ST-Segment Elevation Myocardial Infarction

1. Admit to: Coronary care unit

2. Diagnosis: Rule out myocardial infarction 3 Condition:

1. Vital Signs: q1h. Call(Buy now from http://www.drugswell.com) physician if pulse >90,<60; BP >150/90,<90/60; R>25, <12; T >38.5°C.

2. Activity: Bed rest with bedside commode.

1. Nursing: Guaiac stools. If patient has chest pain, obtain 12lead ECG and Call(Buy now from http://www.drugswell.com) physician.

2. Diet: Cardiac diet, 1-2 gm sodium, low-fat, low-cholesterol diet.No caffeine or temperature extremes.

1. IV Fluids: D5W at TKO

2. Special Medications:

-Oxygen 2-4 L/min by NC.

-Aspirin 325 mg PO, chew and swallow immediately, then aspirinEC 162 mg PO qd OR Clopidogrel (Plavix) 75 mg PO qd (if allergic to aspirin).

-Nitroglycerin 10 mcg/min infusion (50 mg in 250-500 mL D5W,100-200 mcg/mL). Titrate to control symptoms in 5-10 mcg/minsteps, up to 1-3 mcg/kg/min; maintain systolic BP >90 OR

-Nitroglycerin SL, 0.4 mg (0.15-0.6 mg) SL q5min until pain free(up to 3 tabs) OR -Nitroglycerin spray (0.4 mg/aerosol spray) 1-2 sprays under thetongue q 5min; may repeat x 2.

-Heparin 60 U/kg IV (max 4000 U) push, then 12 U/kg/hr (max1000 U/hr) by continuous IV infusion for 48 hours to maintainaPTT of 50-70 seconds. Check aPTTq6h x 4, then qd. RepeataPTT 6 hours after each heparin dosage change.

Thrombolytic Therapy (within first 6 hours of onset of chestpain)

Absolute Contraindications to Thrombolytics: Active internal bleeding, suspected aortic dissection, known intracranialneoplasm, previous intracranial hemorrhagic stroke at anytime, other strokes or cerebrovascular events within 1 year,head trauma, pregnancy, recent non-compressible vascularpuncture, uncontrolled hypertension (>180/110 mm Hg).

Relative Contraindications to Thrombolytics: Severe hypertension, cerebrovascular disease, recent surgery (within 2weeks), cardiopulmonary resuscitation.

A. Alteplase (tPA, tissue plasminogen activator, Activase):

1. 15 mg IV push over 2 min, followed by 0.75 mg/kg (max 50mg) IV infusion over 30 min, followed by 0.5 mg/kg (max 35mg) IV infusion over 60 min (max total dose 100 mg).

2. Labs: INR/PTT, CBC, fibrinogen.

B. Reteplase (Retavase):

1. 10 U IV push over 2 min; repeat second 10 U IV push after30 min.

2. Labs: INR, aPTT, CBC, fibrinogen.

C. Tenecteplase (TNKase): <60 kg 30 mg IVP60-69 kg 35 mg IVP70-79 kg 40 mg IVP80-89 kg 45 mg IVP$90 kg 50 mg IVP

C. Streptokinase (Streptase):

1. 1.5 million IU in 100 mL NS IV over 60 min. Pretreat with diphenhydramine (Benadryl) 50 mg IV push AND Methylprednisolone (Soln-Medrol) 250 mg IV push.

2. Check baseline fibrinogen level and q6h for 24h until level>100 mg/dL.

3. No IM or arterial punctures, watch IV for bleeding.Beta-Blockers (within the first 12 hours of onset of chestpain): Contraindicated in cardiogenic shock.

-Metoprolol (Lopressor) 5 mg IV q2-5min x 3 doses; then 25 mgPO q6h for 48h, then 100 mg PO q12h; hold if heart rate<60/min or systolic BP <100 mm Hg OR

-Atenolol (Tenormin), 5 mg IV, repeated in 5 minutes, followedby 50-100 mg PO qd OR

-Esmolol (Brevibloc) 500 mcg/kg IV over 1 min, then 50mcg/kg/min IV infusion, titrated to heart rate >60 bpm (max300 mcg/kg/min).

Angiotensin Converting Enzyme Inhibitor (within the first 24hours of onset of chest pain):

-Lisinopril (Zestril, Prinivil) 2.5-5 mg PO qd; titrate to 10-20 mgqd.

Long-Acting Nitrates:-Nitroglycerin patch 0.2 mg/hr qd. Allow for nitrate-free period toprevent tachyphylaxis.-Isosorbide dinitrate (Isordil) 10-60 mg PO tid [5,10,20, 30,40mg] OR -Isosorbide mononitrate (Imdur) 30-60 mg PO qd.

Aldosterone Receptor Blocker if EF <40%:

-Eplerenone (Inspra) 24 mg PO qd

-Spironolactone (Aldactone) 25 mg PO qd

Statins: -Rosuvastatin (Crestor) 10 mg PO qhs OR -Atorvastatin (Lipitor) 10 mg PO qhs OR -Pravastatin (Pravachol) 40 mg PO qhs OR -Simvastatin (Zocor) 40 mg PO qhs OR -Lovastatin (Mevacor) 20 mg PO qhs OR -Fluvastatin (Lescol)10-20 mg PO qhs.

11. Symptomatic Medications:

-Morphine sulfate 2-4 mg IV push prn chest pain.-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn head

ache. -Lorazepam (Ativan) 1-2 mg PO tid-qid prn anxiety-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.-Docusate (Colace) 100 mg PO bid.-Ondansetron (Zofran) 2-4 mg IV q4h prn nausea or vomiting.-Famotidine (Pepcid) 20 mg IV/PO bid OR -Lansoprazole (Prevacid) 30 mg qd.

1. Extras: ECG stat and in 12h and in AM, portable CXR, impedance cardiography, echocardiogram. Cardiology consult.

2. Labs: SMA7 and 12, magnesium. Cardiac enzymes: CPK,CPK-MB, troponin, myoglobin STAT and q8h x 3. CBC,INR/PTT, UA.

Non-ST Segment Elevation MyocardialInfarction (NSTEMI) and Unstable Angina

1. Admit to: Coronary care unit

2. Diagnosis: Acute coronary syndrome 3 Condition:

1. Vital Signs: q1h. Call(Buy now from http://www.drugswell.com) physician if pulse >90,<60; BP >150/90,<90/60; R>25, <12; T >38.5°C.

2. Activity: Bed rest with bedside commode.

1. Nursing: Guaiac stools. If patient has chest pain, obtain 12lead ECG and Call(Buy now from http://www.drugswell.com) physician.

2. Diet: Cardiac diet, 1-2 gm sodium, low fat, low cholesterol. Nocaffeine or temperature extremes.

1. IV Fluids: D5W at TKO

2. Special Medications:

-Oxygen 2-4 L/min by NC. -Aspirin 325 mg PO, chew and swallow immediately, then

aspirin EC 162 mg PO qd OR -Clopidogrel (Plavix) 75 mg PO qd (if allergic to aspirin) OR -Aspirin 325 mg to chew and swallow, then 81-162 mg PO qd

PLUS clopidogrel 300 mg PO x 1, then 75 mg PO qd.

-Nitroglycerin infusion 10 mcg/min infusion (50 mg in 250-500mL D5W, 100-200 mcg/mL). Titrate to control symptoms in5-10 mcg/min steps, up to 1-3 mcg/kg/min; maintain systolicBP >90 OR

-Nitroglycerin SL, 0.4 mg mg SL q5min until pain-free (up to 3tabs) OR -Nitroglycerin spray (0.4 mg/aerosol spray) 1-2 sprays underthe tongue q 5min; may repeat 2 times.

-Heparin 60 U/kg IV push, then 15 U/kg/hr by continuous IVinfusion for 48 hours to maintain aPTT of 50-70 seconds. Check aPTTq6h x 4, then qd. Repeat aPTT 6 hours aftereach dosage change.

Glycoprotein II_b/III_a Blockers in High-Risk Patients and Thosewith Planned Percutaneous Coronary Intervention (PCI): -Eptifibatide (Integrilin) 180 mcg/kg IVP, then 2 mcg/kg/min for 48-72 hours OR -Tirofiban (Aggrastat) 0.4 mcg/kg/min for 30 min, then 0.1mcg/kg/min for 48-108 hours.

Glycoprotein IIb/IIIa Blockers for Use During PCI: -Abciximab (ReoPro) 0.25 mg/kg IVP, then 0.125 mcg/kg/minIV infusion for 12 hours OR -Eptifibatide (Integrilin) 180 mcg/kg IVP, then 2 mcg/kg/min for 18-24 hours. Beta-Blockers: Contraindicated in cardiogenic shock.

-Metoprolol (Lopressor) 5 mg IV q2-5min x 3 doses; then 25mg PO q6h for 48h, then 100 mg PO q12h; keep HR<60/min, hold if systolic BP <100 mm Hg OR

-Atenolol (Tenormin), 5 mg IV, repeated in 5 minutes, followedby 50-100 mg PO qd OR

-Esmolol (Brevibloc) 500 mcg/kg IV over 1 min, then 50mcg/kg/min IV infusion, titrated to heart rate >60 bpm (max300 mcg/kg/min).

Angiotensin Converting Enzyme Inhibitors:

-Lisinopril (Zestril, Prinivil) 2.5-5 mg PO qd; titrate to 10-20 mg

qd. -Benazepril (Lotensin) 10 mg qd OR -Rampril (Altace) 5-10 mg qd OR -Perindopril (Aceon) 4-8 mg qd.

Long-Acting Nitrates:

-Nitroglycerin patch 0.2 mg/hr qd. Allow for nitrate-free periodto prevent tachyphylaxis.-Isosorbide dinitrate (Isordil) 10-60 mg PO tid [5,10,20, 30,40mg] OR -Isosorbide mononitrate (Imdur) 30-60 mg PO qd.

Statins: -Rosuvastatin (Crestor) 10 mg PO qd OR -Atorvastatin (Lipitor) 10 mg PO qhs OR -Pravastatin (Pravachol) 40 mg PO qhs OR -Simvastatin (Zocor) 40 mg PO qhs OR -Lovastatin (Mevacor) 20 mg PO qhs OR -Fluvastatin (Lescol)10-20 mg PO qhs.

11. Symptomatic Medications:

-Morphine sulfate 2-4 mg IV push prn chest pain.-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn head

ache. -Lorazepam (Ativan) 1-2 mg PO tid-qid prn anxiety. -Zolpidem (Ambien) 5-10 mg qhs prn insomnia. -Docusate (Colace) 100 mg PO bid. -Ondansetron (Zofran) 2-4 mg IV q4h prn N/V. -Famotidine (Pepcid) 20 mg IV/PO bid OR -Lansoprazole (Prevacid) 30 mg qd.

1. Extras: ECG stat and in 12h and in AM, portable CXR,impedance cardiography, echocardiogram. Cardiology consult.

2. Labs: SMA7 and 12, magnesium. Cardiac enzymes: CPK,CPK-MB, troponin, myoglobin STAT and q6h for 24h. CBC,INR/PTT, UA.

Congestive Heart Failure

1. Admit to:

2. Diagnosis: Congestive Heart Failure

3. Condition:

4. Vital Signs: q1h. Call(Buy now from http://www.drugswell.com) physician if P >120; BP >150/100<80/60; T >38.5EC; R >25, <10.

1. Activity: Bed rest with bedside commode.

2. Nursing: Daily weights, measure inputs and outputs. Head-ofbed at 45 degrees, legs elevated.

3. Diet: 1-2 gm salt, cardiac diet.

4. IV Fluids: Heparin lock with flush q shift.

9. Special Medications:

-Oxygen 2-4 L/min by NC.

Diuretics: -Furosemide (Lasix) 10-160 mg IV qd-bid or 20-80 mg POqAM-bid [20, 40, 80 mg] or 10-40 mg/hr IV infusion OR -Torsemide (Demadex) 10-40 mg IV or PO qd; max 200mg/day [5, 10, 20, 100 mg] OR -Bumetanide (Bumex) 0.5-1 mg IV q2-3h until response; then0.5-1.0 mg IV q8-24h (max 10 mg/d); or 0.5-2.0 mg PO qAM.-Metolazone (Zaroxolyn) 2.5-10 mg PO qd, max 20 mg/d; 30min before loop diuretic [2.5, 5, 10 mg].

ACE Inhibitors: -Quinapril (Accupril) 5-10 mg PO qd x 1 dose, then 20-80 mgPO qd in 1 to 2 divided doses [5, 10, 20, 40 mg] OR -Lisinopril (Zestril, Prinivil) 5-40 mg PO qd [5, 10, 20, 40 mg]OR -Benazepril (Lotensin) 10-20 mg PO qd-bid, max 80 mg/d [5,10, 20, 40 mg] OR -Fosinopril (Monopril) 10-40 mg PO qd, max 80 mg/d [10, 20mg] OR -Ramipril (Altace) 2.5-10 mg PO qd, max 20 mg/d [1.25, 2.5, 5,10 mg].-Captopril (Capoten) 6.25-50 mg PO q8h [12.5, 25,50,100 mg]OR -Enalapril (Vasotec) 1.25-5 mg slow IV push q6h or 2.5-20 mgPO bid [5,10,20 mg] OR -Moexipril (Univasc) 7.5 mg PO qd x 1 dose, then 7.5-15 mgPO qd-bid [7.5, 15 mg tabs] OR -Trandolapril (Mavik) 1 mg qd x 1 dose, then 2-4 mg qd [1, 2, 4mg tabs].

Angiotensin-II Receptor Blockers:-Irbesartan (Avapro) 150 mg qd, max 300 mg qd [75, 150, 300mg].-Losartan (Cozaar) 25-50 mg bid [25, 50 mg].-Valsartan (Diovan) 80 mg qd; max 320 mg qd [80, 160 mg].-Candesartan (Atacand) 8-16 mg qd-bid [4, 8, 16, 32 mg].-Telmisartan (Micardis) 40-80 mg qd [40, 80 mg].

Adosterone Receptor Blockers:

-Spironolactose (Aldactone) 25 mg PO qd

-Eplerenone (Inspra) 25 mg PO qd.

Beta-Blockers: -Carvedilol (Coreg) 1.625-3.125 mg PO bid, then slowly increase the dose every 2 weeks to target dose of 25-50 mgbid [tab 3.125, 6.25, 12.5, 25 mg] OR -Metoprolol (Lopressor) start at 12.5 mg bid, then slowly increase to target dose of 100 mg bid [50, 100 mg] OR -Bisoprolol (Zebeta) start at 1.25 mg qd, then slowly increaseto target of 10 mg qd [5,10 mg] OR -Metoprolol XL (Toprol XL) 50-100 mg PO qd.

Digoxin (Lanoxin) 0.125-0.25 mg PO or IV qd [0.125, 0.25, 0.5

mg].

Inotropic Agents:-Dobutamine (Dobutrex) 2.5-10 mcg/kg/min IV, max of 14mcg/kg/min (500 mg in 250 mL D5W, 2 mcg/mL) OR -Dopamine (Intropin) 3-15 mcg/kg/min IV (400 mg in 250 ccD5W, 1600 mcg/mL), titrate to CO >4, CI >2; systolic >90OR -Milrinone (Primacor) 0.375 mcg/kg/min IV infusion (40 mg in200 mL NS, 0.2 mg/mL); titrate to 0.75 mgc/kg/min;arrhythmogenic; may cause hypotension.

Vasodilators: -Nitroglycerin 5 mcg/min IV infusion (50 mg in 250 mL D5W).Titrate in increments of 5 mcg/min to control symptoms andmaintain systolic BP >90 mmHg.-Nesiritide (Natrecor) 2 mcg/kg IV load over 1 min, then 0.010mcg/kg/min IV infusion. Titrate in increments of 0.005mcg/kg/min q3h to max 0.03 mcg/kg/min IV infusion.

Potassium:

-KCL (Micro-K) 20-60 mEq PO qd if the patient is taking

loop diuretics.

Pacing:-Synchronized biventricular pacing if ejection fraction <40%and QRS duration >135 msec.

10. Symptomatic Medications:-Morphine sulfate 2-4 mg IV push prn dyspnea or anxiety.-Heparin 5000 U SQ q12h or enoxaparin (Lovenox) 1 mg/kgSC q12h.-Docusate (Colace) 100-200 mg PO qhs.-Famotidine (Pepcid) 20 mg IV/PO q12h OR -Lansoprazole (Prevacid) 30 mg qd.

1. Extras: CXR PA and LAT, ECG now and repeat if chest painor palpitations, impedance cardiography, echocardiogram.

2. Labs: SMA 7&12, CBC; B-type natriuretic peptide (BNP), cardiac enzymes: CPK, CPK-MB, troponin, myoglobin STAT and q6hfor 24h. Repeat SMA 7 in AM. UA.

Supraventricular Tachycardia

1. Admit to:

2. Diagnosis: PSVT

3. Condition:

4. Vital Signs: q1h. Call(Buy now from http://www.drugswell.com) physician if BP >160/90, <90/60; apicalpulse >130, <50; R >25, <10; T >38.5EC

5. Activity: Bedrest with bedside commode.

6. Nursing

1. Diet: Low fat, low cholesterol, no caffeine.

2. IV Fluids: D5W at TKO.

9. Special Medications:Attempt vagal maneuvers (Valsalva maneuver) before drugtherapy.

Cardioversion (if unstable or refractory to drug therapy):

1. NPO for 6h, digoxin level must be less than 2.4 and potassium and magnesium must be normal.

2. Midazolam (Versed) 2-5 mg IV push.

3. If stable, cardiovert with synchronized 10-50 J, and increaseby 50 J increments if necessary. If unstable, start with 100 J,then increase to 200 J and 360 J.

Pharmacologic Therapy of Supraventricular Tachycardia:-Adenosine (Adenocard) 6 mg rapid IV over 1-2 sec, followedby saline flush, may repeat 12 mg IV after 2-3 min, up tomax of 30 mg total OR -Verapamil (Isoptin) 2.5-5 mg IV over 2-3 min (may give calcium gluconate 1 gm IV over 3-6 min prior to verapamil);then 40-120 mg PO q8h [40, 80, 120 mg] or verapamil SR120-240 mg PO qd [120, 180, 240 mg] OR -Esmolol(Brevibloc) 500 mcg/kg IV over 1 min, then 50mcg/kg/min IV infusion, titrated to HR of <80 (max of 300mcg/kg/min) OR -Diltiazem (Cardizem) 0.25 mg/kg IV over 2-5 minutes, followed by 5 mg/h IV infusion. Titrate to max 15 mg/h; thendiltiazem-CD (Cardizem-CD) 120-240 mg PO qd OR -Metoprolol (Lopressor) 5 mg IVP q4-6h; then 50-100 mg PObid, or metoprolol XL (Toprol-XL) 50-100 mg PO qd OR -Digoxin (Lanoxin) 0.25 mg q4h as needed; up to 1.0-1.5 mg;then 0.125-0.25 mg PO qd.

10.Symptomatic Medications:-Lorazepam (Ativan) 1-2 mg PO tid prn anxiety.

11.Extras: Portable CXR, ECG; repeat if chest pain. Cardiology

consult.

12.Labs: CBC, SMA 7 & 12, Mg, thyroid panel. UA.

Ventricular Arrhythmias

1. Ventricular Fibrillation and Tachycardia: -If unstable (see ACLS protocol): Defibrillate with unsynchronized 200 J, then 300 J.-Oxygen 100% by mask.-Lidocaine (Xylocaine) loading dose 75-100 mg IV, then 2-4mg/min IV OR

-Amiodarone (Cordarone) 300 mg in 100 mL of D5W, IV infusion over 10 min, then 900 mg in 500 mL of D5W, at 1mg/min for 6 hrs, then at 0.5 mg/min thereafter; or 400 mgPO q8h x 14 days, then 200-400 mg qd. -Also see “other antiarrhythmics” below.

2. Torsades de Pointes Ventricular Tachycardia:-Correct underlying causes, including hypomagnesemia, andhypokalemia, and consider discontinuing quinidine, procainamide, disopyramide, moricizine, amiodarone, sotalol,ibutilide, phenothiazine, haloperidol, tricyclic and tetracyclicantidepressants, ketoconazole, itraconazole, bepridil.-Magnesium sulfate 1-4 gm in IV bolus over 5-15 min, or infuse3-20 mg/min for 7-48h until QTc interval <440 msec.-Isoproterenol (Isuprel), 2-20 mcg/min (2 mg in 500 mL D5W,4 mcg/mL).-Consider ventricular pacing and/or cardioversion.

3. Other Antiarrhythmics:Class I:

-Moricizine (Ethmozine) 200-300 mg PO q8h, max 900 mg/d

[200, 250, 300 mg].

Class Ia: -Quinidine gluconate (Quinaglute) 324-648 mg PO q8-12h [324mg].-Procainamide (Procan, Procanbid)

IV: 15 mg/kg IV loading dose at 20 mg/min, followed by 2-4 mg/min continuous IV infusion. PO: 500 mg (nonsustained release) PO q2h x 2 doses, then Procanbid 1-2 gm PO q12h [500, 1000 mg].

-Disopyramide (Norpace, Norpace CR) 100-300 mg PO q6-8h[100, 150, mg] or disopyramide CR 100-150 mg PO bid[100, 150 mg].

Class Ib: -Lidocaine (Xylocaine) 75-100 mg IV, then 2-4 mg/min IV-Mexiletine (Mexitil) 100-200 mg PO q8h, max 1200 mg/d [150,200, 250 mg].-Tocainide (Tonocard) loading 400-600 mg PO, then 400-600mg PO q8-12h (1200-1800 mg/d) PO in divided doses q812h [400, 600 mg].-Phenytoin (Dilantin), loading dose 100-300 mg IV given as 50mg in NS over 10 min IV q5min, then 100 mg IV q5min prn.

Class Ic: -Flecainide (Tambocor) 50-100 mg PO q12h, max 400 mg/d[50, 100, 150 mg].-Propafenone (Rythmol) 150-300 mg PO q8h, max 1200 mg/d[150, 225, 300 mg].

Class II: -Propranolol (Inderal) 1-3 mg IV in NS (max 0.15 mg/kg) or 2080 mg PO tid-qid [10, 20, 40, 60, 80 mg]; propranolol-LA(Inderal-LA), 80-120 mg PO qd [60, 80, 120, 160 mg]-Esmolol (Brevibloc) loading dose 500 mcg/kg over 1 min, then50-200 mcg/kg/min IV infusion-Atenolol (Tenormin) 50-100 mg/d PO [25, 50, 100 mg].-Nadolol (Corgard) 40-100 mg PO qd-bid [20, 40, 80, 120, 160mg].-Metoprolol (Lopressor) 50-100 mg PO bid-tid [50, 100 mg], ormetoprolol XL (Toprol-XL) 50-200 mg PO qd [50, 100, 200mg].

Class III: -Amiodarone (Cordarone), PO loading 400-1200 mg/d in divided doses for 2-4 weeks, then 200-400 mg PO qd (5-10mg/kg) [200 mg] or amiodarone (Cordarone) 300 mg in 100mL of D5W, IV infusion over 10-20 min, then 900 mg in 500mL of D5W, at 1 mg/min for 6 hrs, then at 0.5 mg/min thereafter. -Sotalol (Betapace) 40-80 mg PO bid, max 320 mg/d in 2-3divided doses [80, 160 mg].

1. Extras: CXR, ECG, Holter monitor, signal averaged ECG,

2. cardiology consult.
1. Labs: SMA 7&12, Mg, calcium, CBC, drug levels. UA.

Hypertensive Emergencies

1. Admit to:

2. Diagnosis: Hypertensive emergencies

3. Condition:

4. Vital Signs: q30min until BP controlled, then q4h.

5. Activity: Bed rest

1. Nursing: Intra-arterial BP monitoring, daily weights, inputs and outputs.

2. Diet: Clear liquids.

8. IV Fluids: D5W at TKO.

9. Special Medications:-Nitroprusside sodium 0.25-10 mcg/kg/min IV (50 mg in 250mL of D5W), titrate to desired BP-Labetalol (Trandate, Normodyne) 20 mg IV bolus (0.25mg/kg), then 20-80 mg boluses IV q10-15min, titrate todesired BP or continuous IV infusion of 1.0-2.0 mg/min,titrate to desired BP. Ideal in patients with thoracic or aorticabdominal aneurysm.-Fenoldopam (Corlopam) 0.01mcg/kg/min IV infusion. Adjustdose by 0.025-0.05 mcg/kg/min q15min to max 0.3mcg/kg/min. [10 mg in 250 mL D5W].-Nicardipine (Cardene IV) 5 mg/hr IV infusion, increase rate by

2.5 mg/hr every 15 min up to 15 mg/hr (25 mg in D5W 250mL).

-Enalaprilat (Vasotec IV) 1.25- 5.0 mg IV q6h. Do not use inpresence of acute myocardial infarction or bilateral renalstenosis.

-Esmolol (Brevibloc) 500 mcg/kg/min IV infusion for 1 minute,then 50 mcg/kg/min; titrate by 50 mcg/kg/min increments to300 mcg/kg/min (2.5 gm in D5W 250 mL).

-Clonidine (Catapres), initial 0.1-0.2 mg PO followed by 0.1 mgper hour until DBP <115 (max total dose of 0.8 mg).-Phentolamine (pheochromocytoma), 5-10 mg IV, repeated asneeded up to 20 mg.-Trimethaphan (Arfonad [dissecting aneurysm]) 2-4 mg/min IVinfusion (500 mg in 500 mL of D5W).

10. Symptomatic Medications:

-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn head

ache.

-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.

-Docusate sodium (Colace) 100-200 mg PO qhs.

1. Extras: Portable CXR, ECG, impedance cardiography,echocardiogram.

2. Labs: CBC, SMA 7, UA with micro. TSH, free T4, 24h urine for metanephrine. Plasma catecholamines, urine drug screen.

Hypertension

I. Initial Diagnostic Evaluation of Hypertension

A. 15-Lead electrocardiography may document evidence ofischemic heart disease, rhythm and conduction disturbances, or left ventricular hypertrophy.

B. Screening labs. Complete blood count, glucose, potassium, calcium, creatinine, BUN, uric acid, and fasting lipidpanel.

C. Urinalysis. Glucose, protein, and hemoglobin.

D. Selected patients may require plasma renin activity, 24hour urine catecholamines.

II.

Antihypertensive Drugs

A.

Thiazide Diuretics

1. Hydrochlorothiazide (HCTZ, HydroDiuril), 12.5-25 mg qd [25 mg].

2. Chlorothiazide (Diuril) 250 mg qd [250, 500 mg].

3. Thiazide/Potassium Sparing Diuretic Combinations

a.

Maxzide (hydrochlorothiazide 50/triamterene 75 mg) 1 tab qd.

b.

Moduretic (hydrochlorothiazide 50 mg/amiloride 5mg) 1 tab qd.

c.

Dyazide (hydrochlorothiazide 25 mg/triamterene37.5) 1 cap qd.

B. Beta-Adrenergic Blockers

1. Cardioselective Beta-Blockers

a.

Atenolol (Tenormin) initial dose 50 mg qd, then 50100 mg qd, max 200 mg/d [25, 50, 100 mg].

b.

Metoprolol XL (Toprol XL) 100-200 mg qd [50, 100, 200 mg tab ER].

c.

Bisoprolol (Zebeta) 2.5-10 mg qd; max 20 mg qd [5,10 mg].

2. Non-Cardioselective Beta-Blockers

a.

Propranolol LA (Inderal LA), 80-160 mg qd [60, 80, 120, 160 mg].

b.

Nadolol (Corgard) 40-80 mg qd, max 320 mg/d [20,40, 80, 120, 160 mg].

c.

Pindolol (Visken) 5-20 mg qd, max 60 mg/d [5, 10 mg].

d.

Carteolol (Cartrol) 2.5-10 mg qd [2.5, 5 mg].

C. Angiotensin-Converting Enzyme (ACE) Inhibitors

1. Ramipril (Altace) 2.5-10 mg qd, max 20 mg/day [1.25, 2.5, 5, 10 mg].

2. Quinapril (Accupril) 20-80 mg qd [5, 10, 20, 40 mg].

3. Lisinopril (Zestril, Prinivil) 10-40 mg qd [2.5, 5, 10, 20, 40 mg].

4. Benazepril (Lotensin) 10-40 mg qd, max 80 mg/day [5, 10, 20, 40 mg].

5. Fosinopril (Monopril) 10-40 mg qd [10, 20 mg].

6. Enalapril (Vasotec) 5-40 mg qd, max 40 mg/day [2.5, 5, 10, 20 mg].

7. Moexipril (Univasc) 7.5-15 mg qd [7.5 mg].

D. Angiotensin Receptor Blockers

1. Losartan (Cozaar) 25-50 mg bid [25, 50 mg].

2. Valsartan (Diovan) 80-160 mg qd; max 320 mg qd [80, 160 mg].

1. Irbesartan (Avapro) 150 mg qd; max 300 mg qd [75,

2. 150, 300 mg].
3. Candesartan (Atacand) 8-16 mg qd-bid [4, 8, 16, 32 mg].

4. Telmisartan (Micardis) 40-80 mg qd [40, 80 mg].

E. Calcium Entry Blockers

1. Diltiazem SR (Cardizem SR) 60-120 mg bid [60, 90, 120 mg] or Cardizem CD 180-360 mg qd [120, 180, 240, 300 mg].

1. Nifedipine XL (Procardia-XL, Adalat-CC) 30-90 mg qd[30, 60, 90 mg].

2. Verapamil SR (Calan SR, Covera-HS) 120-240 mg qd[120, 180, 240 mg].

1. Amlodipine (Norvasc) 2.5-10 mg qd [2.5, 5, 10 mg].

2. Felodipine (Plendil) 5-10 mg qd [2.5, 5, 10 mg].

Syncope

1. Admit to: Monitored ward

2. Diagnosis: Syncope

1. Condition:

2. Vital Signs: q1h, postural BP and pulse q12h. Call(Buy now from http://www.drugswell.com) physician ifBP >160/90, <90/60; P >120, <50; R>25, <10

3. Activity: Bed rest.

1. Nursing: Fingerstick glucose.

2. Diet: Regular

3. IV Fluids: Normal saline at TKO.

4. Special medications: High-Grade AV Block with Syncope:

-Atropine 1 mg IV x 2.-Isoproterenol 0.5-1 mcg/min initially, then slowly titrate to 10mcg/min IV infusion (1 mg in 250 mL NS).-Transthoracic pacing. Drug-Induced Syncope:

-Discontinue vasodilators, centrally acting hypotensive agents,tranquilizers, antidepressants, and alcohol use.

Vasovagal Syncope:

-Scopolamine 1.5 mg transdermal patch q3 days.

Postural Syncope:-Midodrine (ProAmatine) 2.5 mg PO tid, then increase to 5-10mg PO tid [2.5, 5 mg]; contraindicated in coronary arterydisease. -Fludrocortisone 0.1-1.0 mg PO qd.

10. Symptomatic Medications:-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn headache. -Docusate sodium (Colace) 100-200 mg PO qhs.

1. Extras: CXR, ECG, 24h Holter monitor, electrophysiologicstudy, tilt test, CT/MRI, EEG, impedance cardiography,echocardiogram.

2. Labs: CBC, SMA 7&12, CPK, CK-MB, troponin, myoglobin,Mg, calcium, drug levels. UA, urine drug screen.

Pulmonary Disorders

Asthma

1. Admit to:

2. Diagnosis: Exacerbation of asthma

3. Condition:

4. Vital Signs: q6h. Call(Buy now from http://www.drugswell.com) physician if P >140; R >30, <10; T >38.5EC; pulse oximeter <90%

1. Activity: Up as tolerated.

2. Nursing: Pulse oximeter, bedside peak flow rate before andafter bronchodilator treatments.

3. Diet: Regular, no caffeine.

4. IV Fluids: D5 ½ NS at 125 cc/h.

9. Special Medications:

-Oxygen 2 L/min by NC. Keep O2 sat >90%.

Beta-Agonists, Acute Treatment:-Albuterol (Ventolin) 0.5 mg and ipratropium (Atrovent) 0.5 mgin 2.5 mL NS q1-2h until peak flow meter $200-250 L/min and sat $90%, then q4h OR -Levalbuterol (Xopenex) 0.63-1.25 mg by nebulization q6-8h prn.-Albuterol (Ventolin) MDI 3-8 puffs, then 2 puffs q3-6h prn, orpowder 200 mcg/capsule inhaled qid.-Albuterol/Ipratropium (Combivent) 2-4 puffs qid.

Systemic Corticosteroids:-Methylprednisolone (Solu-Medrol) 60-125 mg IV q6h; then 3060 mg PO qd. OR -Prednisone 20-60 mg PO qAM.

Aminophylline and Theophylline (second-line therapy):-Aminophylline load dose: 5.6 mg/kg total body weight in 100mL D5W IV over 20 min. Maintenance of 0.5-0.6 mg/kg ideal body weight/h (500 mg in 250 mL D5W); reduce if elderly,heart/liver failure (0.2-0.4 mg/kg/hr). Reduce load 50-75% iftaking theophylline (1 mg/kg of aminophylline will raise levels2 mcg/mL) OR -Theophylline IV solution loading dose 4.5 mg/kg total bodyweight, then 0.4-0.5 mg/kg ideal body weight/hr.-Theophylline (Theo-Dur) 100-400 mg PO bid (3 mg/kg q8h);80% of total daily IV aminophylline in 2-3 doses.

Maintenance Inhaled Corticosteroids (adjunct therapy):-Advair Diskus (fluticasone/salmeterol) one puff bid [doses of100/50 mcg, 250/50 mcg, and 500/50 mcg]. Not appropriatefor acute attacks. -Beclomethasone (Beclovent) MDI 4-8 puffs bid, with spacer 5min after bronchodilator, followed by gargling with water.-Triamcinolone (Azmacort) MDI 2 puffs tid-qid or 4 puffs bid.-Flunisolide (AeroBid) MDI 2-4 puffs bid.-Fluticasone (Flovent) 2-4 puffs bid (44 or 110 mcg/puff).

Maintenance Treatment: -Salmeterol (Serevent) 2 puffs bid; not effective for acuteasthma because of delayed onset of action.-Pirbuterol (Maxair) MDI 2 puffs q4-6h prn.

-Bitolterol (Tornalate) MDI 2-3 puffs q1-3min, then 2-3 puffs q4

8h prn. -Fenoterol (Berotec) MDI 3 puffs, then 2 bid-qid. -Ipratropium (Atrovent) MDI 2-3 puffs tid-qid.

Prevention and Prophylaxis:

-Cromolyn (Intal) 2-4 puffs tid-qid. -Nedocromil (Tilade) 2-4 puffs bid-qid. -Montelukast (Singulair) 10 mg PO qd. -Zafirlukast (Accolate) 20 mg PO bid. -Zileuton (Zyflo) 600 mg PO qid.

Acute Bronchitis -Ampicillin/sulbactam (Unasyn) 1.5 gm IV q6h OR -Cefuroxime (Zinacef) 750 mg IV q8h OR -Cefuroxime axetil (Ceftin) 250-500 mg PO bid OR -Trimethoprim/sulfamethoxazole (Bactrim DS), 1 tab PO bid

OR

-Levofloxacin (Levaquin) 500 mg PO/IV PO qd [250, 500 mg].-Amoxicillin 875 mg/clavulanate 125 mg (Augmentin 875) 1 tabPO bid.

10. Symptomatic Medications:

-Docusate sodium (Colace) 100 mg PO qhs. -Famotidine (Pepcid) 20 mg IV/PO q12h OR -Lansoprazole (Prevacid) 30 mg qd. -Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn head

ache. -Zolpidem (Ambien) 5-10 mg qhs prn insomnia.

1. Extras: Portable CXR, ECG, pulmonary function tests beforeand after bronchodilators; pulmonary rehabilitation; impedancecardiography, echocardiogram.

2. Labs: ABG, CBC with eosinophil count, SMA7, B-typenatriuretic peptide (BNP). Theophylline level stat and after 24h ofinfusion. Sputum Gram stain, C&S.

Chronic Obstructive Pulmonary Disease

1. Admit to:

2. Diagnosis: Exacerbation of COPD

3. Condition:

4. Vital Signs: q4h. Call(Buy now from http://www.drugswell.com) physician if P >130; R >30, <10; T >38.5EC; O2 saturation <90%.

1. Activity: Up as tolerated; bedside commode.

2. Nursing: Pulse oximeter. Measure peak flow with portablepeak flow meter bid and chart with vital signs. No sedatives.

3. Diet: No added salt, no caffeine. Push fluids.

4. IV Fluids: D5 1/2 NS with 20 mEq KCL/L at 125 cc/h.

9. Special Medications:

-Oxygen 1-2 L/min by NC or 24-35% by Venturi mask, keep O2saturation 90-91%.

Beta-Agonists, Acute Treatment:

-Albuterol (Ventolin) 0.5 mg and ipratropium (Atrovent) 0.5 mgin 2.5 mL NS q1-2h until peak flow meter $200-250 L/min, then q4h prn OR

-Levalbuterol (Xopenex) 0.63-1.25 mg by nebulization q6-8h

prn. -Albuterol (Ventolin) MDI 2-4 puffs q4-6h. -Albuterol/Ipratropium (Combivent) 2-4 puffs qid.

Maintenance Corticosteroids and Anticholinergics:

-Methylprednisolone (Solu-Medrol) 60-125 mg IV q6h or 3060 mg PO qd. Followed by:-Prednisone 20-60 mg PO qd.-Triamcinolone (Azmacort) MDI 2 puffs qid or 4 puffs bid.-Beclomethasone (Beclovent) MDI 4-8 puffs bid with spacer,

followed by gargling with water OR -Flunisolide (AeroBid) MDI 2-4 puffs bid OR -Ipratropium (Atrovent) MDI 2 puffs tid-qid OR -Fluticasone (Flovent) 2-4 puffs bid (44 or 110 mcg/puff).

Aminophylline and Theophylline (second line therapy):

-Aminophylline loading dose, 5.6 mg/kg total body weight over20 min (if not already on theophylline); then 0.5-0.6 mg/kgideal body weight/hr (500 mg in 250 mL of D5W); reduce ifelderly, or heart or liver disease (0.2-0.4 mg/kg/hr). Reduceloading to 50-75% if already taking theophylline (1 mg/kg ofaminophylline will raise levels by 2 mcg/mL) OR

-Theophylline IV solution loading dose, 4.5 mg/kg total bodyweight, then 0.4-0.5 mg/kg ideal body weight/hr.-Theophylline long acting (Theo-Dur) 100-400 mg PO bid-tid (3mg/kg q8h); 80% of daily IV aminophylline in 2-3 doses.

Acute Bronchitis

-Trimethoprim/sulfamethoxazole (Septra DS) 160/800 mg PO

bid or 160/800 mg IV q12h (10-15 mL in 100 cc D5W tid) OR -Cefuroxime (Zinacef) 750 mg IV q8h OR -Ampicillin/sulbactam (Unasyn) 1.5 gm IV q6h OR -Doxycycline (Vibra-tabs) 100 mg PO/IV bid OR -Azithromycin (Zithromax) 500 mg x 1, then 250 mg PO qd x 4

or 500 mg IV q24h OR -Clarithromycin (Biaxin) 250-500 mg PO bid OR -Levofloxacin (Levaquin) 500 mg PO/IV qd [250, 500 mg].

10. Symptomatic Medications:

-Docusate sodium (Colace) 100 mg PO qhs. -Famotidine (Pepcid) 20 mg IV/PO bid OR -Lansoprazole (Prevacid) 30 mg qd. -Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn head

ache. -Zolpidem (Ambien) 5-10 mg qhs prn insomnia.

1. Extras: Portable CXR, PFTs with bronchodilators, ECG, impedance cardiography, echocardiogram.

2. Labs: ABG, CBC, SMA7, UA. Theophylline level stat and after12-24h of infusion. Sputum Gram stain and C&S, alpha 1antitrypsin level.

Hemoptysis

1. Admit to: Intensive care unit

2. Diagnosis: Hemoptysis

1. Condition:

2. Vital Signs: q1-6h. Orthostatic BP and pulse bid. Call(Buy now from http://www.drugswell.com) physician if BP >160/90, <90/60; P >130, <50; R>25, <10; T>38.5EC; O2 sat <90%.

1. Activity: Bed rest with bedside commode. Keep patient inlateral decubitus, Trendelenburg’s position, bleeding sidedown.

2. Nursing: Quantify all sputum and expectorated blood, suction prn. O2 at 100% by mask, pulse oximeter. Discontinue narcotics and sedatives. Have double lumen endotracheal tube available for use. Foley to closed drainage.

1. Diet: NPO

2. IV Fluids: 1 L of NS wide open ($6 gauge), then transfusePRBC. Then infuse D5 1/2 NS at 125 cc/h.

9. Special Medications:-Transfuse 2-4 U PRBC wide open.-Promethazine/codeine (Phenergan with codeine) 5 cc PO q46h prn cough. Contraindicated in massive hemoptysis.-Initiate empiric antibiotics if bronchitis or infection is present.

1. Extras: CXR PA, LAT, ECG, VQ scan, contrast CT, bronchoscopy. PPD, pulmonary and thoracic surgery consults.

2. Labs: Type and cross 2-4 U PRBC. ABG, CBC, platelets,SMA7 and 12, ESR. Anti-glomerular basement antibody, rheumatoid factor, complement, anti-nuclear cytoplasmic antibody. Sputum Gram stain, C&S, AFB, fungal culture, and cytology qAM for 3days. UA, INR/PTT, von Willebrand Factor. Repeat CBC q6h.

Anaphylaxis

1. Admit to:

2. Diagnosis: Anaphylaxis

3. Condition:

4. Vital Signs: q1-4h; Call(Buy now from http://www.drugswell.com) physician if BP systolic >160, <90;diastolic >90, <60; P >120, <50; R>25, <10; T >38.5EC

5. Activity: Bedrest

6. Nursing: O2 at 6 L/min by NC or mask. Keep patient inTrendelenburg's position, No. 4 or 5 endotracheal tube atbedside. Foley to closed drainage.

1. Diet: NPO

2. IV Fluids: 2 IV lines. Normal saline or LR 1 L over 1-2h, then D5 ½ NS at 125 cc/h.

3. Special Medications:Gastrointestinal Decontamination:

-Gastric lavage with normal saline until clear fluid if indicatedfor recent oral ingestion.-Activated charcoal 50-100 gm, followed by magnesium citrate6% solution 150-300 mL PO.

Bronchodilators: -Epinephrine (1:1000) 0.3-0.5 mL SQ or IM q10min or 1-4mcg/min IV OR in severe life-threatening reactions, give 0.5mg (5.0 mL of 1: 10,000 solution) IV q5-10min prn. Epinephrine, 0.3 mg of 1:1000 solution, may be injected SQ at site ofallergen injection OR -Albuterol (Ventolin) 0.5%, 0.5 mL in 2.5 mL NS q30min bynebulizer prn OR -Aerosolized 2% racemic epinephrine, 0.5-0.75 mL in 2-3 mLsaline nebulized q1-6h.

Corticosteroids: -Methylprednisolone (Solu-Medrol) 250 mg IV x 1, then 125 mgIV q6h OR -Hydrocortisone sodium succinate 200 mg IV x 1, then 100 mgq6h, followed by oral prednisone 60 mg PO qd, tapered over5 days.

Antihistamines: -Diphenhydramine (Benadryl) 25-50 mg PO/IV q4-6h OR -Hydroxyzine (Vistaril) 25-50 mg IM or PO q2-4h.-Cetrizine (Zyrtec) 5-10 mg PO qd.-Cimetadine (Tagamet) 300 mg PO/IV q6-8h.

Pressors and Other Agents:-Norepinephrine (Levophed) 8-12 mcg/min IV, titrate to systolic100 mm Hg (8 mg in 500 mL D5W) OR -Dopamine (Intropin) 5-20 mcg/kg/min IV.

1. Extras: Portable CXR, ECG, allergy consult.

2. Labs: CBC, SMA 7&12.

Pleural Effusion

1. Admit to:

2. Diagnosis: Pleural effusion

3. Condition:

4. Vital Signs: q shift. Call(Buy now from http://www.drugswell.com) physician if BP >160/90, <90/60;P>120, <50; R>25, <10; T >38.5EC

5. Activity:

6. Diet: Regular.

1. IV Fluids: D5W at TKO

2. Extras: CXR PA and LAT, repeat after thoracentesis; left andright lateral decubitus x-rays, ECG, ultrasound, PPD; pulmonary consult.

9. Labs: CBC, SMA 7&12, protein, albumin, amylase, ANA, ESR,INR/PTT, UA. Cryptococcal antigen, histoplasma antigen, fungalculture.

Thoracentesis: Tube 1: LDH, protein, amylase, triglyceride, glucose (10 mL). Tube 2: Gram stain, C&S, AFB, fungal C&S (20-60 mL,heparinized).Tube 3: Cell count and differential (5-10 mL, EDTA).Syringe: pH (2 mL collected anaerobiCall(Buy now from http://www.drugswell.com)y, heparinized on ice).Bag or Bottle: Cytology.

Hematologic Disorders

Anticoagulant Overdose

Unfractionated Heparin Overdose:

1. Discontinue heparin infusion.

2. Protamine sulfate, 1 mg IV for every 100 units of heparininfused in preceding hour, dilute in 25 mL fluid, and give IVover 10 min (max 50 mg in 10 min period).

Low-Molecular-Weight Heparin (Enoxaparin) Overdose:-Protamine sulfate 1 mg IV for each 1 mg of enoxaparin given.Repeat protamine 0.5 mg IV for each 1 mg of enoxaparin, ifbleeding continues after 2-4 hours. Measure factor Xa.

Warfarin (Coumadin) Overdose:-Gastric lavage with normal saline until clear fluid and activatedcharcoal if recent oral ingestion. Discontinue coumadin andheparin, and monitor hematocrit q2h.Partial Reversal: -Vitamin K (Phytonadione), 0.5-1.0 mg IV/SQ. Check INR in 24hours, and repeat vitamin K dose if INR remains elevated.Minor Bleeds: -Vitamin K (Phytonadione), 5-10 mg IV/SQ q12h, titrated todesired INR. Serious Bleeds: -Vitamin K (Phytonadione), 10-20 mg in 50-100 mL fluid IVover 30-60 min (check INR q6h until corrected) AND -Fresh frozen plasma 2-4 units x 1.-Type and cross match for 2 units of PRBC, and transfusewide open.-Cryoprecipitate 10 U x 1 if fibrinogen is less than 100mg/dL.

Labs: CBC, platelets, PTT, INR.

Deep Venous Thrombosis

1. Admit to:

2. Diagnosis: Deep vein thrombosis

3. Condition:

4. Vital Signs: q shift. Call(Buy now from http://www.drugswell.com) physician if BP systolic >160, <90diastolic, >90, <60; P >120, <50; R>25, <10; T >38.5EC.

5. Activity: Bed rest with legs elevated; bedside commode.

1. Nursing: Guaiac stools, warm packs to leg prn; measure calfand thigh circumference qd; no intramuscular injections.

2. Diet: Regular

1. IV Fluids: D5W at TKO

2. Special Medications:Anticoagulation:

-Heparin (unfractionated) 80 U/kg IVP, then 18 U/kg/hr IVinfusion. Check PTT 6 hours after initial bolus; adjust q6huntil PTT 1.5-2.0 times control (50-80 sec). Overlap heparinand warfarin (Coumadin) for at least 4 days and discontinueheparin when INR has been 2.0-3.0 for two consecutivedays OR

-Enoxaparin (Lovenox) outpatient: 1 mg/kg SQ q12h for DVTwithout pulmonary embolism. Overlap enoxaparin andwarfarin for 4-5 days until INR is 2-3.

-Enoxaparin (Lovenox) inpatient: 1 mg/kg SQ q12h or 1.5mg/kg SQ q24 h for DVT with or without pulmonary embolism. Overlap enoxaparin and warfarin (Coumadin) for atleast 4 days and discontinue heparin when INR has been2.0-3.0 for two consecutive days.

-Warfarin (Coumadin) 5-10 mg PO qd x 2-3 d; maintain INR2.0-3.0. Coumadin is initiated on the first or second day onlyif the PTT is 1.5-2.0 times control [tab 1, 2, 2.5, 3, 4, 5, 6,7.5, 10 mg].

10. Symptomatic Medications:-Propoxyphene/acetaminophen (Darvocet N100) 1-2 tab POq3-4h prn pain OR -Hydrocodone/acetaminophen (Vicodin), 1-2 tab q4-6h PO prnpain.-Docusate sodium (Colace) 100 mg PO qhs.-Famotidine (Pepcid) 20 mg IV/PO q12h OR -Lansoprazole (Prevacid) 30 mg qd.-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.

1. Extras: CXR PA and LAT, ECG; Doppler scan of legs. V/Qscan, chest CT scan.

2. Labs: CBC, INR/PTT, SMA 7. Protein C, protein S,antithrombin III, anticardiolipin antibody. UA with dipstick forblood. PTT 6h after bolus and q4-6h until PTT 1.5-2.0 x controlthen qd. INR at initiation of warfarin and qd.

Pulmonary Embolism

1. Admit to:

2. Diagnosis: Pulmonary embolism

3. Condition:

4. Vital Signs: q1-4h. Call(Buy now from http://www.drugswell.com) physician if BP >160/90, <90/60; P>120, <50; R >30, <10; T >38.5EC; O2 sat < 90%

1. Activity: Bedrest with bedside commode

2. Nursing: Pulse oximeter, guaiac stools, O2 at 2 L by NC.Antiembolism stockings. No intramuscular injections. Foley toclosed drainage.

3. Diet: Regular

1. IV Fluids: D5W at TKO.

2. Special Medications:Anticoagulation:

-Heparin IV bolus 5000-10,000 Units (100 U/kg) IVP, then1000-1500 U/h IV infusion (20 U/kg/h) [25,000 U in 500 mLD5W (50 U/mL)]. Check PTT 6 hours after initial bolus;adjust q6h until PTT 1.5-2 times control (60-80 sec). Overlap heparin and Coumadin for at least 4 days and discontinue heparin when INR has been 2.0-3.0 for two consecutive days.

-Enoxaparin (Lovenox) 1 mg/kg SQ q12h for 5 days for uncomplicated pulmonary embolism. Overlap warfarin as outlined above.

-Warfarin (Coumadin) 5-10 mg PO qd for 2-3 d, then 2-5 mgPO qd. Maintain INR of 2.0-3.0. Coumadin is initiated onsecond day if the PTT is 1.5-2.0 times control. Check INR atinitiation of warfarin and qd [tab 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10mg].

Thrombolytics (indicated for hemodynamic compromise):Baseline Labs: CBC, INR/PTT, fibrinogen q6h.Alteplase (recombinant tissue plasminogen activator,

Activase): 100 mg IV infusion over 2 hours, followed byheparin infusion at 15 U/kg/h to maintain PTT 1.5-2.5 xcontrol OR

Streptokinase (Streptase): Pretreat with methylprednisolone250 mg IV push and diphenhydramine (Benadryl) 50 mg IVpush. Then give streptokinase, 250,000 units IV over 30min, then 100,000 units/h for 24-72 hours. Initiate heparininfusion at 10 U/kg/hour; maintain PTT 1.5-2.5 x control.

10. Symptomatic Medications:

-Meperidine (Demerol) 25-100 mg IV prn pain. -Docusate sodium (Colace) 100 mg PO qhs. -Famotidine (Pepcid) 20 mg IV/PO q12h OR -Lansoprazole (Prevacid) 30 mg qd.

1. Extras: CXR PA and LAT, ECG, VQ scan; chest CT scan, pulmonary angiography; Doppler scan of lower extremities, impedance cardiography.

2. Labs: CBC, INR/PTT, SMA7, ABG, cardiac enzymes. ProteinC, protein S, antithrombin III, anticardiolipin antibody. UA . PTT 6hours after bolus and q4-6h. INR now and qd.

Sickle Cell Crisis

1. Admit to:

2. Diagnosis: Sickle Cell Crisis

3. Condition:

4. Vital Signs: q shift.

5. Activity: Bedrest with bathroom privileges.

6. Nursing

1. Diet: Regular diet, push oral fluids.

2. IV Fluids: D5 ½ NS at 100-125 mL/h.

9. Special Medications:

-Oxygen 2 L/min by NC or 30-100% by mask. -Meperidine (Demerol) 50-150 mg IM/IV q4-6h prn pain. -Hydroxyzine (Vistaril) 25-100 mg IM/IV/PO q3-4h prn pain. -Morphine sulfate 10 mg IV/IM/SC q2-4h prn pain OR -Ketorolac (Toradol) 30-60 mg IV/IM, then 15-30 mg IV/IM q6h

prn pain (maximum of 3 days).-Acetaminophen/codeine (Tylenol 3) 1-2 tabs PO q4-6h prn.-Folic acid 1 mg PO qd.-Penicillin V (prophylaxis), 250 mg PO qid [tabs 125,250,500

mg].-Ondansetron (Zofran) 4 mg PO/IV q4-6h prn nausea or vomiting.

10. Symptomatic Medications:

-Zolpidem (Ambien) 5-10 mg qhs prn insomnia. -Docusate sodium (Colace) 100-200 mg PO qhs.

Vaccination:

-Pneumovax before discharge 0.5 cc IM x 1 dose. -Influenza vaccine (Fluogen) 0.5 cc IM once a year in the Fall.

1. Extras: CXR.

2. Labs: CBC, SMA 7, blood C&S, reticulocyte count, blood typeand screen, parvovirus titers. UA.

Infectious Diseases

Meningitis

1. Admit to:

2. Diagnosis: Meningitis.

3. Condition:

4. Vital Signs: q1h. Call(Buy now from http://www.drugswell.com) physician if BP systolic >160/90, <90/60;P >120, <50; R>25, <10; T >39EC or less than 36EC

5. Activity: Bed rest with bedside commode.

6. Nursing: Respiratory isolation, inputs and outputs, lumbarpuncture tray at bedside.

1. Diet: NPO

2. IV Fluids: D5 1/2 NS at 125 cc/h with KCL 20 mEq/L.

3. Special Medications:

Empiric Therapy 15-50 years old:-Vancomycin 1 gm IV q12h AND EITHER -Ceftriaxone (Rocephin) 2 gm IV q12h (max 4 gm/d) OR

Cefotaxime (Claforan) 2 gm IV q4h.

Empiric Therapy >50 years old, Alcoholic, Corticosteroids or

Hematologic Malignancy or other Debilitating Condition:-Ampicillin 2 gm IV q4h AND EITHER -Cefotaxime (Claforan) 2 gm IV q6h OR

Ceftriaxone (Rocephin) 2 gm IV q12h.-Use Vancomycin 1 gm IV q12h in place of ampicillin if drug-resistant pneumococcus is suspected.

10. Symptomatic Medications:

-Dexamethasone (Decadron) 0.4 mg/kg IV q12h x 2 days tocommence with first dose of antibiotic. -Heparin 5000 U SC q12h or pneumatic compression stock

ings.-Famotidine (Pepcid) 20 mg IV/PO q12h.-Acetaminophen (Tylenol) 650 mg PO/PR q4-6h prn temp

>39°C. -Docusate sodium 100-200 mg PO qhs.

1. Extras: CXR, ECG, PPD, CT scan.

2. Labs: CBC, SMA 7&12. Blood C&S x 2. UA with micro, urine C&S. Antibiotic levels peak and trough after 3rd dose, VDRL.

Lumbar Puncture: CSF Tube 1: Gram stain, C&S for bacteria (1-4 mL). CSF Tube 2: Glucose, protein (1-2 mL). CSF Tube 3: Cell count and differential (1-2 mL). CSF Tube 4: Latex agglutination or counterimmunoelectro

phoresis antigen tests for S. pneumoniae, H. influenzae

(type B), N. meningitides, E. coli, group B strep, VDRL,cryptococcal antigen, toxoplasma titers. India ink, fungalcultures, AFB (8-10 mL).

Infective Endocarditis

1. Admit to:

2. Diagnosis: Infective endocarditis

3. Condition:

4. Vital Signs: q4h. Call(Buy now from http://www.drugswell.com) physician if BP systolic >160/90, <90/60;P >120, <50; R>25, <10; T >38.5EC

5. Activity: Up ad lib, bathroom privileges.

1. Diet: Regular

2. IV Fluids: Heparin lock with flush q shift.

8. Special Medications: Subacute Bacterial Endocarditis Empiric Therapy:

-Penicillin G 3-5 million U IV q4h or ampicillin 2 gm IV q4h

AND

Gentamicin 1-1.5/mg/kg IV q8h.

Acute Bacterial Endocarditis Empiric Therapy-Gentamicin 2 mg/kg IV; then 1-1.5 mg/kg IV q8h AND Nafcillin or oxacillin 2 gm IV q4h OR Vancomycin 1 gm IV q12h (1 gm in 250 mL of D5W over 1h).

Streptococci viridans/bovis:-Penicillin G 3-5 million U IV q4h for 4 weeks OR Vancomycin 1 gm IV q12h for 4 weeks AND Gentamicin 1 mg/kg q8h for first 2 weeks.

Enterococcus: -Gentamicin 1 mg/kg IV q8h for 4-6 weeks AND Ampicillin 2 gm IV q4h for 4-6 weeks OR Vancomycin 1 gm IV q12h for 4-6 weeks.

Staphylococcus aureus (methicillin sensitive, native valve):-Nafcillin or Oxacillin 2 gm IV q4h for 4-6 weeks OR Vancomycin 1 gm IV q12h for 4-6 weeks AND Gentamicin 1 mg/kg IV q8h for first 3-5 days.

Methicillin-resistant Staphylococcus aureus (native valve):-Vancomycin 1 gm IV q12h (1 gm in 250 mL D5W over 1h) for4-6 weeks AND Gentamicin 1 mg/kg IV q8h for 3-5 days.

Methicillin-resistant Staph aureus or epidermidis (prostheticvalve):

-Vancomycin 1 gm IV q12h for 6 weeks AND Rifampin 600 mg PO q8h for 6 weeks AND Gentamicin 1 mg/kg IV q8h for 2 weeks.

Culture Negative Endocarditis:-Penicillin G 3-5 million U IV q4h for 4-6 weeks OR Ampicillin 2 gm IV q4h for 4-6 weeks AND Gentamicin 1.5 mg/kg q8h for 2 weeks (or nafcillin, 2 gm IVq4h, and gentamicin if Staph aureus suspected in drugabuser or prosthetic valve).

Fungal Endocarditis:-Amphotericin B 0.5 mg/kg/d IV plus flucytosine (5-FC) 150mg/kg/d PO.

9. Symptomatic Medications:-Famotidine (Pepcid) 20 mg IV/PO q12h.-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn temp>39^N C. -Docusate sodium 100-200 mg PO qhs.

1. Extras: CXR PA and LAT, echocardiogram, ECG.

2. Labs: CBC with differential, SMA 7&12. Blood C&S x 3-4 over 24h, serum cidal titers, minimum inhibitory concentration, minimum bactericidal concentration. Repeat C&S in 48h, then once aweek. Antibiotic levels peak and trough at 3rd dose. UA, urineC&S.

Pneumonia

1. Admit to:

2. Diagnosis: Pneumonia

3. Condition:

4. Vital Signs: q4-8h. Call(Buy now from http://www.drugswell.com) physician if BP >160/90, <90/60; P>120, <50; R>25, <10; T >38.5EC or O2 saturation <90%.

1. Activity: Up ad lib, bathroom privileges.

2. Nursing: Pulse oximeter, inputs and outputs, nasotrachealsuctioning prn, incentive spirometry.

3. Diet: Regular.

4. IV Fluids: IV D5 ½ NS at 125 cc/hr.

9. Special Medications:-Oxygen by NC at 2-4 L/min, or 24-50% by Ventimask, or100% by non-rebreather (reservoir) to maintain O2 saturation >90%.

Moderately Ill Patients Without Underlying Lung Disease

From the Community:-Cefuroxime (Zinacef) 0.75-1.5 gm IV q8h OR Ampicillin/sulbactam (Unasyn) 1.5 gm IV q6h AND EITHER -Erythromycin 500 mg IV/PO q6h OR Clarithromycin (Biaxin) 500 mg PO bid OR Azithromycin (Zithromax) 500 mg PO x 1, then 250 mg PO qdx 4 OR Doxycycline (Vibramycin) 100 mg IV/PO q12h.

Moderately Ill Patients With Recent Hospitalization or Debilitated Nursing Home Patient:

-Ceftazidime (Fortaz) 1-2 gm IV q8h OR Cefepime (Maxipime) 1-2 gm IV q12h AND EITHER Gentamicin 1.5-2 mg/kg IV, then 1.0-1.5 mg/kg IV q8h or 7

mg/kg in 50 mL of D5W over 60 min IV q24h OR -Ciprofloxacin (Cipro) 400 mg IV q12h or 500 mg PO q12h.

CritiCall(Buy now from http://www.drugswell.com)y Ill Patients:

-Initial treatment should consist of a macrolide with 2

antipseudomonal agents for synergistic activity: -Erythromycin 0.5-1.0 gm IV q6h AND EITHER -Cefepime (Maxipime) 20 mg IV q12h OR

Piperacillin/tazobactam (Zosyn) 3.75-4.50 gm IV q6h OR Ticarcillin/clavulanate (Timentin) 3.1 gm IV q6h OR Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6h AND EI

THER -Levofloxacin (Levaquin) 500 mg IV q24h OR Ciprofloxacin (Cipro) 400 mg IV q12h OR

Tobramycin 2.0 mg/kg IV, then 1.5 mg/kg IV q8h or 7 mg/kg IVq24h.

Aspiration Pneumonia (community acquired):

-Clindamycin (Cleocin) 600-900 mg IV q8h (with gentamicin or3rd gen cephalosporin) OR -Ampicillin/sulbactam (Unasyn) 1.5-3 gm IV q6h (with gentamicin or 3rd gen cephalosporin)

Aspiration Pneumonia (nosocomial):

-Tobramycin 2 mg/kg IV then 1.5 mg/kg IV q8h or 7 mg/kg in50 mL of D5W over 60 min IV q24h OR Ceftazidime (Fortaz) 1-2 gm IV q8h AND EITHER -Clindamycin (Cleocin) 600-900 mg IV q8h OR Ampicillin/sulbactam or ticarcillin/clavulanate, orpiperacillin/tazobactam or imipenem/cilastatin (see above)

OR

Metronidazole (Flagyl) 500 mg IV q8h.

10. Symptomatic Medications:

-Acetaminophen (Tylenol) 650 mg 2 tab PO q4-6h prn temp

>38°C or pain.-Docusate sodium (Colace) 100 mg PO qhs.-Famotidine (Pepcid) 20 mg IV/PO q12h.-Heparin 5000 U SQ q12h or pneumatic compression stockings.

1. Extras: CXR PA and LAT, ECG, PPD.

2. Labs: CBC with differential, SMA 7&12, ABG. Blood C&S x 2. Sputum Gram stain, C&S. Methenamine silver sputum stain(PCP); AFB smear/culture. Aminoglycoside levels peak andtrough 3rd dose. UA, urine culture.

Specific Therapy for Pneumonia

Pneumococcus: -Ceftriaxone (Rocephin) 2 gm IV q12h OR -Cefotaxime (Claforan) 2 gm IV q6h OR -Erythromycin 500 mg IV q6h OR -Levofloxacin (Levaquin) 500 mg IV q24h OR -Vancomycin 1 gm IV q12h if drug resistance.

Staphylococcus aureus:-Nafcillin 2 gm IV q4h OR -Oxacillin 2 gm IV q4h.

Klebsiella pneumoniae:

-Gentamicin 1.5-2 mg/kg IV, then 1.0-1.5 mg/kg IV q8h or 7

mg/kg in 50 mL of D5W over 60 min IV q24h OR Ceftizoxime (Cefizox) 1-2 gm IV q8h OR Cefotaxime (Claforan) 1-2 gm IV q6h.

Methicillin-resistant staphylococcus aureus (MRSA):

-Vancomycin 1 gm IV q12h.

Vancomycin-Resistant Enterococcus:

-Linezolid (Zyvox) 600 mg IV/PO q12h; active against MRSAas well OR -Quinupristin/dalfopristin (Synercid) 7.5 mg/kg IV q8h (does notcover E faecalis).

Haemophilus influenzae:-Ampicillin 1-2 gm IV q6h (beta-lactamase negative) OR -Ampicillin/sulbactam (Unasyn) 1.5-3.0 gm IV q6h OR -Cefuroxime (Zinacef) 1.5 gm IV q8h (beta-lactamase pos) OR -Ceftizoxime (Cefizox) 1-2 gm IV q8h OR -Ciprofloxacin (Cipro) 400 mg IV q12h OR -Ofloxacin (Floxin) 400 mg IV q12h.-Levofloxacin (Levaquin) 500 mg IV q24h.

Pseudomonas aeruginosa:

-Tobramycin 1.5-2.0 mg/kg IV, then 1.5-2.0 mg/kg IV q8h or 7

mg/kg in 50 mL of D5W over 60 min IV q24h AND EITHER -Piperacillin, ticarcillin, mezlocillin or azlocillin 3 gm IV q4h OR -Cefepime (Maxipime) 2 gm IV q12h.

Enterobacter Aerogenes or Cloacae:

-Gentamicin 2.0 mg/kg IV, then 1.5 mg/kg IV q8h AND EITHER Meropenem (Merrem) 1 gm IV q8h OR Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6h.

Serratia Marcescens: -Ceftizoxime (Cefizox) 1-2 gm IV q8h OR -Aztreonam (Azactam) 1-2 gm IV q6h OR -Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6h OR -Meropenem (Merrem) 1 gm IV q8h.

Mycoplasma pneumoniae:-Clarithromycin (Biaxin) 500 mg PO bid OR -Azithromycin (Zithromax) 500 mg PO x 1, then 250 mg PO qd

for 4 days OR -Erythromycin 500 mg PO or IV q6h OR -Doxycycline (Vibramycin) 100 mg PO/IV q12h OR -Levofloxacin (Levaquin) 500 mg PO/IV q24h.

Legionella pneumoniae:-Erythromycin 1.0 gm IV q6h OR -Levofloxacin (Levaquin) 500 mg PO/IV q24h.-Rifampin 600 mg PO qd may be added to erythromycin orlevofloxacin.

Moraxella catarrhalis:

-Trimethoprim/sulfamethoxazole (Bactrim, Septra) one DS tab

PO bid or 10 mL IV q12h OR -Ampicillin/sulbactam (Unasyn) 1.5-3 gm IV q6h OR -Cefuroxime (Zinacef) 0.75-1.5 gm IV q8h OR -Erythromycin 500 mg IV q6h OR -Levofloxacin (Levaquin) 500 mg PO/IV q24h.

Anaerobic Pneumonia: -Penicillin G 2 MU IV q4h OR -Clindamycin (Cleocin) 900 mg IV q8h OR -Metronidazole (Flagyl) 500 mg IV q8h.

Pneumocystis Carinii Pneumonia andHIV

1. Admit to:

2. Diagnosis: PCP pneumonia

3. Condition:

4. Vital Signs: q2-6h. Call(Buy now from http://www.drugswell.com) physician if BP >160/90, <90/60; P>120, <50; R>25, <10; T >38.5EC; O2 sat <90%

1. Activity: Bedrest, bedside commode.

2. Nursing: Pulse oximeter.

3. Diet: Regular, encourage fluids.

4. IV Fluids: D5 ½ NS at 125 cc/h.

9. Special Medications:Pneumocystis Carinii Pneumonia:

-Oxygen at 2-4 L/min by NC or by mask.

-Trimethoprim/sulfamethoxazole (Bactrim, Septra) 15 mg ofTMP/kg/day (20 mL in 250 mL of D5W IVPB q8h) for 21days [inj: 80/400 mg per 5 mL].

-If severe PCP (PaO2 <70 mm Hg): add prednisone 40 mg PObid for 5 days, then 40 mg qd for 5 days, then 20 mg qd for11 days OR Methylprednisolone (Solu-Medrol) 30 mg IVq12h for 5 days, then 30 mg IV qd for 5 days, then 15 mg IVqd for 11 days.

-Pentamidine (Pentam) 4 mg/kg IV qd for 21 days, with prednisone as above. Pentamidine is an alternative if inadequateresponse or intolerant to TMP-SMX.

Pneumocystis Carinii Prophylaxis (previous PCP or CD4 <200,

or constitutional symptoms):-Trimethoprim/SMX DS (160/800 mg) PO qd OR -Pentamidine, 300 mg in 6 mL sterile water via Respirgard IInebulizer over 20-30 min q4 weeks OR -Dapsone (DDS) 50 mg PO bid or 100 mg twice a week; contraindicated in G-6-PD deficiency.

Antiretroviral Therapy:

A. Combination therapy with 3 agents (two nucleoside analogsand a protease inhibitor) is recommended as initial therapy.Nucleotide analogs are similar to nucleosides and may beused interchangeably. Combination of atazanavir plustenofovir or lamivudine plus abacavir plus tenofovir shouldbe avoided because of the risk of treatment failure.

B. Nucleoside Analogs

1. Abacavir (Ziagen) 300 mg PO bid [300 mg, 20 mg/mL].

2. Didanosine (Videx, ddI) 200 mg bid for patients >60 kg;or 125 mg bid for patients <60 kg. [chewable tabs: 25,50, 100, 150 mg; pwd 100, 167, 250 mg packets].

3. Emtricitabine (Emtriva) 200 mg PO qd.

4. Lamivudine (Epivir, 3TC) 150 mg twice daily [150 mg].

5. Stavudine (Zerit, D4T) 40 mg bid [15 mg, 20 mg, 30 mgand 40 mg capsules].

6. Zalcitabine (Hivid, ddC) 0.75 mg tid [0.375, 0.75].

7. Zidovudine (Retrovir, AZT) 200 mg tid (100, 200 mgcaps, 50 mg/5 mL syrup).

C. Protease Inhibitors

1. Amprenavir (Agenerase) 1200 mg bid [50, 150 mg].

2. Atazanavir (Reyataz) 400 mg PO qd.

3. Indinavir (Crixivan) 800 mg tid [200, 400 mg].

4. Lopinavir/ritonavir (Kaletra) 400 mg/100 mg PO bid.

5. Nelfinavir (Viracept) 750 mg PO tid [250 mg].

6. Ritonavir (Norvir) 600 mg bid [100 mg, 80 mg/dL].

7. Saquinavir (Invirase) 600 mg tid with a meal [cap 200mg].

D. Non-Nucleoside Reverse Transcriptase Inhibitors

1. Delavirdine (U-90) 400 mg tid.

2. Efavirenz (Sustiva) 600 mg PO qd [50, 100, 200 mg].

3. Nevirapine (Viramune) 200 mg qd for 2 weeks, then bid[200 mg].

E. Nucleotide Analogs

1. Tenofovir (Viread) 300 mg PO qd with food.Postexposure HIV Prophylaxis

A. The injury should be immediately washed and scrubbedwith soap and water.

B. Zidovudine 200 mg PO tid and lamivudine (3TC) 150 mgPO bid, plus indinavir (Crixivan) 800 mg PO tid for highest risk exposures. Treatment is continued for onemonth.

Zidovudine-Induced Neutropenia/Ganciclovir-InducedLeucopenia

-Recombinant human granulocyte colony-stimulating factor (GCSF, Filgrastim, Neupogen) 1-2 mcg/kg SQ qd until absolute neutrophil count 500-1000; indicated only if endogenous erythropoietin level is low.

10. Symptomatic Medications:-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn headache or fever. -Docusate sodium 100-200 mg PO qhs.

1. Extras: CXR PA and LAT.

2. Labs: ABG, CBC, SMA 7&12. Blood C&S x 2. Sputum forGram stain, C&S, AFB. Giemsa immunofluorescence for Pneumocystis. CD4 count, HIV RNA, VDRL, serum cryptococcalantigen, UA.

Diverticulitis

1. Admit to:

2. Diagnosis: Diverticulitis

3. Condition:

4. Vital Signs: qid. Call(Buy now from http://www.drugswell.com) physician if BP systolic >160/90, <90/60;P >120, <50; R>25, <10; T >38.5EC.

5. Activity: Up ad lib.

1. Nursing: Inputs and outputs.

2. Diet: NPO. Advance to clear liquids as tolerated.

3. IV Fluids: 0.5-2 L NS over 1-2 hr then, D5 ½ NS at 125 cc/hr.NG tube at low intermittent suction (if obstructed).

9. Special Medications:Regimen 1:

-Gentamicin or tobramycin 100-120 mg IV (1.5-2 mg/kg), then80 mg IV q8h (5 mg/kg/d) or 7 mg/kg in 50 mL of D5W over60 min IV q24h AND EITHER

Cefoxitin (Mefoxin) 2 gm IV q6-8h OR Clindamycin (Cleocin) 600-900 mg IV q8h.

Regimen 2:-Metronidazole (Flagyl) 500 mg q8h AND Ciprofloxacin (Cipro) 250-500 mg PO bid or 200-300 mg IVq12h.

Outpatient Regimen:

-Metronidazole (Flagyl) 500 mg PO q6h AND EITHER Ciprofloxacin (Cipro) 500 mg PO bid OR Trimethoprim/SMX (Bactrim) 1 DS tab PO bid.

10. Symptomatic Medications:

-Meperidine (Demerol) 50-100 mg IM or IV q3-4h prn pain.-Zolpidem (Ambien) 5-10 mg qhs PO prn insomnia.

1. Extras: Acute abdomen series, CXR PA and LAT, ECG, CT scan of abdomen, ultrasound, surgery and GI consults.

2. Labs: CBC with differential, SMA 7&12, amylase, lipase,blood cultures x 2, drug levels peak and trough 3rd dose. UA,C&S.

Lower Urinary Tract Infection

1. Admit to:

2. Diagnosis: UTI.

3. Condition:

4. Vital Signs: q shift. Call(Buy now from http://www.drugswell.com) physician if BP <90/60; >160/90; R>30, <10; P >120, <50; T >38.5EC.

5. Activity: Up ad lib

6. Nursing

7. Diet: Regular

1. IV Fluids:

2. Special Medications:Lower Urinary Tract Infection (treat for 3-7 days):-Trimethoprim-sulfamethoxazole (Septra) 1 double strength tab

(160/800 mg) PO bid.-Norfloxacin (Noroxin) 400 mg PO bid.-Ciprofloxacin (Cipro) 250 mg PO bid.-Levofloxacin (Levaquin) 500 mg IV/PO q24h.-Lomefloxacin (Maxaquin) 400 mg PO qd.-Enoxacin (Penetrex) 200-400 mg PO q12h; 1h before or 2h

after meals. -Cefpodoxime (Vantin) 100 mg PO bid. -Cephalexin (Keflex) 500 mg PO q6h. -Cefixime (Suprax) 200 mg PO q12h or 400 mg PO qd. -Cefazolin (Ancef) 1-2 gm IV q8h.

Complicated or Catheter-Associated Urinary Tract Infection:

-Ceftizoxime (Cefizox) 1 gm IV q8h. -Gentamicin 2 mg/kg, then 1.5/kg q8h or 7 mg/kg in 50 mL of

D5W over 60 min IV q24h. -Ticarcillin/clavulanate (Timentin) 3.1 gm IV q4-6h -Ciprofloxacin (Cipro) 500 mg PO bid. -Levofloxacin (Levaquin) 500 mg IV/PO q24h.

Prophylaxis ($3 episodes/yr):

-Trimethoprim/SMX single strength tab PO qhs.

Candida Cystitis

-Fluconazole (Diflucan) 100 mg PO or IV x 1 dose, then 50 mgPO or IV qd for 5 days OR -Amphotericin B continuous bladder irrigation, 50 mg/1000 mLsterile water via 3-way Foley catheter at 1 L/d for 5 days.

10. Symptomatic Medications:

-Phenazopyridine (Pyridium) 100 mg PO tid. -Docusate sodium (Colace) 100 mg PO qhs. -Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn temp

>39^N C. -Zolpidem (Ambien) 5-10 mg qhs prn insomnia.

1. Extras: Renal ultrasound.

2. Labs: CBC, SMA 7. UA with micro, urine Gram stain, C&S.

Pyelonephritis

1. Admit to:

2. Diagnosis: Pyelonephritis

3. Condition:

4. Vital Signs: tid. Call(Buy now from http://www.drugswell.com) physician if BP <90/60; >160/90; R >30,<10; P >120, <50; T >38.5EC.

5. Activity:

1. Nursing: Inputs and outputs.

2. Diet: Regular

3. IV Fluids: D5 ½ NS at 125 cc/h.

9. Special Medications:

-Trimethoprim-sulfamethoxazole (Septra) 160/800 mg (10 mLin 100 mL D5W IV over 2 hours) q12h or 1 double strengthtab PO bid.

-Ciprofloxacin (Cipro) 500 mg PO bid or 400 mg IV q12h. -Norfloxacin (Noroxin) 400 mg PO bid. -Ofloxacin (Floxin) 400 mg PO or IV bid. -Levofloxacin (Levaquin) 500 mg PO/IV q24h. -In more severely ill patients, treatment with an IV third-genera

tion cephalosporin, or ticarcillin/clavulanic acid, orpiperacillin/tazobactam or imipenem is recommended withan aminoglycoside.

-Ceftizoxime (Cefizox) 1 gm IV q8h. -Ceftazidime (Fortaz) 1 gm IV q8h. -Ticarcillin/clavulanate (Timentin) 3.1 gm IV q6h. -Piperacillin/tazobactam (Zosyn) 3.375 gm IV/PB q6h. -Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6-8h. -Gentamicin or tobramycin, 2 mg/kg IV, then 1.5 mg/kg q8h or

7 mg/kg in 50 mL of D5W over 60 min IV q24h.

10. Symptomatic Medications:

-Phenazopyridine (Pyridium) 100 mg PO tid. -Meperidine (Demerol) 50-100 mg IM q4-6h prn pain. -Docusate sodium (Colace) 100 mg PO qhs. -Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn temp

>39^N C.

-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.

1. Extras: Renal ultrasound, KUB.

2. Labs: CBC with differential, SMA 7. UA with micro, urine Gram stain, C&S; blood C&S x 2. Drug levels peak and troughthird dose.

Osteomyelitis

1. Admit to:

2. Diagnosis: Osteomyelitis

3. Condition:

4. Vital Signs: qid. Call(Buy now from http://www.drugswell.com) physician if BP <90/60; T >38.5EC.

1. Activity: Bed rest with bathroom privileges.

2. Nursing: Keep involved extremity elevated. Range of motionexercises tid.

3. Diet: Regular, high fiber.

4. IV Fluids: Heparin lock with flush q shift.

9. Special Medications:

Adult Empiric Therapy:-Nafcillin or oxacillin 2 gm IV q4h OR -Cefazolin (Ancef) 1-2 gm IV q8h OR -Vancomycin 1 gm IV q12h (1 gm in 250 cc D5W over 1h). -Add 3rd generation cephalosporin if gram negative bacilli on

Gram stain. Treat for 4-6 weeks.

Post-Operative or Post-Trauma:-Vancomycin 1 gm IV q12h AND ceftazidime (Fortaz) 1-2 gm IV q8h.-Imipenem/cilastatin (Primaxin)(single-drug treatment) 0.5

1.0 gm IV q6-8h.-Ticarcillin/clavulanate (Timentin)(single-drug treatment) 3.1

gm IV q4-6h.-Ciprofloxacin (Cipro) 500-750 mg PO bid or 400 mg IV q12h

AND

Rifampin 600 mg PO qd.

Osteomyelitis with Decubitus Ulcer:

-Cefoxitin (Mefoxin), 2 gm IV q6-8h. -Ciprofloxacin (Cipro) and metronidazole 500 mg IV q8h. -Imipenem/cilastatin (Primaxin), 0.5-1.0 gm IV q6-8h. -Nafcillin, gentamicin and clindamycin; see dosage above.

10. Symptomatic Medications:

-Meperidine (Demerol) 50-100 mg IM q3-4h prn pain. -Docusate (Colace) 100 mg PO qhs. -Heparin 5000 U SQ bid.

1. Extras: Technetium/gallium bone scans, multiple X-ray views, CT/MRI.

2. Labs: CBC with differential, SMA 7, blood C&S x 3, MIC, MBC, UA with micro, C&S. Needle biopsy of bone for C&S.Trough antibiotic levels.

Active Pulmonary Tuberculosis

1. Admit to:

2. Diagnosis: Active Pulmonary Tuberculosis

3. Condition:

4. Vital Signs: q shift

1. Activity: Up ad lib in room.

2. Nursing: Respiratory isolation.

3. Diet: Regular

8. Special Medications:

-Isoniazid 300 mg PO qd (5 mg/kg/d, max 300 mg/d) AND Rifampin 600 mg PO qd (10 mg/kg/d, 600 mg/d max) AND Pyrazinamide 500 mg PO bid-tid (15-30 mg/kg/d, max 2.5 gm)

AND

Ethambutol 400 mg PO bid-tid (15-25 mg/kg/d, 2.5 gm/d max).

-Empiric treatment consists of a 4-drug combination ofisoniazid (INH), rifampin, pyrazinamide (PZA), and eitherethambutol or streptomycin. A modified regimen is recommended for patients known to have INH-resistant TB. Treatfor 8 weeks with the four-drug regimen, followed by 18weeks of INH and rifampin.

-Pyridoxine 50 mg PO qd with INH.

Prophylaxis

-Isoniazid 300 mg PO qd (5 mg/kg/d) x 6-9 months.

1. Extras: CXR PA, LAT, ECG.

2. Labs: CBC with differential, SMA7 and 12, LFTs, HIV serology. First AM sputum for AFB x 3 samples.

Cellulitis

1. Admit to:

2. Diagnosis: Cellulitis

3. Condition:

4. Vital Signs: tid. Call(Buy now from http://www.drugswell.com) physician if BP <90/60; T >38.5EC

5. Activity: Up ad lib.

1. Nursing: Keep affected extremity elevated; warm compresses prn.

2. Diet: Regular, encourage fluids.

3. IV Fluids: Heparin lock with flush q shift.

9. Special Medications:

Empiric Therapy Cellulitis-Nafcillin or oxacillin 1-2 gm IV q4-6h OR -Cefazolin (Ancef) 1-2 gm IV q8h OR -Vancomycin 1 gm q12h (1 gm in 250 cc D5W over 1h) OR -Erythromycin 500 IV/PO q6h OR -Dicloxacillin 500 mg PO qid; may add penicillin VK, 500 mg

PO qid, to increase coverage for streptococcus OR -Cephalexin (Keflex) 500 mg PO qid.

Immunosuppressed, Diabetic Patients, or Ulcerated Lesions:

-Nafcillin or cefazolin and gentamicin or aztreonam. Add

clindamycin or metronidazole if septic.-Cefazolin (Ancef) 1-2 gm IV q8h.-Cefoxitin (Mefoxin) 1-2 gm IV q6-8h.-Gentamicin 2 mg/kg, then 1.5 mg/kg IV q8h or 7 mg/kg in 50

mL of D5W over 60 min IV q24h OR aztreonam (Azactam) 1-2 gm IV q6h PLUS -Metronidazole (Flagyl) 500 mg IV q8h or clindamycin 900 mg

IV q8h.

-Ticarcillin/clavulanate (Timentin) (single-drug treatment) 3.1 gm IV q4-6h.

-Ampicillin/Sulbactam (Unasyn) (single-drug therapy) 1.5-3.0 gm IV q6h.

-Imipenem/cilastatin (Primaxin) (single-drug therapy) 0.5-1 mg IV q6-8h.

10. Symptomatic Medications:-Acetaminophen/codeine (Tylenol #3) 1-2 PO q4-6h prn pain.-Docusate (Colace) 100 mg PO qhs.-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn temp>39^N C. -Zolpidem (Ambien) 5-10 mg qhs prn insomnia.

1. Extras: Technetium/Gallium scans.

2. Labs: CBC, SMA 7, blood C&S x 2. Leading edge aspirate forGram stain, C&S; UA, antibiotic levels.

Pelvic Inflammatory Disease

1. Admit to:

2. Diagnosis: Pelvic Inflammatory Disease

3. Condition:

4. Vital Signs: q8h. Call(Buy now from http://www.drugswell.com) physician if BP >160/90, <90/60; P >120,<50; R>25, <10; T >38.5EC

5. Activity: Up ad lib.

1. Nursing: Inputs and outputs.

2. Diet: Regular

3. IV Fluids: D5 ½ NS at 100-125 cc/hr.

9. Special Medications:-Cefotetan (Cefotan), 2 g IV q12h, or cefoxitin (Mefoxin, 2 g IVq6h) plus doxycycline (100 mg IV or PO q12h) OR -Clindamycin (Cleocin), 900 mg IV q8h, plus gentamicin (1-1.5mg/kg IV q8h)-Ampicillin-sulbactam (Unasyn), 3 g IV Q6h plus doxycycline(100 mg IV or PO Q12h)-Parenteral administration of antibiotics should be continued for 24 hours after clinical response, followed by doxycycline(100 mg PO BID) or clindamycin (Cleocin, 450 mg PO QID)for a total of 14 days.-Levofloxacin (Levaquin), 500 mg IV q24h, plus metronidazole(Flagyl, 500 mg IV q8h). With this regimen, azithromycin(Zithromax, 1 g PO once) should be given as soon as thepatient is tolerating oral intake.

10. Symptomatic Medications:

-Acetaminophen (Tylenol) 1-2 tabs PO q4-6h prn pain or tem

perature >38.5EC.

-Meperidine (Demerol) 25-100 mg IM q4-6h prn pain.

-Zolpidem (Ambien) 10 mg PO qhs prn insomnia.

11. Labs: beta-HCG pregnancy test, CBC, SMA 7&12, ESR. GCculture, chlamydia direct fluorescent antibody stain. UA withmicro, C&S, VDRL, HIV, blood cultures x 2. Pelvic ultrasound.

Gastrointestinal Disorders

Gastroesophageal Reflux Disease

1. Admit to:

2. Diagnosis: Gastroesophageal reflux disease.

3. Condition:

4. Vital Signs: q4h. Call(Buy now from http://www.drugswell.com) physician if BP >160/90, <90/60; P >120, <50; T >38.5EC.

5. Activity: Up ad lib. Elevate the head of the bed by 6 to 8 inches.

6. Nursing: Guaiac stools.

1. Diet: Low-fat diet; no cola, citrus juices, or tomato products;avoid the supine position after meals; no eating within 3 hoursof bedtime.

2. IV Fluids: D5 ½ NS with 20 mEq KCL at TKO.

3. Special Medications:-Pantoprazole (Protonix) 40 mg PO/IV q24h OR -Nizatidine (Axid) 300 mg PO qhs OR -Omeprazole (Prilosec) 20 mg PO bid (30 minutes prior to

meals) OR -Lansoprazole (Prevacid) 15-30 mg PO qd [15, 30 mg caps]

OR

-Esomeprazole (Nexium) 20 or 40 mg PO qd OR

-Rabeprazole (Aciphex) 20 mg delayed-release tablet PO qd

OR

-Ranitidine (Zantac) 50 mg IV bolus, then continuous infusionat 12.5 mg/h (300 mg in 250 mL D5W at 11 mL/h over 24h)or 50 mg IV q8h OR

-Cimetidine (Tagamet) 300 mg IV bolus, then continuous infusion at 50 mg/h (1200 mg in 250 mL D5W over 24h) or 300mg IV q6-8h OR

-Famotidine (Pepcid) 20 mg IV q12h.

10. Symptomatic Medications:-Mylanta Plus or Maalox Plus 30 mg PO q2h prn.-Trimethobenzamide (Tigan) 100-250 mg PO or 100-200 mgIM/PR q6h prn nausea OR -Prochlorperazine (Compazine) 5-10 mg IM/IV/PO q4-6h or 25mg PR q4-6h prn nausea.

1. Extras: Upright abdomen, KUB, CXR, ECG, endoscopy. GIconsult, surgery consult.

2. Labs: CBC, SMA 7&12, amylase, lipase, LDH. UA.

Peptic Ulcer Disease

1. Admit to:

2. Diagnosis: Peptic ulcer disease.

3. Condition:

4. Vital Signs: q4h. Call(Buy now from http://www.drugswell.com) physician if BP >160/90, <90/60; P >120, <50; T >38.5EC.

5. Activity: Up ad lib

1. Nursing: Guaiac stools.

2. Diet: NPO 48h, then regular diet, no caffeine.

3. IV Fluids: D5 ½ NS with 20 mEq KCL at 125 cc/h. NG tube atlow intermittent suction (if obstructed).

9. Special Medications:-Ranitidine (Zantac) 50 mg IV bolus, then continuous infusionat 12.5 mg/h (300 mg in 250 mL D5W at 11 mL/h over 24h)or 50 mg IV q8h OR -Cimetidine (Tagamet) 300 mg IV bolus, then continuous infusion at 50 mg/h (1200 mg in 250 mL D5W over 24h) or 300mg IV q6-8h OR -Famotidine (Pepcid) 20 mg IV q12h OR -Pantoprazole (Protonix) 40 mg PO/IV q24h OR -Nizatidine (Axid) 300 mg PO qhs OR -Omeprazole (Prilosec) 20 mg PO bid (30 minutes prior tomeals) OR -Lansoprazole (Prevacid) 15-30 mg PO qd prior to breakfast[15, 30 mg caps].

Eradication of Helicobacter pylori

A. Bismuth, Metronidazole, Tetracycline, Ranitidine

1. 14 day therapy.

2. Bismuth (Pepto Bismol) 2 tablets PO qid.

3. Metronidazole (Flagyl) 250 mg PO qid (tid if cannot tolerate the qid dosing).

4. Tetracycline 500 mg PO qid.

5. Ranitidine (Zantac) 150 mg PO bid.

6. Efficacy is greater than 90%.

B. Amoxicillin, Omeprazole, Clarithromycin (AOC)

1. 10 days of therapy.

2. Amoxicillin 1 gm PO bid.

3. Omeprazole (Prilosec) 20 mg PO bid.

4. Clarithromycin (Biaxin) 500 mg PO bid.

C. Metronidazole, Omeprazole, Clarithromycin (MOC)

1. 10 days of therapy

2. Metronidazole 500 mg PO bid.

3. Omeprazole (Prilosec) 20 mg PO bid.

4. Clarithromycin (Biaxin) 500 mg PO bid.

5. Efficacy is >80%

6. Expensive, usually well tolerated.

D. Omeprazole, Clarithromycin (OC)

1. 14 days of therapy.

2. Omeprazole (Prilosec) 40 mg PO qd for 14 days, then 20mg qd for an additional 14 days of therapy.

3. Clarithromycin (Biaxin) 500 mg PO tid.

E. Ranitidine-Bismuth-Citrate, Clarithromycin (RBC-C)

1. 28 days of therapy.

2. Ranitidine-bismuth-citrate (Tritec) 400 mg PO bid for 28days.

3. Clarithromycin (Biaxin) 500 mg PO tid for 14 days.

4. Efficacy is 70-80%; expensive

10. Symptomatic Medications:-Mylanta Plus or Maalox Plus 30 mg PO q2h prn.-Trimethobenzamide (Tigan) 100-250 mg PO or 100-200 mgIM/PR q6h prn nausea OR -Prochlorperazine (Compazine) 5-10 mg IM/IV/PO q4-6h or 25mg PR q4-6h prn nausea.

1. Extras: Upright abdomen, KUB, CXR, ECG, endoscopy. GIconsult, surgery consult.

2. Labs: CBC, SMA 7&12, amylase, lipase, LDH. UA,Helicobacter pylori serology. Fasting serum gastrin qAM for 3days. Urea breath test for H pylori.

Gastrointestinal Bleeding

1. Admit to:

2. Diagnosis: Upper/lower GI bleed

3. Condition:

4. Vital Signs: q30min. Call(Buy now from http://www.drugswell.com) physician if BP >160/90, <90/60; P>120, <50; R>25, <10; T >38.5EC; urine output <15 mL/hr for 4h.

5. Activity: Bed rest

6. Nursing: Place nasogastric tube, then lavage with 2 L of roomtemperature normal saline, then connect to low intermittentsuction. Repeat lavage q1h. Record volume and character oflavage. Foley to closed drainage; inputs and outputs.

1. Diet: NPO

2. IV Fluids: Two 16 gauge IV lines. 1-2 L NS wide open; transfuse 2-6 units PRBC to run as fast as possible, then repeatCBC.

3. Special Medications:

-Oxygen 2 L by NC.

-Pantoprazole (Protonix) 80 mg IV over 15min, then 8 mg/hr IVinfusion OR 80 mg IV q12h.

-Ranitidine (Zantac) 50 mg IV bolus, then continuous infusionat 12.5 mg/h [300 mg in 250 mL D5W over 24h (11 cc/h)],or 50 mg IV q6-8h OR

-Famotidine (Pepcid) 20 mg IV q12h.-Vitamin K (Phytonadione) 10 mg IV/SQ qd for 3 days (if INR iselevated).

Esophageal Variceal Bleeds:-Somatostatin (Octreotide) 50 mcg IV bolus, followed by 50mcg/h IV infusion (1200 mcg in 250 mL of D5W at 11mL/h).Vasopressin/Nitroglycerine Paste Therapy:-Vasopressin (Pitressin) 20 U IV over 20-30 minutes, then 0.2

0.3 U/min [100 U in 250 mL of D5W (0.4 U/mL)] for 30 min,followed by increases of 0.2 U/min until bleeding stops ormax of 0.9 U/min. If bleeding stops, taper over 24-48h AND

-Nitroglycerine paste 1 inch q6h OR nitroglycerin IV at 10-30mcg/min continuous infusion (50 mg in 250 mL of D5W).

1. Extras: Portable CXR, upright abdomen, ECG. Surgery and GI consults. Upper GI Bleeds: Esophagogastroduodenoscopy with coagulation or sclerotherapy; Linton-Nachlas tube for tamponade ofesophageal varices.Lower GI Bleeds: Sigmoidoscopy/colonoscopy (after a GoLytelypurge 6-8 L over 4-6h), technetium 99m RBC scan, angiographywith embolization.

2. Labs: Repeat hematocrit q2h; CBC with platelets q12-24h.Repeat INR in 6 hours. SMA 7&12, ALT, AST, alkalinephosphatase, INR/PTT, type and cross for 3-6 U PRBC and 2-4 UFFP.

Cirrhotic Ascites and Edema

1. Admit to:

2. Diagnosis: Cirrhotic ascites and edema

3. Condition:

4. Vital Signs: Vitals q4-6 hours. Call(Buy now from http://www.drugswell.com) physician if BP >160/90,<90/60; P >120, <50; T >38.5EC; urine output <25 cc/hr for 4h.

1. Activity: Bed rest with legs elevated.

2. Nursing: Inputs and outputs, daily weights, measure abdominal girth qd, guaiac all stools.

3. Diet: 2500 calories, 100 gm protein; 500 mg sodium restriction;fluid restriction to 1-1.5 L/d (if hyponatremia, Na <130).

4. IV Fluids: Heparin lock with flush q shift.

9. Special Medications:

-Diurese to reduce weight by 0.5-1 kg/d (if edema) or 0.25 kg/d(if no edema).-Spironolactone (Aldactone) 25-50 mg PO qid or 200 mg POqAM, increase by 100 mg/d to max of 400 mg/d.

-Furosemide (Lasix [refractory ascites]) 40-120 mg PO or IVqd-bid. Add KCL 20-40 mEq PO qAM if renal function isnormal OR

-Torsemide (Demadex) 20-40 mg PO/IV qd-bid. -Metolazone (Zaroxolyn) 5-10 mg PO qd (max 20 mg/d). -Captopril (Capoten) 6.75 mg PO q8h; increase to max 50 mg

PO q8h for refractory ascites caused by

hyperaldosteronism. -Famotidine (Pepcid) 20 mg IV/PO q12h. -Vitamin K 10 mg SQ qd for 3 days. -Folic acid 1 mg PO qd. -Thiamine 100 mg PO qd. -Multivitamin PO qd. Paracentesis: Remove up to 5 L of ascites if peripheral

edema, tense ascites, or decreased diaphragmatic excursion. If large volume paracentesis without peripheral edemaor with renal insufficiency, give salt-poor albumin, 12.5 gmfor each 2 liters of fluid removed (50 mL of 25% solution);infuse 25 mL before paracentesis and 25 mL 6h after.

10. Symptomatic Medications:

-Docusate (Colace) 100 mg PO qhs. -Lactulose 30 mL PO bid-qid prn constipation. -Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn head

ache.

1. Extras: KUB, CXR, abdominal ultrasound, liver-spleen scan, GI consult.

2. Labs: Ammonia, CBC, SMA 7&12, LFTs, albumin, amylase,lipase, INR/PTT. Urine creatinine, Na, K. HBsAg, anti-HBs, hepatitis C virus antibody, alpha-1-antitrypsin.

Paracentesis Ascitic Fluid Tube 1: Protein, albumin, specific gravity, glucose, bilirubin,

amylase, lipase, triglyceride, LDH (3-5 mL, red top tube).Tube 2: Cell count and differential (3-5 mL, purple top tube). Tube 3: C&S, Gram stain, AFB, fungal (5-20 mL); inject 20 mLinto bottle of blood culture at bedside. Tube 4: Cytology (>20 mL). Syringe: pH (2 mL).

Viral Hepatitis

1. Admit to:

2. Diagnosis: Hepatitis

3. Condition:

4. Vital Signs: qid. Call(Buy now from http://www.drugswell.com) physician if BP <90/60; T >38.5EC.

5. Activity:

1. Nursing: Stool isolation.

2. Diet: Clear liquid (if nausea), low fat (if diarrhea).

8. Special Medications:

-Famotidine (Pepcid) 20 mg IV/PO q12h. -Vitamin K 10 mg SQ qd for 3d. -Multivitamin PO qd.

9. Symptomatic Medications:

-Meperidine (Demerol) 50-100 mg IM q4-6h prn pain.-Trimethobenzamide (Tigan) 250 mg PO q6-8h prn pruritus ornausea q6-8h prn.-Hydroxyzine (Vistaril) 25 mg IM/PO q4-6h prn pruritus or nausea. -Diphenhydramine (Benadryl) 25-50 mg PO/IV q4-6h prn pruritus.

1. Extras: Ultrasound, GI consult.

2. Labs: CBC, SMA 7&12, GGT, LDH, amylase, lipase,INR/PTT, IgM anti-HAV, IgM anti-HBc, HBsAg, anti-HCV; alpha-1antitrypsin, ANA, ferritin, ceruloplasmin, urine copper.

Cholecystitis and Cholangitis

1. Admit to:

2. Diagnosis: Bacterial cholangitis

3. Condition:

4. Vital Signs: q4h. Call(Buy now from http://www.drugswell.com) physician if BP systolic >160, <90; diastolic. >90, <60; P >120, <50; R>25, <10; T >38.5EC.

5. Activity: Bed rest

6. Nursing: Inputs and outputs

1. Diet: NPO

2. IV Fluids: 0.5-1 L LR over 1h, then D5 ½ NS with 20 mEqKCL/L at 125 cc/h. NG tube at low constant suction. Foley toclosed drainage.

3. Special Medications:

-Ticarcillin or piperacillin 3 gm IV q4-6h (single agent).

-Ampicillin 1-2 gm IV q4-6h and gentamicin 100 mg (1.5-2mg/kg), then 80 mg IV q8h (3-5 mg/kg/d) and metronidazole500 mg IV q8h.

-Imipenem/cilastatin (Primaxin) 1.0 gm IV q6h (single agent).

-Ampicillin/sulbactam (Unasyn) 1.5-3.0 gm IV q6h (single agent).

10. Symptomatic Medications:

-Meperidine (Demerol) 50-100 mg IV/IM q4-6h prn pain. -Hydroxyzine (Vistaril) 25-50 mg IV/IM q4-6h prn with

meperidine. -Omeprazole (Prilosec) 20 mg PO bid. -Heparin 5000 U SQ q12h. -Enoxaparin (Lovenox) 30 mg SQ q12h.

1. Extras: CXR, ECG, RUQ ultrasound, HIDA scan, acute abdomen series. GI consult, surgical consult.

2. Labs: CBC, SMA 7&12, GGT, amylase, lipase, blood C&S x

2. UA, INR/PTT.

Acute Pancreatitis

1. Admit to:

2. Diagnosis: Acute pancreatitis

3. Condition:

4. Vital Signs: q1-4h, Call(Buy now from http://www.drugswell.com) physician if BP >160/90, <90/60; P>120, <50; R>25, <10; T >38.5EC; urine output < 25 cc/hr for more than 4 hours.

5. Activity: Bed rest with bedside commode.

6. Nursing: Inputs and outputs, fingerstick glucose qid, guaiacstools. Foley to closed drainage.

1. Diet: NPO

2. IV Fluids: 1-4 L NS over 1-3h, then D5 ½ NS with 20 mEqKCL/L at 125 cc/hr. NG tube at low constant suction (if obstruction).

3. Special Medications:

-Ranitidine (Zantac) 6.25 mg/h (150 mg in 250 mL D5W at 11mL/h) IV or 50 mg IV q6-8h OR Famotidine (Pepcid) 20 mg IV q12h.

-Antibiotics are indicated for infected pancreatic pseudocysts orfor abscess. Uncomplicated pancreatitis does not requireantibiotics.

-Ticarcillin/clavulanate (Timentin) 3.1 gm IV, orampicillin/sulbactam (Unasyn) 3.0 gm IV q6h or imipenem(Primaxin) 0.5-1.0 gm IV q6h.

-Heparin 5000 U SQ q12h.-Total parenteral nutrition should be provided until the amylaseand lipase are normal and symptoms have resolved.

10. Symptomatic Medications:

-Meperidine 50-100 mg IM/IV q3-4h prn pain.

1. Extras: Upright abdomen, portable CXR, ECG, ultrasound,CT with contrast. Surgery and GI consults.

2. Labs: CBC, platelets, SMA 7&12, calcium, triglycerides,amylase, lipase, LDH, AST, ALT; blood C&S x 2, hepatitis Bsurface antigen, INR/PTT, type and hold 4-6 U PRBC and 2-4 UFFP. UA.

Acute Gastroenteritis

1. Admit to:

2. Diagnosis: Acute Gastroenteritis

3. Condition:

4. Vital Signs: q6h; Call(Buy now from http://www.drugswell.com) physician if BP >160/90, <80/60; P >120;R>25; T >38.5EC.

5. Activity: Up ad lib

1. Nursing: Daily weights, inputs and outputs.

2. Diet: NPO except ice chips for 24h, then low residual elemental diet; no milk products.

3. IV Fluids: 1-2 L NS over 1-2 hours; then D5 ½ NS with 40 mEqKCL/L at 125 cc/h.

9. Special Medications: Febrile or gross blood in stool or neutrophils on microscopic exam or prior travel:

-Ciprofloxacin (Cipro) 500 mg PO bid OR -Levofloxacin (Levaquin) 500 mg PO qd OR -Trimethoprim/SMX (Bactrim DS) (160/800 mg) one DS tab PO

bid.

1. Extras: Upright abdomen. GI consult.

2. Labs: SMA7 and 12, CBC with differential, UA, blood culture x 2. Stool studies: Wright's stain for fecal leukocytes, ova and parasites x 3, clostridium difficile toxin, culture for enteric pathogens, Ecoli 0157:H7 culture.

Specific Treatment of AcuteGastroenteritis

Shigella:

-Trimethoprim/SMX, (Bactrim) one DS tab PO bid for 5 days

OR -Ciprofloxacin (Cipro) 500 mg PO bid for 5 days OR -Azithromycin (Zithromax) 500 mg PO x 1, then 250 mg PO qdx 4.

Salmonella (bacteremia):-Ofloxacin (Floxin) 400 mg IV/PO q12h for 14 days OR -Ciprofloxacin (Cipro) 400 mg IV q12h or 750 mg PO q12h for

14 days OR -Trimethoprim/SMX (Bactrim) one DS tab PO bid for 14 days

OR

-Ceftriaxone (Rocephin) 2 gm IV q12h for 14 days.

Campylobacter jejuni:-Erythromycin 250 mg PO qid for 5-10 days OR -Azithromycin (Zithromax) 500 mg PO x 1, then 250 mg PO qdx 4 OR -Ciprofloxacin (Cipro) 500 mg PO bid for 5 days.

Enterotoxic/Enteroinvasive E coli (Travelers Diarrhea):-Ciprofloxacin (Cipro) 500 mg PO bid for 5-7 days OR -Trimethoprim/SMX (Bactrim), one DS tab PO bid for 5-7 days.

Antibiotic-Associated and Pseudomembranous Colitis (Clos

tridium difficile):-Metronidazole (Flagyl) 250 mg PO or IV qid for 10-14 days OR -Vancomycin 125 mg PO qid for 10 days (500 PO qid for 10-14 days, if recurrent).

Yersinia Enterocolitica (sepsis):

-Trimethoprim/SMX (Bactrim), one DS tab PO bid for 5-7 days

OR -Ciprofloxacin (Cipro) 500 mg PO bid for 5-7 days OR -Ofloxacin (Floxin) 400 mg PO bid OR -Ceftriaxone (Rocephin) 1 gm IV q12h.

Entamoeba Histolytica (Amebiasis):

Mild to Moderate Intestinal Disease: -Metronidazole (Flagyl) 750 mg PO tid for 10 days OR -Tinidazole 2 gm per day PO for 3 days Followed By: -Iodoquinol 650 mg PO tid for 20 days OR -Paromomycin 25-30 mg/kg/d PO tid for 7 days.

Severe Intestinal Disease: -Metronidazole (Flagyl)750 mg PO tid for 10 days OR -Tinidazole 600 mg PO bid for 5 days Followed By:-Iodoquinol 650 mg PO tid for 20 days OR -Paromomycin 25-30 mg/kg/d PO tid for 7 days.

Giardia Lamblia: -Quinacrine 100 mg PO tid for 5d OR -Metronidazole 250 mg PO tid for 7 days OR -Nitazoxanide (Alinia) 200 mg PO q12h x 3 days.

Cryptosporidium:-Paromomycin 500 mg PO qid for 7-10 days [250 mg] OR -Nitazoxanide (Alinia) 200 mg PO q12h x 3 days.

Crohn’s Disease

1. Admit to:

2. Diagnosis: Crohn’s disease.

3. Condition:

4. Vital Signs: q8h. Call(Buy now from http://www.drugswell.com) physician if BP >160/90, <90/60; P >120,<50; R>25, <10; T >38.5EC

5. Activity: Up ad lib.

1. Nursing: Inputs and outputs. NG at low intermittent suction (ifobstruction).

2. Diet: NPO except for ice chips and medications for 48h, thenlow residue or elemental diet, no milk products.

3. IV Fluids: 1-2 L NS over 1-3h, then D5 ½ NS with 40 mEqKCL/L at 125 cc/hr.

9. Special Medications:

-Mesalamine (Asacol) 400-800 mg PO tid or mesalamine(Pentasa) 1000 mg (four 250 mg tabs) PO qid OR -Sulfasalazine (Azulfidine) 0.5-1 gm PO bid; increase over 10days to 0.5-1 gm PO qid OR

-Olsalazine (Dipentum) 500 mg PO bid.-Infliximab (Remicade) 5 mg/kg IV over 2 hours; may repeatat 2 and 6 weeks

-Prednisone 40-60 mg PO qd OR -Hydrocortisone 50-100 mg IV q6h OR -Methylprednisolone (Solu-Medrol) 10-20 mg IV q6h. -Metronidazole (Flagyl) 250-500 mg PO q6h. -Vitamin B12, 100 mcg IM for 5d, then 100-200 mcg IM q month. -Multivitamin PO qAM or 1 ampule IV qAM. -Folic acid 1 mg PO qd.

1. Extras: Abdominal x-ray series, CXR, colonoscopy. GI consult.

2. Labs: CBC, SMA 7&12, Mg, ionized calcium, blood C&S x 2;stool Wright's stain, stool culture, C difficile antigen assay, stoolova and parasites x 3.

Ulcerative Colitis

1. Admit to:

2. Diagnosis: Ulcerative colitis

3. Condition:

4. Vital Signs: q4-6h. Call(Buy now from http://www.drugswell.com) physician if BP >160/90, <90/60; P>120, <50; R>25, <10; T >38.5EC.

5. Activity: Up ad lib in room.

1. Nursing: Inputs and outputs.

2. Diet: NPO except for ice chips for 48h, then low residue orelemental diet, no milk products.

3. IV Fluids: 1-2 L NS over 1-2h, then D5 ½ NS with 40 mEqKCL/L at 125 cc/hr.

4. Special Medications:-Mesalamine (Asacol) 400-800 mg PO tid OR -5-aminosalicylate (Mesalamine) 400-800 mg PO tid or 1 gm

PO qid or enema 4 gm/60 mL PR qhs OR -Sulfasalazine (Azulfidine) 0.5-1 gm PO bid, increase over 10

days as tolerated to 0.5-1.0 gm PO qid OR -Olsalazine (Dipentum) 500 mg PO bid OR -Hydrocortisone retention enema, 100 mg in 120 mL saline bid.-Methylprednisolone (Solu-Medrol) 10-20 mg IV q6h OR -Hydrocortisone 100 mg IV q6h OR -Prednisone 40-60 mg PO qd.-B12, 100 mcg IM for 5d then 100-200 mcg IM q month.-Multivitamin PO qAM or 1 ampule IV qAM.-Folate 1 mg PO qd.

10. Symptomatic Medications:

-Loperamide (Imodium) 2-4 mg PO tid-qid prn, max 16 mg/d

OR

-Kaopectate 60-90 mL PO qid prn.

1. Extras: Upright abdomen. CXR, colonoscopy, GI consult.

2. Labs: CBC, SMA 7&12, Mg, ionized calcium, liver panel,blood C&S x 2; stool Wright's stain, stool for ova and parasites x3, culture for enteric pathogens; Clostridium difficile antigenassay, UA.

Enteral Nutrition

General Considerations: Daily weights, inputs and outputs,nasoduodenal feeding tube. Head-of-bed at 30E while enteral feeding and 2 hours after completion.

Enteral Bolus Feeding: Give 50-100 mL of enteral solution (Pulmocare, Jevity, Vivonex, Osmolite, Vital HN) q3h. Increaseamount in 50 mL steps to max of 250-300 mL q3-4h; 30 kcal of nonprotein calories/kg/d and 1.5 gm protein/kg/d. Before eachfeeding, measure residual volume, and delay feeding by 1h if>100 mL. Flush tube with 100 cc of water after each bolus.

Continuous enteral infusion: Initial enteral solution (Pulmocare,Jevity, Vivonex, Osmolite) 30 mL/hr. Measure residual volumeq1h for 12h then tid; hold feeding for 1h if >100 mL. Increaserate by 25-50 mL/hr at 24 hr intervals as tolerated until finalrate of 50-100 mL/hr. Three tablespoonfuls of protein powder(Promix) may be added to each 500 cc of solution. Flush tubewith 100 cc water q8h.

Special Medications:-Metoclopramide (Reglan) 10-20 mg IV/NG OR -Erythromycin 125 mg IV or via nasogastric tube q8h.-Famotidine (Pepcid) 20 mg IV/PO q12h OR -Ranitidine (Zantac) 150 mg NG bid.

Symptomatic Medications:

-Loperamide (Imodium) 2-4 mg NG/J-tube q6h prn, max 16mg/d OR -Diphenoxylate/atropine (Lomotil) 1-2 tabs or 5-10 mL (2.5mg/5 mL) PO/J-tube q4-6h prn, max 12 tabs/d OR

-Kaopectate 30 cc NG or in J-tube q8h.Extras: CXR, plain abdominal x-ray for tube placement, nutrition consult.

Labs: Daily labs: SMA7, osmolality, CBC, cholesterol, triglyceride. SMA-12

Weekly labs when indicated: Protein, Mg, INR/PTT, 24hurine nitrogen and creatinine. Pre-albumin, retinol-bindingprotein.

Hepatic Encephalopathy

1. Admit to:

2. Diagnosis: Hepatic encephalopathy

3. Condition:

4. Vital Signs: q1-4h, neurochecks q4h. Call(Buy now from http://www.drugswell.com) physician if BP>160/90,<90/60; P >120,<50; R>25,<10; T >38.5EC.

5. Allergies: Avoid sedatives, NSAIDS or hepatotoxic drugs.

6. Activity: Bed rest.

1. Nursing: Keep head-of-bed at 40 degrees, guaiac stools; turnpatient q2h while awake, chart stools. Seizure precautions, eggcrate mattress, soft restraints prn. Record inputs and outputs.Foley to closed drainage.

2. Diet: NPO for 8 hours, then low-protein nasogastric enteralfeedings (Hepatic-Aid II) at 30 mL/hr. Increase rate by 25-50mL/hr at 24 hr intervals as tolerated until final rate of 50-100mL/hr as tolerated.

9. IV Fluids: D5W at TKO. 10.Special Medications:

-Sorbitol 70% solution, 30-60 gm PO now.-Lactulose 30-45 mL PO q1h for 3 doses, then 15-45 mL PObid-qid, titrate to produce 3 soft stools/d OR -Lactulose enema 300 mL added to 700 mL of tap water; instill

200-250 mL per rectal tube bid-qid AND -Neomycin 1 gm PO q6h (4-12 g/d) OR -Metronidazole (Flagyl) 250 mg PO q6h.-Ranitidine (Zantac) 50 mg IV q8h or 150 mg PO bid OR -Famotidine (Pepcid) 20 mg IV/PO q12h.-Flumazenil (Romazicon) 0.2 mg (2 mL) IV over 30 seconds

q1min until a total dose of 3 mg; if a partial response occurs,continue 0.5 mg doses until a total of 5 mg. Flumazenil mayhelp reverse hepatic encephalopathy, irrespective of benzodiazepine use.

-Multivitamin PO qAM or 1 ampule IV qAM. -Folic acid 1 mg PO/IV qd. -Thiamine 100 mg PO/IV qd. -Vitamin K 10 mg SQ qd for 3 days if elevated INR.

1. Extras: CXR, ECG; GI and dietetics consults.

2. Labs: Ammonia, CBC, platelets, SMA 7&12, AST, ALT, GGT,LDH, alkaline phosphatase, protein, albumin, bilirubin, INR/PTT,ABG, blood C&S x 2, hepatitis B surface antibody. UA.

Alcohol Withdrawal

1. Admit to:

2. Diagnosis: Alcohol withdrawals/delirium tremens.

3. Condition:

4. Vital Signs: q4-6h. Call(Buy now from http://www.drugswell.com) physician if BP >160/90, <90/60; P>130, <50; R>25, <10; T >38.5EC; or increase in agitation.

5. Activity:

1. Nursing: Seizure precautions. Soft restraints prn.

2. Diet: Regular, push fluids.

3. IV Fluids: Heparin lock or D5 ½ NS at 100-125 cc/h.

9. Special Medications:Withdrawal syndrome:

-Chlordiazepoxide (Librium) 50-100 mg PO/IV q6h for 3 days

OR

-Lorazepam (Ativan) 1 mg PO tid-qid.

Delirium tremens:

-Chlordiazepoxide (Librium) 100 mg slow IV push or PO, repeat q4-6h prn agitation or tremor for 24h; max 500 mg/d.Then give 50-100 mg PO q6h prn agitation or tremor OR

-Diazepam (Valium) 5 mg slow IV push, repeat q6h until calm,then 5-10 mg PO q4-6h.

Seizures: -Thiamine 100 mg IV push AND -Dextrose water 50%, 50 mL IV push.-Lorazepam (Ativan) 0.1 mg/kg IV at 2 mg/min; may repeat x 1

if seizures continue.

Wernicke-Korsakoff Syndrome:

-Thiamine 100 mg IV stat, then 100 mg IV qd.

10. Symptomatic Medications:

-Multivitamin 1 amp IV, then 1 tab PO qd. -Folate 1 mg PO qd. -Thiamine 100 mg PO qd. -Acetaminophen (Tylenol) 1-2 PO q4-6h prn headache.

1. Extras: CXR, ECG. Alcohol rehabilitation and social work consult.

2. Labs: CBC, SMA 7&12, Mg, amylase, lipase, liver panel,urine drug screen. UA, INR/PTT.

Toxicology

Poisoning and Drug Overdose

Decontamination: -Gastric Lavage: Place patient left side down, placenasogastric tube, and check position by injecting air andauscultating. Lavage with normal saline until clear fluid, thenleave activated charcoal or other antidote. Gastric lavage iscontraindicated for corrosives. -Cathartics:

-Magnesium citrate 6% solution 150-300 mL PO

-Magnesium sulfate 10% solution 150-300 mL PO.

-Activated Charcoal: 50 gm PO (first dose should be givenusing product containing sorbitol). Repeat q2-6h for largeingestions.

-Hemodialysis should be for isopropanol, methanol, ethyleneglycol, severe salicylate intoxication (>100 mg/dL), lithium,or theophylline (if neurotoxicity, seizures, or coma).

Antidotes: Narcotic Overdose:

-Naloxone (Narcan) 0.4 mg IV/ET/IM/SC, may repeat q2min.

Methanol Ingestion:-Ethanol (10% in D5W) 7.5 mL/kg load, then 1.4 mL/kg/hr IVinfusion until methanol level <20 mg/dL. Maintain ethanollevel of 100-150 mg/100 mL.

Ethylene Glycol Ingestion:-Fomepizole (Antizol) 15 mg/kg IV over 30 min, then 10 mg/kgIV q12h x 4 doses, then 15 mg/kg IV q12h until ethyleneglycol level is less than 20 mg/dL AND -Pyridoxine 100 mg IV q6h for 2 days and thiamine 100 mg IVq6h for 2 days.

Carbon Monoxide Intoxication: -Hyperbaric oxygen therapy or 100% oxygen by mask ifhyperbaric oxygen is not available.

Tricyclic Antidepressants Overdose:-Gastric lavage-Magnesium citrate 300 mg PO/NG x1.-Activated charcoal premixed with sorbitol 50 gm NG roundthe-clock until level is less than the toxic range.

Benzodiazepine Overdose:-Flumazenil (Romazicon) 0.2 mg (2 mL) IV over 30 secondsq1min until a total dose of 3 mg; if a partial response occurs,repeat 0.5 mg doses until a total of 5 mg. If sedation persists, repeat the above regimen or start a continuous IVinfusion of 0.1-0.5 mg/h.

Labs: Drug screen (serum, gastric, urine); blood levels, SMA 7,

fingerstick glucose, CBC, LFTs, ECG.

Acetaminophen Overdose

1. Admit to: medical(Buy now from http://www.drugswell.com) intensive care unit.

2. Diagnosis: Acetaminophen overdose

1. Condition:

2. Vital Signs: q1h with neurochecks. Call(Buy now from http://www.drugswell.com) physician if BP>160/90, <90/60; P >130, <50 <50; R>25, <10; urine output<20 cc/h for 3 hours.

1. Activity: Bed rest with bedside commode.

2. Nursing: Inputs and outputs, aspiration and seizure precautions. Place large bore (Ewald) NG tube, then lavage with 2 Lof NS.

3. Diet: NPO

4. IV Fluids:

9. Special Medications:-Activated charcoal 30-100 gm doses, remove via nasogastricsuction prior to acetylcysteine.-Acetylcysteine (Mucomyst, NAC) 5% solution loading dose140 mg/kg via nasogastric tube, then 70 mg/kg via NG tubeq4h x 17 doses OR acetylcysteine 150 mg/kg IV in 200 mLD5W over 15 min, followed by 50 mg/kg in 500 mL D5W,infused over 4h, followed by 100 mg/kg in 1000 mL of D5Wover next 16h. Complete all NAC doses even ifacetaminophen levels fall below toxic range.-Phytonadione (Aquamephyton) 5 mg IV/IM/SQ (if INR increased).-Fresh frozen plasma 2-4 U (if INR is unresponsive toAquamephyton).-Trimethobenzamide (Tigan) 100-200 mg IM/PR q6h prn nausea.

1. Extras: ECG.

2. Labs: CBC, SMA 7&12, LFTs, INR/PTT, acetaminophen levelnow and in 4h. UA.

Theophylline Overdose

1. Admit to: medical(Buy now from http://www.drugswell.com) intensive care unit.

2. Diagnosis: Theophylline overdose

1. Condition:

2. Vital Signs: Neurochecks q2h. Call(Buy now from http://www.drugswell.com) physician if BP >160/90,<90/60; P >130; <50; R >25, <10.

3. Activity: Bed rest

6. Nursing: ECG monitoring until level <20 mcg/mL, aspirationand seizure precautions. Insert single lumen NG tube andlavage with normal saline if recent ingestion.

1. Diet: NPO

2. IV Fluids: D5 ½ NS at 125 cc/h

9. Special Medications:-Activated charcoal 50 gm PO round-the-clock, with sorbitolcathartic, until theophylline level <20 mcg/mL. Maintainhead-of-bed at 30-45 degrees to prevent aspiration of charcoal. -Charcoal hemoperfusion should be considered if the serumlevel is >60 mcg/mL or if signs of neurotoxicity, seizure, coma are present. -Seizure: Lorazepam (Ativan) 0.1 mg/kg IV at 2 mg/min; may

repeat x 1 if seizures continue.

1. Extras: ECG.

2. Labs: CBC, SMA 7&12, theophylline level now and in q6-8h;INR/PTT, liver panel. UA.

Tricyclic Antidepressant Overdose

1. Admit to: medical(Buy now from http://www.drugswell.com) intensive care unit.

2. Diagnosis: TCA Overdose

1. Condition:

2. Vital Signs: Neurochecks q1h.

3. Activity: Bedrest.

6. Nursing: Continuous suicide observation. ECG monitoring,measure QRS width hourly, inputs and outputs, aspiration andseizure precautions. Place single-lumen nasogastric tube andlavage with 2 liters of normal saline if recent ingestion.

1. Diet: NPO

2. IV Fluids: NS at 100-150 cc/hr.

3. Special Medications:

-Activated charcoal premixed with sorbitol, 50 gm via NG tubeq4-6h round-the-clock until the TCA level decreases to therapeutic range. Maintain head-of-bed at 30-45 degree angle toprevent charcoal aspiration.

-Magnesium citrate 300 mL via nasogastric tube x 1 dose.

10. Protection Against Cardiac Toxicity:

-If mechanical ventilation is necessary, hyperventilate to maintain pH 7.50-7.55.

-Administer sodium bicarbonate 50-100 mEq (1-2 amps or 1-2mEq/kg) IV over 5-10 min, followed by infusion of sodiumbicarbonate (2 amps in D5W 1 L) at 100-150 cc/h. Adjust rateto maintain pH 7.50-7.55.

1. Extras: ECG.

2. Labs: Urine toxicology screen, serum TCA levels, liver panel,CBC, SMA-7 and 12, UA.

Neurologic Disorders

Ischemic Stroke

1. Admit to:

2. Diagnosis: Ischemic stroke

3. Condition:

4. Vital Signs: Vital signs and neurochecks q30minutes for 6hours, then q60 minutes for 12 hours. Call(Buy now from http://www.drugswell.com) physician if BP>185/105, <110/60; P >120, <50; R>24, <10; T >38.5EC; or change in neurologic status.

5. Activity: Bedrest.

1. Nursing: Head-of-bed at 30 degrees, turn q2h when awake,range of motion exercises qid. Foley catheter, eggcrate mattress. Guaiac stools, inputs and outputs.Bleeding precautions: check puncture sites for bleeding orhematomas. Apply digital pressure or pressure dressing toactive compressible bleeding sites.

2. Diet: NPO except medications for 24 hours, then dysphagiaground diet with thickened liquids.

3. IV Fluids and Oxygen: 0.45% normal saline at 100 cc/h.Oxygen at 2 L per minute by nasal cannula.

9. Special Medications:Ischemic Stroke <3 hours:

a.

Tissue plasminogen activator (t-PA, Alteplase) is indicated ifthe patient presents within 3 hours of onset of symptomsand the stroke is non-hemorrhagic; 0.9 mg/kg (max 90 mg)over 60 min. Give 10% of the total dose as an initial bolus over 1 minute.

b.

Repeat CT scan or MRI 24 hours after completion of tPA.Begin heparin if scan results are negative for hemorrhage.

c.

Heparin 12 U/kg/h continuous IV infusion, without a bolus.Check aPTT q6h to maintain 1.2-1.5 x control.

Completed Ischemic Stroke >3 hours:-Aspirin enteric coated 325 mg PO qd OR -Clopidogrel (Plavix) 75 mg PO qd OR -Aspirin 25 mg/dipyridamole 200 mg (Aggrenox) 1 tab PO bid

OR -Aspirin 325 mg PO qd PLUS Clopidogrel (Plavix) 75 mg PO qd

10. Symptomatic Medications:

-Famotidine (Pepcid) 20 mg IV/PO q12h. -Omeprazole (Prilosec) 20 mg PO bid or qhs. -Docusate sodium (Colace) 100 mg PO qhs -Bisacodyl (Dulcolax) 10-15 mg PO qhs or 10 mg PR prn. -Acetaminophen (Tylenol) 650 mg PO/PR q4-6h prn temp

>38°C or headache.

1. Extras: CXR, ECG, CT without contrast or MRI with gadolinium contrast; carotid duplex scan; echocardiogram, 24-hourHolter monitor; swallowing studies. Physical therapy consult forrange of motion exercises; neurology and rehabilitation medicineconsults.

2. Labs: CBC, glucose, SMA 7&12, fasting lipid profile, VDRL,ESR; drug levels, INR/PTT, UA. Lupus anticoagulant,anticardiolipin antibody.

Transient Ischemic Attack

1. Admit to:

2. Diagnosis: Transient ischemic attack

3. Condition:

4. Vital Signs: q1-4h with neurochecks. Call(Buy now from http://www.drugswell.com) physician if BP>160/90, <90/60; P >120, <50; R>25, <10; T >38.5EC; or change in neurologic status.