ↓ serum K (increased K excretion), ↓ serum bicarb RTA Type II (proximal) inability of proximal tubule to reabsorb bicarb. Urine pH > 5.3. ↓↓ serum bicarb. Associated with Fanconi’s syndrome. RTA Type IV (hypo-aldosterone) decreased ammonia excretion. ↑ serum K Diarrhea (loss of bicarb) Ureteroenteric fistula Pancreatic fistula Indications for emergent hemodialysis (AEIOU Metabolic acidosis Electrolyte disturbance (↑↑K,) Ingestion/drug overdose Fluid overload Uremia SHOCK Type Distributive Cardiogenic Obstructive Hypovolemic Causes Sepsis Anaphylaxis Neurogenic ↓CO MI, arrhythmia PE Tension pneumo Tamponade Hemorrhagic Dehydration Skin Warm Pink Cool Pale Cool Pale Cool Pale Cardiac output ↑ ↓↓ ↓ ↓ SVR ↓↓ ↑(initially) → normal → decreased ↑ ↓ CVP ↓ ↑ ↑ ↓ HR ↑ NC or ↓ ↑ ↑ Treatment Antibiotics Fluids Pressors Steroids Oxygen Pressors IABP Treat cause Fluids Blood Adequate Urine Output = 50 ml/kg/hr BUN/Cr ratio: > 20 = pre-renal Light’s Criteria The fluid is an exudate if: Pleural protein/serum protein > 0.5 Pleural LDH/serum LDH > 0/6 Pleural LDH > 67% normal CARDIOLOGY TOPICS: Digoxin loading: 500 mg IV → 6 hours later followed by 250 mg IV → 6 hours later 250 mg IV followed by PO Digoxin + ↑K (often in the setting of AKI) → emergent dialysis. Do NOT give calcium gluconate (leads to stone heart) Quick Tips to Decoding an EKG LVH: Single lead R or S >25 R or S in any two leads > 35 (I like V3 and V5) aVL > 11 Posterior MI: V1-V3 tall R waves LAFB: Left axis, QRS 100-120 ms, deep S in II, III, aVF, tall R in aVL, I, V5-V6 PFB: Right axis, QRs 100-120 ms, tall R in II, III, aVF, deep S in aVL, I, V5-V6 RBBB: QRS > 120 ms, RSR’ in V1-V2, reciprocal changes in lateral leads LBBB: QRS > 120 ms, RSR’ in V5-V6, broad notched R wave, may have ST depression or TWI in lateral leads RBBB + LAFB: QRS > 120 ms, LAD, RSR’ in V1-V2 RBBB + PFB: QRS > 120 ms, RAD, RSR’ in V1-V2 Types of Cardiac Stents Bare Metal Stents (BMS): Requires dual anti-platelet therapy for 30 days Drug Eluding Stents (DES): Requires dual anti-platelet therapy for 1 year unless significant bleeding event occurs Aortic Stenosis: Avoid afterload reduction (ACE inhibitors, hydralazine, Imdur). This will lead to increased pressure gradient between the aorta and the LV leading to decreased profusion. Stress Tests Imaging (1) Echocardiogram: Assesses wall motion, valvular abnormalities Nuclear Perfusion: Radiotracer tagged RBC resting vs. stress images. Reversible defect = ischemia. Fixed defect = infarction or interference Stress (2) Exercise: Best physiologic and functional assessment of cardiac ability, able to see EKG changes Adenosine/Lexiscan: Contraindicated if patient actively wheezing, caffeine intake within 12 hours Dobutamine (least preferred): 1+2 → exercise stress echo OR Lexiscan stress nuclear OR Dobutamine stress echo OR exercise stress nuclear study INSULIN Basal Bolus Weight kg x (0.3-0.7 depending on insulin sensitivity) = total daily dose (TDD) TDD/2 = Lantus dose + total for three meals Meals / 3 = total for each meal Example: 100 kg female, insulin naïve TDD: 100 x 0.3 = 30 30/2 = 15 for lantus and 15 for meals 15/3 = 5 units for each meal Steroids: Increase serum WBC due to decreased WBC adherence to endothelial wall Increase blood glucose due to increased liver gluconeogenesis and anti-insulin effects on peripheral tissues HEMATOLOGY - DIFFERENTIATING ANEMIA Microcytic (MCV < 80): Order iron studies, retic count, peripheral smear Iron Deficiency: ↓ total iron, ↓ Ferritin, ↑ TIBC, ↑RDW α,β Thalassemia: ↓HbA, normal RDW Lead Poisoning: ↓heme, ↑ lead levels Sideroblastic: ↑ total iron, ↑ Ferritin, ↑ TIBC, ringed sideroblasts (nucleated RBC with iron deposits) Sickle Cell: HbS Hyperthyroidism Macrocytic (MCV > 100): Order B12, folate levels, retic count, peripheral smear Folate Deficiency: ↓ DNA production, hypersegmented PMNs, normal MMA, takes months to develop B12 Deficiency: hypersegmented PMNs, ↑MMA, takes years to develop. Consider pernicious anemia (60s) Acute leukemia Reticulocytosis: ↑ retic count Alcohol abuse Myelodysplastic syndrome Hypothyroid Normocytic Anemia: Order iron studies, retic count, peripheral smear Anemia of chronic disease: ↓ Iron, ↑ Ferritin, ↓ TIBC Renal failure → ↓ EPO Dilutional (pregnancy) Aplastic Anemia: Parvo B19 Spherocytosis – defect in RBC membrane protein leading to hemolytic anemia DIC/TTP/HUS Chronology of Leukemia: ALL → AML (Auer rods) → CML (Philadelphia chromosome- BCL-Abl) → CLL Disseminated Intravascular Coagulation (DIC) Hypercoagulable state → thrombosis → depletion of clotting factors → hemorrhage Causes: Sepsis, placental abruption, crush injuries, heat stroke, burns Labs: ↓↓ platelets, ↑PT/PTT, ↓ Fibrinogen (+d-dimer), schistocytes Treatment: Treat underlying cause! Can give platelets, FFP but will be degraded Thrombotic Thrombocytic Purpura (TTP) FAT RN (need 3/5): Fever, anemia (hemolytic), thrombocytopenia, renal failure, neurologic changes Labs: ↓↓ platelets, PT/PTT normal!, schistocytes on peripheral smear Treatment: Plasmaphoresis Hypercoagulable State Workup ↓ Protein C, S Factor V Leiden Prothrombin mutation Antiphospholipid, anti-cardiolipin antibodies Anti-thrombin III deficiency Malignancy Tumor Lysis Syndrome: Common with acute leukemia and initiating treatment ↑K, ↑ uric acid, ↑ phos, ↓ Ca, ↑LDH Prophylaxis: Allopurinol Neutropenia: Absolute PMN count < 500 + fever = neutropenic fever. Must treat with broad spectrum Antibiotics. If fever persists, consider anti-fungals ANC = WBC x (Polys + Bands/100) Bone Scan detects osteoBlastic activity only. Useful in detecting metabolically active sites (inflammation, infection, malignancy.) Do not order when evaluating skeleton for multiple myeloma or osteoporosis as these are predominately osteoClastic mechanisms. Order skeletal survey (plain XR) COMPLICATIONS of HYPOXIA (PaO2<60) Anaerobic metabolism → ↑ lactic acid Peripheral vasodilation Pulmonary vasoconstriction → shunting Fall off the Hb dissociation curve CAUSES of UNCONSCIOUSNESS AEIOU CHESS TIPPS Alcohol, Epilepsy, insulin, overdose, uremia Cardiac (MI), hypoxia, environmental (hypothermia), stroke, sepsis Trauma, ingestion, psych, phenothiazine, salicylates Common Hospital Admissions CAP Azithromycin + Rocephin OR Levaquin Albuterol/Atrovent nebs Oxygen – wean to maintain sats > 92% Blood, respiratory cultures Strep pneumonia or legionella antigen HCAP Hospitalized within the last 3 months, resident of nursing home Need MRSA, anaerobic and double pseudomonal coverage Example: Vancomycin + Cefepime + Levaquin Treat the same as CAP UTI Is it really an UTI? WBC on microscopy? Urine culture Check for previous urine cultures and sensitivities IV antibiotics – IV Rocephin is a good one to start with IVF if needed AKI? Sepsis Do they meet SIRS criteria (HR, RR, Temp, WBC) IVF needed Foley to monitor I/Os? Blood/urine/respiratory cultures Appropriate antibiotics Lactic acid Acute (on Chronic?) Renal Failure Pre-renal: FENa <1% (kidneys try to reabsorb Na) Renal: FENa >1% (tubular damage, unable to resorb Na) – most common cause is ATN Discontinue NSAIDs, ACE/ARB and uploads/Geographie/ intern-survival-guide.pdf