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Moonlight Medicine

Adrian Paul J Rabe, MD, DPCP

8 Targets of Moonlight Medicine

• • • • • • • • Infectious Disease Cardiovascular Medicine Pulmonary Medicine Endocrinology Gastroenterology Poisons and Snakebites Pain Medication Electrolyte Correction

Infectious Disease

• • • • • • URTI Pneumonia UTI Dengue Typhoid Leptospirosis

Infectious Disease

URTI

URTI: Presentation

• • Symptoms – Cough, colds – 3 to 5 days duration Signs – Nasal discharge (clear or yellowish) – Clear breath sounds – No signs of sepsis – Hemodynamically unstable

URTI: Order Sheet

• • • No labs necessary Medications – – – Amoxicillin 500 mg TID or 1 g TID Clindamycin 300 mg QID for 5 days Azithromycin 250 mg OD x 5 days or 500 mg OD x 3 days or 1 g OD x 1 dose – – Avoid using broad-spectrum antibiotics Avoid prolonged regimens Advice – Increased oral fluid intake (at least 2L/day)

URTI: Watch Out For…

• • Persistence – Fever should lyse within 24-48 hours – Post-infectious cough occurs in 40% of patients Recurrence – Consider allergic rhinitis – refer to an allergologist • • • Seasonal pattern History of asthma or atopy Relation to exposure to allergens/certain settings (bedroom, work) – If also with weight loss, obstructive ssx, refer to ORL

Infectious Disease

Pneumonia

Pneumonia (CAP): Presentation

• • Symptoms – – – Cough with/without sputum production Fever Generalized weakness, anorexia Signs – – Crackles Decreased breath sounds • • Increased fremiti – consolidation/mass Decreased fremiti – pleural effusion – Wheezing

CAP: Order Sheet

• Initial Diagnostics – Chest X-ray – CBC with platelet count

CAP: 2010 Guidelines

Does the patient have: 1. RR ≥ 30/min 2. PR ≥ 125/min 3. Temp ≥ 40 0 C or ≤ 36 0 C 4. SBP < 90 or DBP ≤ 60 5. Altered mental status, acute 6. Suspected aspiration 7. Unstable co-morbids 8. Chest X-ray: multilobar, pleural effusion, abscess No

Low Risk CAP

Yes

Moderate Risk vs High RIsk

• • • • • • • • Co-morbidities DM Active Malignancy Neurologic disease in evolution CHF Class II-IV Unstable CAD Renal failure on dialysis Uncompensated COPD Decompensated Liver Disease

CAP: 2010 Guidelines

Does the patient have: 1. Severe Sepsis 2. Septic Shock 3. Need for mechanical Ventilation No

Moderate Risk CAP

Yes

High Risk CAP

CAP: Antibiotics

• • • Amoxicillin Extended macrolides – Azithromycin – Clarithromycin B-lactam/B-lactamase inhibitor combination (oral) – Co-amoxyclav – Amoxicillin-sulbactam – Sultamicillin

CAP: Antibiotics

• • Oral second generation cephalosporin – Cefaclor – Cefuroxime axetil Oral third generation cephalosporin – Cefdinir – Cefixime – Cefpodoxime proxetil

CAP: Antibiotics

• IV non-antipseudomonal B-lactam – – – – – – – – – Co-amoxyclav Ampicillin-sulbactam Cefotiam Cefoxitin Cefuroxime Cefotaxime Ceftizoxime Ceftriaxone Ertapenem

CAP: Antibiotics

• • Respiratory fluoroquinolones – Levofloxacin – Moxifloxacin Aminoglycosides – Gentamicin – Tobramycin – Netilmicin – Amikacin

CAP: Antibiotics

• IV antipseudomonal B-lactam – Cefoperazone-sulbactam – Piperacillin-tazobactam – Ticarcillin-clavulanic acid – Cefepime – Cefpirome – Imipinem-cilastin – Meropenem

CAP: Low Risk

• • Subsequent Diagnostics – Sputum GS/CS optional Antibiotics – Previously healthy • • Amoxicillin Extended macrolides – Stable co-morbid condition (cover enteric G- bacilli) • • • B-lactam/B-lactamase inhibitor 2 nd generation oral cephalosporins +/- extended macrolide 3 rd generation oral cephalosporin +/- extended macrolide

CAP: Moderate Risk (Admit)

• • Subsequent Diagnostics – Blood CS – Sputum GS/CS – Urine antigen for L. pneumophila – Direct fluorescent Ab test for L. pneumophila Antibiotics – IV non-antipseudomonal B-lactam + extended macrolide – IV non-antipseudomonal B-lactam + respiratory fluoroquinolones

CAP: High Risk (ICU)

• Subsequent Diagnostics – Blood CS – Sputum GS/CS – Urine antigen for L. pneumophila – Direct fluorescent Ab test for L. pneumophila – ABG

CAP: High Risk (ICU)

• • Antibiotics – no risk for Pseudomonas aeruginosa – Same as moderate risk Antibiotics – with risk for Pseudomonas aeruginosa – IV antipseudomonal B-lactam + IV extended macrolide + aminoglycoside – IV antipseudomonal B-lactam + IV Ciprofloxacin or Levoflocacin (High dose)

CAP: Watch Out For

• • Pleural effusion, Lung abscess – Do thoracentesis – Refer to TCVS for CTT if warranted Hemodynamic instability/Progressing sepsis – Refer to Pulmo, IDS • • Hospital-acquired pneumonia – Proper precautions in intubated patients Exacerbation of co-morbid diseases

CAP: Resolution

• • • • For low-risk – Follow-up after 3 to 5 days For moderate-/high-risk – – Step down when clinically improving Some infections (e.g. ESBL organisms) require a full course via the IV route Chest X-ray findings – May take up to 6 months to completely resolve Vaccination (including those with co-morbids) – – Pneumococcal: one time, then q5years Influenza: annually

Infectious Disease

Urinary Tract Infection

Urinary Tract Infection

• • Symptoms of Urethritis – Acute dysuria, hematuria – Frequency – Pyuria – Recent sexual partner change Symptoms of Cystitis – Dysuria, Urgency – Suprapubic pain – Hematuria, foul-smelling urine, turbid urine

UTI: Presentation

• • Symptoms of Acute Pyelonephritis – Rapid development – Fever, shaking chills – Nausea, vomiting, abdominal pain – Diarrhea – Diabetes, immunosuppression Symptoms of catheter-related UTI – Minimal symptoms – Usually no fever

UTI: Presentation

• • Signs of Urethritis – Grossly purulent discharge expressed in genital tract Signs of Cystitis – Suprapubic tenderness – Fever • Signs of Acute pyelonephritis – Costoverterbal angle tenderness at side of involved kidney – Fever, signs of sepsis

UTI: Presentation

• Signs of catheter-related UTI – Turbid/foul-smelling urine – Purulent discharge – Suprapubic tenderness

UTI 2004 Guidelines

• Does the patient have complicating risk factors?

– – – – – – – – – – Anatomic abnormality Functional abnormality Renal disease/transplant Immunosuppresion DM Hospital-acquired Symptoms for > 7 days

AFRRAID CH7

Recent UTI or Tract instrumentation (past 2 weeks) Antibiotic use (Past 2 weeks) Catheter, indwelling/intermittent

UTI 2004 Guidelines

• Uncomplicated Cystitis – Medications (do 7 day regimen in males) • • • • • • Cotrimoxazole 800/160 PO BID x 3 days Ciprofloxacin 250 mg PO BID x 3 days Ofloxacin 200 mg PO BID x 3 days Norfloxacin 400 mg PO BID x 3 days Nitrofurantoin 100 mg QID x 7 days Cefuroxime 125-250 mg PO BID x 3-7 days – Increase OFI – No need for U/A or urine cultures except in males – If unresolved after 7 days, consider as COMPLICATED

UTI 2004 Guidelines

• Acute Uncomplicated Pyelonephritis – Urinalysis (expect increased WBC; bacteriuria not the defining parameter; WBC cast is pathognomonic) – Urine GS/CS – Outpatient treatment: • • • • No signs and symptoms of sepsis Non-pregnant Likely to comply with treatment Follow-up after 3-5 days

UTI 2004 Guidelines

• Acute Uncomplicated Pyelonephritis – Empiric regimen should be started after culture is taken (Oral) • • • • • • Ofloxacin 400 mg BID x 14 days Ciprofloxacin 500 mg BID x 7-10 days Levofloxacin 250 mg OD x 7-10 days Cefixime 400 mg OD x 14 days Cefuroxime 500 mg BID x 14 days Co-amoxyclav 625 mg TID x 14 days (if GS is G+)

UTI 2004 Guidelines

• Acute Uncomplicated Pyelonephritis – Empiric regimen should be started after culture is taken (IV, given until patient is afebrile) • • • • • Ceftriaxone 1-2 g IV OD Ciprofloxacin 200-400 mg IV q12 Levofloxacin 250-500 mg IV OD Ampicillin-Sulbactam 1.5 g IV q6 (if GS is G+) Piperacillin-Tazobactam 2.25-4.5 g IV q6-8 – Post-treatment cultures are unnecessary

UTI 2004 Guidelines

• Acute Uncomplicated Pyelonephritis: WOF – Fever after 72 hours of treatment, or recurrence of symptoms • Imaging studies (KUB-UTZ , KUB-IVP if Creatinine clearance acceptable) • • Repeat urine culture If without urologic abnormality, treatment duration is 2 weeks based on culture • If same organism between initial and repeat culture, treatment duration is 4-6 weeks

UTI 2004 Guidelines

• Asymptomatic bacteriuria – Defined as ≥ 100,000 cfu in 2 consecutive midstream urine specimens or 1 catheterized specimen – Should screen for, and treat in • Patients who will undergo GU manipulation or instrumentation • • Post-renal transplant patients up to first 6 months DM with poor glycemic control, autonomic neuropathy or azotemia • All pregnant women – Same antibiotics as acute uncomplicated cystitis

UTI 2004 Guidelines

• Recurrent UTI – – More 2x a year, with no urinary tract abnormalities May give prophylaxis (if symptoms are unacceptable) • • • • • • • Post-coital (immediately after intercourse) Daily for 6 to 12 months Nitrofurantoin 100 mg at bedtime Cotrimoxazole 200/40 mg at bedtime Ciprofloxacin 125 mg at bedtime Norfloxacin 200 mg at bedtime Cefalexin 125 mg at bedtime – Same antibiotics as acute uncomplicated cystitis, or may also take 2 double strength Cotrimoxazole single dose as soon as symptoms first appear

UTI 2004 Guidelines

• Complicated UTI – Urine GS/CS – Outpatient • No signs of sepsis • • • Without marked debilitation Inability to comply with treatment Inability to maintain oral hydration/take oral medications

UTI 2004 Guidelines

• Complicated UTI – Oral • • • • Ciprofloxacin 250 – 500 mg BID x 14 days Norfloxacin 400 mg BID x 14 days Ofloxacin 200 mg BID x 14 days Levofloxacin 250 – 500 mg OD x 10-14 days

UTI 2004 Guidelines

• Complicated UTI – Parenteral • • • • • • • • Ampicillin-sulbactam 1.5 – 3 g IV q6 Ceftazidime 1-2 g IV q8 Ceftriaxone 1-2 g IV OD Imipenem-cilastin 250-500 mg IV q6-8 Piperacillin-Tazobactam 2.25 g IV q6 Ciprofloxacin 200-400 mg IV q12 Ofloxacin 200-400 mg IV q12 Levofloxacin 500 mg IV OD – At least 7 to 14 days of therapy

UTI 2004 Guidelines

• Complicated UTI – At least 7 to 14 days of therapy – Urine culture should be repeated 1 to 2 weeks after completion of medications • If persistent, refer to urology/nephrology – If no response, may do • • • Plain KUB x-ray KUB-UTZ Helical CT scan

UTI 2004 Guidelines

• Catheter-associated UTI – If asymptomatic, no need to treat, except if • • • • With bacterial agents with high-incidence bacteremia With neutropenia Pregnant Will undergo urologic procedures/post-renal transplant – Indwelling catheter should be removed – Long-term indwelling catheters should be replaced before treatment

UTI 2004 Guidelines

• Candiduria – May treat if • • • • Symptomatic Critically ill Neutropenic Will undergo urologic procedures/post-renal transplant – Control diabetes (if present) – Remove catheter, other urinary tract instruments (if present)

UTI 2004 Guidelines

• Candiduria – Cystitis • Fluconazole 400 mg LD then 200 mg OD x 7-14 days – Pyelonephritis • • Surgical drainage Fluconazole 6 mg/kg/day or Amphotericin B IV 0.6 mg/kg/day for 2 to 6 weeks

Infectious Disease

Dengue Fever

Dengue Fever: Presentation

• • Symptoms – – – – – Fever (Breakbone fever, saddleback fever) Myalgia, retro-orbital pain (“trangkaso”) Anorexia, nausea, vomiting Cutaneous hypersensitivity Epistaxis, petechiae, bleeding of pre-existing GI lesions near the time of defervescence – Sudden-onset to acute symptoms Signs – – Bleeding (petechiae on trunk, spreading face, extremities) Fever

Dengue Fever: Order Sheet

• Initial Diagnostics – CBC with PC • • • Leukopenia Thrombocytopenia Hemoconcentration – Dengue IgM – Crea, Na, K, AST, ALT • Elevated AST more than ALT

Dengue Fever: Order Sheet

• • • Hydration – – – Oral fluid intake Crystalloids: pNSS 1L x 6 0 or 8 0 Colloids (for severe cases) or FFP Defervescence – – Paracetamol Tepid/Cold sponge bath Platelet replacement – – 1 unit of platelet concentrate per kg BW Serial platelet counts (q12 to daily)

Dengue Fever: WOF

• • Continued hemorrhage – Aggressive control of fever – Platelet replacement Shock – Lasts for only 1-2 days – Intensive care may be necessary

Dengue Fever: Resolution

• • 1 week course Discharge if – Increasing trend of platelet count – No bleeding – No hemodynamic instability • Advice regarding mosquito control – Ablation of mosquito breeding grounds – Mosquito nets rather than mosquito repellents

Infectious Disease

Typhoid Fever

Typhoid Fever: Presentation

• • Symptoms – Fever in past 1 to 2 weeks – Abdominal pain (not always present) – Headache, chills, cough, myalgia/arthalgia, diarrhea or constipation Signs – Relative bradycardia at the peak of fever – Hepatosplenomegaly, abdominal tenderness – Rose spots: faint, salmon-colored blanching rash usually located on the trunk

Typhoid Fever: Order Sheet

• • Diagnostics – CBC with PC (leukocytosis, sometimes leukopenia, neutropenia) – – – – – Crea, Na, K, AST, ALT (slightly elevated LFTs) Blood CS (sensitivity 90% in first week) Bone marrow CS (even up to 5 days of theapy) Duodenal string test/culture Stool CS (positive in 3 rd week if untreated) Admit if… – Vomiting, diarrhea, abdominal distension

Typhoid Fever: Order Sheet

• • Empirical treatment – Ceftriaxone 1-2 g IV OD x 7-14 days – Cefixime 400 mg PO BID x 7-14 days – Azithromycin 1g PO OD x 5 days Multidrug resistant – Ciprofloxacin 500 mg PO BID x 5-7 days – Ciprofloxacin 400 mg IV q12 x 5-7 days – Ceftriaxone 2-3 g IV OD x 7-14 days – Azithromycin 1g PO OD x 5 days

Typhoid Fever: Order Sheet

• Critically ill (shock, obtundation) – Add Dexamethasone 3 mg IV then 1 mg/kg q6 x 8 doses – Admit to ICU – Refer to IDS – Repeat cultures if none were positive

Typhoid Fever: WOF

• • Perforation/Obstruction – Due to invasion of Peyer’s patches – Refer to Surgery Continued fever – Lack of susceptibility – Consider another etiology – Refer to an Infectious Disease specialist

Typhoid Fever: Resolution

• • Defervescence in 1 week Return to normal values also in 1 week

Infectious Disease

Leptospirosis

Leptospirosis: Presentation

• Symptoms – Wading in floodwater/exposure to mud – Influenza-like illness: chills, headache, nausea, vomiting, muscle pain (calves, back or abdomen) – Fever, conjunctival suffusion/hemorrhage – Hemoptysis – Decreased urine output, tea-colored urine – Overt jaundice – Diarrhea – Course progresses within 1 week, rarely 2 weeks

Leptospirosis: Presentation

• Signs – Fever – Conjunctival suffusion – Jaundice and icterus – Calf tenderness – Decreased sensorium

Leptospirosis: Order Sheet

• Initial Diagnostics – – Lepto MAT/Dri-Dot Urine culture (positive at 2 nd several months after) – – to 4 th week, and for Chest X-ray (check for pulmonary hemorrhage) BUN, Crea, Na, K, Cl, alb, Ca, Mg (check for acute renal failure, electrolyte losses) – Urinalysis (concentrated urine vs renal failure; picture of UTI may confuse you) – – CBC with PC (anemia, leukocytosis) Stool CS (for patients with diarrhea)

Leptospirosis: Order Sheet

• • Mild Leptospirosis – – – Doxycycline 100 mg PO BID Ampicillin 500-750 mg PO QID Amoxicillin 500 mg PO QID Moderate/Severe Leptospirosis – – – – – Penicillin G 1.5 M u IV QID Ampicillin 1 g IV QID Amoxicillin 1 g IV QID Ceftriaxone 1 g IV OD Erythromycin 500 mg IV QID

Leptospirosis: Order Sheet

• • Hydration – Based on urine output – Replace electrolytes lost Transfusion – Based on losses detected by CBC • Control of hemoptysis – Hydrocortisone 50 mg IV q6 – Tranexamic Acid 500 mg TID

Leptospirosis: WOF

• Weil’s syndrome – Heralded by hemoptysis, renal failure, severe liver dysfunction, or sepsis – Refer to Infectious Disease specialist – Refer to Renal service for early dialysis – Transfer to ICU

Leptospirosis: WOF

• Jarisch-Herxheimer reaction – Occurs in response to antimicrobial therapy, when massive spirochete kill releases lipoproteins – Simulates worsening of disease • • • • Fever, chills, myalgias, headache Tachycardia, tachypnea Increased WBC, neutrophils Hypotension – Supportive therapy – Subsides after 12-24 hours without revision of meds

Leptospirosis: Resolution

• • Jaundice to resolve in 2 to 4 weeks May discharge if – Creatinine clearance is on upward trend – Urine output at least 0.5 cc/kg/hr – Electrolytes corrected – Platelet/hemoglobin corrected – No ongoing hemoptysis • Prophylaxis – Doxycycline 200 mg PO once a week if exposed

Cardiology

Cardiovascular Medicine

• • • Hypertension Angina Myocardial Infarction

Hypertension

Cardiology

Hypertension: Presentation

• • Symptoms – Frequently asymptomatic – Aching nape/occipital area – Symptoms of target organ damage Signs: Try to detect both cause and effect… – Kidney disease: anemia, oliguria, sallow skin – Cushing’s syndrome: obesity, striae, moon facies, etc – Hyper/hypothyroidism – Heart failure

Hypertension: Presentation

• Signs: Taking Blood Pressure – Aneroid instrument vs mercury based instruments – Seated quietly for 5 minutes (Quiet, private, with comfortable room temperature) – Bladder cuff is at least half of arm circumference – Deflation is 2 mmHg/s – Measure both arms, in supine, sitting and standing positions (detects coarctation, orthostatic changes) – Measure 1 leg at least once (take ABI)

Hypertension: Presentation

• Signs – Palpate all possible pulses – Cardiac examination is important – Auscultate carotid and renal bruits

Hypertension: Classification

Classification Normal Prehypertension Stage 1 Stage 2 Systolic, mmHg < 120 120-139 140-159 ≥ 160 And Or Or Or Diastolic, mmHg < 80 80-89 90-99 ≥ 100

Hypertension: Order Sheet

• Diagnostics – Urinalysis (renal cause and complication) – BUN, Crea, Na, K, Ca, alb (low K is clue for aldosteronism and pheochromocytoma) – FBS, Lipid profile (co-morbidities) – CBC (anemia) – ECG (LVH, other abnormalities)

Hypertension: Order Sheet

• Lifestyle changes

BEADS

– BMI < 25 kg/m2 – Exercise: Near-daily to daily aerobic activity – Alcohol avoidance/moderation – DASH diet: fruits, vegetables, low fat dairy, reduced saturated and total fat – Salt-restriction: NaCl < 6 g/d

Hypertension: Order Sheet

• Medications: Diuretics – Examples • • • Hydrochlorothiazide 12.5 – 25 mg OD-BID Furosemide 40-80 mg BID-TID Spironolactone 25-100 mg OD-BID – Good for heart failure – Caution in DM, gout, renal failure – K reducer: furosemide, HCTZ – K retainer: spironolactone

Hypertension: Order Sheet

• Medications: Beta blockers – Examples • • • • Atenolol 25-100 mg OD Metoprolol 25-100 mg OD-BID Propranolol 40-160 mg BID (not cardioselective) Carvedilol 12.5-50 mg BID (combined alpha and beta) – Good for heart failure, angina, MI, tachycardia – Caution in 2 nd or 3 rd degree AV block, asthma/COPD

Hypertension: Order Sheet

• Medications: ACE inhibitors – Examples • • • • Captopril 25-200 mg BID-TID Enalapril 5-20 mg OD Lisinopril 10-40 mg OD Ramipril 2.5-20 mg OD-BID – Good for heart failure, MI, DM – Caution in renal failure, hyperkalemia, renal artery stenosis, pregnancy – May cause cough, angioedema

Hypertension: Order Sheet

• Medications: Angiotensin receptor blockers – Examples • • • Losartan 25-100 mg OD-BID Valsartan 80-320 mg OD Candesartan 2-32 mg OD-BID – Good for heart failure, MI, DM – Caution in renal failure, hyperkalemia, renal artery stenosis, pregnancy – Used as second-line to ACE-inhibitors

Hypertension: Order Sheet

• Medications: Dihydropyridine CCBs – Examples • • Amlodipine 5-10 mg OD Long-acting Nifedipine 30-60 mg OD – Good for angina – Caution in heart failure, 2 nd or 3 rd degree AV block – Causes peripheral edema

Hypertension: Order Sheet

• Medications: Non-Dihydropyridine CCBs – Examples • • Long-actingVerapamil 120-360 mg OD-BID Long-acting Diltiazem 180-420 mg OD – Good for angina, MI, DM, tachycardia – Caution in heart failure, 2 nd or 3 rd degree AV block – Causes peripheral edema

Hypertension: Order Sheet

• Medications: Direct Vasodilators – Examples • • • ISMN 30-60 mg OD ISDN 5-10 mg BID-TID Hydralazine 25-100 mg BID-TID – – Nitrates good for angina, MI Nitrates cause hypotension, headache (must have at least 8 hours a day drug free), and has reaction with sildenafil – Hydralazine should not be used in severe coronary artery disease

Hypertension: Follow-up

• • BP goal – – – General: < 140/90 Cardiac risk factors: < 130/80 Albuminuria: < 125/75 Adjustment – – – – – Diuretics: daily to weekly (electrolyte imbalances) Beta-blockers: every 2 weeks ACE-inhibitors and ARBs: every 1 – 2 weeks CCBs: every 1 – 2 weeks Vasodilators: Every 1 – 2 weeks

Hypertension: WOF

• Secondary Hypertension – CGN/Nephrotic syndrome/CKD: urinary findings, edema – Pheochromocytoma: sweating, palpitations, headache, early target organ damage – Primary aldosteronism: resistant to medications, low K, weakness – Connective Tissue Disease: pulse discrepancy, systemic symptoms – Refer to Renal/Endo/Rheuma

Hypertension: WOF

• Hypertensive Urgency vs Emergency – Both require admission – Emergency: presence of target organ damage • Reduce blood pressure by 25% over minutes to 2 hours • Parenteral agents – Urgency: No target organ damage • • Reduce blood pressure over hours Oral agents

Hypertension: WOF

• Hypertensive Urgency vs Emergency – Nitroprusside: 0.3 ug/kg/min, maximum at 10 ug/kg/min; discontinue if no response after 10 minutes – Nitroglycerin drip: 5 ug/min, titrate at 5-10 ug/min at 3 to 5 minute intervals • – Nicardipine drip: 5 mg/h, titrate by 2.5 mg/h at 5-15 minute intervals, maximum at 15 mg/h • 10 mg/10mL or 50 mg/50 mL, diluted to 10 mg in 100 mL 2 mg/2mL or 10 mg/10mL, diluted to 10-20 mg in 100 mL

Cardiology

Angina and the Acute Coronary Syndromes

Angina: Presentation

• Symptoms – Heaviness, pressure, squeezing, localized retrosternally – Crescendo vs decrescendo – Radiates anywhere between the mandible and umbilicus – Related to exertion • Signs – High/low blood pressure, tachy/bradycardia – Heart failure

Angina: Order Sheet

• • Complete bed rest • • • Oxygenation – Target O2 saturation > 90% – Nasal cannula vs face mask vs intubation Cardiac monitor Vital signs Ask about sildenafil use in past 24 hours – Viagra, cialis, ambigra, adonix, erefil, neo-up

Angina: Order Sheet

• Give nitrates – Nitroglycerin 0.3-0.6 mg, or via buccal spray – ISDN 5 mg sublingual – 3 doses 5 minutes apart – If persistent, start Nitroglycerin drip • • 10 mg in 100 mL, start at 5 ug, and increased by 5-10 ug/min Titrated every 3 to 5 minutes until symptoms are relieved or systolic arterial pressure falls to < 100 mmHg – Good for pulmonary congestion – Caution in: inferior wall/right-sided infarcts (hypotension)

Angina: Order Sheet

• Initial Diagnostics – 12-lead ECG (within 10 minutes) – 2D-echocardiogram – Nuclear perfusion scan, cardiac MRI, cardiac PET – BUN, Crea, Na, K, Ca, alb, Mg, AST – Cardiac enzymes: Trop I/T > CKMB > CKtotal – Urinalysis – Chest X-ray – PT/PTT

UA

/NSTEMI/STEMI

• Loading Dose – Aspirin 80 mg/tab 4 tabs chewed and swallowed – Clopidogrel 75 mg/tab 4 tabs chewed and swallowed – Metoprolol 5 mg IV q5 up to 15 mg (3 doses), then followed in 1-2 hours by 25-50 mg PO q6 – Morphine 2-5 mg IV repeated q5-30 minutes – Captopril 25 mg/tab ½ to 1 tab q8 – Heparinization

Angina: STEMI

• • Decide whether to do PCI or not – – – Referral center should be no more than 30 mins away Door-to-balloon time should be at most 90 mins Golden period: not more than 6h, may give 12h after Refer to CVS for thrombolysis – – Take informed consent Streptokinase 1.5 M u in pNSS to make 100 cc to consume over 1 hour – – Pre-medication with Diphenhydramine 1 amp IV Can have hemorrhage, allergic reactions

Angina: STEMI

• Absolute contraindications to thrombolysis – – – Cerebrovascular hemorrhage at any time Known structural cerebral vascular lesion (e.g. AVM) Non-hemorrhagic stroke/event in the past year • Ischemic stroke within 3 months, except if within 3 hours – – Hypertension (SBP > 180, DBP > 110) Suspicion of aortic dissection • Must do Chest/abdominal CT stat if suspected – – – Active internal bleeding except menses Any known malignant neoplasm Significant closed head/facial trauma in past 3 months

Angina: STEMI

• Admit to ICU/CCU

UA

/NSTEMI/STEMI

UA

/NSTEMI/STEMI

• Aspirin and Clopidogrel – Part of antithrombotic therapy – Maintenance • Aspirin 80 mg/tab 1 tab OD (with a meal) • Clopidogrel 75 mg/tab 1 tab OD – WOF GI bleed, allergy to aspirin

UA

/NSTEMI/STEMI

• Beta blockers – Part of anti-ischemic therapy – Maintenance • Metoprolol 50 mg BID – Target: HR 50-60 bpm – Caution in hypotension, asthma, COPD. Severe pulmonary edema

UA

/NSTEMI/STEMI

• Calcium channel blockers – – Part of anti-ischemic therapy Used in patients with contraindication to beta blockers – Maintenance • • Long-actingVerapamil 120-360 mg OD-BID Long-acting Diltiazem 180-420 mg OD – – – Target: HR 50-60 bpm, no chest pain Avoid rapid-release CCB (e.g. nifedipine) Caution in pulmonary edema, severe LV dysfunction, hypotension, bradycardia, heart-block

UA

/NSTEMI/STEMI

• Morphine – Part of anti-ischemic therapy – Maintenance • None – PRN use only – Target: no chest pain – Caution in inferior wall/right ventricular infarction, hypotension, respiratory depression, confusion, obtundation

UA

/NSTEMI/STEMI

• ACE-inhibitors – Part of long-term cardiac therapy – Maintenance • Captopril 25 mg 1 tab q8 • Enalapril 5-20 mg OD – Gradual increase as patient stabilizes – Good for LV dysfunction, anterior wall MI – Caution in hypotension, renal failure, hyperkalemia

UA

/NSTEMI/STEMI

• Statins – Part of long-term cardiac therapy – Plaque stabilization – Maintenance (@HS doses) • • • Atorvastatin 10 mg, max 80 mg Rosuvastatin 10 mg, max 40 mg Simvastatin 20 mg, max 80 mg – Gradual increase over a period of 2 months – Good for dyslipidemia, MI – Caution in liver disease, rhabdomyolysis

UA

/NSTEMI/STEMI

• Heparin – Part of anti-thrombotic therapy – Types • • UFH 60 U LD, then 12U/kg/h target PTT 1.5-2.0x normal Enoxaparin 30 mg IV LD then 1 mg/kg SC q12 (OD if creatinine clearance < 30 mL/min) • Fondaparinux 2.5 mg SC OD – If patient is unstable, has poor hemodynamic status, or has risk of bleeding, age > 75 y/o, UFH is preferred – PTT measurements should be done q6 – Duration is 2 to 5 days

UA

/NSTEMI/STEMI

• Targets – Activity (SUPERVISED) • • • • • • First 12 hours: Bed rest 12-24 hours: Dangling legs/sitting in a chair 2 nd -3 rd day: Ambulation in room, go to shower 3 rd day and beyond: 185 m (600 feet) at least 3x a day Sexual activity: 2-4 weeks after event Work: 1 month after event

UA

/NSTEMI/STEMI

• Targets – Diet • • First 4-12 hours: NPO If stable: Complex carbohydrates (50-55%), Fat < 30%, total cholesterol < 200 mg/d, fiber rich – Bowel care • • • Stool softeners Bedside commode rather than bedpan Laxative

UA

/NSTEMI/STEMI

• Targets – Sedation • • Quiet, reassuring environment Diazepam 5 mg TID-QID – Tight glycemic control • • • • Insulin drip preferred in acute setting Pre-prandial: 90-130 mg/dL (critical care: < 110) Post-prandial: < 180 mg/dL (critical care: < 180) Long-term: HbA1c < 7%

UA

/NSTEMI/STEMI

• Targets – Electrolyte • • • Mg 1.0 mmol/L K Ca 4.0-4.5 mmol/L 2.12-2.52

– Discontinue O2 • May discontinue starting 6 hours after admission, if O2 saturation > 90%

Angina: Watch Out For…

• • Arrhythmia – – Defibrillate with maximum dose available up to 3x Amiodarone 150 mg in 50 to 100 cc pNSS over 10 minutes, then drip 360 mg in D5W x 6 hours – Refer to CVS Mechanical complications – – – – Wall rupture New-onset mitral regurgitation Pericarditis Refer to CVS/TCVS

Angina: Resolution

• Follow-up after 2 weeks – for treadmill exercise test (if appropriate) – Titration of medications – Strengthen previous advice

Chronic Stable Angina

• • Symptoms – Same as acute angina – Symptoms > 2 weeks – No worsening, crescendo pattern over hours/weeks – No increase in frequency Signs – Hemodynamically stable – Complete cardiovascular PE should be done

Chronic Stable Angina

• Diagnostics – 12-L ECG – Treadmill exercise test – 2D-echo – Crea, Na, K, Mg. Ca, alb – Lipid profile, FBS – Chest X-ray

Chronic Stable Angina

• Medications – Anti-platelet – Beta blocker – ACE inhibitor – Statin

Chronic Stable Angina

• Medications – Anti-platelet • • Aspirin 80 mg OD Clopidogrel 75 mg OD if ASA-intolerant – Beta blocker • • • Atenolol 25-100 mg OD Metoprolol 50-100 mg OD-BID Carvedilol 6.25-50 mg BID

Chronic Stable Angina

• Medications – ACE inhibitor • • • • Captopril 25-200 mg BID-TID Enalapril 5-20 mg OD Lisinopril 10-40 mg OD Ramipril 2.5-20 mg OD-BID – Statin • • • Atorvastatin 10 mg, max 80 mg @HS Rosuvastatin 10 mg, max 40 mg @HS Simvastatin 20 mg, max 80 mg @HS

Chronic Stable Angina

• If with high-risk features, or positive stress test, advice coronary angiography with intervention – Useless to do CA without intervention – PCI vs CABG depends on clinical picture – Refer to CVS in an institution with PCI/CABG capability

Moonlight Medicine

Adrian Paul J Rabe, MD, DPCP

Pulmonology

Pulmonary Medicine

• • Asthma COPD

Asthma

Pulmonology

Asthma: Presentation

• Symptoms – Trigger • • • • • • Allergen URTI/Pneumonia Beta blockers. Aspirin Exercise. Cold air, hyperventilation, laughter Occupational asthma (Mondays) Stress – Dyspnea, shortness of breath, chest tightness • Night exacerbations – – Cough Younger age group

Asthma: Presentation

• Signs – Tachypnea – Tachycardia, hypertension – Wheezing – Absence of wheezing = severe – Clubbing = uncontrolled

Asthma: Order Sheet

• Diagnostics – ABG (hypercarbia, hypoxemia, alkalosis) – Chest X-ray (rule out infection, other differentials) – 12-L ECG (rule out cardiac causes of dyspnea – CBC with PC (infection)

Asthma: Order Sheet

• • • Oxygenation – O2 support • Intubation if in impending/frank respiratory failure Short acting inhaled beta-agonists – – Salbutamol nebulization q5-15 WOF tremors, palpitations Inhaled anti-cholinergics – – Ipatropium bromide nebulization q5-15 WOF Dry mouth, decreased sputum production/dry cough

Asthma: Order Sheet

• • Glucocorticoids – Hydrocortisone 50 mg IV q6 or 100 mg IV q8 – – Budesonide nebule q8 WOF Hoarseness, dysphonia, oral candidiasis, systemic effects Aminophylline drip – Mix as 1mg/mL – LD 6 mg/kg over 20-30 minutes – Maintenance at 1 mg/kg/hr (use lower dose in elderly, or in nonsmokers) – – Hook to cardiac monitor WOF flushing, diarrhea, nausea, vomiting, arrhythmias

Asthma: Order Sheet

• • • • If with status asthmaticus, admit to ICU Refer to anesthesia if previous measures don’t work – Propofol, Halothane Treat infection – Most common is still viral URTI (supportive therapy) – See CAP guidelines if with pneumonia Check if drug is the trigger

Asthma: Resolution

• Discharge – No wheezing and tolerates room air – No IV glucocorticoids – Infection is treated

Asthma: Resolution

• Discharge Medications – – Home medications: Oral steroid with tapering schedule • Prednisone at 0.5 -1 mg/kg/d in 2/3-1/3 dosing – Combination inhaled corticosteroid with long-acting inhaled beta-agonist • • Budesonide + Formoterol 160/4.5 or 80/4.5 ug 1-2 puffs BID Fluticasone + Salmeterol 500/50 or 250/50 or 100/50 1-2 puffs BID • Gargle after use – Rescue doses of short acting inhaled beta-agonists • Salbutamol neb PRN

Asthma: Outpatient Care

OCS LABA LABA LABA ICS low dose ICS low dose ICS high dose ICS high dose Symptoms Night

Short Acting Bet a agonist

Mild intermittent Mild persistent Moderate persistent Severe persistent Very Severe persistent ≤2/week ≤2/month 3-6/week 3-4/month Daily ≥5/month Daily Frequently Unremitting Nightly

Asthma: Outpatient Care

• • • Smoking cessation Influenza vaccination annually Pneumococcal vaccination once then q5 years

COPD

Pulmonology

COPD: Presentation

• • Symptoms – – – – – Cough, sputum production, exertional dyspnea Smoking Decreased functional capacity Chronic symptoms Older age group Signs – – – Wheezing Clubbing, cyanosis Barrel-chest

COPD: Presentation

• Diagnostics – ABG (hypercarbia, hypoxemia) – Chest X-ray (infection, chronic changes – hyperinflation, fibrosis, cause of COPD) – CBC with PC (infection) – 12-L ECG (consider cardiac etiology)

COPD: Order Sheet

• • • Oxygenation – O2 support • Intubation if in impending/frank respiratory failure Short acting inhaled beta-agonists AND inhaled anti-cholinergics – – Salbutamol nebulization q5-15 Ipatropium bromide nebulization q5-15 Methylxanthine – – Theophylline 10-15 mg/kg in 2 divided doses Comes in 100, 200, 300, 400, 450 mg

COPD: Order Sheet

• Glucocorticoids – Hydrocortisone 50 mg IV q6 or 100 mg IV q8 – Budesonide nebule q8 – Shift to Prednisolone/Prednisone 30-40 mg to complete 2 weeks • Antibiotics – Bronchiectasis with increased sputum production – 2 weeks of antibiotics directed against pathogen

COPD: Resolution

• • • Complete smoking cessation Pulmonary Rehabilitation (Refer to Rehab) Lung volume reduction surgery in severe emphysema • • • Oxygen therapy – Resting O2 sat < 88% – O2 sat < 90% if with pulmo HTN, cor pulmonale Influenza vaccination annually Pneumococcal vaccine once then q5 years

COPD: WOF

• Cor Pulmonale – Right heart enlargement on X-ray, ECG – Prominent neck veins and peripheral edema – Careful diuresis • • Furosemide 20-40 mg BID Spironolactone 25-100 mg OD-BID

Endocrinology

• • Diabetes Mellitus Thyroid Disease

Endocrinology

Diabetes Mellitus

DM: Presentation

• Symptoms – – – – – – – – – Weight loss, unexplained Polyuria, polydipsia Frothy urine Decreased vision Poorly healing wounds, frequent infections Paresthesias, numbness Stroke, MI previously DKA: abdominal pain, nausea, vomiting, young HHS: poor appetite, increased sleeping time, elderly

DM: Presentation

• Signs – – – – Decreased sensation Non-healing wound Skin atrophy, Muscle atrophy Diabetic dermopathy (necrobiosis lipiodica diabeticorum) – – – Renal failure Retinopathy DKA: ketone breath, normal abdomen, tachycardic, tachypneic – HHS: obtundation, dehydration

DM Emergency: Order Sheet

• – – – – Diagnostics – – CBC with PC (infection, anemia) RBS, BUN, Crea, Na, K, Cl, Ca, alb, Mg, P (azotemia, low albumin, electrolyte imbalances, anion gap) – – – Plasma ketones if available ABG Chest X-ray (and X-ray of involved extremity if with non healing wound) Urinalysis with ketones 12-L ECG HBA1c (instead of FBS) CBG

DM Emergency: Order Sheet

• Computations – Osmolality • • 2(Na + K) + BUN + RBS (in mmol/L) Normal is 276-290 mmol/L – Anion gap • • Na – (Cl + HCO3) Normal is 10-12 mmol/L

DM Emergency: Order Sheet

Parameters DKA HHS Glucose (mg/dL) 250-600 600-1200 Blood Chem ABG Both Na K Mg Cl P Crea Osmolality Ketones HCO3 pH pCO2 Anion gap 125-135 Normal to Inc Normal Normal Dec Slight Inc 300-320 ++++ < 15 mEq/L 6.8-7.3

20-30 Inc 135-145 Normal Normal Normal Normal Moderately Inc 330-380 +/ Normal to slightly dec > 7.3

Normal Normal to slightly Inc

DM Emergency: Order Sheet

• • ICU admission – If unstable – pH < 7.00

– Decreased sensorium Refer to Endo

DM Emergency: Order Sheet

• • Replace fluids – 2-3 L pNSS over first 1-3 hours (10-15 mL/kg/h) – 0.45% NSS at 150-300 mL/h – – – D5 0.45%NSS at 100-200 mL/h if CBG ≤ 250 mg/dL WOF congestion, hyperchloremia HHS: if Na > 150, use 0.45% NSS at the onset Insulin – Start only if K > 3.3

– – 0.1-0.15 u/kg IV bolus 0.1 u/kg/h IV infusion, target CBG 150-250 mg/dL • 20 or 100 units regular insulin in pNSS to make 100 cc in soluset dripped via infusion pump (1cc = 1u if 100 u used)

DM Emergency: Order Sheet

• • • • Assess precipitant – Noncompliance/missed insulin dose – Infection (UTI, pneumonia) – Myocardial infarction – Drugs CBG q1-2 hours Electrolytes and ABG q4 for first 24 hours NVS, I/O q1

DM Emergency: Order Sheet

• • Correct potassium – – K < 5.5: 10 mEq/h K < 3.5: 40-80 mEq/h Correct acidosis only if pH < 7.0 after initial hydration – pH 6.9-7.0: 50 mEqs NaHCO3 + 10 mEqs KCl in 200 mL sterile water x 1h – pH < 6.9: 100 mEqs NaHCO3 + 20 mEqs KCl in 400 mL sterile water x 2h – – Repeat ABG 2 hours after Repeat dose q2 hours until pH > 7.0

DM Emergency: Order Sheet

• Correct magnesium – Target 0.8 to 1 mmol/L – Each gram of Mg will increase Mg by 0.1 mmol/L • 3g MgSO4 in D5W 250 cc x 12h = 0.3 additional Mg

DM Emergency: Order Sheet

• • ICU admission – If unstable – pH < 7.00

– Decreased sensorium May apply hydration and insulin drip for hyperglycemic states • Refer to Endo

DM Emergency: Resolution

• • Decrease insulin until 0.05-0.1 u/kg/h As soon as patient is awake and tolerates feeding, may start patient on diet • Overlap insulin with subcutaneous insulin – Calculate insulin requirements from insulin drip used in past 24 hours

DM Inpatient: Insulin Regimens

• NPH Insulin + Regular Insulin – Total Insulin requirement: 0.5-1 u/kg BW • 2/3 pre-breakfast: 2/3 NPH, 1/3 Regular Insulin • 1/3 pre-supper: ½ NPH, ½ Regular Insulin – pB = NPH pre-supper – pL = Regular insulin pre-breakfast – pS = NPH pre-breakfast – HS = Regular insulin pre-supper

DM Inpatient: Insulin Regimens

• Glargine Insulin + Lispro Insulin – Total insulin requirement: 0.5-1 u/kg BW • • Glargine (Basal) insulin: ½ of total, given at night Lispro insulin: other half given in 3 divided doses, 15 minutes before each meal – pB = Basal insulin – pL = Lispro insulin pre-breakfast – pS = Lispro insulin pre-lunch – HS = Lispro insulin pre-supper

DM Inpatient: Order Sheet

• • Inpatient goals – Pre-prandial 90-130 mg/dL – Post-prandial < 180 mg/dL For thin, insulin sensitive patients – Add 1 unit to errant insulin for every 50 mg/dL above target • For obese, insulin resistant patients – Add 2 units to errant insulin for every 50 mg/dL above target

DM Inpatient: WOF

• • • • • Nephropathy – Refer to Renal if with decreasing urine output, low creatinine clearance, for possible HD Ophthalmopathy/Retinopathy – Refer to Ophtha Diabetic foot ulcer – Refer to Ortho/TCVS Deterioration in sugar control – – See previous orders Refer to Endo Acute coronary event

DM Outpatient: Order Sheet

• Diagnostics: – FBS, 2-hour post-prandial glucose – Lipid profile – HBA1c

DM Outpatient: Order Sheet

• Targets – HBA1c < 7% – Pre-prandial glucose (FBS) 90-130 mg/dL – Post-prandial glucose (2h PPBS) < 180 mg/dL – BP < 130/80 (< 125/75 for patients with renal insufficiency) – Lipid modification (order of decreasing priority) • • • LDL < 100 mg/dL HDL > 40 mg/dL in males, > 50 in females TG < 150 mg/dL

DM Outpatient: Order Sheet

• Medications: Biguanides – Dose • • Metformin 500 mg-1g OD, BID, TID Adjust every 2-3 weeks – Goal effect • • Reduces HBA1c by 1-2% Reduces fasting plasma glucose – – Good: weight loss Caution: Renal insufficiency (Crea > 124 mmol/L), lactic acidosis, GI effects – Hold 24h prior to procedures, while critically ill

DM Outpatient: Order Sheet

• Medications: Sulfonylureas – Dose • • • Glimepiride 1-8 mg OD Glipizide 2.5-40 mg OD-BID Take shortly before meals – Goal effect • • Reduces HBA1c by 1-2% Reduces fasting and post-prandial plasma glucose – Caution: weight gain, hypoglycemia, renal insufficiency (Crea > 124 mmol/L), liver disease

DM Outpatient: Order Sheet

• Medications: Thiazolidinediones – Dose • • Pioglitazone 15-45 mg OD Rosiglitazone 1-4 mg OD-BID – Goal effect • • • Reduces HBA1c by 0.5-1.5% Reduces fasting and post-prandial plasma glucose Reduces insulin requirements – Caution: weight gain but redistributes to peripheral areas, hypoglycemia, renal insufficiency (Crea > 124 mmol/L), liver disease, edema, heart failure

DM Outpatient: Order Sheet

• Medications: DPP-IV inhibitors – Dose • • Sitagliptin 50-100 mg OD Vildagliptin 50 mg OD-BID – Goal effect • • Reduces HBA1c by 0.5-1.0% Reduces insulin requirements – Good: does not cause weight gain, minimal hypoglycemia – Caution: Renal insufficiency (use 50 mg OD if Crea > 124 mmol/L), headache, diarrhea, URTI

DM Outpatient: Order Sheet

• Medications: Alpha-glucosidase inhibitors – Dose • • Acarbose 25 mg with evening meal Maximize to 50 - 100 mg with every meal – Goal effect • • Reduces HBA1c by 0.5-0.8% Reduces post-prandial plasma glucose – Good: weight loss – Caution: GI effects (diarrhea, flatulence, abdominal distention), Renal insufficiency (Crea > 177 mmol/L)

DM Outpatient: Order Sheet

• Medications – If 2 drugs aren’t sufficient, insulin is recommended – Cost and compliance are of prime importance

DM Outpatient: Order Sheet

• Diet – Fat 20-35% • • • • Minimal saturated fat (<7%) Minimal transfat Decreased cholesterl (<200 mg/d) At least 2 servings of fish (Omega-3 fatty acids) – Carbohydrates 45-65% • • Low glycemic index Sucrose containing food with adjustments in meds/insulin – – Protein 10-35% High fiber

DM Outpatient: Order Sheet

• • At least 150 minutes/week Monitor blood sugar before, during and after exercise – CBG > 250 mg/dL, delay exercise – CBG < 100 mg/dL, eat carbohydrate before exercise – Pre-exercise insulin modification • • Decrease dose Inject into non-exercising muscle

DM Outpatient: Follow-up

• • • • • • • • Home monitoring of glucose HbA1c q3-6 months Medical nutrition therapy and education Eye examination annually Foot examination daily by patient, annually by MD Screening for albuminuria annually Lipid profile and Crea annually BP measurement q4 months

Endocrinology

Thyroid Disease

Thyroid Disease

• • Hyperthyroidism Hypothyroidism

Hyperthyroidism: Presentation

• • Symptoms – – – – – Hyperactivity, irritability Heat intolerance, sweating Palpitations Weakness, weight loss, diarrhea Polyuria, oligomenorrhea Signs – – – – Tachycardia, sometimes atrial fibrillation Warm, moist skin Tremors, muscle weakness Anterior neck mass

Hyperthyroidism: Order Sheet

• Diagnostics – CBC with PC (infection) – 12-L ECG (atrial fibrillation, tachycardia) – Chest X-ray (rule out infection, cardiomegaly) – Urinalysis (infection) – Free T4 and TSH (high FT4, low TSH) – Crea, Na, K (low K) – Thyroid UTZ (especially if with nodule/s)

Hyperthyroidism: Order Sheet

• Burch-Wartofsky scoring – Components • • • • • • • Temperature CNS GI CVS: heart rate CVS: heart failure CVS: atrial fibrillation Precipitant history – Score • • 25-44: impending storm ≥45: storm

Hyperthyroidism: Order Sheet

• Therapeutics – Propylthiouracil 600 mg LD then 200-300 mg q6 • • Orally/NGT By rectum – Saturated solution of Potassium Iodide (SSKI) 5 drops q6-8, 1 hour after every PTU dose

Hyperthyroidism: Order Sheet

• Therapeutics – Propranolol 40-60 mg PO q4 • If still no rate control: Verapamil 2.5-5 mg SIVP q15-30 minutes, maximum of 20 mg • Use digoxin rarely (decreased potency in hyperthyroidism) – Glucocorticoids • • Dexamethasone 2 mg IV q6 Hydrocortisone 50 mg IV q6 – Treat infection, fever aggressively – Correct electrolytes

Hyperthyroidism: Order Sheet

• • ICU admission – If stable, may admit to Ward Refer to Endo

Hyperthyroidism: Resolution

• Discharge – Taper PTU to 200 mg TID – Heart rate controlled with Propranolol BID – Infection/precipitant treated

Hyperthyroidism: Out-patient

• • • Medication adjustment – – Preferably Methimazole 30 mg OD Taper Propranolol until PRN Follow-up – – – 2-4 weeks with repeat FT4 (same laboratory) Adjust methimazole based on FT4 TSH may be taken eventually to prove suppression Dietary avoidance – – Seafood Iodized salt

Hyperthyroidism: Out-patient

• • 30 to 50% achieve remission on medical treatment alone – Usually after 12-18 months Definitive treatment: once euthyroid – RAI – Surgery – Refer to Endo and GS/ORL

Hyperthyroidism: WOF

• Ophthalmopathy – Steroids • Prednisone 1 mg/kg in 2 divided doses – Artificial tears – Refer to Ophtha

Hypothyroidism: Presentation

• • Symptoms – Weakness – – – – Dry skin, hair loss, impaired healing Difficulty concentrating Weight gain, poor appetite Heart failure Signs – Dry coarse skin, cool peripheral extremities – – – – Puffy face, hands and feet; alopecia Bradycardia Serous cavity effusions (pericardial, pleural, peritoneal) Hyporeflexia

Hypothyroidism: Order Sheet

• Diagnostics – Free T4, TSH (low FT4, High TSH) – CBC with PC – 12-L ECG (documentation of heart rate) – Chest X-ray (enlarged heart, pleural effusion) – Crea, Na, K (hypokalemia) – Thyroid UTZ

Hypothyroidism: Order Sheet

• Diagnostics – Free T4, TSH (low FT4, High TSH) – Anti-TPO – CBC with PC – 12-L ECG (documentation of heart rate) – Chest X-ray (enlarged heart, pleural effusion) – Crea, Na, K (hypokalemia) – Thyroid UTZ

Hypothyroidism: Order Sheet

• Therapeutics – Levothyroxine 1.6 ug/kg BW in single dose before breakfast – If missed dose: may take 2-3 doses of skipped tablets at once due to long half-life

Hypothyroidism: Follow-up

• Repeat TSH after 2-4 weeks – Use same laboratory – Target lower half of TSH range

Gastroenterology

• • Peptic Ulcer Disease and GERD Approach to Jaundice

Gastroenterology

Peptic Ulcer Disease

PUD: Presentation

• • Symptoms – – – – – PUD: Epigastric pain, usually at night Metallic/acid taste in the mouth Melena NSAID use Weight loss, early satiety, vomiting Signs – – – Epigastric tenderness Epigastric mass Melena on DRE (uncommon)

PUD: Order Sheet

• Diagnostics – CBC with PC – EGD with H. pylori biopsy – Urea breath test – FOBT – Chest X-ray

PUD: Order Sheet

• Therapeutics (Active Bleeding) – PPI drip • • Omeprazole 80 mg IV bolus Omeprazole 80 mg in pNSS to make 100 cc x 10 cc/h (8 mg/h) – Immediate endoscopy

PUD: Order Sheet

• Therapeutics – Proton pump inhibitors • • • • • Omeprazole 20 mg/d Esomeprazole 20 mg/d Lansoprazole 30 mg/d Administer BEFORE a meal Long-term: pneumonia, osteoporosis – H2-receptor antagonists • • Ranitidine 300 mg @HS Famotidine 40 mg @HS

PUD: Order Sheet

• Therapeutics – Antacids • • • Usually for symptom relief Aluminum hydroxide-Magnesium hydroxide WOF nephrotoxicity

PUD: Order Sheet

• Therapeutics (H. pylori positive) – OCA/OCM regimen • • • • Omeprazole 20 mg BID Clarithromycin 250-500 mg BID Amoxicillin 1g BID or Metronidazole 500 mg BID – Refer to GI if no response

PUD: Resolution

• Follow-up after 2-4 weeks – Decision to continue PPI dependent on symptoms – Gastric ulcers have risk for malignancy

Gastroenterology

GERD

GERD: Presentation

• • Symptoms – Burning retrosternal chest pain worsening/precipitated by recumbency – Regurgitation of sour material into mouth – Cough – Dysphagia Signs – Obesity – Usually normal abdominal PE

GERD: Order Sheet

• Diagnostics – EGD – CBC with PC

GERD: Order Sheet

• Therapeutics – Proton-pump inhibitors • • • Omeprazole 20 mg/d Esomeprazole 40 mg/d Take 30 minutes before breakfast – – – Weight reduction Elevation of head by 4-6 inches during recumbency Avoid • • • • Smoking Fatty food, large quantities of food/fluid Alcohol, mint, orange juice Calcium channel blockers

Gastroenterology

Jaundice: How to work it up

Jaundice: Work-up

• History – Chronicity – Medications – Hospitalizations, blood transfusions – Sexual history – Drug intake

Jaundice: Work-up

• Diagnostics – TB, DB, IB – AST, ALT, Alkaline Phosphatase – PT – Albumin – Hepatitis profile – HBT-UTZ – Coomb’s test

Jaundice: Work-up

Initial Work-up Isolated elevation of bilirubin Bilirubin and other tests elevated

Jaundice: Work-up

Isolated elevation of bilirubin Elevated DB (DB > 15%) Elevated IB (DB < 15%) Drugs Hemolytic Disorders Inherited disorders Inherited disorders

Indirect Bilirubinemia

• • • Drugs – – History is diagnostic Rifampicin Hemolytic disorders – – – – Precipitated by infection, or other illnesses Enlarged spleen Diagnosed by PBS, Coomb’s test AST, LDH may be elevated Inherited Disorders – – Criggler-Najjar syndrome, Gilbert’s syndrome Present in childhood

Direct Bilirubinemia

• Inherited Disorders – Dubin-Johnson syndrome – Rotor syndrome – Present in young to middle-aged

Jaundice: Work-up

Bilirubin and other tests elevated ALT/AST predominant (Hepatocellular pattern) Alk Phos predominant (Cholestatic pattern) Drugs Viral Hepatitis Autoimmune Hepatitis Ultrasound

Hepatocellular Pattern

• • • Drugs – Alcohol – Paracetamol ingestion – Other hepatotoxic drugs Viral Hepatitis – Detectable by serology Autoimmune Hepatitis – ANA positive in some cases • May do liver biopsy if no diagnosis at this point

Jaundice: Work-up

Alk Phos predominant (Cholestatic pattern) Dilated Ducts on Ultrasound No Dilated Ducts on Ultrasound Extrahepatic Intrahepatic

Extrahepatic Pattern

• Do CT scan or ERCP to assess cause of obstruction • • Carcinoma – Periampullary CA – Gallbladder CA – Cholangiocarcinoma Stone – Filling defect • Parasitic disease

Intrahepatic Pattern

• • • • • • • Viral Hepatitis Drugs – – Alcoholic Hepatitis Steroids Cholestasis of Pregnancy TPN Sepsis TB Lymphoma

Poisons

Poisons and Snakebites

• • • • • • General Principles of Management Alcohol Toxicity and Withdrawal Silver Jewelry Cleaner Ingestion Organophosphate Ingestion Kerosene Ingestion Acid and Alkali Ingestion

General Principles

Poisons

General Principles

1. Emergency Stabilization 2. Clinical Evaluation 3. Elimination of the poison 4. Excretion of absorbed substance 5. Administration of antidotes 6. Supportive Therapy and Observation 7. Disposition

General Principles

1. Emergency Stabilization – Airway – Breathing: Oxygenation and Ventilation – Circulation: Inotropes – Convulsion cessation – Electrolyte/metabolic correction – Coma

General Principles

2. Clinical Evaluation – History: • • • • Time, Mode/Route Circumstances prior Pre-existing illnesses or co-morbidities Home remedies/treatment given – PE • • • Complete Breath odor Neurologic PE

General Principles

2. Clinical Evaluation – Laboratory Examinations • • • • • • • • CBC with PC Urinalysis RBS, BUN, Creatinine, Na, K, Ca, alb, Mg ABG 12-L ECG Bilirubins, PT, AST, ALT, Alk Phos Chest X-ray (best if PA-upright) Plain abdominal X-ray

General Principles

3. Elimination of the poison – External decontamination • • • • Discard all clothing Thorough bathing Eye irrigation Protective gear for personnel – Empty stomach • • Induction of emesis (if ingestion occurred within 1 hour) Gastric Lavage (50-60 mL of tepid sterile water) – – Don’t do in ingestion of caustics, kerosene!

Don’t do if patient is convulsing!

General Principles

3. Elimination of the poison – Limit GI absorption • • • • Activated charcoal: 50-100 g in 200 mL H2O Do multiple doses if with enterohepatic recirculation Contraindicated in caustics Follow with Na sulfate up to 2 doses, then soap sud enema for BM – Demulcent agents • Raw egg albumin: whites of 8-12 eggs – Cathartics • • Na sulfate 15 g in 100 mL H2O Contraindicated in caustics, easily absorbable chemicals, ileus, severe fluid and electrolyte imbalances

General Principles

4. Excretion of absorbed substances – Forced diuresis • Mannitol 20% 1 mL/kg within 10 minutes then 2.5-5 mL/kg q6 x 8 doses • Must have good urine output – Alkalinization (for weak acids) • NaHCO3 1mEq/kg/dose IV targeting urine pH > 7.5

– Acidification (for weak bases) • Ascorbic Acid 1g IV q6 until urine pH ≤ 5.5

– Dialysis

General Principles

5. Antidotes 6. Supportive Therapy – – – – Fluid replacement for losses Electrolyte correction Prevention of aspiration, decubitus ulcers Monitorin VS and I/O 7. Disposition – – – ER vs Ward vs ICU Psychiatric evaluation Social evaluation

Alcohol

Poisons

Alcohol Intoxication

Blood Ethanol (mg/dL) < 50 50-100 100-300 300-500 > 500 Symptoms Talkativeness, euphoria Decreased inhibition/increased confidence, emotional instability, slow reaction Ataxia, slurred speech , diplopia, decreased attention span Visual impairment, severe ataxia, stupor Respiratory Failure, coma Brain affected Frontal Lobe Parietal Lobe Occipital Lobe Cerebellum Midbrain Medulla

Alcohol Intoxication

Category Beer Wine Fortified Wine Distillates Local distilled Hygiene Products Specific Lager Pilsen Strong Red/White Champagne Whiskey, rye, rhum, bourbon, gin Lambanog, tuba Perfume/cologne Mouth wash % Ethanol 2-3% 5-6% 9-14% 7-12% 15-20% 40-50% 60-80% 25-95% 15-25%

Alcohol Intoxication

Local Term Lapad Bilog Kwatro kantos Long neck Beer grande Beer (regular) Volume 325 mL 325 mL 325 mL 750 mL 1000 mL 320 mL

Alcohol Intoxication

• • • Blood alcohol (mg/dL) – mL ingested x % alcohol x 0.8

6 x kg BW Metabolism – Non-alcoholic: 13 to 25 mg/dL per hour – Alcoholic: 30 mg/dL per hour Estimated time of recovery – Blood alcohol/metabolic rate

Alcohol Intoxication

• • History – Amount ingested – With what substance PE – Evidence of trauma – Level of sensorium

Alcohol Intoxication: Order Sheet

• Labs – Urine ketones – CK MB, MM – Amylase – FOBT

Alcohol Intoxication: Order Sheet

• Therapeutics – NPO – Insert NGT – IVF: D5 0.9 NaCl 1L x 8h Conscious Unconscious

Alcohol Intoxication: Order Sheet

Conscious • Therapeutics – Thiamine 100 mg IM/IV – D50-50 100 mL fast drip IV – Refer to Psych – Evaluate for withdrawal – Observe for 6 hours – Discharge on • Thiamine 50 mg TID OR • • Vitamin B complex 1 tab TID Folic Acid OD, Multivitamins OD

Alcohol Intoxication: Order Sheet

• Therapeutics Unconscious – Thiamine 100 mg IM/IV now then q8 – D50-50 100 mL fast drip IV – Refer to Neurology – Observe for return of consciousness • Fully awake: Observe for 5-7 days, refer to Psychiatry • • Partially awake: Work-up for decreased sensorium (NSS?) Comatose: Naloxone 2 mg IV q2 minutes for a total of 10 mg; work-up for decreased sensorium, consider HD – Same discharge plans

Alcohol Withdrawal: Presentation

• Symptoms/Signs – Autonomic hyperactivity (sweating, tachycardia) – Increased tremors – Insomnia – Nausea/vomiting – Hallucinations/illusions – Psychomotor agitation/anxiety – Seizures

Alcohol Withdrawal: Order Sheet

• Therapeutics – Diazepam 2.5-5mg q8 x 3 days then taper for next 2 days before discontinuation – Vitamin B complex TID – Folic Acid OD

Alcohol: Resolution

• • Enrol in quitting program Advice moderation

Paracetamol

Poisons

Paracetamol: Presentation

• • Toxic dose if 150-300 mg/kg Symptoms vary based on time after exposure – 0-24 hours: asymptomatic, nausea, vomiting – 24-36 hours: asymptomatic, upper abdominal pain – 36-72 hours: onset of liver/renal failure – 72-120 hours: jaundice, bleeding, liver/renal failure

Paracetamol

• • History – Time, mode – Intake of other substances/meds – Co-morbidities PE – Heart, liver, kidneys – Neurologic examination

Paracetamol: Order Sheet

• Diagnostics – Serum paracetamol – AST, ALT, PT

Paracetamol: Order Sheet

Volume ingested?

Known Unknown < 150 mg/kg Observe for 24h (+) SSx or AST, ALT or PT abn ≥ 150 mg/kg N-acetylcysteine Test dose: 0.1 mL in 0.9 mL NSS IV Diphenhydramine 1 mg/kg prior to phases Phase 1: 150 mg/kg in 200 mL D5W x 1h Phase 2: 50 mg/kg in 500 mL D5W x 4h Phase 3: 100 mg/kg in 1L D5W x 16h (+) SSx (-) SSx Observe for 72h (+) SSx or AST, ALT or PT abn

Paracetamol: Order Sheet

Normalization after 72 hours Discharge

Paracetamol: WOF

• • • • Acute Renal Failure – – IVF hydration Refer to Renal for possible Dialysis Bleeding – – Vitamin K 10 mg IV up to q6 Target PT > 60% activity Hepatic insufficiency – – Vitamin B complex Vitamin K Electrolyte abnormalities – Hypoglycemia, acidosis, hypokalemia, hypocalcemia

Silver Jewelry Cleaner

Poisons

Silver Jewelry Cleaner

• • Active compound is cyanide-derived Binds to cytochrome oxidase enzymes, inhibiting cellular respiration

SJC: Order Sheet

• • Diagnostics – ABG – Serum cyanide – CBC with PC Anticipatory Care – ICU admission – Close monitoring – Treatment for co-ingestants (e.g. alcohol)

SJC: Order Sheet

• Therapeutics – Oxygenation • • High flow Prophylactic intubation esp if with decreased sensorium – Na nitrite 300 mg SIVP (over 5 minutes) • • Vasodilator, displaces cyanide, producing methemoglobin Causes hypotension – Na thiosulfate 12.5 g (50 mL of a 25% solution) SIVP (over 10 minutes) • Speeds the displacement of cyanide by providing sulfur for binding

SJC: WOF

• • • Decreased sensorium – Aspiration precautions – Prophylactic intubation if warranted Seizures – Diazepam – Increased oxygen delivery Hypoxic encephalopathy – Rapidly reversible if antidote given early – If still not reversed, need prognostication by Neuro

Kerosene

Poisons

Kerosene

• • History – Time – Amount – Mucous membrane irritation – CNS depression, seizures PE – Lung findings: crackles, respiratory distress – Arrhythmia, tachycardia – Sensorial changes

Kerosene: Order Sheet

• Diagnostics – Chest X-ray (6 hours post-ingestion) – ABG Volume ingested?

≤ 60 mL ≤ 60 mL + other toxic substance > 60 mL or unknown

Kerosene: Order Sheet

Volume ingested?

≤ 60 mL • • • Na Sulfate (BM) Clean anal area with petroleum jelly ≤ 60 mL + other toxic substance • • Insert NGT Lavage with Activated Charcoal > 60 mL or unknown • • Insert NGT Lavage with water

Kerosene: Order Sheet

Sensorial Change Pneumonia Toxic substances Observe for 12 24 hours • • Refer to Psych Discharge Observe for 3 days Supportive Care

Kerosene: WOF

• • • • Pneumonia – – – Penicillin G 200,000 u/kg/d in 6 divided doses Clindamycin 300 mg PO/IV q6 Metronidazole 500 mg PO/IV q6 Gastritis – Al-hydoxide-Mg-hydroxide 30 mL q6 Prolonged PT – Vitamin K 10 mg OD Seizures – – Diazepam 2.5-5 mg SIVP Refer to Neuro

Acids

Poisons

Acids

• • Causes coagulation necrosis which forms eschars – Damage is self-limiting Eventual stenosis of viscus

Acids: Order Sheet

• Diagnostics – Cross-matching – Urine hemoglobin – Chest X-ray upright, plain abdomen – Emergency EGD

Acids: Order Sheet

• Therapeutics – Copious amounts of water to decontaminate externally – – – – – NPO IVF: D5NSS 1L x 8h Meperidine 25-50 mg IM Famotidine 20 mg IV q12 Concentrated acids: Enhance excretion with Mannitol • • • Test dose: 1 mL/kg within 10 mins If with good urine output: 2.5-5.0 mL/kg q6 x 8 doses Discontinue mannitol if with poor urine output x 2h

Acids: Order Sheet

Grade 0 1 2A 2B 3A 3B Findings Normal Edema, hyperemia of mucosa Friability, blisters, hemorrhages, erosions, whitish membranes, exudates, superficial ulcerations 2A + deep discrete or circumferential ulceration Small scattered areas of multiple ulcerations and areas of necrosis Extensive necrosis

Endoscopy Grade 0-1 Grade 2a/b Admit Observe for 48 h Liquid diet for 48h H2 blockers PO/IV Demulcent, antacids or sucralfate No Admit to ICU NPO IV hydration, TPN H2 blockers IV Repeat EGD 24-48h Psych Referral Discharge Ff-up with GS/GI Perforation, Necrosis?

Yes Laparotomy Grade 3a/b Admit to ICU NPO IV hydration/TPN H2 blockers IV Hydrocortisone 100 mg IV q6 for shock Meperidine Antibiotics (anarobes, Gram negatives) Repeat EGD 24-48h

Acids: WOF

• • • • Acute abdomen – – Surgery Lifelong vitamin B12 if gastrectomy done Shock – Fluids, antibiotics as appropriate Upper airway obstruction – – Tracheostomy Hydrocortisone 100 mg IV q6 Upper GI Bleed – Blood transfusion, surgery

Alkali

Poisons

Alkali

• Causes liquefaction necrosis – Damage spreads, and may continue for days

Alkali: Order Sheet

• Diagnostics – Cross-matching – Urine hemoglobin – Chest X-ray upright, plain abdomen – Emergency EGD

Alkali: Order Sheet

• Therapeutics – Copious amounts of water to decontaminate externally – NPO – IVF: D5NSS 1L x 8h – Meperidine 25-50 mg IM – Famotidine 20 mg IV q12

Alkali: Order Sheet

Extent First degree Findings Superficial mucosal hyperemia, mucosal edema, superficial sloughing Second degree Deeper tissue damage, transmucosal (all layers of the esophagus), with exudages, erosions Third degree Through the esophagus and into the periesophageal tissues (mediastinum , pleura or peritoneum), deep ulcerations, black coagulum

Endoscopy First degree Second degree Admit Observe for 48 h Liquid diet for 48h Demulcent, antacids Psych Referral Discharge Ff-up with GS/GI No Admit to ICU NPO IV hydration, TPN Hydrocortisone 100 mg IV q6 H2 blockers IV Sucralfate Repeat EGD 24-48h Yes Laparotomy Perforation?

Third degree Admit to ICU NPO IV hydration/TPN H2 blockers IV Hydrocortisone 100 mg IV q6 for shock Meperidine Antibiotics (anarobes, Gram negatives) Repeat EGD 24-48h

Alkali: WOF

• • • • Acute abdomen – – Surgery Lifelong vitamin B12 if gastrectomy done Shock – – Hypovolemic/Septic: Fluids, antibiotics as appropriate Neurogenic: Mepedirine 1 mg/kg/dose IV Upper airway obstruction (Glottic edema) – – Tracheostomy Hydrocortisone 100 mg IV q6 Upper GI Bleed – Blood transfusion, surgery

National Poison Control and Management Center

(02) 554-8400 loc 2311 (02) 524-1078 0922-896-1541

Pain Pharmacopeia

Pain Medication

• • Most common complaint Best treatment: address the cause

Pain Pharmacopeia

NSAIDs

Pain Medication: NSAIDs

• • • • • • ASA 80-160 mg PO OD Paracetamol 500-650 mg PO up to q4 Ibuprofen 400 mg PO up to q4 Naproxen 250-500 mg up to q12 Ketorolac 15-60 mg IM/IV up to q4 Celecoxib 100-200 mg PO up to q12

Pain Medication: NSAIDs

• • • Advantages – Deals well with inflammatory pain (muscle and joint pain, malaise from infection, etc) – Absorbed well from the GI tract Disadvantages – GI irritation (except paracetamol) – – – Peptic ulcer Nephropathy Increases blood pressure Selectivity for COX-2 – Decreases GI symptoms – Increases cardiovascular risk

Pain Pharmacopeia

Narcotics

Pain Medication: Narcotics

• • Morphine 60 mg PO up to q4 Tramadol 50-100 mg PO up to q4

Pain Medication: Narcotics

• • Advantages – Broadest efficacy – Very rapid especially if IV Disadvantages – Nausea and vomiting – Constipation – Sedation – Respiratory depression

Pain Pharmacopeia

Anti-depressants

Pain Medication: Anti-depressants

• • • • • Duloxetine 30-60 mg/d Desipramine 50-300 mg/d Imipramine 75-400 mg/d Amitriptyline 25-300 mg/d Doxepin 75-400 mg/d

Pain Medication: Anti-depressants

• Advantages – Very useful for chronic pain • • • • • • Post-herpetic neuralgia Diabetic neuropathy Tension headache Migraine Rheumatoid arthritis Cancer – More rapid onset of relief

Pain Medication: Anti-depressants

• Disadvantages – Significant number of side effects • • • • Orthostatic hypotension Heart block/conduction delay Constipation Urinary retention

Pain Pharmacopeia

Anti-convulsants

Pain medication: Anti-convulsants

• • • • • Phenytoin 300 mg @ HS Carbamazepine 200-300 mg up to q6 Clonazepam 1mg up to q6 Gabapentin 600-1200 mg up to q8 Pregabalin 150-600 mg up to BID

Pain medication: Anti-convulsants

• • Advantages – Effective for neuropathic pain (e.g. trigeminal neuralgia, DM nephropathy) Disadvantages – Hepatic toxicity – Dizziness – GI symptoms – Heart conduction disturbances