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CCP > Treatments > Flashcards

Treatments Flashcards

1
Q

Hyperkalemia Tx

A 
500-1000mg Calcium chloride
1-4mcg/min epinephrine infusion
20mg nebulized Salbutamol
Insulin and dextrose
High dose isotonic NaHCO3 infusion
40-80mg Lasix
*Make sure Mg++ levels are adequate
Dialysis
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2
Q

Toxic Alcohol Poisoning Tx

A

Establish there is an osmolar gap
Treat with ethanol (requires ICU care) or fomepizol ($$$)
-Fomepizole 15mg/kg bolus, then 10mg/kg q. 12h
Thiamine, magnesium, folic acid
Dialysis
Target pH > 7.3 with bicarbonate

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3
Q

ASA Toxicity Tx

A

Activated charcoal
Crystalloids
Target serum pH to 7.4 and urine pH to 7.5-8.0
-Sodium bicarbonate bolus (2mEq/kg)
-Sodium bicarbonate infusion (3 amps into 1L of D5W)
KCl or KPO4 to keep K+ > 4.0
Avoid intubation, but maintain adequate ventilation!

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4
Q

Urosepsis Tx

A

Remove any in situ device

Ceftriaxone, or piptazo if necessary

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5
Q

TBI Mgmt

A
  • Levophed to keep MAP > 80
  • Propofol, labetalol, then hydralazine to keep SBP < 180
  • PaO2 > 150 (FiO2/PEEP < 12)
  • PaCO2 35-40
  • Temp 36.0-37.5
  • Propofol infusion to target RASS -4/-5
  • Reverse anticoagulation (FFP, cryo, vit K, prothrombin, antidote)
  • Adequate Hgb, Plts, INR
  • HOB 30, loosen collars/ties
  • Normal glucose
  • TXA
  • ABx (encef) for free air in skull
  • Neuro V/S q. 15
  • Intubate if M5 or less
  • Consider seizure prophylaxis
  • Low flight for pneumocranium
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6
Q

Increased ICP (non-herniation) Tx

A
  • HTS3% - 100ml
  • Mannitol - 0.25-0.5g/kg (caution: hypovolemia/electrolyte shift)
  • Propofol to target RASS -4/-5
  • OG tube/parecentesis/PEEP < 12
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7
Q

Increased ICP (herniation) Tx

A
  • Mannitol 1g/kg - watch for hypovolemia/electrolyte shift
  • HTS3% 250ml
  • Propofol infusion to target RASS -4/-5
  • PaCO2 30-35mmHg
  • OG tube/parecentesis/PEEP < 12
  • Avoid Tx of bradycardia
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8
Q

When to consider seizure prophylaxis in TBI:

A
  • Presented with seizure
  • Deep skull F#
  • Temporal lobe involvement
  • Underlying seizure disorder
  • Penetrating trauma
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9
Q

Spontaneous (arterial) SAH Tx

A
  • Labetalol (5->10->20->40 to max 300mg), then hydralazine (10-20mg) to keep SBP < 140
  • Levophed to keep MAP > 80
  • MgSO4 to target Mg++ > 0.8, KCl to target K+ > 4.0, PO4 > 0.8
  • Watch for increased ICP (obstructive hydrocephalus)
  • Tx SIADH with HTS3%.
  • Monitor QTc and 12 lead
  • Benzos/dilantin for seizure mgmt
  • Continue any statin therapy
  • Rebleeding is common in first 3 days, then vasospasm is more likely to occur.
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10
Q

Status Epilepticus Tx

A
  • Midazolam (2.5-50mg) and Phenytoin (20mg/kg)
  • Propofol (40mcg/kg/min) and midazolam (10mg/hr)
  • Ketamine (10-100mg/hr) or barbiturates
  • Magnesium sulphate (2-5g over 20 min)
  • Verapamil
  • Acetaminophen if febrile
  • Paralyze with Roc
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11
Q

Seizure Tx, in the setting of toxic overdose:

A

*Avoid phenytoin. Same pathway as SE, but use Keppra 500-1000mg OG instead

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12
Q

Spinal shock Tx

A
  • If no T1, use dopamine 2-20mcg/min to keep MAP > 85
  • 2L of crystaloid
  • PaO2 > 100
  • Low G takeoff
  • Assess vital capacity and C5/6 (shoulders, biceps) for possible ventilator support
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13
Q

Ischemic CVA Tx

A
  • tPA if < 3.5hrs, or thrombecotmy if < 6hrs
  • Lysis attempted: Labetalol/hydralazine to keep SBP < 180
  • Lysis not attempted: keep SBP < 220
  • HOB 0
  • 1L crystaloid
  • PaO2 > 100
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14
Q

Hemorrhagic CVA Tx

A

-Reverse anticoagulation
-Labetalol/hydralazine:
Wake/following commands: SBP < 140
Comatose: SBP < 180, MAP > 80

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15
Q

STEMI Launch Mgmt

A

-Pads on
-324mg ASA
-90, or 180mg Ticagrelor
-Treat dysrhythmias (amiodarone, MgSO4, lidocaine)
+/-25mg Metoprolol PO for tachycardia (Killip < 2) but treat causes of tachycardia first.
+/- TNG infusion (CI in RVMI, ED drugs)
+/-Morphine/fentanyl only for considerable pain
+/-Oxygen to keep SpO2 > 92% or avoid SOB
-Ativan?

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16
Q

NSTEMI Pathway

A
  • 324mg ASA
  • 150 or 300mg of Plavix, or 90 or 180mg of Ticagrelor
  • 80mg Atorvastatin
  • Enoxaparin or heparin
  • TNG infusion or patches
  • ACE I for hypertension
  • 25mg Metoprolol for tachycardia (Killip < 2, tachy < 110, no AV block)
  • Morphine only for considerable pain
  • Manage Mg++ > 1.0 and K+ > 4.0
  • Pantaloc 80mg bolus -> 8mg/hr)
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17
Q

ADHF Tx

A
  • BIPAP
  • Differentiate between poor flow (MR) and poor contractility (MI)
  • Lasix if hypervolemic (double home PO dose for IV dose)
  • TNG (10-300mcg/min)
  • Morphine if needed to blunt the SNS
  • Captopril
  • Dobutamine and Levophed
  • Avoid beta blockers
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18
Q

RV Infarct Tx

A

-Same as STEMI pathway but give at least 500mL fluid and avoid TNG, morphine, PPV and acidemia.

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19
Q

PE Tx

A
  • Heparin
  • Vasoactive support: epinephrine or vasopressin (RV loves epi; vasopressin causes pulmonary dilation).
  • 5mg milrinone down the tube!
  • Nebulized nitro…?
  • Half dose tPA, but only if confirmed beforehand and about to die. Don’t run heparin and tPA at the same time. Wait 6-8 hours before you start heparin again.
  • Avoid intubation if you can.
  • Get code orders before you fly
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20
Q

Your RV Infarct has now turned into RV failure. What do you do?

A
  • Stop fluids and diurese with Lasix
  • Minimize PEEP/BVM and maximize FiO2
  • Minimize acidemia
  • Milrinone (0.125mcg/kg/min)
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21
Q

Tamponade Tx

A
  • 500mL crystaloid bolus
  • Allow tachycardia
  • Levophed +/- Dobutamine with phenylephrine on SBY
  • Avoid PPV
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22
Q

Aortic dissection Tx

A

Type A (surgery), type B (non-surgical)

  • Labetalol (20mg bolus, then 0.5-2mg/min, total 300mg)
  • Nitroprusside (0.25-0.5mcg/kg/min)
  • Avoid hydralazine
  • Treat the pain!!
  • Target SBP 100-120 and HR 50-70
23
Q

HTN Crisis Tx

A

Signs of end-organ damage with SBP > 180 and/or DBP > 120:

  • Labetalol (2-5mg/min) with nitroprusside (0.5mcg/kg/min)
  • Reduce MAP by 25% within 2 hours
24
Q

Acetaminophen OD Tx

A
  • N-acetylcyctine (NAC) within 8 hours (150mg/kg over 1 hour, then 50mg/kg over 4 hours, then 100mg/kg over 16 hours until APAP < 10mcg/mL)
  • Acitvated charcoal in the first hour
25
Q

Variceal UGIB Tx

A
  • 1g TXA, then infusion (1g over 8h)
  • HGB > 70, reverse anticoagulants
  • 80mg pantoprazole, then 8mg/hr infusion
  • Levophed to keep MAP > 65
  • Octreotide (50mcg bolus, then 50mcg/hr), or vasopressin
  • Blakemore
  • ABx
26
Q

Hepatic encephalopathy

A

-Lactulose

27
Q

Pancreatitis Tx

A

Crystalloids
Analgesia
ABx
Q? ARDS

28
Q

Beta Blocker OD Tx

A
  • Activated charcoal
  • IV fluids
  • 1 to 2g of CaCl
  • 3 to 5mg of glucagon slow push, q 10min to max of 10mg (watch for barf!)
  • Insulin and dextrose
  • Levophed to keep MAP > 65
  • Sodium bicarbonate
  • Pacing
  • If giving insulin, remember K+ will shift and you may need to administer KCl/KPO4.
29
Q

CCB OD Tx

A
  • Activated charcoal
  • IV fluids
  • 1 to 2g of CaCl
  • Insulin and dextrose
  • Pacing
30
Q

TCA OD Tx

A
  • Activated charcoal
  • IV fluid, Levophed if necessary
  • NaHCO3 1-2mEq/kg bolus
  • NaHCO3 infusion
  • Benzos for seizures (never phenytoin)
  • 200ml HTS if wide complex persists (keep pH < 7.55)
31
Q

SSRI OD Tx

A
  • Keep temp < 41.0
  • Dantrolene?
  • Paralyze to help keep temp down
32
Q

Cocaine OD Tx

A

1-2mEq/kg NaHCO3
Benzos
Phentalomine, never B blockers
Never sux

33
Q

Cyanide poisoning Tx

A 
Hydroxocobalamin 5g if:
High suspicion of enclosed fire with one of the following:
-lactate > 8
-hypotension
-DLOC
34
Q

Organophosphate Poisoning Tx

A
  • Decontaminate (can be absorbed dermaly)
  • Double 1mg atropine q. 2-3min (Max 500mg, or until secretions dry up)
  • Pralidoxime (2-PAM), 1-2g over 15-30min
  • Paralyze
35
Q

Trauma Mgmt Principles

A
  • Warmth, oxygen, pain relief
  • Permissive hypotension (especially for penetrating/arterial)
  • TXA (1g over 10 min, then 1g over 8h)
  • Bind pelvis
  • Transfuse 1:1:1 if Hgb<100, SBP < 100, HR > 100; penetrating or positive FAST; reverse anticoagulants
  • CaCl2 1g every 4 units PRBCs
  • Consider ketamine bolus (15-25mg), then low dose infusion (20mg/hr)
  • Crystalloids, only if decreased EOP in blunt trauma
  • Bilateral large bore PIVs
  • Avoid permissive hypotension in pregnant, TBI, SCI
36
Q

CAP Tx

A
  • Fluid resuscitation guided by IVC/PLR
  • Ceftriaxone +/- azithromycin
  • Piptazo if they’re really sick
  • Q? HAP, give vancomycin
  • Meropenem if immunocompromised
37
Q

ARDS Pathway

A
  • Measure P:F ratio
  • Paralyze early
  • 6 -> 4mL/kg with PLATs < 30 (esophageal balloon)
  • Follow PEEP ladder
  • Permissive hypercapnia, while keeping pH > 7.15 (consider NaHCO3 infusion)
  • Pressure mode, then inverse ratio ventilation
  • Recruitment maneuvers
38
Q

COPD Tx

A
  • Measure baseline autoPEEP
  • Paralyze if on vent
  • Hypotensive? (pop off vent)
  • Prednisone if conscious, or methylprednisone if not
  • ABx
  • Bronchodilators
  • Optimize I:E and PEEP matching
39
Q

Asthma Tx

A
  • Measure baseline autoPEEP
  • Continuos salbutamol
  • 0.5mg atrovent
  • Epinephrine infusion 1-10mcg/min, nebulized Epi
  • 2g magnesium sulfate
  • IV glucocorticoids (methylprednisone)
  • IV Ketamine (up to 3mg/kg if already sedated)
  • Take them off circuit to let them exhale
  • Paralyze and give uncomfortably long I:E with a propofol or ketmaine infusion for sedation.
  • Inhaled anesthetics
40
Q

Dive injury management

A
  • Get an ABG
  • FiO2 1.0
  • Supine position
  • Salbutamol
  • BIPAP
  • Fluid
  • Pressurize aircraft, low flight
  • U/S for lung sliding sign
41
Q

PAH: To give fluid, or not to give fluid?

A
  • Use short axis cardiac view to look at septum. If LV is D shaped during diastole, the RV is overloaded and there is too much volume. If it is D-shaped during systole, there is too much pressure (afterload) so dial in some milrinone.
  • If giving fluid, also consider vasopressin in order to improve diastolic coronary blood flow. Vasopressin has some mild bronchodilatory effects despite its systemic vasoconstriction.
42
Q

Treat Mitral Valve Regurgitation

A

Reduce afterload with TNG or hydralazine. Keep preload low. Maybe try milrinone or dobutamine?

42
Q

Treat Mitral Valve Stenosis:

A
  • Slow heart rate to allow for better diastolic filling

- Keep in sinus rhythm!

43
Q

Treat Aortic Regurgitation:

A

Use dobutamine to keep heart rate elevated and SVR low.

44
Q

Treat Aortic Stenosis:

A
  • Slow heart rate (B-blockers) and increase afterload (phenylephrine) in order to improve coronary blood flow and contractility.
  • Caution with Beta Blockers if any sign of cardiogenic shock.
  • Balance fluid levels. Too little and they will die. Too much and the RV will bog down, eventually decreasing LV output and they will die then too.
45
Q

Treat Hypertrophic Obstructive Cardiomyopathy (and explain it while you’re at it):

A
  • Left ventricular outflow tract is obstructed due to a combination of enlarged myocardium and septal leaf of mitral valve being ‘sucked’ towards aorta (SAM).
  • Use B blockers to improve diastolic filling time, give fluid to increase preload and give phenylephrine to increase SVR (to prevent ‘suck’).
  • Maintain or reduce contractility to prevent SAM
  • Maintain sinus rhythm
46
Q

DKA Tx:

A
  • 2 to 4 litres of Plasmalyte (has 4 mEq of K+ in it)
  • Aggressively treat hypokalemia to keep it > 4.0mmol
  • Consider A-line for serial Chem-7 monitoring
  • 10 units at a time of regular insulin in 500cc D10W until ketones resolve AND glucose < 12.0
  • Sodium bicarbonate if pH < 6.9
  • Keep Mg++ and PO4 > 0.8mmol
47
Q

Anticonvulsant treatment for eclampsia:

A
  • MgSO4 4-6g over 20 min, then 2g/hr for maintenance
  • Phenytoin 10-20mg/kg to a max of 50mg/min
  • Diazepam 5mg/min to a max of 20mg
48
Q

Anti-hypertensive agents used in Preeclampsia

A
  1. Hydralazine (5mg IV) q. 20 min to a max of 20mg
  2. Labetalol (20mg, doubled q. 10 min to a max of 220mg
  3. Nifedipine 10mg PO
  4. Nitroprusside
49
Q

PPH Tx

A

Tone (70% of causes of PPH)

  • Oxytocin
  • Fundal massage
  • Positioning

Tissue
-Direct uterine manipulation

Trauma

  • Sutures
  • TXA

Thrombin (Coagulopathy like low platelests in HELLP)
-Blood products

Be prepared for massive transfusion with CaCl2.

50
Q

Potential therapies for hyponatremia

A
  • 100-150cc of HTS3 if neuro emergency
  • Lactated Ringer’s if unstable hypovolemia (250cc) so sodium doesn’t rise too fast.
  • KCL, if their potassium is also low
  • 1mcg DDAVP if urine output >100mL/hr but urine osmolarity < 100.
51
Q

Cerebral vasospasm Tx

A
  • Hemodilution (monitor Na+), but eurovolemia.
  • Correct all electrolytes.
  • Milrinone bolus of 0.1-0.2mg/kg, then 0.75mcg/kg/min infusion.
  • Levophed to keep MAP > 90.
  • Repeat Milrinone bolus after 30 minutes.
52
Q

Why isotonic NaHCO3 for hyperkalemia?

A

Alkalizing the blood will help shift K+ back into the cell, but the shift is negated if you use hypertonic NaHCO3 because of its hyperosmolarity. Use 3 amps of bicarbonate in a 1000cc bag of D5W for more effective shift.

CCP (18 decks)

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