Treatments Flashcards
Hyperkalemia Tx
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
Toxic Alcohol Poisoning Tx
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
ASA Toxicity Tx
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!
Urosepsis Tx
Remove any in situ device
Ceftriaxone, or piptazo if necessary
TBI Mgmt
- 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
Increased ICP (non-herniation) Tx
- HTS3% - 100ml
- Mannitol - 0.25-0.5g/kg (caution: hypovolemia/electrolyte shift)
- Propofol to target RASS -4/-5
- OG tube/parecentesis/PEEP < 12
Increased ICP (herniation) Tx
- 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
When to consider seizure prophylaxis in TBI:
- Presented with seizure
- Deep skull F#
- Temporal lobe involvement
- Underlying seizure disorder
- Penetrating trauma
Spontaneous (arterial) SAH Tx
- 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.
Status Epilepticus Tx
- 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
Seizure Tx, in the setting of toxic overdose:
*Avoid phenytoin. Same pathway as SE, but use Keppra 500-1000mg OG instead
Spinal shock Tx
- 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
Ischemic CVA Tx
- 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
Hemorrhagic CVA Tx
-Reverse anticoagulation
-Labetalol/hydralazine:
Wake/following commands: SBP < 140
Comatose: SBP < 180, MAP > 80
STEMI Launch Mgmt
-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?
NSTEMI Pathway
- 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)
ADHF Tx
- 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
RV Infarct Tx
-Same as STEMI pathway but give at least 500mL fluid and avoid TNG, morphine, PPV and acidemia.
PE Tx
- 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
Your RV Infarct has now turned into RV failure. What do you do?
- Stop fluids and diurese with Lasix
- Minimize PEEP/BVM and maximize FiO2
- Minimize acidemia
- Milrinone (0.125mcg/kg/min)
Tamponade Tx
- 500mL crystaloid bolus
- Allow tachycardia
- Levophed +/- Dobutamine with phenylephrine on SBY
- Avoid PPV
Aortic dissection Tx
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
HTN Crisis Tx
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
Acetaminophen OD Tx
- 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
Variceal UGIB Tx
- 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
Hepatic encephalopathy
-Lactulose
Pancreatitis Tx
Crystalloids
Analgesia
ABx
Q? ARDS
Beta Blocker OD Tx
- 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.
CCB OD Tx
- Activated charcoal
- IV fluids
- 1 to 2g of CaCl
- Insulin and dextrose
- Pacing
TCA OD Tx
- 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)
SSRI OD Tx
- Keep temp < 41.0
- Dantrolene?
- Paralyze to help keep temp down
Cocaine OD Tx
1-2mEq/kg NaHCO3
Benzos
Phentalomine, never B blockers
Never sux
Cyanide poisoning Tx
Hydroxocobalamin 5g if: High suspicion of enclosed fire with one of the following: -lactate > 8 -hypotension -DLOC
Organophosphate Poisoning Tx
- 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
Trauma Mgmt Principles
- 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
CAP Tx
- Fluid resuscitation guided by IVC/PLR
- Ceftriaxone +/- azithromycin
- Piptazo if they’re really sick
- Q? HAP, give vancomycin
- Meropenem if immunocompromised
ARDS Pathway
- 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
COPD Tx
- 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
Asthma Tx
- 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
Dive injury management
- Get an ABG
- FiO2 1.0
- Supine position
- Salbutamol
- BIPAP
- Fluid
- Pressurize aircraft, low flight
- U/S for lung sliding sign
PAH: To give fluid, or not to give fluid?
- 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.
Treat Mitral Valve Regurgitation
Reduce afterload with TNG or hydralazine. Keep preload low. Maybe try milrinone or dobutamine?
Treat Mitral Valve Stenosis:
- Slow heart rate to allow for better diastolic filling
- Keep in sinus rhythm!
Treat Aortic Regurgitation:
Use dobutamine to keep heart rate elevated and SVR low.
Treat Aortic Stenosis:
- 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.
Treat Hypertrophic Obstructive Cardiomyopathy (and explain it while you’re at it):
- 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
DKA Tx:
- 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
Anticonvulsant treatment for eclampsia:
- 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
Anti-hypertensive agents used in Preeclampsia
- Hydralazine (5mg IV) q. 20 min to a max of 20mg
- Labetalol (20mg, doubled q. 10 min to a max of 220mg
- Nifedipine 10mg PO
- Nitroprusside
PPH Tx
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.
Potential therapies for hyponatremia
- 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.
Cerebral vasospasm Tx
- 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.
Why isotonic NaHCO3 for hyperkalemia?
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.
