Warfarin acts by inhibiting the synthesis of vitamin K-dependent clotting

factors, which include Factors II, VII, IX, and X, and the anticoagulant proteins C
and S 1972
the longest half life for this factor 7 day ,, so this way we see the effect of
.warfarin after 7 d
when we use enoxaparin as bridge therapy with warfarin we can stop it two
constitutive INR within the goal
levofloxacin it functions by inhibiting DNA gyrase and topoisomerase IV
levofloxacin s/e : hallucination , photosensitivity, nephrotoxicity, QT
prolongation
,glargine insulin :given on fixed time , peakless
psychiatric pt with obstructive sleep apnea ,oxygen thereby due to sever
obesity ,infection , DIC
d/5 wter and have metabolic acidosis >give normak sline, positive budding yeast
in urine, acino bacter >colstin dose actul wt

Criteria for brain death: fixed pupil , irreversible loss of brain function (functional brain death )
loss of the brain nerve reflexes including the light reflex

Tamiflu (oseltamivir):prodrug when active is a neuraminidase inhibitor

treatment dose( when h1n1 positive not flu a) 75 bid for 10 days
prophylaxis dose :75 mg once for 5 days

ticoplanin Glycopeptide antibiotics: inhibits peptidoglycan synthesis

Initial: IV: 400-800 mg every 12 hours for 3-5 doses maintenenance 6-12 mg/kg once daily
Tecoplanin need dose adjustment in loading dose (not in maintenance dose ) if
crcl less 20
adj CrCl 30-80 mL/minute: maintenance dose once every 48 hours, or administer one-half of
previous maintenance dose once daily
CrCl <30 mL/minute (including hemodialysis patients): Administer previous maintenance dose once
every 72 hours, or administer one-third of previous maintenance dose once daily
tecoplanin indication : mrsa > catheter>gram positive

not all pt have fever with budding yeast positive in urine should start
fluconazole
we should r/o bacterial infection first by covers all thing then if still febrile and
hymodynmic unstable we can start
fluconazole 200mg iv once daily require dis adj renal 50% dose
fluconazole maxim dose 800

normally we can find pt with sepsis with normal wbc since the criteria for
sepsis is wbc>12 or less 4

nifedipine>CCB> dihydropyridine>S/E >edema ,constipation when given with

vepramil diltiazem
reflex tachycardia , in long term gingival hyperplasia
moxonidine> antihypertensive> selective agonist at the imidazoline receptor
subtype 1
intial dose 0,2 maximum daily dose of 0.6 mg>>GFR 30-60 mL/minute: Maximum single
dose: 0.2 Maximum daily dose: 0.4 mg ; GFR <30 mL/minute: Use is
contraindicated

< Haloperidol> typical antipsychotic medication> prn

s/e wt gain , Extrapyramidal s/e including: Distonia ,Muscle rigidity Akathisia,
Parkinsonism
Extrapyramidal antidote> diphenhydramine>BZD>BB>cholinergic
final Q : Haloperidol s/e Neuroleptic malignant syndrome (NMS)( consists of
muscle rigidity, fever, autonomic instability) what is the antidote ? . Dantrolene

the major s/e of hydralazine lupus like syndrome(type of allergy)

allopurinol > allopurinol for tumor lysis syndrome (TLS) prophylaxis
TLS >increase uric aced ,phosphors ,ca
inhibitor allopurinol is a purine analog; of the enzyme xanthine oxidase
daily dose 300-600 mg in divided dose the maximum daily dose 800mg/daily
CrCl 10 to 20 mL/minute: 200 mg/day
.CrCl 3 to 10 mL/minute: Do not exceed 100 mg/day
CrCl <3 mL/minute: The dosing interval may need to be extended; do not exceed
100 mg/day
major s/e allopurinol skin allergy ,kft monitoring

digoxin :nhibition of the sodium/potassium ATPase pump, Direct suppression of the AV node
digoxin toxicity sign :gi s/e ,cardiovascular>brady or tache arthmia ,vf ,cnc s/e ,,ophthalmic s/e>green
, yellow spoting
antidote :fab antibodi

dexamethasone
Extubation or airway edema: Oral, IM, IV: 0.5 to 2 mg/kg/day in divided doses
every 6 hours beginning 24 hours prior to extubation and continuing for 4 to 6
doses afterwards
Cerebral edema: IV: 10 mg stat, 4 mg IM/IV (should be given as sodium
phosphate) every 6 hours until response is maximized, then switch to oral
regimen, then taper off if appropriate; dosage may be reduced after 2 to 4 days
and gradually discontinued over 5 to 7 days

enxoparin max dose 225

hydrocortisone:14 days then oral
hydrocortisone tapering : every 3days decrease the dose 2.5-5 mg until to
reach the lowest dose which is 5mg then u d/c it
dic management
in dic fibrinogen level is low and high FDB (degradation product of fibrinogen)
but in some condition like sepsis fibrinogen level will be normal or high
DIC is suspected, platelet count, PT, PTT, plasma fibrinogen level, and plasma
d-dimer level
rbc indication
fresh frozen plasma contain clotting factor so given in case bleeding
indication for fresh frozen plasma (FFP):1-elevation in INR(1,5) 2- PT(apove 45)
3-active bleed all3
in case we give FFP and the patient still bleeding and the fibrinogen less than 1
,so we give cryoprecipitated (antihaemophilic factor(factor a))
indication for platelet ? 1- platelet cunt less 10.000 regardless if there is
bleeding or no
platelet cunt less 30,000 and their is risk of bleeding 3-pletelet less 50.000 -2
and have active bleeding
condition cause of dic :sepsis ,cancer ,hepatitis, snake bite

Topic in quiz : 1-shock and sepsis and septic shock

DVT and stress ulcer prophylaxis
DVT :contraindication for enoxaparin 2-dose enoxaparin in DVT treatment and
prophylaxis dose adj
unfractionated heparin prophylaxis dose
stress ulcer : major/minor criteria (one major or two minor)5726

topic 2
head trauma and sub-arachnoid hemorrhage
head trauma >falling down or rod traffic accident(rta) and this may led to )
(fracture
we have types of fracture:1- simple skull fracture 2- depressed skull fracture 3-
compound depressed skull fracture 4- Basal fracture (the most dangerous one
cuz of risk of leakage of CF fluid and risk of meningitis
Basal fracture have two sign : Raccoon eyes(ecchymosis around eyes) and
battle sign(ecchymosis temporal eria)
: management
mainly we do management for complication
sizure : we give seizure prophylaxis -1
phenytoin : for 7 days >>>>if he developed seizure 6-12month
note :if pt exceed 7 days and still on phenytoin but he on Mechanical ventilation
and not stable so we keep him on phenytoin
we should know phenytoin vs levetiracetam dose and every thing *

elevation intracranial pressure So we expected ischemic or hemorrhage -2

cerebral perfusion pressure = MAP - ICP
if ICP >MAP so cerebral perfusion well decrease and we expected ischemic
? how we decrease intracranial pressure *
non pharma :surgery+ cefazolin surgery prophylaxis
: pharmalogical
first line :hypertonic saline 3%
second line :mannitol (dose, contraindications, duration of treatment not exeed 3
day why ?)
in mannitol we should calc serum osmalirety if the result more 325: mannitol
contraindication

some study recommend to give combination mannitol and furosemide low dose
10-20mg since its give synergistic diuretic effect to decreases cerebral edema

? meningitis: we should know when to start meningitis prophylaxis and what -3

we usually give ceftriaxone and vancomycin but if frontal area involve we add
metronidazole to cover anaerobic

criteria for meningitis prophylaxis*

sub-arachnoid hemorrhage: the main complication vasospasm so we give -4

nimodipine (dose: 60mg po q ? duration 21 days) after the pt be com stable
other complication include :1-rebleeding2-sizure 3- hemorrhage 4-
( hyponatremia ??)

Two mechanisms have been proposed as causes: syndrome of inappropriate anti-diuretic hormone
and cerebral salt wasting

topic 3
glycemic control
we give regular insulin as continues infusion cuz mixterid contain NPH ,and particles occlusion iv line

topic 4
acid-and base disturbances and electrolyte disturbances
antibiotic case

:sepsis
we treat :hypotension ,infection and supportive (stress ulcer and DVT prophylaxis)
* hypotension: 500-1000 bolus normal saline then maintenance
:if pt still hypotension despite adequate fluid resuscitation so we give vasopressors
norepinephrine first line why ? cuz it work both in alpha and beta resptor but more in
alpha so less risk of tachycardia and more vasoconstriction
epinephrine a=b
dopamine=low dose dopamine receptor mod dose :b high :alpha
the most risk for elevate hr with dopamine so not use in arrhythmia

bp=co x pvr
to give dobutamine 1-SBP>90 2-hct>30%(cuz its increase risk of hypoxia) 3-cardic
index low(EF Less 45)

dose and when to use each one

norepinephrine maximum dose In septic shock 3mic/kg/min
other type of shock :30mic/min
dose range
dopamine :max dose practically 20mic/kg/min theoretically 50
dobutamine : max dose practically 20mic/kg/min theoretically40

S/E of dopamine and norepinephrine is renal failure and skin necrosis so we make .==
irrigation and give ( antidote nitroglycerine topical or phentolamine topical ) alpha
antagonist

last option is hydrocortisone 100mg q8h max 300 for 7days

infection
FINAL Q :culture with Pseudomonas and positive cocci's :to antibiotic should be given
?homework four indication for double coverage for pseudomonas

supportive

what is complications for sepsis? End organ damage ,dic Acute Respiratory Distress

The APACHE II Scoring System is designed to measure the severity of disease in

patients admitted to the intensive care unit

, type of shock cardiogenic shock