Internal Medicine

Intern Survival Guide

2022-2023
 THIS BOOK BELONGS TO:

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Disclaimer

This handbook is meant to serve as a guide to the practice of

internal medicine. All information contained within is believed to
be reliable and accurate but is by no means exhaustive on any one
topic. The guidelines found within are only recommendations as to
the practice of medicine. The editors of this book do not provide
any guarantee of their accuracy or completeness.
~For internal academic use only~
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Table of Contents
Tips for Residency ......................................................................... 6
Mandatory Attending Notifications ............................................. 8
The Nurses Call You About….......................................................... 9
Internal Medicine General Topics .................................................20
A. Electrolytes ..............................................................................20
Hypomagnesaemia ....................................................................20
Hypokalemia .............................................................................20
Hyperkalemia ............................................................................21
Hypophosphatemia ...................................................................22
Hyperphosphatemia ..................................................................22
Hypocalcemia ............................................................................23
Hypercalcemia...........................................................................23
Hypernatremia ..........................................................................24
Hyponatremia ...........................................................................24
Albumin: ...................................................................................25
IV Fluids: ...................................................................................25
B. Cardiology ................................................................................26
Basic EKG Interpretation ............................................................26
Sgarbossa’s Criteria ...................................................................30
Pacemakers ...............................................................................31
Post-procedure patients ............................................................33
Clopidogrel (Plavix) vs Ticagrelor (Brilinta) vs Prasugrel (Effient) .35
C. Pulmonology ............................................................................36
Basic Chest Radiograph Interpretation .......................................36
Asthma Stepwise Treatment ......................................................37
COPD GOLD Group Treatment (2022) ........................................38
D. Gastroenterology .....................................................................39
Abdominal Pain Differential .......................................................39
Elevated Liver Enzymes ..............................................................39
GI bleed ....................................................................................39
Colonoscopy ..............................................................................40
E. Nephrology ..............................................................................42
Chronic Kidney Disease (CKD).....................................................42
Acute Kidney Injury (AKI) ...........................................................43
Acid-Base Disorders ...................................................................43

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F. Endocrine .................................................................................45
G. Infectious Disease ....................................................................46
Antibiotic Tips ...........................................................................46
Vancomycin dosing ....................................................................46
H. Neurology/Psych ......................................................................49
Dizziness ...................................................................................49
Seizure ......................................................................................49
Stroke .......................................................................................51
I. Hematology/Oncology .............................................................52
Transfusion Medicine ................................................................55
J. Allergy .....................................................................................57
Anaphylaxis ...............................................................................57
K. Geriatrics .................................................................................59
Falls ..........................................................................................59
Dementia ..................................................................................59
L. End of Life ................................................................................59
Comfort care .............................................................................59
Pronouncing Death ....................................................................60
M. Critical Care Medicine.......................................................62
Daily considerations in the ICU...................................................62
Respiratory Failure ....................................................................62
Types of Supplemental Oxygen ..................................................63
Intubation Medications..............................................................64
Rapid Sequence Intubation ........................................................66
Troubleshooting vent.................................................................67
Can I take them off vent?...........................................................68
Supportive Ventilation Basic Primer ...........................................68
Sepsis ........................................................................................70
Vasopressors .............................................................................70
VTE Prophylaxis .........................................................................73
Stress Ulcer Prophylaxis .............................................................73
USPSTF Preventative Services ......................................................75
Useful Websites & Resources .....................................................80
Mississippi Prescription Monitoring Program:.............................80
Commonly Used Calculators/Formulas .......................................80
Practical Tips to Running a Code...................................................84
Notes ...........................................................................................92

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Notes ...........................................................................................93

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 Tips for Residency
• Remember, patient care takes priority over chart review,
writing notes, etc. Go see your patients first thing in the
morning (ideally before morning report) and check in on
them periodically during the day.

• Don’t forget to communicate with your patient’s family

members. Get contact information for your patient’s
emergency contact on admission.

• If you need help, ask for it. When a patient looks sick, call
your upper level or attending. It’s always better to be safe
than sorry!

• Just because you order it, doesn’t mean it will happen. Be

proactive and check to see your orders have been done.
Go over complicated orders with the nurses, pharmacists,
etc.

• Things will get easier in time. By the end of intern year,

you’ll be a pro at all this stuff.

• Check your orders twice.

Procedure Policy
• Complete minimum number
• Any staff who is credentialed or any resident who has been
signed off to perform the procedure independently can
observe
• Log procedure in New Innovations
• If not signed off in New Innovations to do independent ->
don’t do it independently.

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 Levels of Supervision
Direct Supervision:
1) The supervising physician is physically present with
the resident during the key portions of the patient
interaction.
- PGY-1 residents must initially be supervised
directly.
- A supervising physician must be
immediately available to be physically
present for PGY-1 residents on inpatient
rotations who have demonstrated the skills
sufficient to progress to indirect
supervision.

2) The supervising physician and/or patient is not

physically present with the resident and the
supervising physician is concurrently monitoring the
patient care through appropriate telecommunication
technology.

Indirect Supervision: The supervising physician is not

providing physical or concurrent visual or audio
supervision but is immediately available to the resident for
guidance and is available to provide appropriate direct
supervision.

Oversight: The supervising physician is available to provide

review of procedures/encounters with feedback provided
after care is delivered.

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Mandatory Attending Notifications
• To ensure timely communication and patient safety the
resident is required to immediately communicate directly
(telephone or in person) with attending for any event listed
below:
• Emergency room consults that will be discharged to home
• Clinic consults that will be discharged to home
• Admissions
• ICU transfers from floor or from another hospital
• Discharges to include against medical advice
• Transfers to another hospital, skilled nursing facility, or
inpatient rehab center
• Patient death
• Any significant clinical deterioration
• Prior to performing any invasive procedure
• Change in code status
• Any event that may compromise patient safety
• Questions or concerns
• Error in care
• Family request
• Palliative care discussion
• Transition of care within MHG
• Code situation
• Conflict with patient or family
• Conflict with staff member

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 The Nurses Call You About….
Chest Pain
• GO TO BEDSIDE. Ask nurse to get vital signs and EKG on the
phone.
• Complete EKG, troponin, CXR, tele review.
• Consider can’t miss causes (ACS, dissection, tamponade, PE,
pneumothorax, pericarditis, esophageal rupture or impaction,
etc)
• If STEMI, immediately call on-call cardiologist and start heparin
drip, aspirin load, and plavix or brilinta load +ICU transfer.
• If angina, give nitro Q3-5 min. If not relieved by 2nd dose, call
cards and consider a nitro GTT.
• If NSTEMI, consider suspicion for CABG before you give Plavix
(requires period to wash out if they need a CABG).
• If it sounds like GI pain, can consider GI cocktail (for
symptomatic relief)

Shortness of Breath/Hypoxia/Tachypnea
• GO TO BEDSIDE. Ask nurse to get vital signs on the phone
• Do not simply turn up oxygen and walk away.
• Consider can’t miss causes (PTX, PE, pulm edema/fluid
overload, ARDS, PNA, overdose, bronchospasm, MI, anemia)
• If decompensating, call RRT, get ABG and stat portable CXR;
consider EKG.
• Get help! Upper level, respiratory, RRT
• Escalate therapy: NC, oxymask, high flow, BiPAP, intubation
• If pt needs intubation, it’s better to start earlier than later. Call
pulm.
• Targeted tx like diuretics (crackles, volume overload) and nebs
as appropriate
• Prove to yourself this isn’t a PE. (Wells score, look for unilateral
leg swelling, low threshold for CT/PE)

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 Acute Cough/Hemoptysis
• Make sure there’s no dyspnea, tachypnea, hypoxia, worsening
pulmonary edema, hemoptysis. If so, consider CXR/CT, ABG,
CBC
• Consider causes: PND, meds, GERD and tx appropriately
• Otherwise tx symptoms: robitussin, cepacol, Tessalon perles,
albuterol nebs, Atrovent nebs

Nausea
• Zofran 4mg IV q6-12h PRN (watch QTc)
• Phenergan 12.5-25mg PO/IV/IM/PR q4-6h PRN (watch QTc)
• Compazine 5-10mg PO q6-8h or IV q3-4h PRN (watch QTc)
• Caution in Parkinson’s pts as blocking the dopamine can mimic
neuroleptic malignant syndrome.
• Non-QTc prolonging options:
o Vitamin B6: 10-25mg 3-4x daily PRN
o Tigan: 200mg IM 3-4x daily PRN, 300mg PO 3-4x
daily PRN
o Can also try smelling an alcohol swab or ginger ale

Constipation
• Always check bowel sounds & ask if pt is passing flatus
• If suspecting obstruction/ileus- check KUB before giving any
further treatments. Consider obstruction before giving
laxatives.
• Many options including:
o Laxatives: Miralax, Senna, Dulcolax, Bisacodyl 5-
10mg PO, lactulose.
o Chocolate Bomb: 30cc milk of mag, 30cc mineral oil,
senekot crushed all mixed with chocolate ice
cream/pudding/apple sauce
• If impaction, consider Soap suds enema, Tap water enema,
HOG enema
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• Opioid-induced:
o Avoid fiber or bulking agents, it just makes the
problem worse
o Consider Relistor (methylnaltrexone) if laxatives
fail-- remember risk of bowel perforation. (Oral
narcan also option)

Diarrhea
• Is this actually diarrhea? Determine number of episodes and
stool description. Consider overflow incontinence from
constipation (KUB if needed to check stool burden)
• If large volume, check RFP and volume status of pt
• Rule out CDiff/infectious causes before considering Imodium
• GI PCR includes CDiff, but obtain CDiff first if diarrhea starts
during hospitalization.
• Need “special contact” precautions while CDiff test is pending.
• A positive CDiff does not make the diagnosis. Consider if
several episodes of large volume watery diarrhea or high
suspicion given context (recent abx)

Pain
• If new or changed, be sure to consider ddx and investigate
further if appropriate (i.e. don’t just give morphine to a
hypertensive guy with new tearing back pain). Do treat pain
and listen to patients.
• Caution with opiates (esp elderly and AKI/CKD)
• When transitioning on/off PCA and between opiates, use MME
calculator
• Always start bowel regimen and order PRN naloxone with
opioids
• Mild Pain:
o Acetaminophen 500mg PO 1-2 tabs q6hrs PRN
(preferred)
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 o Ibuprofen 400-800mg PO q6-8hrs PRN
• Moderate Pain:
o Ofirmev (Acetaminophen) IV 1g x1
o Toradol (NSAID) 30-60mg IV/IM x1 (watch kidneys)
o Tramadol 50mg PO q4-6h PRN, or 50-100mg IV/IM
x1
o Roxicodone (oxycodone IR): 5-10mg q4-6h PRN
(Requires renal dosing)
o Tylenol #3 (with codeine) 30/300mg PO q4h PRN
(no renal dosing)
o Percocet 5/325mg 1-2 tabs PO q4-6hrs PRN (no
renal dosing)
o Vicodin 5/500mg 1-2 tabs PO q 4-6hrs PRN (no
renal dosing)
• Severe Pain:
o Morphine 1-4mg IV q2-4h PRN (↓ dose in renal
failure)
o Dilaudid 0.5-2mg IV q4hrs PRN
o Fentanyl 25mcg IV Q1 PRN (ICU setting)

Headache
• Can’t miss causes: (ICH, meningitis, mass lesion, HTN
emergency, GCA)
• Consider need for CT, LP
• However, sinister causes starting while inpatient without
preceding fall or history of symptoms prior to admission are
rare. Most common causes include tension HA, migraine,
medication induced.
• Symptomatic tx: Tylenol, Toradol, triptans if mod-severe
migraine without contraindication to triptan (ex. CAD, CVA), IV
Mg, anti-nausea meds

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 Altered Mental Status
• Go to bedside. Get vitals with pulse ox, accucheck. Full neuro
exam.
• Consider alcohol withdrawal. People aren’t always honest
about their use.
• Eval for AEIOU-TIPS: Alcohol/acidosis/ammonia/arrhythmias,
Electrolytes/Encephalopathy, Infection, Ischemia,
Oxygen/Opiates/Overdose, Uremia, Temperature/Trauma,
Insulin (Hypo/hyper), Poisoning/psychiatric, Stroke/seizure
• Consider Head CT to evaluate for mass/bleeding
• Consider workup w/glucose, CMP, TSH, B12/folate, UDS, ETOH,
CX
• Tx TONG: thiamine, O2, narcan, glucose
• For sundowning/hospital delirium, reorient as first option. Turn
off TV, turn on lights, deescalate as able. Encourage family at
bedside. Use delirium order set, consider stopping overnight
vitals checks
• If severe agitation: Haldol (QTc), Geodon, Seroquel, olanzapine,
risperidone, etc.

Insomnia
• Especially tricky in elderly as these medications are notorious
for inducing delirium and agitation. Use with caution.
o Melatonin 3-6mg PO (least effective but least side
effects, try first)
o Lunesta Start 1mg, increase to 2-3mg if indicated
o Ambien (avoid in age >70) 5mg PO (can use 10mg
in younger pts)
o Benadryl 25mg PO (avoid in age >70)
o Restoril 15-30mg PO (avoid in age > 70)

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 Decreased Urine Output
• If there is a foley, is it flushing? If not, consider exchanging
foley.
• If no foley, bladder scan. If >400cc or symptomatic, consider in
and out catheterization and rescan in several hours.
• If confirmed they are not making adequate urine, consider
reasons for worsening renal function. Consider volume
challenge with small fluid bolus if hypovolemic. Consider Lasix
if hypervolemic. Get UA first so you have accurate sample for
microscopy/urine studies if needed.
• If retaining urine, place foley and eval med list for any
anticholinergic drugs.

Fever
• Get full set vitals. Fever is T>100.4F (38C) for an hour or T>101F
(38.3C) once.
• Always calculate ANC if chemo patient/cancer patient. Severe
neutropenia = ANC <500 or anticipated nadir <500 within 48h
• Neutropenic fever: BCX, UA and UCX, CXR. Start cefepime or zosyn
(+ vanc if unstable, or if suspect pna or SSTI, or vasc access infx.
Vesicular lesions, add acyclovir)
• Ddx: Infection, malignancy, autoimmune, drug, endocrine.
• Infection: Labs and imaging based on suspected source. Re-
culture (2 straight stick peripherals and from any lines/ports).
• Start/broaden abx if new infxn or pt worsening clinically
• Tx with tylenol if sx bothersome to pt. Remember tylenol may
mask fever.

Hypothermia
• Get full set of VITALS. T <36C=hypothermia, T<95F (35C) should be
eval’d.
• Ddx: sepsis, infxn, hypothyroid, adrenal insuff, burns, spinal injury.
• Rectal temp is more accurate. No rectal temp in neutropenia!

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• Correct underlying problem- can also use warming blankets/bear
hugger

Hypotension
• Get full set of vitals and immediately go to bedside to evaluate
patient.
• DO NOT simply treat the number, investigate the cause, ddx:
• Hypovolemic (bleeding, volume depletion, third spacing)
• Cardiogenic (MI, arrhythmia, CHF, valvular)
• Distributive (Sepsis, neurogenic, anaphylactic)
• Obstructive (PE, PTX, Tamponade)
• Medications (anti-HTN, anaphylaxis, BPH drugs etc.)
• Recheck manual BP (ensuring appropriate cuff size) and other
vitals
• Careful physical exam, signs of end organ perfusion (orthostats,
AMS, UOP)
• Labs and imaging should be based on suspected cause. Note that
in an older or immunocompromised person, the only sign of a
bacteremia and impending MOF might be persistent hypotension.
• Give IVF bolus if hypovolemic. (If CHF or hypervolemic, use
wisely). Do a double leg raise first to test fluid responsiveness
• If hypotension is fluid refractory and symptomatic, start presssors:
• Levophed can use prior to central line only for short time. (PICC =
CVC)
• Vasopressin (2nd choice pressor in most cases, non-titratable)
• Epinephrine

Hypertension
• Consider can’t miss causes: withdrawal from ETOH or meds,
drugs, cushing’s reflex, aortic dissection, ischemic stroke, ICH,
thyrotoxicosis
• HTN Emergency: Hypertension >180 SBP and >120 DBP + end
organ damage (brain, CV, kidney, heme, optho)
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• Assess for end organ damage:
o Ask about AMS, headache, chest pain, SOB,
lightheadedness, hematuria
o Exam including neuro exam with fundoscopy
o Consider checking trop, EKG, CXR, CTA chest, CT head,
UA, BMP, CBC, peripheral smear based on hx/exam
• Hypertensive Emergency:
• ICU admission, a- line, use a titratable gtt (cardene, esmolol)
o Choice of tx agent & BP goal varies based on specific
scenario!!
o In general: lower MAP by ~ 25% in first hour, & then (if
stable) to 160/100 mm Hg by ~6 hours, w/ cautious
return to normal BP over next 24-48 hours (Exceptions
below)
o Ischemic stroke: Allow HTN. Tx w/ tPA: goal BP <
180/105 1st 24 hrs; use labetalol, nicardipine, cleviprex.
Not tx with tPA: goal <220/120
o Dissection: Decrease fast! Goal SBP < 120 mm Hg in 20
min, HR ≤ 60 bpm. Beta blocker first (Ie. Esmolol) If not
at goal, add nitroprusside OR nicardipine. (tx w/ BB first
then vasodilator TOGETHER). Call Vascular Surgery
before admit (if we have coverage)
o ICH: acutely lower SBP to <140. Nicardipine, clevidipine,
esmolol etc
• No evidence of end-organ damage:
o Treat with PO meds, targeting BP <160/100 in 24 hours

Bradycardia
• Get full set of VITALS. Stat EKG. Review tele.
• Consider can’t miss causes:
o Meds (BB, CCB, dig, antiarrhythmics, lithium, Aricept)
o Cardiac: SSS, inferior MI, 2nd or 3rd degree AV block,
pacemaker malfunction, vasovagal (transient)
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 o Other: hypothyroid, hypothermia, K derangement etc
• Are they unstable or symptomatic (AMS, dizzy, chest pain,
syncope)?
o Follow ACLS guidelines (atropine 0.5-1mg IV)
• Call an RRT or even code if you need help.
• Place pacer pads on the patient (can always take them off)
• If ECG shows either Type II 2nd degree or 3rd degree AV block,
place pacer pads, consider transcutaneous pacing. Call
Cardiology ASAP for possible transvenous pacing. Transfer to
ICU.
• Consider BB, CCB, digoxin overdose; check dig level; consider
reversal (give calcium, glucagon, consider epi gtt)
• If stable, keep atropine at bedside and monitor on telemetry.

Tachycardia
• Get full set of VITALS, follow ACLS guidelines as indicated
• Ensure patient is stable, EKG, a printout of tele strip to see how
rhythm started (gradual or rapid onset), go see the patient.
• If Wide QRS: This is VT until proven otherwise and you should
be attaching defibrillator pads as you call the senior
resident/Code Blue.
• For non-sustained VT, check to see if pt had symptoms.
• Check and treat electrolyte abnormalities.
• If becomes unstable, defibrillate (120-200 J biphasic). ACLS.
• If Narrow Complex QRS: SVT differential includes: Sinus
tachycardia, atrial fib, atrial flutter, AVNRT, AVRT.
• If unable to tell what the underlying rhythm is, consider
slowing the rate with Valsalva (standard or modified),
adenosine push
• AFib/Aflutter with RVR
o Metoprolol (5mg IV q5min IV x3, 25-100mg po q6-q12),
follow w/ esmolol GTT (call cards first)
o Diltiazem (0.25-0.35 mg/kg IV, or 10-15 mg/hr gtt)
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 (monitor BP).
▪ Avoid in HFrEF
o Consider Amiodarone load (150mg IV load → 1mg/min
x6hr → 0.5mg/min x18h) or Digoxin (0.25mg q6h x2);
Call cards
o If unstable, consider Cardioversion (call your upper
level)
• New AFib will need work up; echo, thyroid, eval reversible
causes
• For Sinus Tachycardia, treat underlying cause (pulmonary
embolus, pain, hypovolemia, hypoxia, anemia, anxiety,
infection, fever, etc.)

Elevated PTT on a Heparin Drip (GTT)

• A patient is on a heparin drip, and the nurses call you about the
PTT suddenly jumping to 100+++
• Tell them to draw it from the opposite arm from the one
where the heparin is going in and call you back with the repeat
lab. If still high, ask them follow the protocol.

Can we take the patient’s IV out?

• With very limited exceptions (pt d/c’ing on hospice or pt
outright refusal) you always need to keep an IV in the hospital,
for ACLS reasons. (new nurses will call about this frequently.)

The patient’s evening blood sugar is high!

• Inpatient blood glucose goal for most is 140 – 180 (NICE-
SUGAR). Stricter goal for post-surgical patients.
• Prior to giving basal insulin, consider current diet (NPO?), prior
hypoglycemic events, is the patient insulin naïve.
• If patient uses home insulin, consider 70-80% of home total
daily dose
• Make sure your correction dose and BG check orders have the

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same timing (AC&HS vs TIDWM)

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 Internal Medicine General Topics

A. Electrolytes
Hypomagnesaemia
• Goal 2, must correct before correcting potassium
• Usually caused by poor intake, malabsorption, or GI/renal
losses
• Can lead to hypokalemia, hypocalcemia, arrhythmia, seizures.
• Symptoms include lethargy, weakness, AMS, malaise.
• PO: 400mg Mg Oxide PO BID-TID. Takes several days, (causes
diarrhea)
• IV: 2-8g Mg Sulfate in NS/D5W (max 4g/100cc), consider
following:
o 1.6-1.9 give 2g Mg Sulfate over 1-2 hrs
o 1.0-1.5 give 4g Mg Sulfate over 4-12 hrs
o <1.0 give 8g Mg Sulfate over 12-24 hrs
• Expect approximately a 0.1 increase for every gram given IV

Hypokalemia
• Mild (3.1-3.5), moderate (2.5-3.0), severe (<2.5 or sx)
• General goal potassium around 4.0 (for cardiac patients)
• Causes: Lasix, GI and renal losses, insulin, poor intake,
alkalosis, hyperaldosteronsim, Cushings, hypomagnesemia, B-
agonists, DTS, DKA
• Leads to arrhythmia, illeus, weakness, inc cardiac digoxin
susceptibility
• Labs: consider hypoMg
• ECG changes: U waves, flat/inverted T waves, QT
prolongation, VT
• Replacement: (~100mEq K increases K by 1mEq/L (i.e. from 3
to 4)
• PO is preferred to IV, MUST be conservative in CKD/AKI pts

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• Always replete Mg. Recheck K levels after IV correction
• For PO: Replace with KCl or K-HCO3 (if acidotic) 40meq PO
(pill or elixir) Q4hour if able
• For IV: *NEVER push IV potassium, go low&slow, inc freq not
dose
o Give KCl 10meq/100 mL / hr via PIV, or
o 20meq/100mL/ hr via CVC/PICC
• For severe (<3.0), can use both oral and IV

Hyperkalemia
This is an emergency!
• Mild (5.5-5.9), mod (6.0-6.5), severe (>6.5 or >5.5 w/sx or ECG
changes)
• Causes: AKI/CKD, oliguria/anuria, ACE-I/ARBs, K-sparing
diuretics, Bactrim, cyclosporine, rhabdo, hemolysis, insulin
deficiency, metabolic acidosis, pseudohyperK, digoxin toxicity,
excess intake, low aldo
• Review meds and stop any that could be contributing
• Sx: weakness, paralysis, decreased bowel motility
• Leads to fatal arrhythmia! Get stat EKG & see the patient- esp
if >6.0 ,
• If K>6.0 or EKG changes (peaked T waves, PR prolongation,
wide QRS):
o Give 1 amp Calcium Gluconate IV push (10-20mL 10% IV
soln over 2-3 min, can cause transient BP drop; lasts 30-60
min). May repeat in 5 min if no response.
o Shift K: one amp D50, 10 units regular insulin IV (monitor
for low FSG), & Albuterol neb
o Remove K: IV Lasix (give fluid back if necessary), Patiromer
(less gut necrosis than kayexalate)
o Dialysis as a last resort (For A, E, I, O, U)
• Check labs frequently - call nephro if not improving, don’t
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 check TTKG

Hypophosphatemia
• Goal 2-3, treat to goal. Needed to make ATP
• Can be given via PO or IV routes, equally effective.
• Oral replacement:
o Neutra-phos 1-2 packets QID (note high sodium load
~800mg/day)
o KPhos 2 tablets 500 BID x1, TID, TID with meals, or QID
o Consider adding 1-2 containers of skim milk to each meal
• Consider IV replacement ONLY when symptomatic OR serum
concentration
o <1 as IV can precipitate hypocalcemia, ARF
o 2.3-3 give 0.08-0.16mmol/kg (KPhos or NaPhos mixed in
NS/D5W with max 15mmol/100cc) and infuse over 4-8 hrs
o 1.5-2.3 give 0.16-0.32mmol/kg over 4-8 hrs
o <1.5 give 0.32- 0.64mmol/kg over 4-8 hrs

Hyperphosphatemia
• Causes: TLS, Rhabdo, Exogenous phosphate, AKI/CKD,
hypoparathyroidism, acromegaly, bisphosphonates, vit d tox
• Acute hyperphosphatemia with hypocalcemia can be life
threatening if renal function is intact hyperphos usually
resolves within 6 to 12 hours and phos excretion can be
increased with NS infusion (may increase hypocalcemia)
• Hemodialysis may be indicated for acute management.
• Progressive or persistent hyperphosphatemia >4.5mg/dl is
indication for treatment
• Restrict dietary phosphate intake (renal diet,
intake<900mg/day)
• Consider addition of phos-binders for phos>6mg/dl
• Phos binders – calcium versus non-calcium
• Non-calcium – consider sevelamer 800mg TID with meals
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 Hypocalcemia
• Causes: Removal of parathyroids, neck irradiation,
autoimmune destruction, infiltrative dz, plasmaphoresis, vit D
def, hypoMg, pancreatitis, rhabdo, kidney failure, TLS,
pseudohypoparathyroidism
• Corrected Calcium: Ca + [(4-serum albumin)0.8]
• If unsure about the corrected calcium, order ionized calcium
• Sxs: paresthesias,
Chvosteks/Trousseau’s,tetany,seizures,heart block,↑QTc
• ECG to evaluate for QTc prolongation, check for & tx hypoMg
• PO (asymptomatic patients): Ca gluconate 500-1000 mg PO
TID, TUMS (Calcium Carbonate) OTC 600 mg PO TID (200mg of
elemental Ca)
• IV: 1 gram CaGluc (0.465 mEq, 9.3 mg/mL elemental Ca) or 1g
of CaCl (1.4 mEq, 27mg/mL elemental Ca, *Vesicant, give via
central line*), consider:
o If Ionized Ca: 4-5mg/dL, 1-1.2mmol/L); 2g CaGluc over
2hrs
o If Ionized Ca: <4 mg/dL, <1mmol/L); 4g CaGluc over 4hrs
o If severe sx seizure/tetany;1-2g CaGluc over 10 min;Q1H
til sx resolve
• Emergency (arrhythmia): 1-2 amps of Calcium Gluconate
• Repeat Ca levels 2-6 hours post infusion

Hypercalcemia
• Mild ULN -12 mg/dL; Mod 12-14mg/dL; Severe >14mg/dL
• Common causes: malignancy, most common outpatient cause is
primary hyperparathyroidism(check PTH first), other causes
lithium, thiazides, excessive Vit D/Ca intake, sarcoidosis
• Sx: nephrolithiasis, bone pain, GI complaints, confusion, coma
(stones, bones, groans, moans, psych overtones)
• Aggressive IVF to goal UOP 100-150cc/hour

23
• +/- calcitonin 4 IU/kg IM or SC Q12hours, efficacy limited to 1st 48
hrs
• +/- zoledronic acid 4mg IV over 15 min - caution in renal
impairment
• +/- glucocorticoids if 2/2 to sarcoid/granulomatous dz, lymphoma

Hypernatremia
• Assess volume status. Caused by water deficit relative to sodium
concentration.
• Most common cause is impaired free water access/intake (If pt is
tube fed, consider need for increasing free water flushes; discuss
with nutrition).
• Other etiologies to consider: central/nephrogenic diabetes
insipidus, osmotic diarrhea, intracranial mass, alcohol use
• Eval with urine and serum osm, urine sodium, RFP. Don’t forget to
correct sodium for glucose (will correct higher if hyperglycemic).
• Calculate free water deficit (MDCalc).
• If chronic, correct by no more than 10 meq in 24h to avoid
cerebral edema. Use D5W or 1/2NS to reduce salt load.
• The best way to correct is via the gut (Drink to thirst, NG tube if
in)

Hyponatremia
• There is a great algorithm on uptodate for determining etiology.
• First thing to determine – acute (<48H confirmed) or chronic
(correct acute immediately, chronic must be corrected slowly).
• Obtain urine/serum osm, urine sodium, urine K, RFP
• Assess volume status:
o Hypovolemic, provide volume resuscitation with NS or LR.
o Hypervolemic, provide diuresis and closely monitor.
o Euvolemic, determine if ADH is inappropriately present (pain,
nausea, pulmonary disease, malignancy). Also consider
decreased solute intake (tea and toast, beer potomania),
24
 primary polydipsia.
• Free water restriction and treat underlying cause (engage
nutrition if decreased solute intake)
• Chronic: 4-6meq correction per day. Monitor closely for over-
correction to avoid osmotic demyelination syndrome. Can
give DDAVP if correcting to quickly and urine output rapidly
increasing.

Albumin:
• Usually does not need repleted, but in a few cases it does:
o Large volume para: >5L fluid taken = give 6-8 G/L 25%
albumin
o SBP: give 25% albumin IV 1-1.5 g/kg ideal body weight
(max 100 g) within 6 hrs and again day 3.
o ARDS: 25 g 25% Q8, give with Lasix infusion
o You may see 5% albumin being used as a 2nd line colloid
fluid
solution in hypovolemia, but data is limited.

IV Fluids:
Isotonic, for volume expansion:
• Recent 2022 large meta-analysis:
NS = LR = Plasmalyte for most IM/ICU indications.
• NS = theoretical risk of hyperchloremic metabolic acidosis
(higher risk at volumes >10 L)
• LR = mythical risk of hyperkalemia (1 L of LR = 4 meq K). Also
LR is NOT lactate.
• Very little evidence for colloids in resuscitation

Free Water, for hypernatremia:

• D5W- calculate free water deficit
•

25
 B. Cardiology
Basic EKG Interpretation
X axis = time,10sec; 1 small box = 1mm = 40msec; 1big box = 5
small= 200msec Y axis =voltage; 1 small box = 1mm = 0.1mV;
1big box = 5 small= 0.5mV

Rate: (# of R waves on 10 sec ECG) * 6; or (#R waves in two 3sec

blocks) * 10
--or-- Count each big box between R waves: 300,150,75,60,50,43,
37, 33, 30

Rhythm
• Is the rhythm regular?
• Is there a P for every QRS and QRS for every P?
• Where are the P-waves coming from? Upright in I/II/aVF = sinus
• Is PR interval normal, between 0.12-0.2 sec (< 1 large box) If “no”
to any of the above, then arrhythmia or block present.

Supraventricular Arrhythmias (narrow QRS < 0.12, 3 small boxes)

• Multifocal atrial tachycardia: > 3 dif shape P waves, atrial rate
>100, if <100: wandering atrial pacemaker
• Atrial fibrillation: irregular, chaotic, no P waves, variable vent
rate
• Atrial flutter: regular, saw-toothed, 2:1, 3:1, 4:1 block
• Ectopic Atrial Tachycardia: regular, 100-200 bpm, P waves but
not sinus
• Paroxysmal SVT (PSVT): regular, 150-200 bpm, sporadic, self-
terminating
• AV nodal re-entrant tachycardia (AVNRT): Most common
subtype PSVT (slow-fast > fast-slow > slow-slow), will often see
retrograde conducted (inverted) P waves in ST segment (RP
<70ms)
• AVRT: Less common, accessory pathway dependent. P wave
26
 typically upright, longer RP interval than AVNRT (>70ms)

Ventricular Arrhythmias (wide QRS > 3 small box, below AV

node)
• Ventricular fibrillation: chaotic baseline, no QRS SHOCK
• Ventricular Tachycardia: 120-200 bpm, “tomb stones” SHOCK
• Accelerated Idioventricular: 40-100 bpm. Often this is a
reperfusion rhythm following coronary artery occlusion, usually
transient & benign
• Idioventricular/Ventricular escape rhythm: 20-40 bpm

Ectopic Beats and Rhythms

• Premature Atrial contraction: narrow QRS preceded by (often
non-sinus) P wave
• Premature Junctional contraction: early, narrow QRS, but no
preceding P wave (usually retrograde/inverted during/after QRS)
• Premature Ventricular contraction: wide QRS, no P wave

Axis
• Look at I & II (aVF not needed. Leads I, II can distinguish
normal/abnormal)
• Normal: QRS (+) in I, (+) in II
• LAD: QRS (+) in I, (-) in II
• RAD: QRS (-) in I, (+) in II

Intervals: PR abnormalities
• Pre-excitation/short PR interval
o PR interval <120ms
• 1st degree AV block:
o PR interval > 200ms (1 big box)
• 2nd degree AV block
o Mobitz 1 (Wenckebach): increasing PR interval, then P
w/out QRS
27
 o Mobitz 2: constant PR interval then P wave without QRS
• 3rd degree AV block
o P waves not related to QRS, atrial rate > vent rate

Intervals: QRS abnormal = bundle branch block, fascicular

block
• Normal = <100ms; moderate prolongation 100-120ms
(incomplete BBB/nonspecific IVCD if 110-120ms); severe
prolongation (>120ms)
• RBBB: QRSD ≥120ms; RSR’ V1 & V2 (rabbit ears); deep S wave
in I, V6
• LBBB: QRSD ≥120ms;broad monophasic R in I, aVL, V5-V6;
deep S in V1&V2

Intervals: QTc
• Represents the time taken for ventricular depol & repol
• Varies with heart rate, should be less than ½ R-R interval
• Long QTc predisposes to ventricular arrhythmia; esp. Torsades
• QTc is prolonged if > 440ms in men or > 460ms in women
(O’Keefe >470ms men and >480ms in women)

Hypertrophy
• RVH: typically RAD; R>S in V1, R in V1 ≥ 6mm, S in V5 ≥10mm,
S in V6
≥3mm, R in aVR ≥4mm
• LVH: R in V5/V6 + S in V1 ≥ 35mm or R in aVL ≥11mm
(Sokolov-Lyon criteria). Alternatively R in aVL +S in V3 >28mm
in men or >20mm in women (Cornell)

Ischemia/ Infarct
• Ischemia: ST segment depression, TWI
• Injury: ST segment elevation
• Infarct: Q waves

28
 o Significant Q waves = >20ms duration in V2-V3 or >30ms in
any other lead AND >1mm in depth in 2 contiguous leads for
Q-wave MI
o Q waves in I, aVL, V5/V6 normal as are isolated Q waves in
III, aVR, V1
o Posterior MI: ST elevations II, III, aVF + ST depressions V1-V3
= STEMI if depressions in V1-V3, consider posterior ECG

• T-waves: Typically upright in I, II, V3-V6 and inverted in aVR,

V1

Coronary Artery Territories

• Septal V1, V2 – LAD territory
• Anterior V3, V4 - LAD territory (anteroseptal Q wave MI = V1-
V3)
• Apical V5, V6- distal LAD territory
• Inferior II, III, aVF – RCA territory
• Lateral I, aVL +/- V5, V6 – left circumflex territory
• Posterior V1, V2 (ST depression are really elevations) – RCA vs
LCx

Other
• RAE: P wave > 2.5m in II,III,aVF; & P wave >1.5mm in V1,V2
• LAE: Broad double peaked “bifid” P wave in II; & biphasic P
wave in V1
• RV Strain: ST depression & TWI in leads a/w RV: V1-V3,
II,III,aVF
• LV strain: Ischemia: ST segment depression, TWI
• Hyperkalemia: peaked T wave, ↓QT, ↑ PR, wide QRS
• Hypercalcemia: ↓QT, flat T waves, J point elevation
• Pericarditis: diffuse ST elevations, upward concavity, PR
depression

29
• Pulmonary embolism
sinus tachycardia most common (44%)
o
o associated with: STE V1-3, TWI V1-V4, new RBBB, RAD
o SI QIII TIII pattern – deep S wave in lead I, Q wave in III,
inverted T wave in III. found in only 20% of patients with PE
• Digoxin EKG effect
o Downsloping ST depression with a characteristic “sagging”
o Flattened, inverted, or biphasic T wave
o Shortened QT interval
o Other features: long PR interval, U waves, J point depression,
complete heart block with afib (regularized afib)
• Brugada Syndrome (don’t confuse w/ Brugada Criteria, SVT vs
VT)
o Mutation in cardiac Na channel causing predisposition to
arrhythmia & sudden cardiac death all pts get ICD!
o Type 1: Coved ST segment elevation >2mm in >1 of V1-V3
followed by a negative T wave
o Type 2: > 2mm saddleback shaped ST elevation

Sgarbossa’s Criteria
• To detect MI on EKG in the setting of LBBB, or device. 90%
specificity of STEMI (but only 36% sensitivity). If 3 points or
more, diagnosis of MI.
• ST elevation ≥1 mm in a lead with upward (concordant) QRS
complex - 5 pts
• ST depression ≥1 mm in lead V1, V2, or V3 - 3 pts
• ST elevation ≥5 mm in a lead with downward (discordant) QRS
complex – 2pts

30
 Pacemakers

• PPM indications: high degree AV block (2° II or 3° w/ sx or HR <40

or pause >3s sinus, 5s A-fib), SSS, chronotrop incomp a/w sx,
Tachy/Brady
• CRT/BiV Pacing: LVEF </=35% + NYHA II-IV sx despite GDMT +
LBBB w/ QRS >150ms (c/s LBBB >120, QRS >150, >40% v-pace for
pacing induced CM)
• ICD: 2° prevention following VT/VF arrest w/o reverse cause,
asymp w/ sustained VT +struct heart dis. 1° prev: LVEF <30 post
MI or EF <35 & NYHA II-III sx (>40 days post MI, 90 post revasc)
• Consider Life Vest w/ EF <35% but not met time criteria

Graded Exercise Testing; lead V5 is a good place to start

Indications for GXT Testing

1) Adult px with intermediate pretest probability of CAD based
on age, gender and symptoms (see Table 2)
2) High pretest prob of CAD (Table 2) but (-) GXT may need cath.
3) Known or possible h/o CAD with change in clinical status
4) Known or suspected exercise-induced arrhythmias
5) LVH with <1mm ST depression
6) Post-CABG, intervention or MI for exercise capacity
7) Patients with vasospastic angina

31
8) Identify appropriate setting for rate adaptive pacemaker

Contraindications to Exercise ECG Testing

Absolute:
1) Acute MI w/in 5 days
2) Unstable angina uncontrolled with meds
3) Uncontrolled arrhythmias causing symptoms
4) Symptomatic severe AS
5) Uncontrolled symptomatic CHF
6) Acute PE or PI
7) Acute myocarditis or pericarditis
8) Acute aortic dissection
9) Uninterpretable ECG = LBBB or LVH with strain

Relative:
1) Known left main stenosis
2) Moderate stenotic valvular heart disease
3) Electrolyte abnormalities
4) Uncontrolled HTN: SBP>200 or DPB> 110
5) Tachy or bradyarrhythmias
6) Hypertrophic cardiomyopathy/other outflow obstruction
7) High degree A-V block
8) Inability to exercise 2nd to mental/physical impairment

When to terminate Exercise stress ECG

• Achieve predicted HR (relative-cont. if gauging exercise capacity)
• Pt fatigue, dyspnea, claudication, syncope, refusal, severe angina
Arrhythmias: increase freq., PVC’s, new AV blk, concerning
arryth. V-tach or BBB not distinguishable from VT
• Diagnostic ST changes = CP and ST dep., ST elev.
• BP>150/115, or SBP>10mmHg decrease or failure SBP with
workload

32
 Duke Treadmill Score:
Exercise (time) – 5(ST depression in mm) – 4(angina symptoms)
• Predicts 5-year all-cause mortality, not specifically cardiac

Positive GXT
1) >= 1mm, 60-80ms Jpt-ST depression (flat or Down) over 3
consecutive beats
2) ST segment elevations in 3 consecutive beats
3) Typical angina
5) Failure to augment SBP with workload
6) Inappropriately slow/drop in HR (chronotropic
incompetence)

High Risk GXT

1) >2mm ST depressions over 3 consecutive beats
2) Early (+) = < 6min &/or HR<120
3) Drop SBP> 10mmHG
4) V-tach
5) ST elevations
6) ST changes
7) ST changes persist > 10mm into recovery
8) Angina

Indications for Myocardial Perfusion Imaging with GXT

1) One or more resting EKG changes
a. complete LBBB, pre-excitation, ventricular
pacing
b. 1mm ST depression at rest
2) Pt has CP and cannot exercise – pharm stress and images
3) Equivocal GXT or pt w/intermediate risk
4) Eval correlation b/w coronary stenosis and ischemia
5) Assess myocardial viability post-MI or re-vascularization

Post-procedure patients
• Have higher concern in these patients.
• Post-femoral access complications:
o Bleeding: Bleeding from cath site/hematoma is not

33
 uncommon
o In “high stick”, there is potential for retroperitoneal bleeding
o Treat with pressure for 30 minutes to site
o If Hg drops, consider imaging (non-contrast CT abdomen
pelvis), transfusions, and phone calls to rule this out.
o Cholesterol/Closure Device Emboli
o Be sure to evaluate pulses in both feet immediately after cath
so that you will have a comparison.
o Acutely cold/painful/pale/pulseless feet, requires urgent
intervention
• Post-radial access
o TR band positioned on wrist with small green box immediately
proximal to puncture site. The nurses will slowly deflate TR
band. Can reinflate or apply pressure if bleeding.
o Avoid manipulation of wrist for 24h
o Complications: ischemia, emboli, hematoma as above,
(though cannot lose much blood volume into wrist. If
hematoma forms, apply compression.
• Tamponade:
o Complication of PCI, ICD/pacer placement and revision.
o Remember Beck’s Triad: hypotension, JVD, quiet heart sounds
o Initial treatment is aggressively pushing fluids as a bridge to
percutaneous drainage of pericardial contents. Ultrasound
them
• Stent thrombosis:
o Acute chest pain in a post-PCI pt should be taken very
seriously
o EKG stat and appropriate chest pain treatment. Call upper
level
• Medication complications:
o Most admitted post-cath patients will have undergone PCI and
be on DAPT 6-12 mos, +/- GP Iib/IIIa inhibitor if high risk or no
P2Y12 prior to cath
34
 o Can cause bleeding, but also thrombocytopenia/MAHAs. F/u
post-CBC.

Clopidogrel (Plavix) vs Ticagrelor (Brilinta) vs Prasugrel

(Effient)
• Plavix = use in stable PCI. Prodrug, requires activation via CYP450
(CYP2C19)
• Brillinta = higher risk of bleeding, use in STEMI. Reversible w/
monoclonal ab.
o ADR: bradycardia, dyspnea
• Prasugrel = most potent, no prodrug, use in STEMI.
o Avoid in patient’s w/ hx of TIA/stroke, hepatic
dysfunction

35
 C. Pulmonology
Basic Chest Radiograph Interpretation
Key is systematically reviewing all x-rays the same way
every time
• A: Assessment of Quality & Airway
• Assessment of Quality (PIER Mnemonic)
• P: Position- AP, PA, oblique, lateral
• I: Inspiration - see 9-11 posterior ribs
• E: Exposure - see outline of spinal column below diaphragm
• R: Rotation - spinous processes midline btw clavicle heads
• Airway (Midline, shifted, splayed carina, etc)
• B: Bones and Soft Tissue
• C: Cardiac
• D: Diaphragm
• E: Effusions / Extrathoracic Soft Tissue
• F: Fields, Fissures, Foreign Bodies
• G: Great Vessels / Gastric Bubble
• H: Hila and Mediastinum
• I: Impression

Treating a COPD Exacerbation:

• Hold home inhalers
• Continuous Pulse Ox, change titrate O2 order to 88-92%
• Duonebs Q6h, albuterol nebs Q2h PRN
• Prednisone 40 mg QD x 5 days, Solumedrol 60mg BID if severe
• Antibiotic tx if concern for infection (ie pna), worsened hypoxia,
change in sputum production or purulence
• Outpt:
o FQ if many risk factors
o Azithromycin if not
• Hospitalized, Few risk factors for poor outcomes:
o Macrolide (azithromycin)

36
• Hospitalized, Age >65, FEV <30%, >2 exacerbations in 1 yr, cont
home O2:
o Cefepime or Zosyn (antipseudomonals)
o IV Levoquin or Ceftriaxone if none of above

Asthma Stepwise Treatment

37
 COPD GOLD Group Treatment (2022)

*A separate algorithm is provided for follow-up treatment,

management based on symptoms and exacerbations
(recommendations do not depend on the patient’s GOLD group
at diagnosis)

38
 D. Gastroenterology

Abdominal Pain Differential

• RUQ: cholelithiasis, cholangitis, hepatitis, portal vein thrombosis
• Epigastric: MI, pancreatitis PUD, GERD, gastritis
• LUQ: MI, splenomegaly, splenic infarct, PUD
• RLQ: appendicitis, nephrolithiasis, pyelo, colitis, IBD, hernia,
ovarian cyst/torsion, PID/TOA, ectopic
• LLQ: diverticulitis and RLQ causes
• Suprapubic: UTI, urinary retention

Elevated Liver Enzymes

Per ACG guidelines (straightforward -> read them)
• ALT: 29 to 33 IU/l for males, 19 to 25 IU/l for females
• DDx: Hep A/B/C, NAFLD, alcohol, hemochromatosis,
autoimmune hep, Wilson’s disease, A1AT deficiency, offending
medications, hypotension
• Initial workup usually includes LFTs, RUQUS, viral hepatitis panel,
stopping offending medications.
• Patients with elevated BMI and other features of metabolic
syndrome with mild elevations of ALT should undergo screening
for NAFLD with right upper quadrant ultrasound.
• Those with hepatic steatosis can be scored by FIB-4 or NAFLD
Fibrosis Score (MDCalc) for consideration for risk of progression
to fibrosis/consideration for liver biopsy.

GI bleed
• Upper: above ligament of Trietz
o Sx: n/v, hematemesis, coffee-ground emesis, epigastric pain,
vasovagal, melena, hematochezia (brisk bleed)
o DDx: PUD, varices, gastritis, erosive esophagitis, Mallory-
weiss tear, vascular lesions (AVM, Dieulafoy, GAVE,
Aortoenteric fistula)
39
• Lower: below ligament of Trietz
o Sx: diarrhea, tenesmus, BRBPR, hematochezia, melena (R
colon)
o DDX: Diverticular, polyp/tumor, colitis, vascular/AVMs,
anorectal disorder, vasculitis

• Management:
o Assess severity: tachycardia, orthostatic vitals, hypotension,
drop in Hct 6% or Hgb 2g/dL, or >/= 2u PRBC
o Vitals, 2 large bore IVs in AC fossa
o Volume resuscitate: IVF until normal MS, VS, UOP
o Can anticoagulation/antiplatelet be stopped safely?
o Labs (draw in pediatric tubes): CBC, coags, type and cross
o Goal Hgb >7g/dL or 8g/dL if CAD
o If suspect UGIB: protonix 80mg IVx1,then 40mg IV q12hrs
o If cirrhosis/varices, consider octreotide, ceftriaxone
o If unstable, transfer to ICU and contact GI for potential
emergent scope

Colonoscopy
• ACS, ACG recommends screening at age 45, USPFTF: 50
o Refer to ACG clinical guidelines: colorectal cancer screening
2021

2012 ACG Recs for Surveillance:

40
41
 E. Nephrology
Chronic Kidney Disease (CKD)
• Defined as >/= 3 months of reduced GFR (<60) and/or kidney
damage (imaging/path/markers)
• Can use CKD-EPI to calculate estimated GFR, if no acute changes
in Cr.
• Etiologies: DM (45%), HTN/RAS (27%), glom (10%), interstitial
(5%), PKD (2%)

** Note ** Drops in creatinine in patients with

advanced disease may signify muscle loss due to chronic
42
 disease and NOT improvement of renal fx

Acute Kidney Injury (AKI)

• Abrupt increase in Cr in <48h of >/= 0.3 mg/dl OR Cr >/=50% OR
UOP
• <0.5mL/kg/hr for >6h
• DDX: prerenal, intrinsic, post-renal. Consult pocket med etc for
ddx.
• Initial eval: hx, volume status, RFP, UA, urine microscopy,
calculate FeNa or FeUrea if on diuretics or fluids, consider renal
US for obstruction
• Hold offending meds: NSAIDs, ACEI/ARB, etc. Avoid contrast if
possible. (If you have to give contrast, chase w/ fluids)
• Renal dose meds! CHECK UP TO DATE IF NOT SURE
• Further workup and Tx based on etiology
• Indications for emergent dialysis: AEIOU (Acidemia, Electrolyte
disorder: hyper K, hyper Ca, tumor lysis), Intoxication: methanol,
ethylene glycol, lithium, salicylates, Volume Overload (CHF),
Uremia: pericarditis, encephalopathy, bleeding)

Acid-Base Disorders
1: Is there alkalemia or acidemia present? pH > or < 7.4?
2: Is the disturbance respiratory or metabolic? pCO2 > or < 40?
3: Is there appropriate compensation for the 1° disturbance?
• compensation does not always return pH to normal
• Metabolic Acidosis: Winter’s Formula
Normal values ≈
o PaCO2 = (1.5 x [HCO3-]) +8 (± 2)
• Metabolic alkalosis pH 7.4 (7.35-7.45)
o Increase in PaCO2 =40 + 0.6(ΔHCO3-)
Pa CO2 40 (35-45)
• Acute respiratory acidosis HCO3 24 (22-26)
o Increase in [HCO3-]= ΔPaCO2/10(± 3)
Pa O2 100 (80-100)
• Chronic respiratory acidosis (3-5+ days)

43
 o Increase in [HCO3-]= 3.5(Δ PaCO2/10)
• Acute respiratory alkalosis
o Decrease in [HCO3-]= 2(Δ PaCO2/10)
• Chronic respiratory alkalosis
o Decrease in [HCO3-] = (5-7)(Δ PaCO2/10)
4: Calculate the anion gap
• AG= [Na+]-( [Cl-] + [HCO3-] )-12 ± 2
• A normal anion gap is approximately 9-12 meq/L.
• In patients with hypoalbuminemia, the normal AG is about 2.5
meq/L lower for each 1 gm/dL decrease in the plasma albumin
5: If there is an anion gap, assess the relationship between the
increase in the anion gap and the decrease in [HCO3-]
• Assess the ratio of the change in the anion gap (ΔAG ) to the
change in [HCO3-]: (Δ[HCO3-]): ΔAG/Δ[HCO3-]
• This ratio should be between 1.0 and 2.0 if an uncomplicated
anion gap metabolic acidosis is present.
• If ratio falls outside of range, another metabolic disorder is
present:
o If ΔAG/Δ[HCO3-] < 1.0, then a concurrent non-anion gap
metabolic acidosis is likely to be present.
o If ΔAG/Δ[HCO3-] > 2.0, then a concurrent metabolic alkalosis is
likely to be present.

44
 F. Endocrine

Diabetes
• Type “Insulin”, “Low”, “Medium”, or “High” into the order set
menu to find the insulin sliding scale order set.
• Hold oral meds, GLP-1 agonists while inpatient. Continue
Jardiance if stable renal function and no other contraindication
(increased risk euglycemic DKA)
• Weight based insulin: 0.4 units/kg/day for the average individual.
Half as long-acting, then split the remaining half into 3 doses to
be given with each meal.
• Patients will ideally be on basal/bolus insulin regimens,
particularly if they require insulin outpatient.
• Remember to decrease basal and discontinue bolus if they are
NPO. Also a good idea to decrease insulin doses inpatient as they
will typically not be eating their usual diet (typically 80% of home
dose). For U500, decrease to 50-60%
• Type 1 DM ALWAYS need basal, even if NPO
• Hypoglycemic?
o Recheck glucose 15ming after ½ cup of juice/regular soda (or
other source of simple carbs)
o Altered? 25 ml D50 IV push, repeat until glucose >100 mg/dl

45
 G. Infectious Disease
Cross reference local antibiotic coverage with Antibiogram

Antibiotic Tips
MRSA Coverage
-SSTI: Bactrim, clindamycin, doxycycline (also long-acting
oritavancin)
-Bacteremia: Vancomycin, daptomycin, linezolid, ceftaroline
-> Daptomycin: don’t use for susp Pulm source; inactivated by
surfactant; also check weekly CK levels to check for myopathy

Pseudomonas Coverage
-Zosyn, Ceftaz/cefepime, carbapenems (except erta), Zerbexa, FQ
(PO), aztreonam
-Cefepime doesn’t cover anaerobes, but it does have good CNS
penetration.

Vancomycin dosing
Pharmacy to Dose: Order “Vancomycin per Pharmacy” for
pharmacists to manage therapeutic drug monitoring per 81 MDG
vancomycin protocol. Simply write indication and trough goal in
Essentris order.

Loading dose: A dose of approximately 30mg/kg (actual body

weight) x1 with a maximum dose of 2000mg, or the table below can
be used:
Total 45-65 kg 65-85 kg >85 kg
Body
Weight
Loading 1000mg 1500mg* 2000mg*
dose IVx1 IVx1 IVx1

46
Monitoring: Vancomycin trough levels should be drawn 30 min
before administration of fourth dose, assuming dose given at its

regular dosing interval.

47
48
 H. Neurology/Psych

Dizziness
HINTS EXAM
• “Head Impulse testing, Nystagmus, and a Test of Skew.”
• To distinguish central vs peripheral causes
Dix-Hallpike Maneuver
• To test for BPPV

Seizure
• Place patient in lateral decubitus position, call NEURO
• Pad and protect but do not immobilize
• Do not insert objects or fingers in patient’s mouth
• Make sure the patient has adequate IV access, i.e. 2+ PIVs
• Get an accuchek to rule out hypoglycemia and consider alcohol
withdrawal as cause in patients without seizure history
• For a single first-time seizure that has stopped on its own, no
treatment is warranted beyond treating any provoking factors.
• Status epilepticus (tonic-clonic >5min, 2+ tonic-clonics in a row)
1. Benzos first. Choose one.
o Ativan 0.1mg/kg IV: either max 2mg/min or load 4mg, then 2mg
IV q2min up to 8mg
o Valium 0.15mg/kg IV: max 10mg/dose, then 5mg IV q2min up
to 30mg
o No IV access? IM Versed (or nasal, buccal): pts > 40kg: 10mg,
13-40kg: 5mg
2. Load Anti-Epileptic Drug (AED) at the same time. Choose one.
o Keppra (levetiracetam/LEV): 60 mg/kg (max 4500mg) IV push
over 15 minutes
o Alternatives: Phenytoin, Valproic Acid, fosphenytoin
3. Add a second AED (ask neurology for recs) if still seizing

49
4. Give anesthetic if still seizing. EEG, intubate if not already done
o Versed 200mcg/kg IV load, then 0.75-10mcg/min gtt
o Propofol 1-2mg/kg load, then 2-10mg/kg/hr gtt
o Pentobarbital 5-20mg/kg load, then 1-4mg/kg/hr gtt
5. DDx: Metabolic meds, intox/withdrawal, infection, vascular,
tumor

50
 Stroke
NIHSS - MD-Calc has NIHSS and TPA contraindications

51
 I. Hematology/Oncology
Heme / Onc Urgencies & Emergencies
Acute Leukemia
• Sx: B symptoms, fatigue, infxn, bleeding/petechiae, leukostasis
(SOB,HA,TIA/CVA), DIC, bone pain, LAD, N/V, neuro sx
• Dx: peripheral smear shows over 20% blasts, can see Auer rods
in AML, variable pancytopenia
• Tx: DON’T ADMIT. Transfer out of KMC, emergent induction
chemo
• Major emergency concerns: DIC, TLS, infection, leukostasis

How to Identify a Myeloblast on Smear: 5 ½ Morphologic

Features
1. Large cell size
2. Large nucleus to cytoplasm ratio (5:1, large nucleus, minimal
cytoplasm)
3. Lacey open chromatin (makes sense, DNA is open for rapid
transcription)
4. No granules in cytoplasm (which is minimal & light bluish
color)
5. Nucleoli ( 2+, distinct pale circles in nucleus, make
ribosomes)
+/- Auer rods in AML, Call Heme/Onc if blasts >15%

Leukostasis
• Common in AML, WBC hyperviscosity & occlusion of
microvasculature organ ischemia
• Sx: a/w ischemic organ: hypoxia, SOB, HA, TIA/CVA, MI, HA,
vision Δ’s
• Dx: WBC 50+ & signs/sx of tissue hypoxia, ( lactate)
emergent chemo; if delay in chemo then IVF, leukopheresis,
hydroxyurea

52
Tumor Lysis Syndrome
• Large tumor burden or rapidly proliferating tumor
spontaneous or tx induced rapid cell turnover release
intracellular contents
• Dx: K, , Uric acid, LDH, lactate, Phos causing calcium
(b/c phos binds), DIC, AKI (urate crystals)
• Ddx: high grade lymphoma Burkitt’s, ALL, AML, CML in blast
crisis
• Tx: aggressive IVF, allopurinol 300mg PO BID, rasburicase
0.15mg/kg (check for G6PDH first) or diuretics for goal UOP
80-100cc/hr, treat hyper K, hyper Phos, hypo Ca. Dialysis if
uncontrolled hyper K, oliguria & vol overload, Ca. Consider
sodium bicarb gtt for pH & urine alkalinization to
uric acid solubility (may cause CaPhos precip)
* if suspect from acute leukemia, do not admit, transfer out of
KMC

Brain Metastases causing ICP / neuro sx

• Tx: Do not admit, transfer out of KMC, no Neuro Surg, do
give steroids
• stat dexamethasone 10mg IV & repeat Q6H, emergent
Neuro Surg consult & decompression, consider mannitol &
seizure ppx
*LP CONTRAINDICATED in ICP from mass effect brainstem
herniation
• DO NOT GIVE ANTICOAGULATION to known or suspected
brain mets
w/ focal neuro deficits

• Microangiopathic Hemolytic Anemia (MAHA)

53
• Sx: HUS (renal) triad: plt + MAHA + AKI. TTP
(systemic)pentad: triad + fever + neuro sx (“FATRN”)
• Dx: anemia w/ SCHISTOCYTES, plt, LDH, ( Plt & MAHA)
• Ddx: TTP, HUS, DIC, malignant HTN, mechanical valve,
cancer, eclampsia/HELLP syndrome, drugs, vasculitis
• Tx: emergent plasma exchange in TTP is lifesaving=DON’T
ADMIT (10% die 1st day); FFP if delay to plex; continue plex
until plt >150
*platelet transfusion contraindicated b/c microvascular
thrombosis
Disseminated intravascular coagulation (DIC)
• Trauma, shock, sepsis, cancer, obstetric complications
massive coag cascade activation clots in
microvasculature ischemia + MAHA
consumption of coag factors bleeding
• Sx: clots, bleeding, multi organ failure
• Dx: PT, PTT, FDP/D-dimer, fibrinogen, plts, rbcs
(MAHA/schisto’s)
• Tx: tx underlying cause, support w/ plts, FFP, cryo (goal
fibrinogen >100)

Spinal Cord Compression

• Mxn: mets to vertebrae grow into epidural space, or cause
fracture w/ retropulsed bone fragments into epidural space
• Sx: vertebral pain, neuro sx: strength, sensation,
bowel/bladder dysfn, reflex
• Dx: MRI entire spine
• Tx: dexamethasone 10mg IV stat & then 4mg IV Q6H,
emergent Neuro Surg consult & decompression, emergent
radiation
*do not admit, transfer out of KMC, no Neuro Surg, do give
steroids

54
Transfusion Medicine

55
Iron Panel Tests

4T Score for HIT- Heparin Induced Thrombocytopenia

56
 J. Allergy

Anaphylaxis
• Sudden onset of an illness (minutes to several hours), with
involvement of the skin, mucosal tissue, or both (eg generalizes
hives, itching or flushing, swollen lips-tongue-uvula) AND at least
one of the following:
o Sudden respiratory sxs (SOB, wheeze, cough, stridor,
hypox)
o Sudden reduced BP or sxs of end-organ dysfunction
(hypotonia, collapse, incontinence)
• OR Two or more of the following that occur suddenly after
exposure to a likely allergen or other trigger for that pt (minutes
to hours):
o Sudden skin/mucosal signs (hives, itch, swollen lips-
tongue-uvula)
o Sudden respiratory sxs (SOB, wheeze, cough, stridor,
hypox)
o Sudden reduced BP or sxs of end-organ dysfunction
(hypotonia, collapse, incontinence)
o Sudden GI sxs (crampy ab pain, vomiting)
• OR 3. Reduced BP after exposure to a known allergen for that pt
o SBP <90 or greater than 30% from that pt’s baseline

• Management
o Reduce exposure to trigger (d/c offending medication)
o Assess ABCs, mental status, skin, and body weight
o Inject epinephrine intramuscularly in the mid-anterior
thigh
▪ NOT sub-Q, NOT in another location
o 0.5mg for adults (or 0.01mg/kg if <50kg)
o Repeat dose in 5-15 minutes if needed, usually only need
1-2
57
 o Use IV bolus/slow infusion only if severe shock or cardiac
arrest
o Place pt on back, elevate legs
o High-flow O2 (6-8LPM) by facemask/OPA when indicated
o Large bore IVs, give 1-2L normal saline rapidly. H1/H2
blockers adjunct.
o Monitor BP, cardiac function, and resp status at frequent
intervals

• RISK OF BIPHASIC ANAPHYLAXIS = admit for obs for 24 hrs

*will commonly happen at 10 hrs, but can up to 72.
• If no known trigger, consult/ref to allergy

58
 K. Geriatrics
Falls
• Absolutely must evaluate a patient who has fallen.
• Eval for head trauma and neuro exam and consider head CT
• Look for fractures visually and w/ XR
• Review medication list for anything that may be contributing.
• If significant polypharmacy, consider reducing medications
where clinically reasonable.

Dementia
• Workup should include: CBC, CMP, B12, TSH, RPR, HIV
• Look for anticholinergic meds, depression
• MMSE/MOCA: >27 normal, 20-26 mild, 12-19 moderate, <12
severe

L. End of Life
Comfort care
• The focus of care should be to optimize patient comfort and
to allow a peaceful death in the presence of family and
friends.
• Consider carefully what medications and procedures the
patient is receiving and whether or not they are necessary
(i.e. does the benefit in the short term justify the burden or
disruption in a dying patient?)

• Recommendations:
o General Care- Private room with 24 hour visitation
o STOP nonessential medications.
o STOP unnecessary labs, needle sticks, radiographs, etc.
o Oral Care- Lip balm/ water q4hrs ATC dry lips/ mouth
o Eye Care- Artificial tears 2 drops to eyes q4hrs PRN dry

59
 eyes
o Fever- Acetaminophen 650mg PO/PR q4hrs PRN T > 101
F
o Nausea- Metocloperamide 10mg q6hrs IV/PO q6hrs ATC
o Bowel regimen- Bisacodyl 10mg supp PRN no BM x
48hrs
o Agitated Delirium- Haloperidol 1mg SL q8hrs PRN
agitation
o Seizures- Lorazepam 2mg IV q4hrs PRN seizure > 5 min

o Pain or Dyspnea- Reassess frequently. Titrate to

symptom relief. If patient opioid naïve, consider:
▪ Morphine sulfate 5mg PO q4hrs ATC or
▪ Morphine sulfate 2mg IV q4hrs ATC or
▪ Morphine sulfate 1mg/hr IV continuous infusion
o If patient previously on opioid for symptoms, titrate
starting from current dose and adjust based on patient
needs
▪ Labored breathing/ Anxiety- Lorazepam 0.5mg IV
q4hrs PRN. Use opioids as 1st line treatment and
Lorazepam as adjunct
▪ Excessive secretions- Scopolamine, or
Glycopyrrolate

Pronouncing Death
• ALWAYS contact the family and attending, no matter the
time
• If family is present, prepare yourself before entering the
room, introduce yourself and explain what you’re going to
do.

60
• Feel for carotid pulse, listen for heart/lung sounds, look for
respirations, check pupils for reactivity. Be brief.
• Express your condolences to the family. Ask if they would like
to see the Chaplain. Ask if they would like an autopsy. Ask
name of funeral home.
• Do death note and death certificate. (MS has an online death
registry)

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 M. Critical Care Medicine

Daily considerations in the ICU

• F: Feeding/Fluids • Update family daily

• A: Analgesia • Assess volume status
• S: Sedation and pain control daily
• T: Thromboprophylaxis • Safety risks
• H: Head of bed @ 30 degrees • Meds & drips: Know
• U: Ulcer prophylaxis (GI) current rate/dose
• G: Glycemic control
• S: SBT/supplemental O2
• B: Bowel regimen
• I: Indwelling catheters/lines
• D: Drug De-escalation

Respiratory Failure
• Hypercarbia (PaCO2>45, pH <7.35)
o ↑ CO2 production: fever, sepsis, seizures, high CHO load in
pt w/ underlying pulmonary disease
o ↑ dead space: intrinsic lung disease (asthma, COPD, CF,
pulm fibrosis), chest wall disorders (scoliosis)
o ↓ minute ventilation: Drug overdose, metabolic
derangements (myxedema, hypokalemia), CNS disease
(spinal cord lesions), PNS disease (GBS, MG, ALS, botulism),
muscle disease (myositis, muscular dystrophy), chest wall
disorders (scoliosis), upper airway obstruction
• Hypoxia (PaO2 < 60, SaO2 < 90)
o ↓ FiO2: High altitude, tubing (of ventilator) not connected
(nl A-a gradient, can correct w/ increased FiO2)

62
 o ↓ Diffusion: COPD, parenchymal lung disease (can correct
w/ increased FiO2)
o V/Q mismatch: Large PE, PNA, atelectasis, asthma (high A-
a gradient, can correct w/ ↑FiO2)
o Hypoventilation (nl A-a gradient, can correct w/ ↑FiO2)
o Shunt: Severe ARDS, intracardiac, etc (high A-a gradient,
cannot correct w/ ↑FiO2)
o PAO2 - PaO2 gradient: (713 * FiO2) – [(PaCO2/0.8) – PaO2]
Nrml A-a gradient = (Age/4) + 4 (or use gradient = 0.43 *
age)
o If A-a gradient WNL & PaCO2 is high, then likely 2/2
hypoventilation
o If A-a gradient is high, then the cause is shunt, V/Q
mismatch or DO2/VO2 (O2 Delivery/Consumption)
imbalance such as anemia, low cardiac output or
hypermetabolism.

Treatment goal: correct hypoxemia, high FiO2, restore lung

volumes by recruiting more alveoli (with PEEP)

Types of Supplemental Oxygen

• Nasal cannula: 50 cc reservoir (nasopharynx/oropharynx), O2
flow 1-6 L/min, FiO2 0.24-0.46. FiO2: each liter per minute
adds 3-4% FiO2 to room air 21%
o (ie. 1lpm = 24%, 2lpm = 28%, 3lpm = 32%, 4lpm = 36%,
5lpm = 40%)
• Oxygen face mask: 150-250 cc reservoir, O2 flow 5-10 L/min,
FiO2 0.4-0.6.
• Non-rebreather: 750-1250 cc reservoir, O2 flow 5-10 L/min,
FiO2 0.4-1.
• Non-invasive positive-pressure Ventilation: BiPAP vs. CPAP

63
 o Use CPAP (=IPAP) if primary problem is oxygenation
(hypoxia)
o Use BiPAP if primary problem is ventilation (hypercapnia)

Intubation Medications

• PRETREATMENT : 100% FiO2 & ANALGESIA (if BP tolerates)

o Fentanyl:*use low dose as a sympatholytic premedication,
1-2mcg/kg, 25-50mcg, onset <60sec. Avoid if increased ICP,
hypotensive, resp dep
• SEDATION / INDUCTION
o Etomidate: Nonbarbituate hypnotic. Dosed 0.2-0.3mg/kg
(ask for 40mg, give 20, can give other 20 if need), short
onset (<1min), short duration (3-5 min). Drawbacks:
adrenal suppression (avoid in sepsis), hypotension
o Ketamine: Disassociative hypnotic acting as NDMA
receptor antagonist blocking glutamine; dosed 2mg/kg,
short acting <1min, short duration (5-10min); use: any RSI,
64
 esp if HD unstable, septic, reactive airway dz
o Propofol: acts on GABA, 2 mg/kg, onset 15-45 sec,
duration: 5 – 10 min, use in HD stable pts, reactive airway
dz, status epilepticus. Drawbacks: hypotension, resp dep,
pain on injection, very short acting

• PARALYTICS- immediately after induction agent

o Succinylcholine: Depolarizing paralytic. Dosed 1-1.5mg/kg
(if don’t know weight, 100mg usually works), short onset
(<1min), short duration (6-20min). Many contraindications:
Burns, hyperK, increased ICP, denervation, prolonged
immobility, malignant hyperthermia.
o Rocuronium: Nondepolarizing paralytic; dosed 0.6-
1.2mg/kg, short onset 1-2 min; intermediate duration 20-30
minutes. Use if can’t do succ

• BP Meds
o Liter of IVF- have setup if pt becomes hypotensive during
intubation
o Phenylephrine: Alpha agonist, useful if BP drops during
intubation; dosed 50-500mcg, don’t exceed 500mcg, don’t

65
repeat more than every 10-15m; immediate onset,
intermediate duration 15-20min

Rapid Sequence Intubation

12-step program to intubation:
1) Have a plan (position, blade, oxygen, suction, tube, access,
medications, mask, support staff)
2) Have a back-up plan (glidescope, bouge, LMA, anesthesia,
etc)
3) Communicate said plan
4) Prep patient (get all lines out of way), check equipment
(check bulb of scope, lube tube, get stylet in desired position),
get meds
5) Position patient (sniffing position, head of bed slightly
elevated)
6) Preoxygenate for at least 5 min BVMor high flow O2 (100%
SpO2)
7) Cricoid pressure (if RSI to prevent aspiration)
8) Push meds
9) Continue bag mask ventilation

10) Spread jaw, sweep tongue (if using Mac blade), lift up and
out (think lifting to far corner of room); BURP (back/up/right
pressure) on trachea to help view cords)
11) When you see cords, don’t remove your view, ask for your
equipment (“tube”), push ETT just past cords, inflate cuff
12) Verify position (end tidal CO2 monitor, auscultation, CXR),
adjust tube accordingly and secure

• Set initial ventilator settings based on clinical scenario and

patient factors

66
 See ARDSNET reference
Generic adult setting: Vt 400-500cc (or 5cc/kg), PEEP 5,RR 14,
FiO2 40%

• Goals of ventilation
• Oxygenate patient (PaO2 ~55-60/SpO2 >90% or 88% in
COPD patients, if dramatically over this go down on
FiO2 or PEEP)
• Minimize harm to patient (Peak pressures <35, plateaus
<30, tidal volumes 6mL/kg IBW)
• Ventilate patient (PaCO2 adjusted to achieve pH 7.3-
7.4)
Determinants of oxygenation: PEEP, FIO2 (to lesser extent
PaCO2)
Determinants of ventilation: Minute ventilation = rate x tidal
volume

Troubleshooting vent
• DOPES (Displacement - ETT, Obstruction – tube circuit, PTX,
Equipment failure-vent, Stacked breaths- autopeep)
• Patient starts crumping. Get RT, remove vent, bag ventilate
w/100% O2, examine tubes/lines, examine patient, look at
previous vent trends
• High peak/plateau pressures = pulm edema, consolidation,
atelectasis, mainstemmed tube, tension pneumo, chest wall
trauma. Recs: check tube, suction patient, adjust tube depth
if changed or positioning of patient from last CXR, shoot CXR
• Increased peak/plateau pressure difference = bronchospasm,
secretions, inspiratory circuit obstruction. Recs: suction, nebs
(ipratropium/albuterol)
• Auto-PEEP: Flow loop doesn’t return to baseline, indicative of
obstructive disease. Recs: Nebs and decrease rate or I:E ratio
67
• Inhaled > exhaled volumes: Circuit of cuff leak or
bronchopleural fistula. Check cuff pressure, inflate to goal
~20-30
• Over-breathing vent: Patient has too low tidal volumes or,
more likely, is agitated/in pain. Recs: Check gas, if
overventilated, sedate
• Exhaled > inhaled volumes: Nebulizer in circuit, will cause
autopeep transiently. Recs: Let the neb finish and reassess

Can I take them off vent?

• Daily spontaneous breathing trial (>24 hours on vent, FiO2
50% or less, PEEP 5 or less, off vasopressors or on
≤2mcg/kg/min norepinephrine)
• Use pressure support mode w/PS ≤5cmH20 over PEEP,
leaving PEEP and FiO2 same
• Passes if >1 hour without: RR >35 or <8 for 5 min, SpO2 <90%
for 5 min, abrupt change in mental status, new arrhythmia,
respiratory distress, HR >20% from baseline
• Check RSBI on PS mode if <105, consider extubation if
passing SBT, PaO2 after >80, FiO2 <40, spontaneous RR 10-
20, NIF -20 to -25 or better, cough reflex present, electrolytes
wnl, resolution of inciting event

Supportive Ventilation Basic Primer

1. Noninvasive Positive pressure ventilation
CPAP: continuous positive airway pressure. Patient initiates
breaths and machine provides pressure constantly
BIPAP / BiLevel Positive Airway Pressure: Inspiratory PAP and
Expiratory PAP/PEEP
IPAP: Patient initiates breaths and machine provides
pressure at inspiration
EPAP: after breath initiated by patient, machine continues to
68
 deliver some pressure, and this helps keep the alveoli
open, and thus improves recruitement of alveoli and
decreases work of breathing
• Uses: Effective in treating decompensated COPD, CHF

2. Invasive: intubation + mechanical ventilation

-Indications: Failure of airway maintenance, protection,
oxygenation, ventilation. Anticipated need for intubation
(impending resp fatigue):

• Basic Modes:
• Volume A/C (assist control):
• Pt initiates breath, then machine provides a full set
volume
• Standard settings: PEEP 5,Vt 400-500(5cc/kg),RR 14,
FiO240%
• Check ABGs and Watch for respiratory alkalosis from
hyperventilation, given patient will get full volume
every time a breath is initiated therefore tachypnea
can lead to stacking and cause hyperventilation.
• Pressure controlled
• Fixed pressure. Vt will vary depending on patient’s
lungs compliance. Therefore monitor Vt: can be too
small in poor compliance, which leads to poor
ventilation.
• SIMV (synchronized intermitted mandatory ventilation)
& PEEP
• Patient is allowed to initiate breaths which trigger the
machine to provide a volume or pressure support, but
if the patient does not initiate a breath, the machine
will also provide a minimum set number of mandatory
breaths.

69
 Sepsis
• SOFA >>> SIRS
• SOFA >2 = sepsis
• Calc SOFA: MD CALC, go to “evidence” to est FiO2.
*PaO2: spO2 90% =~ 60mmHG paO2, 100% =~ 90mmHG
• Sepsis: organ dysfunction (SOFA >/= 2) consequent to
infection
• Septic Shock: sepsis w/ hypotension requiring pressors for
MAP >/= 65 and blood lactate >2 despite appropriate volume
resuscitation
• Early goal directed therapy, Surviving Sepsis Campaign. Doing
these within 6hrs of presentation has been shown to
decrease mortality:
• IVF resuscitation with NS, target MAP >65mmHg
• Obtain 2 sets of blood cx, then start broad spectrum
antibiotics
• Vasopressors: see below
• Consider central line and arterial line placements early.
• The following should be done within the FIRST hour of
presentation:
• IVF resuscitation of 30mL/kg (avoid excess fluids)
• Lactate level, trend q6 or until not elevated
• 2 blood cultures before antibiotics
• Broad spectrum antibiotics (vanc/cefepime)
• MRSA nares most sensitive in resp. source sepsis.

Vasopressors
Start immediately if not fluid responsive. Don’t wait! MAP
goal usually 65mmHg. All patients requiring vasopressors
eventually need a-line and central line.
(Can run low dose levophed thru peripheral for a few hours if
needed)

70
• Norepinephrine (1st choice pressor in septic shock)
• All around good pressor for septic & cardiogenic shock.
• Receptors: A1>B1>B2. Mostly increased SVR and pulse
pressure
• Dose range 0.01-3 µg/kg/min
• Start at 5 mcg/min, titrate to MAP (usually goal 65)

• Vasopressin
• Consider in: Vasodilatory shock, often adjunct to
norepinephrine
• Receptors: V1 (SM increases SVR), V2 (renal collecting
system= inc H20 reabsorption)
• Sensitizes vasculature to norepinephrine. Inhibits
vasodilation, inhibits K+ channels and NO production.
Effects preserved during acidosis and hypoxemia
• Infusion 0.04 U/min (no titration)

• Epinephrine
• Good all-around pressor. Increases coronary blood flow
and arterial/venous pulmonary pressures like NE.
• Surviving Sepsis Point: Epinephrine favored when
additional agent is needed to maintain adequate blood
pressure
• Receptors: A1>B1>B2. More alpha at high dose. More beta
at low dose.
• Dose range: 1-10 mcg/min

• Dopamine: Probably won’t use.

• Receptors: D1, D2, B1 (cardiac chronotropy/inotropy), A1
(Systemic vascular resistance)
• Dosing: 0.5-3.0 µg/kg/min

71
• Phenylephrine
• Useful for hypotension, PDE5+nitrate use, HOCM
• May cause compensatory bradycardia 2/2 baroreceptor
response
• Receptors: Alpha 1 = increase in SVR
• Bolus 100-500 µg every 10-15m
• Infusion: 0.4-9.1 µg/kg/min

• Dobutamine:
• Increases myocardial O2 consumption, increases risk of
ischemia, tolerance develops rapidly, proarrhythmogenic
• Receptors: B1: B2 = 3:1 affinity (more inotropy than
chronotropy), A1 (systemic vascular resistance)
• <5 µg/kg/min = B1 and B2 effects> A effects = chronotropy
and inotropy with vasodilation; start 0.5- 1mcg/kg/min
• 5-15 µg/kg/min = B1 and B2 predominate with (minimal)
effects on SVR
• >15 µg/kg/min = A predominates = increase in SVR (max
dose 40 µg/kg/min by manufacturer, ACC/AHA/Surviving
Sepsis say no more than 20 µg/kg/min)

• Milrinone
• Phosphodiesterase 3 inhibitor = increases intracellular
cAMP increasing cardiac contractility and vasodilation in
periphery
• Increases diastolic relaxation, decreases preload,
decreases afterload, decreases SVR
• 50 µg/kg administered over 10 minutes followed by
maintenance dose 0.125-0.75 µg/kg/min
• Recommended Use: Heart failure. Adrenergic receptors are
downregulated and catecholaminergic agents may be less
72
 effective

• Patient critically ill, persistently Hypotensive even on pressors

with no obvious reason? Check a random cortisol
• Stress Dose Steroids = 50mg hydrocortisone q6

VTE Prophylaxis
VTE risk in inpatients is increased 130x compared to gen
population
Prophylaxis recommended for pts with any of the following
RF:
• Age >60, CHF, COPD exacerbation, sepsis, IBD, known
thrombophilia, prolonged immobility >3 days, previous
VTE, elevated D-dimer
Low-risk pts (with no risk factors):
• Early ambulation +/- mechanical prophylaxis sufficient
Moderate (1+ RF) or high-risk patients (critically-ill, cancer,
stroke)
• Heparin +/- mechanical prophylaxis
• LMWH reasonable if CrCl >30
• Not needed if pt already on oral anticoagulant
• Watch for evidence of HIT, esp with UFH
• For pts with a h/o HIT, fondaparinux may be used as
alternate
Contraindications to pharmacologic prophylaxis (heparin):
• Active bleeding or intracranial hemorrhage
• Surgical procedure is planned in the immediate 6 to 12
hours
• Moderate or severe coagulopathy
• Severe bleeding diathesis or thrombocytopenia
Epistaxis and menstrual bleeding are NOT contraindications

Stress Ulcer Prophylaxis

• ASHP Guidelines- GI prophylaxis appropriate for patients

73
 admitted to the ICU with one or more of the following:
• Mechanical ventilation >48 hours
• Coagulopathy
• GI ulcer or bleeding within the past year
• Glasgow Coma Score </= 10
• Thermal injury >35% BSA
• Multiple trauma
• Transplantation patients in the ICU
perioperatively
• Hepatic failure or partial hepatectomy
• Spinal cord injury
• Patients with at least 2 of the following:
• Sepsis
• ICU stay >1 week
• Occult GI bleeding >/= 6 days
• Steroids- >250 mg hydrocortisone or equivalent
per day

74
 USPSTF Preventative Services

Alcohol use
• If high use, get AUDIT-C score

Colon cancer
• Screening recommendations:
▪ Ages 50-75 (Grade A) *Updates currently in progress*
▪ 76-85 consider if >10-yr life expectancy (Grade C)
▪ >85 do not screen (Grade D)
▪ Per ACG, everyone should start at 45yo
▪ If two 1st degree relatives w/ colon ca- start at 40 or 10
years before earliest diagnosis
▪ Screening options: ACG Colorectal Screening Guidelines
2021

Depression
• If positive screen by tech, get PHQ-9 score

Diabetes
• Screen in asymptomatic adults with BP >135/80
• If BP <135/80, consider screening if DM would affect
treatment
• Screening options: ADA recs screening Q3 years.
▪ Fasting FSG ≥ 126 (confirmed on separate day)
▪ 2-hr post-load plasma > 200
▪ Hemoglobin A1C >6.5
▪ Random >200 with symptoms
• In patients with DM:
▪ If uncontrolled, check A1C q3mo
▪ If controlled check A1C q6 mo
▪ Also annual lipids, urine microalb/Cr, eye & foot exams,
vaccines

75
 HBV
• Screen in someone from a country with Hep B prevalence
>2%, or parent from country with prevalence >8% and pt
born in U.S. but not vaccinated in infancy (basically all
countries except North America, West Europe or Australia)
▪ If positive refer to ID

HCV
• Screen in anyone born 1945-1965
▪ If positive refer to ID, can order viral load at the same time

HIV
• Screen at least once age 15-65
• Also recommended in pts with STDs or initiating tx for TB
• Remember to check viral load too if acute infection
suspected
• If positive refer to ID, can order viral load at the same time

Hyperlipidemia
• Screen in men >35 or women >45, repeat every 5 years
• ACC/AHA ASCVD guidelines

Falls risk assessment

• If you think they’re increased risk, perform ‘timed get up and
go test’. If abnormal, refer to PT & check vitamin D. Can
request fall risk reduction program through home health.

Immunizations
• Can send pts directly to immun. clinic in basement, no appt
req
• Asplenic patients: PPSV23, PCV13, Hib, Meningococcal
• Pneumovax(PPSV23): everyone >65
• Prevnar (PCV13): >65, shared decision making (Underlying

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 medical conditions may consider more strongly)
• Shingrex: >50 (regardless of prior varicella or zoster
infection)
• Td: Every 10 years, or with acute wound and status unknown
• Influenza: Yearly, avoid live vacc in COPD, CHF, immunocomp
• Hep B: Pts with DM, cirrhosis, and ESRD on dialysis
• HPV: Women 11-26, Men 9-26 (and 27-45 in HIV+, MSM)

Lung Cancer
• Annual low dose CT
• Asymptomatic adults 50-80 yo w/ 20 pack-year smoking
history and currently smoke or have quit smoking within past
15 years
• Discontinue screening when pt has not smoked for 15 years

Obesity
• If BMI>30, refer to nutrition class and/or counseling
• Bariatric surgery monitoring:
▪ Annually: Anemia, Vitamin A, B12, D, folate, iron, zinc
▪ +/- : Vitamin E, K, selenium, copper, thiamine

Men Only
AAA Screening
• One-time screen in men 65-75 who have ever smoked

Prostate cancer: Routine PSA screening NOT recommended

Women only
Breast Cancer
• Mammogram every year 50-74 yo
• <50 or >75, case by case, risk factors, pt preference
• If abnormal radiology will usually recommend US vs MRI
• Insufficient evidence to support clinical breast exam, digital
mammography, or MRI as screening modalities

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• BRCA genetic counseling:
▪ If positive, get FHS-7 score. If high, consult genetics.
▪ Assess risk at: http://www.cancer.gov/bcrisktool/
▪ Consider tamoxifen, raloxifene, though no data for
improved survival, & there is ↑ risk for DVT/PE, uterine ca
▪ Likely be referred to surgery for prophylactic mastectomy

Osteoporosis
• DEXA Screening recommended for:
▪ Women ≥65
▪ Women <65 whose fx risk is ≥ 65 WF w/o additional RF
▪ Consider screening men >70
• If DEXA shows osteoporosis (T score < -2.5), then treat
• If DEXA shows osteopenia (T score -2.5 to -1.0):
▪ Calculate FRAX score: https://www.shef.ac.uk/FRAX/
▪ If high 10-yr risk (>3% hip or >20% major fx) then treat
• Treatment
▪ Lifestyle- exercise, smoking cess, ↓ EtOH, fall risk assess.
▪ Always check RFP (GFR and Ca) and Vit D prior to tx
▪ If vitamin D <30, replete with weekly Drisdol prior to tx
▪ Bisphosphonates (first-line)
• PO alendronate or risedronate- usually weekly doses
• IV zoledronate (Reclast)- infusion every 2 years
• Contraind in GFR<30, esophageal/GI disorder (for PO)
▪ Denosumab (Prolia)- mAb against RANK-L, ↓osteoclast act
• Q6month Sub-Q injections
• Only consider if failed or contraind to bisphos.
▪ Romosozumab (Evenity) anabolic, mAb that inhibits
sclerostin (promotes bone formation)
• High risk for fracture or intolerant to other therapies
• Not for use if MI or CVA w/in prior year; potential risk
for CV death, MI, CVA
• Q1month Sub-Q injections for 1 year

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 ▪ Teriparatide (Forteo)- PTH analog
• Daily Sub-Q injections
• Preferred in severe OP or steroid-induced OP
▪ Raloxifene, calcitonin- Less efficacy, last-line

Cervical cancer (Pap Smear)

• We don’t do these. Refer to Women’s Health.
• 21-65- Screen with cytology every 3 years
• 30-65- Screen with cytology AND HPV testing every 5 years
• <30- Do not screen with HPV (alone or with cyto)
• <21, >65, or had a hysterectomy (& w/o cervix)- Do not
screen

Smoking Cessation Options

• All patients should be referred to the Smoking Cessation
Clinic at the Health and Wellness Center
• AHLTA “con- smoking cessation”, goes to Joy Schaubhut
(376-3171)
• TRICARE Quit Line: 1-877-414-9949
• Nicorette gum
▪ At onset of craving, can be combined with patch and orals,
pt should cease smoking
▪ Dose depends on #cigarettes/day
• Transdermal patch, combine with gum/orals. Should cease
smoking.
▪ Taper based on #cigarettes/day
• Zyban (Bupropion)- screen for contraindications
▪ If no effect at 7 weeks, unlikely to work
▪ Maintenance up to 6 months
▪ Warning in renal/hepatic patients
▪ Buproprion and nicotine together better than either alone
• Chantix- screen for contraindications
▪ Course of Chantix is 12 weeks, can extend to 24 weeks

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 total
▪ Target starting one week before quitting
▪ Prescribe starter pack, pt should call for continuation pack
▪ Inquire about SI/HI before each time patient fills Chantix
▪ If unsuccessful or relapse, can do another trial

Useful Websites & Resources

Dynamed (bullet point format, cites evidence) Free with ACP
membership
Uptodate
Life in the fast lane (esp. for cardiology, crit care)
Youtube NEJM “procedure name” (tutorial videos for
procedures)
Emcrit website (podcast for EM and Critical care)
FOAM Cast- Free Open Access Medical Education
Curbsiders – Internal Med Podcast on high yield topics
National Comprehensive Cancer Network: www.nccn.org
Guidelines: Resident Resources->Articles & Powerpoints-
>Guidelines
Dotphrase.org

Mississippi Prescription Monitoring Program:

- https://mississippi.pmpaware.net/login
- Can look up prescription history and prescribing providers
of narcotics and other high-risk meds for a given patient

Commonly Used Calculators/Formulas

ACS (STEMI, NSTEMI, UA):

• HEART Score: For chest pain in ED, risk of MACE within 6-
weeks
• GRACE score: In-hospital and 1-yr mortality after ACS
• Killip Class: degree of CHF after ACS, 30-day mortality
• TIMI: 14-day risk of death, MI, or urgent PCI after ACS

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AKI:
• FeNa: <1% suggests prerenal, >1% suggests ATN or post-
renal
• FeUrea: Used when pt on diuretics, <35% suggests
prerenal
Atrial fibrillation
• CHA2DS2-VASc: Yearly risk of CVA with A-fib
• HAS-BLED: Risk of major bleeding with 1-yr on OAC
Cardiovascular risk
• ACC/AHA CV Risk: 10y risk of ASCVD (MI, CVA, coronary
death)
• Framingham Risk Score: 10y risk of ASCVD
CHF
NYHA Functional Class: Level of functionality in CHF
patients
Cirrhosis/Hepatitis
• Discriminant Function/Maddrey Score: Severity of
alcoholic hepatitis
• Lille Model: If alcoholic hepatitis is steroid responsive
• Child Pugh: Severity of cirrhosis, mortality before & after
TIPSS
• MELD: Prognosis in liver failure, prioritizes for liver
transplant
• SAAG (Serum-ascites albumin gradient):
• ≥ 1.1- P-HTN from Liver Fail, Budd-Chiari, Myxedema, SBP
• < 1.1 Peritoneal TB, CA, Nephrotic Synd, or Pancreatitis
Creatinine Clearance
• CrCl CKD-EPI: Best for GFR of ≥60 ml/min
• CrCl Cockcroft-Gault or MDRD: Better for GFR of <60
ml/min
Critically Ill:
• APACHE II- Severity of illness and risk of death
• Aa Gradient= (713x FiO2) - (PaCO2/0.8)-PaO2
• Normal is 0.29 x age

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• PaO2/FiO2 (P/F) ratio: ARDS if <300. Quantifies severity
• SOFA: Level of end-organ dysfunction in ICU patients
CVA/TIA:
• ABCD2- 2,7, and 90 day risk of CVA after TIA
• NIH Stroke Scale: Quantify severity of stroke, track
progress
DVT
Well’s score for DVT- Pretest probability of DVT
Electrolytes:
• Corrected Na in hyperglycemia = serum Na + (1.6 for every
100 md/dL of glucose above 100)
• Corrected Ca in hypoalbuminemia = Ca + [(4.0-Albumin) x
0.8]
• Free water deficit in hypernatremia
= (Kg x 0.6)x[(140 - serum Na)/140]
• Try to give half in the first 8 hrs, then the rest in next 24h
• Usually best to give free water PO or per NG if possible
Endocarditis
DUKE criteria: Makes diagnosis of endocarditis
GI Bleed
GBS score: Likelihood upper GI bleed will need
intervention
HIT
4 T’s: Pretest probability of having HIT
Osteoporosis/enia
FRAX score: 10y risk of major osteoporotic fx
Pancreatitis:
• BISAP: Risk of in-hospital mortality
• Ranson’s Criteria: Mortality in acute panc, outdated, req
48 hrs
Pleural Effusion
Light's Criteria for Transudative Effusion
• Failing any one of the criteria makes it an exudate

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 • 1. Effusion Protein / Serum Protein < 0.5
• 2. Effusion LDH / Serum LDH < 0.6
• 3. Effusion LDH <200
• Etiology:
• Transudate: CHF, Kidney Dz, Cirrhosis
• Exudate: Parapneumonic (>1,000 WBC), Empyema
(>100,000 WBC) + positive gram stain of pleural
fluid, TB, PE, CA, RA, Esophageal rupture,
Pancreatic Fistula, SLE
Pneumonia:
• CURB 65: 30-day mortality, outpatient vs inpatient tx
• Pna Severity Index (PORT): Same as CURB but more
detailed
• Shorr score: for MRSA PNA
Pre-Op:
• NSQIP calculator:
http://riskcalculator.facs.org/RiskCalculator/
• Gupta calculator:
https://qxmd.com/calculate/calculator_245/gupta-
perioperative-cardiac-risk
• RCRI
Pulmonary embolism:
• PERC: Rules out PE if all criteria negative
• PESI: Severity of PE, inpatient vs outpatient
• Well’s Score for PE: Pretest probability of PE

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 Practical Tips to Running a Code

A Few Words
Everyone is nervous during his/her first CODE BLUE
experiences. DON’T WORRY THIS IS TOTALLY NORMAL!
Eventually, with time and practice, you’ll be the one who runs
fastest to get there to competently & confidently run the
show
Take a deep breath, use your ACLS cards, you got this.

REMEMBER:
-The #1 thing for coronary & cerebral perfusion: GOOD
COMPRESSIONS

-Coach & make compressors switch if they look tired

-Study! Practice on paper/in your head/ with a buddy/ in the

sim lab. This grows competency which saves lives and grows
confidence.

-Don’t forget the 5 H’s & T’s (or Kotti- 2 Lungs/ 2 Hearts / 3 up
& 3 down)

-For VF and VT shock! (200 J biphasic)

-Epinephrine is your friend. (1mg q3-5min via IV; 2.5mg q3-

5min via ETT)
(Give every other pulse check)
-Patients aren’t dead unless they’re warm and dead

Good luck! “Whether you think you can or whether you think
you can’t, you’re right.”

Assess and Take Command

84
Ask who’s running the code, if no one is running it, announce
that you are If compressions haven’t been started, check for
pulse & confirm code status
If pulseless and ok for resuscitation:
Go to foot of bed – this is your home now Get a 3 second
update about the situation

Compressions, Breaths, Access, Leads, FSG

Ensure there are adequate people for compressions and
adequate compressions; don’t forget body board under
patient!

-2 inches in, 100/min – encourage and coach!!

-End tidal CO2 at least 10mmHg, goal close to 20mmHg

Check IV Access; patient should have 2 large bore IVs in AC

fossa preferably, any will do, IO if needed
Make sure someone (preferably RT) is bagging patient
Get leads on patient ASAP (you need to know shockable or not
ASAP) CHECK A FINGER STICK GLUCOSE!

Assign Specific People to Specific Roles:

1) Recorder/Timekeeper- This person needs to tell you when 2
minutes is up for each cycle of compressions and when the
next dose of Epi is due
2) RN for medications (immediately get Epi and IVF)
3) RN to collect CODE LABS
4) People for compressions, rotate compressor Q2min, ( 2
inches deep, 100/min, allow recoil, backboard)
5) RT to bag patient ( breath every 6 seconds, 8-10 per minute)
6) Tech to attach leads, cycle BP cuff
7) Someone to pull up chart, get history and get most recent
labs
8) Someone to contact family and update them
9) Enforcer for crowd control

85
 ***DECLARE THE RHYTHM / ALGORHYTHM OUT
LOUD!!!***

Analyze Waveform, Think and Act: PEA / ASYSTOLE

(H&T’s)
• Once leads are attached, stop and check for rhythm and
pulse.
• Think about the potential reasons this patient coded, look for
& treat reversible causes!
• If Asystole/PEA: (5 H’s & T’s), or (Kotti: 2Heart, 2Lungs, 3up
3down)
• Asystole/PEA: CPR q2min check pulse, rhythm, shock if
VT/VF Resume CPR q2min with EpiQ3min repeat

86
 Cause Mxn Sx Tx
Hypovolem Blood / Tachycardia Blood,
ia volume loss Hypotension Fluid Bolus
Hypoxia Airway Low O2 sat, ABG, Secure
obstruction Cyanosis airway, ventilate
(*CO w/ O2, b/l
poison) BS, chest rise
Hydrogen Hypoperfusion, Low QRS ABG, secure
ions Anaerobic airway,
(acidosis) metabolism Ventilate,
Sodium
Bicarb
1meq/kg
Hypokalemia Many Flat T waves, Mg 2gm,
U wave controlled K
infusion
(always
diluted K)
Hyperkalemia Many Peak T wave, Calcium
wide QRS chloride,
Insulin/glucose,
Lasix, Bicarb,
kayexalate,
albuterol,
dialysis
Hypothermia Exposure Pt cold, Warm
bradycardic, blankets/warm
J wave IVF 42’C,
peritoneal
/bladder lavage
meds less
effective
if cold
Hypoglycemi Sepsis AMS, 25g IV dextrose
a Adrenal arrhythmia
failure
Excess insulin

87
 Cause Mxn Sx Tx
Toxins Overdose; Long QTc, -call posion
TCA/Dig/BB/CC check pupil, control
B Cocaine -antiode
Tamponad Fluid in Low -bolus IVF
e pericardium voltage, -
-ineffective tachy, pericardiocentesi
pump narrow qrs, s, subxiphoid aim
JVD, for
muffled shoulder
heart
Tension High pressure Narrow qts, -needle
PTX compresses brady, decompression
thoracic clinical dx, (pt dies if wait
structures tachy, for CXR)
hypotensio
n, JVD,
trach
deviation,
unequal BS
Thrombosi Coronary ST changes, PCI
s (acute plaque rupture TWI, q
MI) waves
CP/trop
Thrombosi Tachycardia Lytics
s (Massive , hypoxia,
PE) JVD

88
 Analyze Waveform, Think and Act: Vtach /VFib
(ELECTRICITY!)
• Once leads are attached, stop and check for rhythm and
pulse. Think about the potential reasons this patient coded!
• If Vtach or Vfib…SHOCK SHOCK SHOCK SHOCK!

• VT/VF: Shock CPR q2min check pulse, rhythm, shock if

VT/VF
Resume CPR q2min with EpiQ3min repeat, (alternate Amio
w/ Epi)

• We typically use biphasic defibrillators

• Initial dose: 200J
• Repeat deliveries can be uptitrated to maximum setting
• When you see a shockable rhythm, continue compressions
&charge…don’t stand there without compressions and wait
till the defibrillator is ready!!
• When ready, hold compressions then… “Everyone clear!”
“Deliver shock”
• Resume compressions for 2 full minutes
• DON’T FORGET END TIDAL CAPNOGRAPHY! (Can stop a code
mid-compression if ETCO2 rises to 35-40 mmHG)

89
 Troubleshooting: All IV lines are blown!
• Epi can be given via ETT! give epi 2.5mg via ETT instead of
1mg IV
• Ask RN to attempt PIV
• Place an intraosseous line takes < 1 min & gets fluid to
heart in 3 sec
• Ask resident to place central line

OMG! Patient got ROSC! What do I do?

• Get Vital signs and an EKG!!!
o If new LBBB or ST elevation, treat per STEMI protcol
• Consider hypothermia protocol (decrease metabolic rate and
reactions that can produce toxic metabolites)
o Indications: best data for comatose VF/Vtach with ROSC <1
hr
o Contraindications: hemorrhagic CVA, trauma, GCS
>8,overdose, pre-existing hypothermia, sepsis, hypotension,
coagulopathy

-Maintain O2 sat >94% -IVF/pressors PRN -

Line patient out
-Treat reversible causes -Update Family -
Write Code Note
-Discuss w/ primary team -Thank the code team

Pressors PRN after ROSC

• Adequate volume resuscitation is essential to minimize risk
of vasopressor- mediated splanchnic hypoperfusion.
• Norepinephrine IV infusion “Levophed” (1st line for septic
shock) 0.1-0.5 mcg/kg per minute (70kg adult = 7-35mcg per
minute)

• Dopamine IV infusion: 5-10mcg/kg/min

90
• Epinephrine IV infusion: 0.1-0.5 mcg/kg/min (70kg = 7-
35mcg/min)

….When do I know to “call it”?

• There is no magic number as to when to call it; case by case
basis. Talk to family if able.
• Factors to consider: pt age, comorbidities, prognosis, QOL
before code

91
Notes

92
Notes

93