ELECTROLYTE SOLUTIONS 5) PEEP 5cm H20

IV Sol’n Glu Na Cl K Ca HCO3

D5W 5mg/L
INDICATIONS FOR WEANING
D10W 100mg/
L
1) Mental status: Awake, Alert
0.9 NSS 154 154 2) PaCO2 > 60 mmHg w/ FIO2 < 50%
D5LR 130 109 4 3 28 3) PEEP < 5 cm
4) PaCO2 < pH acceptable
D5NM 40 40 13
5) Spontaneous TV < 5mL
D5NR 140 98 5 6) VC > 10 ml/kg
D5 0.9 50 mg/L 7) MIP > 25 cm H20
NaCl 8) RR < 30/min
D5NMK 50 mg/L 40 40 30 9) Rapid shallow breathing index < 100 (RBI)
10) Stable vs. Ft a 1-2 hr

Sol’n Na Cl K HCO3 Ca Mg Spontaneous Trial

ECF 142 103 4 27 5 3 FIO2 room air 21%
D5LR 130 109 4 28 5 O2 via nasal prong = # lpm x 0.4 x 20
D5 0.45 77 77
3% NaCl 513 513 ELECTROLYTES
0.9 NaCl 154 154
a) Corrected Ca = (40-lbs) x 0.02 + serCa
b) Corrected Na = Na + RBS mg% - 100 x 1.6 / 100
D5W Osm = 278 c) Na Deficit = (140 – actual) (0.6 x BW)
D5W Osm = 556 d) K Deficit = (D-A) (0.4 x BW)
D5LR Osm = 130 D = 3.5 cardiac
NaHCO3 = 446 4.5 non-cardiac
H20 Deficit = 0.6 x kg BW
D = 15 CKD
18 NCKD

Actual Na – Desired Na / Desired Na

CUSHING’S TRIAD

MECHANICAL VENTILATION 1) Increase systolic BP

2) Widened pulse pressure
Indication for Intubation 3) Bradycardia /AbN˚ respiratory pattern
a. Cheyne Stoke breathing
1) Impending respiratory failure, apnea
2) Respiratory Rate >35
3) PaCO2 > 50 HEMORRHAGIC STROKE TRIAD
4) PaO2 <60
5) Tidal Volume < 3-5 ml/kg 1) Papilledema
6) Vital Capacity < 10-15 ml/kg 2) Headache
7) Inspiratory force < 25 cm H20 3) Vomiting
8) Force Expiratory Volume(FEV) < 10 ml/kg
9) Vq / Vt > 0.6
10) To deliver high FIO2
11) Absent
12) pH <7.35 MEIG’S SYNDROME

1) Pleural Effusion
VENTILATOR SETTING 2) Polycystic Ovary / Fibromatosis
3) Hypoalbuminemia
1) TV: 6-8 ml/kg (ARDS) 8-10 ml/kg
2) Pale: 6-20
3) Mode: AC (Assist Control)
SIMV (Synchronized Intermittent 1 mV
4) FIO2
 713

FIO2: 20 / 4 = L

FOUR SCALE
- Full outline of responsiveness CT SCAN BLEED VOLUME

EYE RESPONSE Given: 58 mm ~ 5.8

a) Eyelids open, tracking, blinking to command 4 23.3 mm ~ 2.3
b) Eyelids open but not tracking 3
c) Eyelids close but open to loud voice 2 5.8 x 2.3 = 13.34 x 5 (constant) = 66.5 x 5.2 (constant) = 34.684 -(estimated
d) Eyelids close but no pain 1 bleeding volume)
e) Eyelids close with pain 0

MOTOR RESPONSE
a) Thumbs up, fist or peace sign 4
b) Localizing to pain 3 DIAGNOSTIC THORACENTESIS DUE TO HEART FAILURE
c) Flexion response to pain 2
d) Extension response to pain 1 1) If the effusion are not bilateral and comparable size
e) No response to pain or generalized myoclonus 0 2) If the patient is febrile
3) If the chest has a pleuritic chest pain
BRAINSTEM REFLEXES 4) If effusion persist despite the diuretics therapy
a) Pupil and Corneal reflex 4
b) One pupil wide and fixed 3
c) Pupil or corneal reflex absent 2
d) Pupil and corneal reflex absent 1
e) Absent pupil, corneal and cough reflex 0 INDICATION FOR CHEST TUBE THORACOSTOMY

RESPIRATION 1) Pneumothorax
a) Not intubated, regular breathing pattern 4 2) Pleural effusion
b) Not intubated, cheyne-stoke breath pattern 3 3) Chylothorax
c) Not intubated, irregular breathing 2 4) Empyema
d) Breath above ventilation rate 1 5) Hemathorax
e) Breath at ventilation rate, apnea 0 6) Hydrothorax

TIMING OF TUBE REMOVAL

 The timing of tube removal depends on clinical and radiological
evidence of complete expulsion of all contents of pleural cavity with
DENGUE complete expansion of the lung
 Minimal drainage should have occurred over the previous 24 hours
GRADE I (<25 ml/kg)
 Fever  When the patient coughs or performs the valsalva maneuver no air
 Non-specific symptoms leak should ensue
o Anorexia  The chest radiograph should confirmed complete expansion of the
o Vomiting lung
o Abdominal pain  The s____ in the fluid in the tube in the underwater seal bottle should
 (+) Torniquet test be minimal, relating to the normal negative pressured in the chest
during the phases of respiration
GRADE II
 Grade I + spontaneous bleeding
INDICATIONS FOR CTT
GRADE III  Gross pus on thoracentesis
 Grade II + severe bleeding + circulatory failure  Presence of organism on gram stain of the pleural fluid
 Pleural fluid glucose < 50 mg / dL
GRADE IV  Pleural fluid pH below 7.00 and 0.15 units lower than arterial pH
 Grade III + irreversible shock + massive bleeding

LIGHT’S CRITERIA
ABG COMPUTATION
1) Pleural fluid protein / serum protein > 0.5
I. 713 (decimal FIO2) – PCO2/0.8 = I 2) Pleural fluid LDH / serum LDH > 0.6
II. pO2/I = II 3) Pleural fluid LDH > 2/3 the upper limit of normal serum LDH
III. (Desired FIO2/II) + pCO2/0.8
________________________ x 100
713 TRANSUDATIVE VS EXUDATIVE FLUID

Desired FIO2 = 104 – (0.43 x age)

Transudative Exudative
A. 713 x FIO2 – PCO2/0.8
B. pO2 / A SG < 1.012 > 1.020
C. 02 for age / B + pC02 / 0.8 Protein < 3 g/dL >3 g / dL
________________________________ FP / SP < 0.5 >0.5
LDH <60% >60%
FLDH/SLDH <0.6 >0.6
Cholesterol <45 mg / dL >45 mg / dL

CLASSIFICATION OF PTB JONES CRITERIA OF RF

Class O- NO PTB EXPOSURE Major:

 Not infected  Carditis
 Polyarthritis
Class 1- HISTORY OF EXPOSURE  Chorea
 Neg. Skin test to tuberculin  Erythema marginatum
 Subcutaneous nodule
Class 2- TB INFECTION
 No disease Minor:
 Positive reaction to tuberculin test  Fever
 No clinical, bacteriologic or radiographic evidence of TB  Polyarthralgia
 Lab: Inc. ESR / Leukocyte count
Class 3- TB CLINICALLY ACTIVE  ECG: Prolong P-R interval
 Clinical, bacteriologic, or radiographic evidence of current disease  Elevated anti-streptolysin O, other strep antibody
 (+) throat culture
Class 4- TB NOT CLINICALLY ACTIVE  Rapid Ag test for Group A
 History of episode of TB  Strep / result: Scarlet Fever
 Abnormal but stable radiographic findings
 No clinical or radiographic evidence of current disease Criteria:
Class 5- TB SUSPECT  2 major/one minor and 2
 (+) evidence of preceding Group A strep infection

ACUTE RESPIRATORY FAILURE

Signs and Symptoms of TB TYPE I or Acute Hypoxemic Respiratory Failure

 Fever  Occurs when alveolar flooding and subsequent intrapulmonary shunt
 Night sweats physiology occurs
 Weight loss  Alveolar flooding may be a consequence of pulmonary edema,
 Anorexia pneumonia or alveolar hemorrhage
 Weakness  Low pressure pulmonary edema
 General Malaise  Defined by diffused bilateral airspace edema
TYPE II Respiratory Failure-Hypercabia
 Occurs as a result of alveolar hyperventilation and results on the
inability to eliminate CO2 effectivity
 Mechanism by which this occurs are categorized by impaired CNS
RECOMMENDED DOSAGE FOR INITIAL TREATMENT OF TB drive to breath, impaired strength with failure of neuromuscular
function in the respiratory ____
1) Isoniazid = 5 mg/kg, max 300 mg  Reason for diminished CNS drive to breath including drug overdose,
2) Rifampicin = 10 mg/kg, max 600 mg brainstem injury, sleep disordered breathing
3) Pyrazinamide = 20-25 mg/kg, max 2 g Overload Respiratory System due to:
4) Ethambutol = 15-20 mg/kg  Increase resistive loads (bronchospasms)
 Reduced lung compliance (alveolar edema)
 Reduced chest wall compliance (pneumothorax)
 Increase minute ventilation (pulmonary embolus)
TYPE III Respiratory Failure
 Occurs as a result of lung atelectasis
 Also called perioperative respiratory failure
 After general anesthesia, decreases in functional residual capacity of
dependent lung units

TYPE IV Respiratory Failure

 Due to hypoperfusion of respiratory muscles in patients in shock, due
LOCATING MYOCARDIAL DAMAGE to pulmonary edema, lactic acidosis, anemic

Anterior = V2-V4 (L) coronary, LAD

Anterolateral = I, qV1, V3 – V6, LAD, circumflexes

Anteroseptal = V1-V4, LAD

Inferior = II, III, aVF, (R) coronary artery

Lateral = I, aVL, V5, V6, circumflex brance of (L) coronary artery

Posterior = V8 – V9 (R) coronary artery, circumflex artery

(R) Ventricular = V4R, V5R, V6R, (R) coronary artery

DEFINITIONS USED TO DESCRIBE THE CONDITION OF SEPTIC PATIENTS CHILD-PVGH CLASSIFICATION OF CIRRHOSIS

Bacteremia Factor Units 1 2 3

 Presence of bacteria in blood as evidenced by positive blood culture s. Bilirubin umol / L <34 34-51 >51
Septicemia mg / dL <2 2-3 >3
 Presence of microbes and their toxins in the blood
s. Albumin g/L >35 30-35 <30
SIRS
g / dL >3.5 3.0-3.5 <3
 Systemic inflammatory response syndrome
 Two or more of the following conditions: Protime sec 0-4 4-6 >6
o Fever (oral temp >38˚C) or hypothermia (<36˚C) INR <1.7 1.7-2.3 >2.3
o Tachycardia (>90 bpm) Ascites None Easily Poorly
o Tachypnea (>24 bpm) controlled controlled
o Leukocytosis (>12,000/uL) or Leukopenia (<4,000/uL) or > Hepatic None Minimal Advanced
10% bands may have a non-infectious etiology encephalopath
Sepsis y
 SIRS that has proven or suspected microbial etiology
 Calculated by adding the score of the 5 factor and can range from 5 –
Severe Sepsis 15
 Similar to sepsis “sepsis syndrome”
 Sepsis with one or more signs of organ dysfunction CHILD-PVGH Class is either:
Septic Shock A. Score of 5 – 6
 Sepsis with hypotension (arterial blood pressure of ≥ 90 mmHg or B. Score of 7 – 9
MAP > 70 mmHg C. Score of 10 or Above
Refractory Septic Shock
 Septic shock that last > 1 hour and does not respond to fluid or Decomposition
pressure administration  indicate cirrhosis
Multi-organ Dysfunction Syndrome  N/A
 Dysfunction of more than 1 organ requiring intervention to maintain  CHILD PVGH Score of 7 or more
homeostasis
Class 8
 Listing for liver transformation (accepted criteria)

Hepatic Fibrogenesis
INDICATIONS FOR INITIATING HEMODIALYSIS  Stellate cell activation
 Failure of conservative management  Collagen production
 Management to relieve
a) Pulmonary congestion (unresponsive to high dose
furosemide)
b) Severe metabolic acidosis CLINICAL STAGE OF HEPATIC ENCEPHALOPATHY
c) Severe hyperkalemia
 BUN >100 mg/dL or creatinine >10mg/dL MS
 Note: For acute renal failure it is best to start dialysis early
Stage I Euphoria, depression, mild confusion, slurred speech,
disturbance in sleep
RHEUMATIC ARTHRITIS Stage II Lethargy, moderate confusion
 Require 4 out of 2 criteria: Stage III Marked confusion, incoherent speech, sleeping but arousable
o Morning stiffness Stage IV Coma, initially responsive to noxious stimuli, ____ response
o Arteritis of 2 or more joints
o Arteritis of hands and joints
o Systemic arthritis COMPLICATIONS OF ERCP
o Rheumatoid nodule
o Serum Rheumatoid factor 1) Infection
o Radiographic changes 2) Perforation
3) Pneumothorax
4) Bleeding

MUSCLE STRENGTH

O – No muscular contraction
1 – Trace contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity
4 – Active movement against gravity & slight resistance
5 – Against full resistance

IDEAL PEAK FLOW

Ideal peak flow: Hg (m) – 100 x 5 (+) 175 (M) (+) 170 (F)
N ≥ 80%
PEFR = Peak flow reading / Ideal peak flow x 100 = _____ %

N ≤ 20%
PEFR variability: Highest reading – Lower x 100 = ______ %
Highest Reading

NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION

CLASS I
 No limitation of physical activity
 No symptoms with ordinary exertion

CLASS II
 Slight limitation of physical activity
 Ordinary activity causes symptoms

CLASS III
 Marked limitation of physical activity
 Less than ordinary activity causes symptoms
 Asymptomatic at rest

CLASS IV
 Inability to carry out any physical activity without discomfort
 Symptomatic at rest

FRAMINGHAM CIRTERIA FOR DIAGNOSIS OF CHF

MAJOR CRITERIA
 Paroxysmal Nocturnal Dyspnea
 Neck vein distention
 Rales
 Cardiomegaly
 Acute pulmonary edema
 S3 gallop
 Increased venous pressure (>16 cmH20)
 Positive hepatojugular reflux

MINOR CRITERIA
 Extremity edema
 Night cough
 Dyspnea on exertion
 Hepatomegaly
 Pleural effusion
 Vital capacity reduced by one-third from normal
 Tachycardia (>120 bpm)

MAJOR OR MINOR
 Weight loss of >4.5 kg over 5 days treatment