ADMITTING ORDERS

P – Problem
C – Condition (Fair, Guarded, Critical)
A – Activity (CBR with/without TP as tolerated)
A – Allergies
D – Diet
N – Nursing Care (TPR and BP monitoring every 4H, I&O
every shift)
I – IVF (PNSS ml/hour)
L – Laboratory tests
M – Medications (see MRF)

DIABETIC DIET
35kcal/kg with 60% CHO, no simple sugars, 40gms
CHON, and the rest as fats, total cholesterol <200mg,
MUFA>PUFA in 3 meals and 2 snacks

UREMIC DIET
Full, uremic diet, 1600kcal/kg, <2gm Na, <2gm K,
<800mg phosphorus, 40gm CHON of high biological
value, the rest as fats, MUFA>PUFA, <200mg cholesterol

DOPAMINE
Doses:
Low (Renal) 1-5 µg/kg/min
Mod (Cardiac) 5-10 µg/kg/min
High (Vasopressor) 10-20 µg/kg/min

SS 13.3 µg/µgtt 200mg/250ml

DS 26.6 µg/µgtt
400mg/250ml

Order:
Start Dopamine (Baxter) 400mg/250cc at 20cc/hr (A.D.
5µg/kg/min), titrate by 5cc/hr to maintain SBP of
>110mmHg
RATE (cc/hr) =
weight (kg) x actual dose (µg/kg/min)
concentration (µg/µgtts)

RATE (cc/hr) = (70kg) x (5µg/kg/min) = 13.1cc/hour

(26.6µg/µgtts)

AD (mg/kg/min) =
rate (cc/hour) x concentration
(µg/µgtts)
weight (kg)

AD (mg/kg/min) =
(13cc/hour) x (26.6µg/µgtts) = 4.9mg/kg/min
(70kg)

DOBUTAMINE
Dose: 2-20 µg/kg/min

SS 16.6 µg/µgtt 200mg/250ml

DS 33.2 µg/µgtt 400mg/250ml

RATE (cc/hour) = weight (kg) x AD (µg/kg/min)

concentration (µg/µgtt)

RATE (cc/hour) = (70kg) x (5µg/kg/min) = 10.54cc/hour

(33.2µg/µgtt)

NOREPINEPHRINE
Doses:
Ave Adult 2-10 µg/kg/min
Refractory Shock up to 30 µg/kg/min
(0.03-1.5 µg/kg/min)
Preparation:
Levophed 4mg/4ml amp
2mg/2ml amp
Norepinephrine 10mg/10ml amp

Concentration:
Levophed 0.53 µg/µgtt 8mg/250ml
Norepinenephrine 0.66 µg/µgtt
10mg/250ml

Noradrenaline (Levophed) drip:

Prep 2mg/2ml amp
D5W 250ml + 4 amps Levophed, start at 15cc/hr
AD = (0.533 x rate) / wt

RATE (cc/hour) = weight x AD

concentration

NICARDIPINE
Dose: 5-15mg/hr
In solution: 10mg in 90cc PNSS
Concentration: 0.1 mg/ml

RATE (cc/hr) = cc x mg x 60min

mg min hr

AD (µg/kg/min) = conc (µg/µgtts) x rate (cc/hr)

weight (kg)

AMIODARONE
Suppress PVCs and VT
Prophylactic control of ventricular arrhythmias
Prevent recurrence of paroxysmal Afib, flutter, SVT, and
WPW dysrhythmias
Vtach refractory to other arrhythmias
Dose:
Loading 1mg/min for first 6hrs
Maintenance 0.5mg/min next 18hrs

Concentration:
2.4mg/cc in 600mg Amiodarone + 250cc D5W

Example:
D5W 250cc + 600mg Amiodarone at 24cc/hour for 6
hours then at 13cc/hour for the next 18 hours

ISDN (ISOKET)
Dose: 1-5mg/hr

Prep: 10mg in 10cc amp

Dilution:
Single Conc 10mg in 90cc PNSS
Double Conc 20mg in 80 cc PNSS

RATE (cc/hr) = dose (mg/hr) x volume (cc)

conc (mg)

RATE (cc/hr) = (2mg/hr) x (100cc) = 20cc/hour

(10mg)

Order:
Start ISDN (Isoket drip): 10mg ISDN (Isoket)
In 90cc NSS at 20cc/hr
OCTREOTIDE (SANDOSTATIN)
Stop bleeding and rebleeding owing to gastroesophageal
varices in liver cirrhosis

Prep: 0.5mg/ml amp

Dose:
Loading IV bolus 100µg (0.2ml)
Maintenance Give 25µg/hr as maintenance
 Add remaining 0.8ml in 500ml D5NM/D5LR
 Infuse preparation for 16hrs

Prep: 0.1mg/ml amp

Dose:
Loading IV bolus 100µg (1ml or 1amp)
Maintenance Give 25µg/hr as maintenance
 Add 2amps of 0.1mg/ml Octreotide in
500ml D5NM/D5LR
 Infuse preparation for 8hrs

PNSS 250ml + Octreotide 0.5mg at 25-50µg/hr

For bleeding esophageal varices, 25 to 50 µg IV bolus,
then
continuous infusion of 25-50 µg/hr for 5 days

SOMATOSTATIN (STILAMIN) DRIP

Give 250µg slow IV, then start infusion with D5W 250ml
+ Somatostatin 3mg at 42ml/hour (250µg/hr) until GI
bleeding has stopped or up to 5 days

ALBUMIN DRIP
- 20% 1 vial to run in 4hrs as side drip then give
Furosemide 20mg IVTT on the third hour of drip
- Albumin drip 25% 50cc to run as PB in 6hrs OD x 3
days
Furosemide 20mg IVTT after drip

MITODEX DRIP
2 amps in 150cc D5W to run in 8hrs

CLASSIFICATION OF DM
Normal IFG/IGT DM
5.6-6.9 >7.0
FPG <5.6 mmol/L
mmol/L mmol/L
100-125
100mg/dl >126 mg/dl
mg/dl
7.8-11.0 >11.1
2hr PG <7.8 mmol/L
mmol/L mmol/L
140-199
140 mg/dl >200 mg/dl
mg/dl
A1c <5.6% 5.7-6.4% >6.5%

METABOLIC SYNDROME (3/5)

Fasting glucose >100 mg/dl
BP >130/80 mmHg
TGL >150 mg/dl
HDL-C <40 mg/dl in men
<50 mg/dl in women
Waist >102 cm/40 inches in
men
>88 cm/35 inches in
women
If Asian waist >90 cm/35 inches in
men
> 80 cm/32 inches in
women

HbA1c APPROXIMATIONS
6% 126 mg/dl
7% 154 mg/dl
8% 183 mg/dl
9% 212 mg/dl
 10% 240 mg/dl
11% 269 mg/dl
12% 298 mg/dl

DIABETES MANAGEMENT IN THE HOSPITAL

Indications for Insulin Infusion:
- DM emergencies
- General pre/intra/post-op care
- Post-op cardiac surgery
- MI or cardiogenic shock
- CVD accidents
- High-dose steroids with hyperglycemia
- DM type 1 on NPO
- Critically ill surgical patient on MV
- Dose finding strategy

Threshold:
Peri-op care > 140mg/dl
Surgical ICU > 110-140mg/dl
Non-surgical illness > 140-180mg/dl
Pregnancy > 100mg/dl

In-patient Insulin Regimen:

Patient on home insulin, controlled:
NPO: Continue 80-100% Glargine or Detemir dose
Continue 50-80% NPH doses or convert to
Glargine or Detemir
DAT: Continue home regimen

New to Insulin:
NPO: Basal insulin 0.20U/kg/day
Correctional RAI every 4-6hrs
IV insulin infusion initially as dose finding
strategy
DAT: Total insulin dose 0.4-1.0U/kg/day
2/3 in AM, 1/3 in PM if premixed used
50% basal and 90% prandial

Less aggressive dosing ranges:

Increased insulin sensitivity (DM, elderly)
Decreased clearance (renal, CHF)
Decreased glycogen stores (severe liver disease,
malnutrition)

More aggressive dosing ranges:

Increased insulin resistance (metabolic syndrome,
obesity, patient markedly hyperglycemic on admission)

Target Goals:
ICU 80-110mg/dl
Medical/Surgical
Preprandial 80-110mg/dl
Postprandial <180mg/dl
Pregnant
Preprandial <100mg/dl
Postprandial <120mg/dl
Labor/delivery <100mg/dl

Insulin-Naïve Patients:
0.4-0.5U/kg for Type I
0.5-0.7U/kg for Type II
0.2-0.3U/kg for CKD, cirrhotic patient, elderly

Example:
Premixed Insulin Regimen:
60kg x 0.5U/kg = 30U/day
2/3 in AM = 20U
1/3 in PM = 10U

Basal-Bolus Regimen:
60kg x 0.5U/kg = 30U/day
½ basal = 15U
Detemir
½ bolus in 3 divided doses = 5U before
meals

Insulin in the Peri-operative:

Patients on OHA:
Metformin hold 3 days prior
Others hold day of OR
On bowel prep, OHA hold once on general
liquids

Patients on insulin:
Hold fixed dose premixed
Need not hold basal insulin (may give 80-
100% of usual dose)

Perioperative orders:
- How much?
Good control (FBS 80-120mg/dl) – 0.5U HR in 1L solution
Fair control (FBS 120-180mg/dl) – 10-15U HR in 1L
solution
Poor control (FBS >180mg/dl) – insulin drip thru soluset
- CBG monitoring?
Minor surgery – every 4hrs
Major surgery or on drip – every hour the every
2hrs once CBG 80-
140mg/dl

Postoperative on DAT:
On OHA – resume OHA
 Shift D5 fluids to PNSS
run in 16hrs
On insulin – resume fixed dose
Discontinue D5 fluid
and insulin drip 2hrs
after giving fixed dose
insulin (1hr after if
premixed insulin
analogues)

Total Parenteral Nutrition (Kabiven, etc):

Method A:
Incorporate 10U HR per bag Kabiven
CBG every 4hrs then give SC correction
Add 2/3 of total units administered SC to next day’s TPN
bag

Method B:
Incorporate 10U HR per bag
Start separate insulin infusion for 24hrs to determine daily
requirement
Add 2/3 to next day’s bag

IV to SC Insulin Therapy:
Ex. Patient received 20U/hr IV during previous 6hrs

- SC total daily dose is 80% of 24hr insulin

requirement
80% of 20U/hr x 24hrs = 38U
- Basal dose is 50% of SC TDD
50% of 38U = 19U of long-acting
- Bolus total dose if 50% of SC TDD
50% of 38U = 19U of total prandial rapid-acting
 Oral feedings, 6U TID ac
NGT feedings, 3U every 4hrs ac

Correction Dose:
If CBG >140mg/dl in ICU patients or >180mg/dl in non-
ICU

CORRECTION DOSE = (actual CBG) – (target CBG)

correction factor

CORRECTION FACTOR = 1600 divided by TDD

Example:
CBG 280mg/dl, target is 140mg/dl
CF = 1600/38U = 40mg/dl
CD = (280mg/dl – 140mg/dl)
40mg/dl
= 3.4U additional on top of due prandial insulin

On HGT: Check crea, especially elderly

(Value – 140)/30 or 40 = U needed

Treatment Goals in Adults with DM:

A1c <7%
Preprandial 70-130 mg/dl
Postprandial <180 mg/dl
BP <130/80 mmHg
LDL <100 mg/dl
HDL >40 mg/dl (male)
>50 mg/dl (female)
TGL <150 mg/dl

INSULIN DRIP
50 units in 50cc PNSS at 5cc/hr
Titrate as follows:
Hgt <80 = close
Hgt 81-180 = 1cc/hr
Hgt 181-200 = 2cc/hr
Hgt 201-250 = 3cc/hr
Hgt 251-300 = 4cc/hr
Hgt 301-350 = 6cc/hr
Hgt 351-400 = 8cc/hr
Hgt >400 = 10cc/hr >refer

Mean Arterial Pressure (MAP)

MAP = SBP + DBP / 3

Normal = 70-100mmHg
Ischemic stroke = 130mmHg
Hemorrhagic stroke = 140 to 160mmHg

ANTI-TB REGIMEN IN ADULTS (Harrison’s 18th

Edition)
THRICE-
DRUG DAILY DOSE
WEEKLY DOSE
5mg/kg 10mg/kg
Isoniazid
Max 300mg Max 900mg
10mg/kg 10mg/kg
Rifampin
Max 600mg Max 600mg
25mg/kg 35mg/kg
Pyrazinamide
Max 2g Max 3g
Ethambutol 15mg/kg 30mg/kg
* Dosages for twice-weekly regimen are the same for INH
and Rifampicin but are higher for Pyrazinamide (50mg/kg,
max 4g/d) and Ethambutol (40-50mg/d)

Isoniazid (H) 5 mg/kg

Rifampicin (R) 10 mg/kg – hepatotoxic
Pyrazinamide (Z) 25 mg/kg – hepatotoxic
Ethambutol (E) 15 mg/kg

Myrin P = 75mg INH

AFB smear (+) 10,000

AFB culture 100,000
AFB cavitary 107-9

MDR – resistance to INH and R

XDR – MDR + resistance to FQ and injectables

EMPIRICAL TREATMENT OF CAP

 Out-patient treatment
Previously healthy and no antibiotics in 3mos
- Macrolide: Clarithromycin 500mg BID PO
Azithromycin 500mg PO once then 250mg OD PO
daily for 4 days
- Doxycycline 100mg BID PO
Comorbidities or antibiotics in 3mos
- Respiratory Quinolone: Moxifloxacin 400mg OD PO
Gemifloxacin 320mg OD PO
Levofloxacin 750mg OD PO
- B-lactam (preferred): high-dose Amoxicillin 1g TID
or Amoxicillin/Clavulanic acid 2g BID
- B-lactam (alternative): Ceftriaxone 1-2g IV
Cefpodoxime 200mg BID PO
Cefuroxime 500mg BID PO
PLUS Macrolide

* Duration: minimum of 5 days, should be afebrile for 48-

72 hours, or until afebrile for 3 days; longer duration of
therapy may be needed if initial therapy was not active
against the identified pathogen or if it was complicated by
extrapulmonary infections

 In-patient treatment
Non-ICU
- Respiratory Quinolone: Moxifloxacin 400mg OD
PO/IV
Gemifloxacin 320mg OD PO
Levofloxacin 750mg OD PO/IV

- B-lactam PLUS Macrolide:

Cefotaxime 1-2g IV q8h
Ceftriaxone 1-2g IV q24h
Ampicillin 1-2g IV q4-6h
Ertapenem 1g IV q24h
PLUS
Clarithromycin 500mg BID PO
 Azithromycin 500mg OD PO then
250mg OD PO
Azithromycin IV 1g once then
500mg OD

* Duration: minimum of 5 days, should be afebrile for 48-

72 hours, stable blood pressure, adequate oral intake,
and room air oxygen saturation of greater than 90%;
longer duration may be needed in some cases

ICU
- B-lactam: Cefotaxime 1-2g IV q8h
Ceftriaxone 1-2g IV q24h
Ampicillin/Sulbactam 2g IV q8h
- PLUS Azithromycin or Quinolone as indicated

* Duration of therapy: 10-14 days

LIGHT’S CRITERIA
Effusion protein/serum protein >0.5mg/dl
Effusion LDH/serum LDH >0.6mg/dl
Effusion LDH >2/3 upper limit of normal serum LDH or
>200mg/dl
- Exudate if any of the criteria
- Exudates: infection, malignancy, PE, collagen
vascular disease
- Transudate: CHF, cirrhosis, nephritic syndrome

HEMOTHORAX
Pleural fluid Hct is at least ½ of blood Hct

CHYLOTHORAX
Triglyceride >110mg/dl
PREPARATIONS/REGIMENS

1. Coronary Angiogram (W. Acusar)

CBC, crea, PT, K
IVF D5NSS
NPO post-midnight
Prepare left and right inguinal areas
Benadryl 25mg PO + Xanor 250mcg PO en route

2. Colonoscopy (PE Lim)

Dulcolax 4 tabs PO at 4PM
Fleet enema 1 bottle per rectum at 8PM
NPO post-midnight
Dulcolax 1-2 supps per rectum at 5AM

3. Colonoscopy (I. Acusar)

Phosphosoda 45ml + 1 glass Sprite followed by another
glass of Sprite at 5PM
No solids after 12MN but may have liquids until 5AM
Phosphosoda 45ml + 1 glass Sprite followed by another
glass of Sprite at 5AM

4. Colonoscopy (R. Go)

Dulcolax 4 tabs PO at 4PM, then 4 tabs after 4hrs
Dulcolax 2 supp per rectum at 5AM
NPO post-midnight

5. Colonoscopy (A. Limquiaco)

Bisacodyl (Dulcolax) 4 tabs orally after dinner
Phosphosoda 45cc orally 1hr after giving Bisacodyl
Fleet enema at 5AM per rectum
General liquids after dinner
NPO post-midnight

6. Cu test positive result (PE Lim)

Amoxicillin 500mg/cap 2 caps BID PO x 10 days
Clarithromycin 500mg/cap 1 cap BID PO x 10 days
Pantoprazole 40mg/tab 1 tab OD PO x 1 month
Rebamipide 100mg/tab 1 tab TID PO x 1 month

7. Thoracentesis (A. Rafanan)

Ab catheter gauge 18
50cc syringe with luer lock
5cc syringe with neede
10cc syringe
Needle gauge 19
Twinsite # 1
Macroset # 1
3 way stopcock # 1
Lidocaine (Xylocaine) 2% # 2
Sterile gloves 7 # 1
Sterile gloves 6 ½ # 1
OS # 5
Betadine swab
Face mask
Empty bottle 1L
Specimen bottle # 3
Band aid
Eye sheet
Hypoallergenic plaster

8. Pleurodesis (A. Rafanan)

Oxytetracycline
Sterile kidney basin
Sterile gloves 7 ½ # 2
Mask # 2
Betadine swab # 2
10ml syringe with needle # 1
50ml, 100ml syringe # 1
50ml PNSS ampule # 1
Lidocaine 2% # 5
Leucoplast # 1
Clamp # 2
Eye sheet
Needle gauge 18 # 1

9. Thoracentesis (Bigornia)
Core needle # 1
Macro drip # 1
3 way stopcock # 1
CTT # 1
Betadine swab # 1
Xylocaine 2% # 2
5ml syringe with needle # 1

Dr. Bigornia Medications:

Bamboterol (Bambec) 10mg
Doxyfylline (Ansimar) 400mg OD
Radixgential (Sinupret) 2 tabs TID
Camandine (Kamilosan) 4 squirts TID
Fusatungine inhaler (Locabiotal) inhaler 2 puffs/nasal TID

10. Thoracentesis (R. Sy)

Needle gauge 19 # 1
Xylocaine 2% # 2
50cc syringe # 1
Sterile forceps # 1
Betadine swab # 2
Eye sheet # 1
Specimen bottle 12 # 1
Sterile specimen bottle # 3
Macroset # 1
5cc syringe # 1
OS pack # 1
Face mask # 2
Sterile gloves 7 # 2

11. Bedside Lung Biopsy (Polloso)

Prep tray
Fixative
Sterile gloves # 2
Lidocaine 2%
15 slides
10cc syringe # 1
Needle gauge 18 # 1
Band aid # 2
Sterile gauze and forceps
Scalpel and eye sheet

INDICATIONS FOR CTT

- Presence of gross pus in pleural space
- (+) gram stain or culture of PF
- PF glucose <3.3 mmol/L or <160mmHg
- PF pH <7.20
- Loculated PF

CKD FOR CONTRAST IMAGING

- N-Ac 600mg BID starting on day prior to contrast
exposure and on day of administration (4 doses
total)
- Hydrate at 1cc/kg/hour for 12hrs before and 12hrs
after
- Hold ACEIs and ARBs
- Repeat urea and crea a day before administration

Stages of CKD GFR (ml/min)

1 – Kidney damage N0 90
* with evidence of kidney damage: proteinuria,
sediments, abnormal imaging, abnormal blood and urine
chemistry
2 – Mild GFR 60-89
3 – Moderate GFR 50-59
4 – Severe GFR 15-29
5 – Renal failure <15

CONTRAST PREMEDICATIONS
(For patients with history of mild contrast allergy,
food/drug allergy, and asthmatic on maintenance
medications)

Oral: 50mg PO of Prednisone 13hrs, 7hrs, and 1hr prior

to procedure and 50mg PO of Benadryl 1hr prior to
procedure

IV: 200mg Hydrocortisone 6hrs and 2hrs prior to

procedure and 50mg PO Benadryl 1hr prior to procedure

ACUTE KIDNEY INJURY (AKI)

- At least 0.3mg/dl rise or 50% higher than baseline
crea within 24-48hrs
- Reduction in UO to 0.5ml/kg/hr for longer than 6hrs

CONTRAST-INDUCED AKI
Crea increased >25% or 0.5mg/dl within 48hrs, peaks 3-
5 days, resolves 7-10 days
INDICATIONS FOR URGENT DIALYSIS
A – Acid-base disturbance (acidemia)
E – Electrolyte disorder (hyperkalemia,
hypercalcemia)
I – Intoxication (methanol, ethylene glycol, lithium,
etc)
O – Overload (CHF)
U – Uremia (pericarditis, encephalopathy, bleeding,
etc)

URINE DIAGNOSTIC INDICES

Prerenal Intrinsic
FENA <1 >1
Urine Na mmol/L <10 >20
Urine crea/Plasma crea >40 >20
Urine urea nitrogen to
>8 <3
Plasma urea nitrogen
Urine SG >1.018 <1.015
Urine osmolality >500 <300
Plasma BUN/crea ratio >20 <10-15
Renal failure index
<1 >1
(UNa/UCr/PCr)
Muddy
Hyaline brown
Urinary sediment
casts granular
casts

Fractional excretion of Na (FeNa) =

urine Na x plasma crea x 100
urine crea x plasma Na
<1% prerenal azotemia
>1% oliguric ATN
H. PYLORI (14 day treatment – Harrison’s)
Triple therapy:
1. OCA: Omeprazole 20mg BID + Clarithromycin
500mg BID + Amoxicillin 1g BID
2. OCM: Omeprazole 20mg BID + Clarithromycin
500mg BID + Metronidazole 500mg BID
3. OBTM: Omeprazole 20mg BID + Bismuth
subsalicylate 2 tabs QID + Tetracycline 500mg QID
+ Metronidazole 500mg TID

* Omeprazole may be replaced with any PPI at equivalent

dosage or with Ranitidine bismuth citrate 400mg

ARTERIAL BLOOD GASES

pH 7.35 – 7.45
PaCO2 35 – 45
HCO3 22 – 26
PaO2 109 – (0.43 x age) ± 4
20yo: 96 – 104
80yo: 71 – 75
80 – 100 in normal
Mild: 60 -80
Moderate: 40 – 60
Severe: <40

Steps:
1. Look at pH
2. Respiratory pCO2
If respiratory change similar to pH then cause
is respiratory (except in combined disorders)
If not similar to pH, respiratory is not the
cause (low pCO2 is compensation for
metabolic acidosis)
3. Metabolic HCO3
If HCO3 is similar to pH then the cause is
metabolic
4. Calculate compensation in metabolic disorders or
determine if acute or chronic if respiratory disorders
5. If metabolic acidosis, compute for anion gap
6. In anion gap disorders, determine the corrected
serum bicarbonate in order to assess coexisting
disturbances

What is the acid base status?

1. Academic or Alkalemic?
2. Bigger % difference is the primary disorder
3. %diff = (actual value – reference value) / reference
value
4. Respiratory or Metabolic?
5. Compensation
6. Oxygenation

If respiratory acidosis or alkalosis – acute or chronic?

RESPIRATORY ACIDOSIS

Acute
Expected pH = 7.4 – [ 0.008 x (actual PaCO2-40) ]

Chronic
Expected pH = 7.4 – [ 0.003 x (actual PaCO2-40) ]

RESPIRATORY ALKALOSIS

Acute
Expected pH = 7.4 + [ 0.008 x (40 – PaCO2) ]

Chronic
Expected pH = 7.4 + [ 0.003 x (40 – PaCO2) ]
RESPIRATORY ACIDOSIS

Acute
Expected HCO3 = 24 + [ ( PCO2/10) x 1 ]

Chronic
Expected HCO3 = 24 + [ ( PCO2/10) x 3 ]

RESPIRATORY ALKALOSIS

Acute
Expected HCO3 = 24 – [ ( PCO2/10) x 2 ]

Chronic
Expected HCO3 = 24 – [ ( PCO2/10) x 4 ]

METABOLIC ACIDOSIS

PCO2 = 1.5 [HCO3] + 8 + 2

METABOLIC ACIDOSIS

PCO2 = 0.7 ( [HCO3] )

If metabolic acidosis – anion gap?

Anion Gap = Na – ( Cl + HCO3 )

Normal value: 12 + 2 meq/L

Normal Anion Gap:

- Hypernatremic dehydration
- Renal tubular acidosis
- Hyper-alimentation
- Diarrhea

If increased anion gap – delta-delta?

Delta/delta = AG -12-
HCO3 -24-

Normal values:
= 1 pure AG metabolic acidosis
> 1 AG metabolic acidosis + metabolic alkalosis
< 1 AG metabolic acidosis + non-AG metabolic acidosis

Causes of Hypoxemia:
- Ventilation/perfusion mismatch
- Shunt effect
- Decreased diffusion of O2
- Alveolar hypoventilation
- High altitude

Determination of the cause of hypoxemia:

If the A-a gradient {P(A-a) O2} is normal
Hypoventilation
Reduction in PIO2
PIO2 = (Barometric pressure – PH2O) x FIO2
If the A-a gradient {P(A-a) O2} is normal
V/Q mismatch
Diffusion defect
Shunt
If the sum of the PaO2 and the PaCO2 is between 110
and 130, breathing room air, hypoxemia is due to overall
hypoventilation
PaO2 + PaCO2 = 110-130
If the sum <110, cause is V/Q mismatch, diffusion defect,
shunt, or due to decreased PIO2
Calculation of A-a gradient
P(A-a) O2 = PAO2 – PaO2
Normal
Young adults: 8-12
4mmHg for every increase of 10 in age
Age/3 + 3

Calculation of PAO2
PAO2 = PIO2 – PaCO2 / 0.8
PIO2 = (760-47) FIO2
0.8 is respiratory quotient
Oxygen uptake equals 250 ml/min
CO2 production equals 200ml/min
PAO2 = (713) FiO2 – PaCO2 / 0.8
On room air: PAO2 = 150 – PaCO2 / 0.8

RENAL TUBULAR ACIDOSIS (RTA)

- If the pH Is high (>6.0), a distal RTA is present
- If the urinary pH is low (<5.5), and remains low
even with HCO3 infusion, a proximal RTA is
suggested
- In patients with a hyperkalemic distal RTA, as seen
with aldosterone deficiency, the urinay pH can be
variable

RETICULOCYTE PRODUCTION INDEX

Corrected Reticulocyte Index =
Reticulocyte count x Actual Hematocrit
Normal Hct (usually
45)

Correct for longer lifespan of prematurely released

reticulocytes in the blood
Hct% Reticulocyte survival (days)
= Correction Factor/Maturation
index
36-45 1.0
26-35 1.5
16-25 2.0
15 and below 2.5

RPI = Corrected Reticulocyte Index

Correction Factor/Maturation Index

RPI = Reticulocyte count x Hgb (observed) x 0.5

Normal Hgb

RI:
<2% Anemia indicates decreased production of
reticulocytes and RBC
Hypoproliferative disorders
Ineffective erythropoiesis (Megaloblastic
anemia)
>3% Anemia indicates loss of RBC leading to
increased
compensatory production of reticulocytes and
replace lost RBC
Hemolytic anemia
Recent hemorrhage
Marrow response to therapy
IRON STUDIES
%
TIBC/Tran Transferriti
Iron UIBC
sferrin n
Saturation
Iron Deficiency
Low High High Low
Anemia
Hemochromatosi
High Low Low High
s
Chronic Illness Low Low Low/N Low
Hemolytic
High N/Low Low/N High
Anemia
Sideroblastic
N/High N/Low Low/N High
Anemia
Iron Poisoning High N Low High

% saturation of Tf = serum iron x 100

TIBC

Tf saturation: <20% - iron deficiency

>50% - iron overload
N0 serum iron 9-27 µmol/L (50-100 µg/dL)
N0 TIBC 54-64 µmol/L (300-360 µg/dL)
N0 Tf sat 20-50% (adults), >16% (children)

HYPONATREMIA
Treatment:
1. Determine required rate of correction
2. Correct the hypo-osmolality at rate desired
3. Correct underlying disorder

Na DEFICIT = 0.6 (males) or 0.5 (females) x

weight (kg) x (Desired Na [140] – Actual Na)

- Asymptomatic patient: increase by no more than

0.3mmol/L per hour and by <8-10mmol/L over first
24hrs and 18mmol/L over first 48hrs
- Severe symptomatic: 3% hypertonic saline at
100ml/hour (1-2mmol/L/hr) for 3-4hrs; no more
than 8mmol/L in first 24hrs
- Severe symptoms (seizures, obtundation, coma):
3% Na infused at 4-6ml/kg/hr

Osmotic Demyelination Syndrome (ODS)

- Flaccid paralysis, dysarthria, dysphagia
- More than 25meq/L elevation of Na in 48hrs
- Overcorrection of Na above 140meq/L

Acute hyponatremia (<48hrs)

- Goal: increase Na ~1-2meq/L/hr for 3-4hrs until
neurologic symptoms subside or Na >120meq/L
Chronic hyponatremia, severe symptomatic
- Correctional not exceed 0.5-1meq/L/hr
- Not exceed 8-12meq/L/day pr 18meq/L in 48hrs
- Correct to safe range no greater than 1120meq/L

HYPERNATREMIA (>145meq/L)

WATER DEFICIT = (Plasma Na – 140) x TBW

140
 TBW = 50% females, 60% males
WATER DEFICIT = {[(160 – 140) ÷ 140] x (0.5 x 50)} =
3.6L

Treatment:
1. Correct water deficit over 48-72hrs
2. Consider ongoing losses
3. Na lowered by 0.5mmol/L/hr and not >12mmol/L
over first 24hrs

Equivalents:
- 2g Na + diet 86meq/day
- 0.9% NaCl 154meq/L
- 1 amp of 8.4% NaHCO3 50meq Na
+ HCO3
- 3% NaCl 513meq/L
- PLR 130meq/L
- NM 40meq/L
- NaCl 1 tab 17meq/tab

HYPOKALEMIA

K DEFICIT = (Desired K – Actual K) x 350 + 50

3

Correct over 3 days

Replacement:
40meq/L via peripheral line
100meq/L via central line
Infusion rate not exceed 20meq/hr

HYPERKALEMIA (>5meq/L)
ECG changes:
5.5-6.5 tall peaked T wave
6.5-7.5 loss of P wave
7-8 widened QRS
>8 sine-wave pattern

Arrhythmias: sinus bradycardia, sinus arrest, slow

idioventricular rhythm, ventricular tachycardia, asystole

Correction:
1. Ca gluconate: 10ml + 1g/1 amp (10% solution)
infused over 2-3mins
Ca gluconate drip: 1g/amp 4 amps (1 amp has 90
elemental Ca) in 1L PNSS to run for 10 hours
Goal: 0.5-1.5mg/kg/hr
2. Insulin/glucose: 10 units regular insulin + D50 50cc
IVTT every 6 hours x 3 doses
Follow with 10% dextrose at 50-75ml/hr
Monitor for hypoglycemia
If blood glucose >200-250mg/dl give insulin only
Repeat serum K
3. Beta agonists(promote cellular uptake of K) IV or
nebulized, onset of action 30mins, effect lasts 2-
4hrs
4. NaHCO3 alkali therapy (ideally reserved for severe
hyperK with metabolic acidosis): 3 ampules per liter
(134 mmol/L NaHCO3 )

CONTRAINDICATIONS TO NIV
1. Cardiac or respiratory arrest
2. Severe encephalopathy
3. Severe GI bleed
4. Hemodynamic instability
5. Unstable angina and MI
6. Facial surgery or trauma
7. Upper airway obstruction
8. High-risk aspiration and/or inability to protect
airways
9. Inability to clear secretions

INDICATIONS FOR INTUBATION

Major criteria (any 1 of the following):
- Respiratory arrest
- LOC with respiratory pauses
- Gasping for air
- Psychomotor agitation requiring sedation
- HR <50bpm with loss of alertness
- Hemodynamic instability with SBP <70mmHg

Minor criteria (2 of the following):

- RR >35cpm
- pH <7.3 and decreased from onset
- PaCO2 <45mmHg despite O2
- Increase in encephalopathy or decreased level of
consciousness

INTUBATION GUIDELINES
Any 1 of the following:
- pH <7.20
- pH 7.2-7.25 on 2 occasions 1hr apart
- Hypercapneic coma (GCS <8 and PaCO2
>60mmHg)
- PaO2 <45mmHg
- CP arrest

2 or more in the context of respiratory arrest:

- RR >35/min or <6/min
- Tidal volume <5ml/kg
- BP changes with SBP <90
- O2 sat <90% despite O2
- PaCO2 >10mmHg increase or acidosis (pH decline
>0.08)
- Obtundation
- Diaphoresis
- Abnormal paradox

NIV INITIAL VENTILATOR

SETTINGS/ADJUSTMENTS
Tidal volume: 5-8ml/kg
Adjust setting if RR >25cpm
O2 saturation >90%
Serial ABG

RSBI WEANING INDEX FOR MV

(Rapid Shallow Breathing Index)
- Done with a handheld spirometer attached to the
ET tube while a patient breathes room air for one
minute without any ventilator assistance

RSBI = Respiratory rate

Tidal volume
RSBI = 25cpm = 100cpm/L
0.25L
<105 = indicating a relatively low respiratory rate
compared to tidal volume is generally considered as an
indication of extubation

INITIAL IPAP/PEEP
Start at 10cm H2O/5cm H2O
Tidal volume 5-7ml/kg

Subsequent adjustments based on ABG:

- Increase IPAP by 2cm H2O if persistent hypercapnia
- Increase IPAP and PEEP by 2cm H2O if persistent
hypoxemia
- Max IPAP limited to 20-25cm
- Max EPAP (PEEP) to 10-15cm
- FiO2 at 1.0, adjust based on O2 sat
- RR 12-16cpm

CHEST X-RAY
Anatomic structures to check:
1. Trachea/bronchi
2. Hilar structures
3. Lung zones
4. Pleura
5. Lung lobes/fissures
6. Costophrenic angles
7. Diaphragm
8. Heart
9. Mediastinum
10. Soft tissue
11. Bones

A - Apices
B - Bone/soft tissue
C - Cardiac shadow
D - Diaphragm
E - Edge of image

RESPIRATORY FAILURE
- Type 1:
Acute hypoxic
Alveolar flooding
- Type 2:
Hypercarbic
Alveolar hypoventilation
- Type 3:
Lung atelectasis
Perioperative respiratory failure
- Type 4:
Hypoperfusion of respiratory muscles in shock
Intubate/attach to MV

ACUTE LUNG INJURY/ARDS

ALI ARDS
PaO2/FiO2 PaO2/FiO2
O2
<300mmHg <200mmHg
Onset Acute
CXR Bilateral alveolar or interstitial infiltrates
No clinical evidence of increased LA
Left atrium
pressure or PCWP <18mmHg

Phases:
1. Exudative - 7 days
2. Proliferative - 7-21 days
3. Fibrotic - >24 days
Initial management:
Initiate TV <6ml/kg PBW
volume/pressure Plateau pressure <30cm H2O
limited ventilation RR <35cpm
FiO2 <0.6
Oxygen PEEP <10cm H2O
SpO2 88-95%
pH >7.30
Minimize acidosis
RR <135cpm
MAP >65mmHg
Diuresis
Avoid hypoperfusion

SEPSIS
 SIRS: 2 or more of the following:
- Temp >38C or <36C
- RR >24cpm
- HR >90bpm
- WBC >12K or <4K or bands >10%
 Sepsis: SIRS + proven or suspected microbial
etiology

 Severe sepsis: organ dysfunction

- Cardio: SBP <90mmHg, MAP <70, responds to
fluids
- Renal: UO <0.5ml/kg/hr for 1hr despite fluids
- Respi: PaO2/FiO2 <250 or lung only <200
- Hema: Plt <80K or 50% decrease from highest
recorded within 2 days
- Unexplained metabolic acidosis: pH <7.30 or base
deficit >5meq/L and plasma lactate >1.5 x upper
limit
- Adequate fluid resuscitation: PAWP >12mmHg or
CVP >8mmHg
 Septic shock: SBP <90 or 40mmHg from normal for
at least 1hr despite fluids or need for vasopressors
 Refractory septic shock: septic shock >1hour
duration and unresponsive to fluids or vasopressors

CURB-65
C - Confusion
U - Urea >7mmol/L
R - RR >30cycles/min
B - BP <90/<60mmHg
65 - >65yo

Score (30-day mortality):

0 - 1.5%
2 - 9.2% Advise admission
>3 - 22% Advise ICU admission

CARDIAC DIAGNOSIS
1. Underlying etiology (congenital, hypertensive,
ischemic, inflammatory)
2. Anatomical abnormality (chambers, hypertrophy,
dilation, valves affected, regurgitation or stenotic,
pericardial involvement MI
3. Physiological abnormalities (arrhythmia, CHF, or MI
evidence)
4. Functional breathing (NYHA class)

HEART FAILURE
NYHA Classification:
I – No limitation of physical activity
II – Slight limitation of physical activity
III – Marked limitation
IV – Symptoms persist even at rest, unable to
carry out activity without discomfort

Stages:
A – At risk for heart failure, have no structural
heart disease or symptoms of HF
B – Have structural heart disease but no
symptoms of HF
C – Have structural heart disease and symptoms
of HF
D – Refractory HF requiring specialized
intervention

TARGET BP GOALS
- Hypertensive encephalopathy: MAP decrease by
max of 20% or to DBP 100-110mmHg within first
hour then gradual reduction in BP to normal range
over 48-72hrs
- Ischemic stroke: MAP decrease no more than 15-
20%, DBP not less than 100-110mmHg in first
24hrs
- Ischemic stroke post tPA: SBP <185mmHg or DBP
<100mmHg
- Intracerebral hemorrhage: MAP lowered by 20-25%
- Hypertensive retinopathy: MAP lowered by 20-25%
- LV failure: MAP to 60-100mmHg
- Aortic dissection: SBP 100-120mmHg
- Acute renal insufficiency: MAP lowered by 20-25%
- Pregnancy-induced HTN: SBP 130-150mmHg and
DBP 80-100mmHg
- Postop HTN: MAP lowered by 20-25%
- Myocardial ischemia infarct: MAP 60-100mmHg
- Hyperadrenergic states: MAP lowered by 20-25%

CHA2DS2-VASC (STROKE RISK ASSESSMENT)

Points Thromboprophylaxis
C – CHF/LV 1 Risk score
dysfunction
H – Hypertension 1 Risk score
2
A – Age >75yo Anticoagulant
(major)
D – Diabetes
1 Risk score
Mellitus
2
S – Stroke/TIA/TE Anticoagulant
(major)
V – Vascular
disease (MI, 1 Risk score
PAOD, etc)
A – Age 65-74yo 1 Risk score
SC – Sex category
1 Risk score
(Female )

Score Stroke rate Thromboprophylaxis

0 0 Aspirin or None
1 1.3 Anticoagulant > Aspirin
2 2.2 Anticoagulant
3 3.2 Anticoagulant
4 4.0 Anticoagulant
5 6.7 Anticoagulant
6 9.8 Anticoagulant
7 9.6 Anticoagulant
8 6.7 Anticoagulant
9 15.2 Anticoagulant
HAS-BLED (BLEEDING RISK SCORE)
Risk factor Points
H – Hypertension 1
A – Abnormal liver and renal failure (1
1 or 2
point each)
S – Stroke 1
B – Bleeding 1
L – Labile INR (unstable/high) 1
E – Elderly (>65yo) 1
D – Drugs or alcohol (1 point each) 1 or 2

Score Bleeds/100 patients

0 1.13
1 1.02
2 1.88
3 3.74
4 8.70
5 12.5
Any score 1.56

FRAMINGHAM CRITERIA (HEART FAILURE)

2 major or 1 major + 2 minor

Major:
- PND
- Weight loss of 4.5kg in 5 days in response to
treatment
- NV distention
- Rales
- Acute pulmonary edema
- Hepatojugular reflux
- S3 gallop
- CVP >16 cm H2O
- Circulation time of 25 secs
- Radiographic cardiomegaly
- Pulmonary edema, visceral congestion, or
cardiomegaly at autopsy

Minor:
- Nocturnal cough
- Dyspnea on ordinary exertion
- Pleural effusion
- Tachycardia (>120bpm)
- Bilateral edema
- Decrease in vital capacity by 1/3 of maximal
recorded

ANKLE-BRACHIAL PRESSURE INDEX (ABI)

0.9 to 1.2 – Normal
>1.3 – Incompressible
0.4 to 0.9 – Mild to moderate arterial disease
0 to 0.4 – Severe arterial disease
INTRACEREBRAL HEMORRHAGE (ICH) SCORING
Walk Independently
Score 30-day Mortality
at 12 months
0 0% 70%
1 13% 60%
2 26% 33%
3 72% 3%
4 99% 8%
5 100% None

Age
<80 years 0
>80 years 1
Hematoma volume
<30 cc 0
>30 cc 1
Intraventricular hemorrhage
No 0
Yes 1
Infratentorial Origin
No 0
Yes 1
GCS
13-15 0
5-12 1
3-4 2
ECG NOTES
1. Standardization
2. Rhythm
3. Rate
4. PR/AV conduction
5. QRS interval
6. QT/QTc
7. Mean QRS axis
8. P waves
9. QRS voltages
10. R wave progression
11. Abnormal Q waves
12. ST segments
13. T waves
14. U waves

A. Rate
B. Rhythm
C. Axis
D. P wave
E. PR interval
F. QRS complex (axis, voltage, duration, morphology)
G. ST segment
H. T wave
I. QT interval
J. U wave

Small square – 0.04 sec/1 mm /1 mV

Big square – 0.20 sec/5 mm/5 mV
Normal Values:
P wave (at lead II 15°-75°) : Not >0.11 sec
Not >2.4 mm
QRS complex : 0.04-0.11 sec
QT interval : 0.36-0.44 sec or ½ of R-R
QTc : QT / √R-R
: <0.44 sec
Heart Rate:
1 – 300
2 – 150
3 – 100
4 – 75
5 – 60
6 – 50

Axis
I aVF II
Normal + +
Normal + - +
Left axis
deviation + - -
Right axis
deviation - +
Far right or
far left - -

Sinus arrhythmia
- P wave followed by QRS
- P-P or R-R vary (>0.16 sec, > 4 small squares)
- P-R interval is normal (0.12-2.0 sec)
- ST segment – normal is sinoelectric, not >1 mm
above or below
- Axis -0.3 to wide eyes
 - >1/3 QT
- Significant Q wave (>0.04 mm wide, 1/3 of R wave)
- R wave 30° to (+) 90°

Chamber Abnormalities
I. Right atrial abnormality
>2.5 mm in lead II, III, or aVF
Peaked morphology
II. Left atrial abnormality
Wide (>40 ms), deep (>1 mm) in V1
Double humped P wave and >130 ms in lead
II, III, aVF (present also in mitral disease)
III. Biatrial abnormality
Combo of tall P waves in lead II, III, aVF
Terminal negative in V1
IV. RVH
Suggested by:
Right axis deviation >90°
Tall R wave in V1 (>7 mm)
R wave in V1 and S wave in V6 >10 mm
R/S ratio in V1 >1
Incomplete RBBB pattern
Right atrial abnormality
S>R in V6
Diagnosis requires exclusion of other causes of tall
R wave in V1
RVH is acquired in pulmonary diseases
Deep S waves across precordium
R wave transition delayed
Right axis deviation and RAA present
Low voltage may be present
V. LVH
Precordial leads (any)
S wave in V1 and R wave in V6 or V5 >35 mm
R wave in V5 or V6 >26 mm
Limb leads (any)
R wave in lead I >14 mm
R wave in aVL >11 mm
LVH frequently accompanied by
ST-T wave abnormality (Strain pattern or
repolarization abnormality)
Low voltage
No QRS with >0.1 mV (10 mm) or no limb
QRS >0.05 mV

Prognostic Criteria for LVH

 Sokolow-Lyon voltage
S in V1 + R in V5 >3.5 mV
R in aVL >1.1 mV
 Cornell voltage
S in V3 + R in aVL >2.8 mV (men)/2.0
(women)
 Romhilt-Estes point score system
Any limb lead R or S wave >2.0 mV (3 points)
S in V1 or S in V2 >3.0 mV (3 points)
R in V5 to V6 >3.0 mV (3 points)
ST-T wave abnormality with no digitalis (3
points)
ST-T wave abnormality with digitalis (1 point)
LAA (3 points)
Left axis deviation >90° (2 points)
QRS >90 ms (1 point)
Intrinsicoid deflection in V5 or V6 >50 ms (1
point)
- Probable LVH if 4 points
 - Definitive LVH >5 points

Intraventricular Conduction Delays (IVCD)

I. RBBB
QRS >120 ms
RSR in V1, V2, or V3R (initial R is missing in
concomitant anteroseptal MI)
Delayed intrinsicoid deflection time in V1, V2,
V3R
Wide S wave in lead I and V6
II. LBBB
QRS >120 ms
Delayed intrinsicoid deflection time lead I and
V6
Broad monophasic R wave in lead I and V6
III. Nonspecific IVCD
QRS >120 ms
QRS fits neither RBBB or LBBB
IV. Left anterior fascicular block (LAFB)
Left axis deviation >45°
Tiny Q in lead I and aVL
Usually slightly prolonged QRS (>90 ms)
No other causes for LAD
V. Left posterior fascicular block (LPFB)
Right axis deviation >100°
Deep S wave in lead I and a small D wave in
lead III

NORMAL VALUES
SGPT 5 – 50
U/L
Alkaline Phosphatase 45 – 125 IU/L
Total Bilirubin 0–1
mg/dl
Direct Bilirubin 0 – 0.3
mg/ dl
Indirect Bilirubin 0 – 0.7
mg/dl
Albumin 3.5 – 5
g/dl
GGT 7 – 72
U/L

Protime
Activity > 70%
INR <= 1.21

TSH 0.3 – 5 µIU/ml

FT4 11-22.5 pmol/L

HbA1C (new) 2.9 – 4.2 %

HbA1C (old) 4.8 – 5.9 %

FBS 60 – 100 mg/dl

Total Cholesterol 150 – 240 mg/dl
Triglycerides 45 – 150 mg/dl
VLDL <40 mg/dl
LDL <150 mg/dl
HDL 30 – 90 mg/dl

Creatinine 0.6 – 1.5 mg/dl

Na+ 134 – 148 mmol/L
K+ 3.3 – 5.3 mmol/L
BUN 6 – 25
Uric Acid 3–8 mg/dl

CBC
WBC 4.8-10.8 10^3/uL
RBC 4.2-5.4 10^6/uL
Hgb 12.0-16.0 g/dL
Hct 37.0-47.0 %
Plt 130-400 10^3/uL

Neu 40 – 74
Lym 19 – 48
Mono 3.4 – 9.0
Eos 0–7
Baso 0 – 1.5

TARGET WITHIN 6 HOURS OF SHOCK

- UO > 0.5ml/kg/hr
- MAP > 65mmHg
- CVP 8-12 mmHg
- CVO2 > 70% of mixed venous > 65%

LIVER WORK-UP
Protime
TB, DB, IB
Alkaline phosphatase
SGPT (ALT)
GGT
Albumin

* Increased GGT = liver cause

Decreased GGT = bone cause
TRANSFUSION INDICATED IN Hgb LEVEL
Cardiac <10 mg/dL
CKD 10-12
Cardiac 7-8
N0 males 14-18
0
N females 12-16

1 unit PRBC transfused = increase in Hgb 1mg/dl or Hct

3%
FFP dose 12-15ml/kg

ACLS
Reversible causes:
Hypovolemia Tension pneumothorax
Hypoxia Tamponade, cardiac
Hydrogen ions (acidosis) Toxins
Hypo/hyperkalemia Thrombosis,
pulmonary
Hypothermia Thrombosis, coronary

Cardiac arrest
- Ventricular fibrillation/Pulseless ventricular
tachycardia
Shock: 120-200J (biphasic), 360J
(monophasic)
Drugs: Epinephrine 1mg q3-5 mins
Vasopressin 40U to replace first
and second doses of Epinephrine
Amiodarone 300mg bolus (first
dose) then 150mg (second dose)
 Lidocaie 1 to 1.5mg/kg (first dose)
then 0.5-0.75mg/kg (second dose
for refractory VT/VF)
- Asystole/Pulseless electrical activity (PEA)
CPR and Epinephrine

Tachyarrhythmias with pulse

- Stable narrow QRS
Regular: SVT
Vagal maneuvers
Adenosine 6mg rapid IV then 20cc
NSS flush, then may give second
dose of 12mg Adenosine
Irregular: AF, atrial flutter, MAT
Diltiazem 0.25mg/kg IV over 2
mins then 0.35mg/kg after 15
mins
Metoprolol 5mg IV q5 mins x 3
doses
Esmolol 500mcg/kg IV over 1 min
Atenolol 2.5-5mg IV over 2 mins
Digoxin 0.5mg IV
- Stable wide QRS
Regular: VT
Amiodarone 150mg IV over 20
mins then repeat PRN with max
dose 2-2.5g in 24hrs
Ready synchronized cardioversion
SVT with aberrancy give
Adenosine
Irregular: consider AF
Pre-excited AF/WPW
Avoid Adenosine,
Digoxin, Diltiazem, and
Verpamil
Consider Amiodarone
Torsades
 Magnesium 1-2g over
5 mins then give
infusion
- Unstable (hypotension, signs of shock, neurologic
changes, ischemic chest pain, acute heart failure)
Synchronized cardioversion
Sedate: Midazolam 2.5mg IV or Diazepam
5mg IV
Narrow regular (atrial flutter, SVT): 50-100J
Narrow irregular (AF): 200J (monophasic),
120-200J (biphasic)
Wide regular (monomorphic VT): 100J
Wide irregular (polymorphic VT): defibrillate!

Infusions for stable wide QRS tachyarrhythmias

- Amiodarone
First dose: 150mg over 10 mins
Second dose: May repeat 150mg then start
infusion of 1mg/min to run in 6 hours then
0.5mg/min
- Lidocaine
Initial bolus 1-1.5mg/kg IV then additional
bolus 0.5-0.75mg/kg over 3-5 mins

- Procainamide
20-50mg/min, max dose 17mg/kg
Maintenance infusion of 1-4mg/min
Avoid if prolonged QT or CHF
- Verapamil (CCB)
2.5-5mg over 2 mins IV then maintenance
every 15-30 mins to max dose of 20mg
- Esmolol (BB)
0.5mg/kg loading dose then maintenance of
50mcg/min
Second dose 0.5mg/kg in 1 min every 4 mins
to max dose of 300mcg/kg/min

Bradyarrhythmia with pulse

- Stable: observe and identify cause
- Unstable:
Atropine IV 0.5mg bolus q3-5 mins to max
dose of 3mg
Dopamine infusion 2-10mcg/kg/min
Epinephrine infusion 2-10mcg/min
Transcutaneous pacing
Transvenous pacing

Indications for synchronized cardioversion

Unstable SVT due to reentry
Unstable atrial fibrillation
Unstable atrial flutter
Unstable monophasic VT