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ELECTROLYTE SOLUTIONS Non-specific symptoms

o Anorexia
IV Soln Glu Na Cl K Ca HCO3 o Vomiting
D5W 5mg/L o Abdominal pain
D10W 100mg/L (+) Torniquet test
0.9 NSS 154 154 GRADE II
D5LR 130 109 4 3 28 Grade I + spontaneous bleeding
D5NM 40 40 13 GRADE III
D5NR 140 98 5 Grade II + severe bleeding + circulatory failure
D5 0.9 50 mg/L GRADE IV
NaCl Grade III + irreversible shock + massive bleeding
D5NMK 50 mg/L 40 40 30
ABG COMPUTATION
Soln Na Cl K HCO3 Ca Mg
I. 713 (decimal FIO2) PCO2/0.8 = I
ECF 142 103 4 27 5 3
II. pO2/I = II
D5LR 130 109 4 28 5
III. (Desired FIO2/II) + pCO2/0.8
D5 0.45 77 77 ________________________ x 100
3% NaCl 513 513 713
0.9 NaCl 154 154
Desired FIO2 = 104 (0.43 x age)
D5W Osm = 278 D5W Osm = 556 D5LR Osm = 130
NaHCO3 = 446 A. 713 x FIO2 PCO2/0.8
MECHANICAL VENTILATION B. pO2 / A
C. 02 for age / B + pC02 / 0.8
Indication for Intubation ________________________________
1) Impending respiratory failure, apnea 713
2) Respiratory Rate >35 FIO2: 20 / 4 = L
3) PaCO2 > 50
4) PaO2 <60
5) Tidal Volume < 3-5 ml/kg CT SCAN BLEED VOLUME
6) Vital Capacity < 10-15 ml/kg
7) Inspiratory force < 25 cm H20 Given: 58 mm ~ 5.8
8) Force Expiratory Volume(FEV) < 10 ml/kg 23.3 mm ~ 2.3
9) Vq / Vt > 0.6
10) To deliver high FIO2 5.8 x 2.3 = 13.34 x 5 (constant) = 66.5 x 5.2 (constant) = 34.684 -(estimated bleeding volume)
11) Absent
12) pH <7.35 DIAGNOSTIC THORACENTESIS DUE TO HEART FAILURE

VENTILATOR SETTING 1) If the effusion are not bilateral and comparable size
1) TV: 6-8 ml/kg (ARDS) 8-10 ml/kg 2) If the patient is febrile
2) Pale: 6-20 3) If the chest has a pleuritic chest pain
3) Mode: AC (Assist Control) 4) If effusion persist despite the diuretics therapy
SIMV (Synchronized Intermittent 1 mV
4) FIO2 INDICATION FOR CHEST TUBE THORACOSTOMY
5) PEEP 5cm H20
1) Pneumothorax
INDICATIONS FOR WEANING 2) Pleural effusion
1) Mental status: Awake, Alert 3) Chylothorax
2) PaCO2 > 60 mmHg w/ FIO2 < 50% 4) Empyema
3) PEEP < 5 cm 5) Hemathorax
4) PaCO2 < pH acceptable 6) Hydrothorax
5) Spontaneous TV < 5mL
6) VC > 10 ml/kg TIMING OF TUBE REMOVAL
7) MIP > 25 cm H20 The timing of tube removal depends on clinical and radiological evidence of complete
8) RR < 30/min expulsion of all contents of pleural cavity with complete expansion of the lung
9) Rapid shallow breathing index < 100 (RBI) Minimal drainage should have occurred over the previous 24 hours (<25 ml/kg)
10) Stable vs. Ft a 1-2 hr When the patient coughs or performs the valsalva maneuver no air leak should ensue
The chest radiograph should confirmed complete expansion of the lung
Spontaneous Trial
FIO2 room air 21% The s____ in the fluid in the tube in the underwater seal bottle should be minimal, relating
O2 via nasal prong = # lpm x 0.4 x 20 to the normal negative pressured in the chest during the phases of respiration
INDICATIONS FOR CTT
ELECTROLYTES Gross pus on thoracentesis
a) Corrected Ca = (40-lbs) x 0.02 + serCa Presence of organism on gram stain of the pleural fluid
b) Corrected Na = Na + RBS mg% - 100 x 1.6 / 100 Pleural fluid glucose < 50 mg / dL
c) Na Deficit = (140 actual) (0.6 x BW) Pleural fluid pH below 7.00 and 0.15 units lower than arterial pH
d) K Deficit = (D-A) (0.4 x BW) LIGHTS CRITERIA
D = 3.5 cardiac
4.5 non-cardiac 1) Pleural fluid protein / serum protein > 0.5
H20 Deficit = 0.6 x kg BW 2) Pleural fluid LDH / serum LDH > 0.6
D = 15 CKD 3) Pleural fluid LDH > 2/3 the upper limit of normal serum LDH
18 NCKD
Actual Na Desired Na / Desired Na
TRANSUDATIVE VS EXUDATIVE FLUID
CUSHINGS TRIAD Transudative Exudative
1) Increase systolic BP SG < 1.012 > 1.020
2) Widened pulse pressure Protein < 3 g/dL >3 g / dL
3) Bradycardia /AbN respiratory pattern
FP / SP < 0.5 >0.5
a. Cheyne Stoke breathing
LDH <60% >60%
HEMORRHAGIC STROKE TRIAD FLDH/SLDH <0.6 >0.6
1) Papilledema Cholesterol <45 mg / dL >45 mg / dL
2) Headache
3) Vomiting
CLASSIFICATION OF PTB
MEIGS SYNDROME
1) Pleural Effusion Class O- NO PTB EXPOSURE
2) Polycystic Ovary / Fibromatosis Not infected
3) Hypoalbuminemia
Class 1- HISTORY OF EXPOSURE
FOUR SCALE Neg. Skin test to tuberculin
- Full outline of responsiveness
Class 2- TB INFECTION
EYE RESPONSE No disease
a) Eyelids open, tracking, blinking to command 4 Positive reaction to tuberculin test
b) Eyelids open but not tracking 3 No clinical, bacteriologic or radiographic evidence of TB
c) Eyelids close but open to loud voice 2
d) Eyelids close but no pain 1 Class 3- TB CLINICALLY ACTIVE
e) Eyelids close with pain 0
Clinical, bacteriologic, or radiographic evidence of current disease
MOTOR RESPONSE
Class 4- TB NOT CLINICALLY ACTIVE
a) Thumbs up, fist or peace sign 4
History of episode of TB
b) Localizing to pain 3
c) Flexion response to pain 2 Abnormal but stable radiographic findings
d) Extension response to pain 1 No clinical or radiographic evidence of current disease
e) No response to pain or generalized myoclonus 0 Class 5- TB SUSPECT

BRAINSTEM REFLEXES Signs and Symptoms of TB


a) Pupil and Corneal reflex 4 Fever
b) One pupil wide and fixed 3 Night sweats
c) Pupil or corneal reflex absent 2 Weight loss
d) Pupil and corneal reflex absent 1 Anorexia
e) Absent pupil, corneal and cough reflex 0 Weakness
General Malaise
RESPIRATION
a) Not intubated, regular breathing pattern 4
b) Not intubated, cheyne-stoke breath pattern 3
c) Not intubated, irregular breathing 2
d) Breath above ventilation rate 1
e) Breath at ventilation rate, apnea 0
RECOMMENDED DOSAGE FOR INITIAL TREATMENT OF TB

1) Isoniazid = 5 mg/kg, max 300 mg


2) Rifampicin = 10 mg/kg, max 600 mg
DENGUE
3) Pyrazinamide = 20-25 mg/kg, max 2 g
GRADE I
4) Ethambutol = 15-20 mg/kg
Fever
s. Albumin g/L >35 30-35 <30
g / dL >3.5 3.0-3.5 <3
LOCATING MYOCARDIAL DAMAGE Protime sec 0-4 4-6 >6
Anterior = V2-V4 (L) coronary, LAD INR <1.7 1.7-2.3 >2.3
Anterolateral = I, qV1, V3 V6, LAD, circumflexes Ascites None Easily controlled Poorly
Anteroseptal = V1-V4, LAD
controlled
Inferior = II, III, aVF, (R) coronary artery
Lateral = I, aVL, V5, V6, circumflex brance of (L) coronary artery Hepatic None Minimal Advanced
Posterior = V8 V9 (R) coronary artery, circumflex artery encephalopathy
(R) Ventricular = V4R, V5R, V6R, (R) coronary artery Calculated by adding the score of the 5 factor and can range from 5 15

JONES CRITERIA OF RF CHILD-PVGH Class is either:


A. Score of 5 6
Major: B. Score of 7 9
Carditis C. Score of 10 or Above
Polyarthritis
Chorea Decomposition
Erythema marginatum indicate cirrhosis
Subcutaneous nodule N/A
CHILD PVGH Score of 7 or more
Minor:
Fever Class 8
Polyarthralgia Listing for liver transformation (accepted criteria)
Lab: Inc. ESR / Leukocyte count
Hepatic Fibrogenesis
ECG: Prolong P-R interval
Stellate cell activation
Elevated anti-streptolysin O, other strep antibody
Collagen production
(+) throat culture
Rapid Ag test for Group A CLINICAL STAGE OF HEPATIC ENCEPHALOPATHY
Strep / result: Scarlet Fever
MS
Criteria: Stage I Euphoria, depression, mild confusion, slurred speech, disturbance in sleep
2 major/one minor and 2 Stage II Lethargy, moderate confusion
(+) evidence of preceding Group A strep infection Stage III Marked confusion, incoherent speech, sleeping but arousable
Stage IV Coma, initially responsive to noxious stimuli, ____ response
ACUTE RESPIRATORY FAILURE

TYPE I or Acute Hypoxemic Respiratory Failure


COMPLICATIONS OF ERCP
Occurs when alveolar flooding and subsequent intrapulmonary shunt physiology occurs
1) Infection
Alveolar flooding may be a consequence of pulmonary edema, pneumonia or alveolar 2) Perforation
hemorrhage 3) Pneumothorax
Low pressure pulmonary edema 4) Bleeding
Defined by diffused bilateral airspace edema
TYPE II Respiratory Failure-Hypercabia
Occurs as a result of alveolar hyperventilation and results on the inability to eliminate CO2 MUSCLE STRENGTH
effectivity
Mechanism by which this occurs are categorized by impaired CNS drive to breath, impaired O No muscular contraction
strength with failure of neuromuscular function in the respiratory ____ 1 Trace contraction
Reason for diminished CNS drive to breath including drug overdose, brainstem injury, sleep 2 Active movement with gravity eliminated
disordered breathing 3 Active movement against gravity
Overload Respiratory System due to: 4 Active movement against gravity & slight resistance
Increase resistive loads (bronchospasms) 5 Against full resistance
Reduced lung compliance (alveolar edema)
Reduced chest wall compliance (pneumothorax)
IDEAL PEAK FLOW
Increase minute ventilation (pulmonary embolus)
TYPE III Respiratory Failure Ideal peak flow: Hg (m) 100 x 5 (+) 175 (M) (+) 170 (F)
Occurs as a result of lung atelectasis
Also called perioperative respiratory failure N 80%
After general anesthesia, decreases in functional residual capacity of dependent lung units PEFR = Peak flow reading / Ideal peak flow x 100 = _____ %

TYPE IV Respiratory Failure N 20%


Due to hypoperfusion of respiratory muscles in patients in shock, due to pulmonary edema, PEFR variability: Highest reading Lower x 100 = ______ %
lactic acidosis, anemic Highest Reading

DEFINITIONS USED TO DESCRIBE THE CONDITION OF SEPTIC PATIENTS


NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION
Bacteremia
Presence of bacteria in blood as evidenced by positive blood culture CLASS I
Septicemia No limitation of physical activity
Presence of microbes and their toxins in the blood No symptoms with ordinary exertion
SIRS
Systemic inflammatory response syndrome CLASS II
Two or more of the following conditions: Slight limitation of physical activity
o Fever (oral temp >38C) or hypothermia (<36C) Ordinary activity causes symptoms
o Tachycardia (>90 bpm)
o Tachypnea (>24 bpm) CLASS III
o Leukocytosis (>12,000/uL) or Leukopenia (<4,000/uL) or > 10% bands may Marked limitation of physical activity
have a non-infectious etiology Less than ordinary activity causes symptoms
Sepsis Asymptomatic at rest
SIRS that has proven or suspected microbial etiology
CLASS IV
Severe Sepsis Inability to carry out any physical activity without discomfort
Similar to sepsis sepsis syndrome
Symptomatic at rest
Sepsis with one or more signs of organ dysfunction
Septic Shock
Sepsis with hypotension (arterial blood pressure of 90 mmHg or MAP > 70 mmHg FRAMINGHAM CIRTERIA FOR DIAGNOSIS OF CHF
Refractory Septic Shock
Septic shock that last > 1 hour and does not respond to fluid or pressure administration MAJOR CRITERIA
Multi-organ Dysfunction Syndrome Paroxysmal Nocturnal Dyspnea
Dysfunction of more than 1 organ requiring intervention to maintain homeostasis
Neck vein distention
INDICATIONS FOR INITIATING HEMODIALYSIS Rales
Failure of conservative management Cardiomegaly
Management to relieve Acute pulmonary edema
a) Pulmonary congestion (unresponsive to high dose furosemide)
b) Severe metabolic acidosis S3 gallop
c) Severe hyperkalemia Increased venous pressure (>16 cmH20)
BUN >100 mg/dL or creatinine >10mg/dL Positive hepatojugular reflux
Note: For acute renal failure it is best to start dialysis early

RHEUMATIC ARTHRITIS MINOR CRITERIA


Require 4 out of 2 criteria: Extremity edema
o Morning stiffness Night cough
o Arteritis of 2 or more joints Dyspnea on exertion
o Arteritis of hands and joints
o Systemic arthritis Hepatomegaly
o Rheumatoid nodule Pleural effusion
o Serum Rheumatoid factor Vital capacity reduced by one-third from normal
o Radiographic changes Tachycardia (>120 bpm)

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

CHILD-PVGH CLASSIFICATION OF CIRRHOSIS


Factor Units 1 2 3
s. Bilirubin umol / L <34 34-51 >51
mg / dL <2 2-3 >3