1. High B.P.new onset CVA(infarction)

SBP<220DBP<130=>observation

SBP>220DBP>130=>Trandate(Labetalol) 1 amp(25mg) IV ST

Repeat every ten minutes up to 160mgif still poor responsetry Nitroprusside

除了new onset CVA

a. Adalat(Nifedipine) 1# SL or PO if SBP180 mmHg

(contraindication:AS, unstable angina, AMI)

                                   b. Trandate(Labetalol) 1 amp IV ST

                                   (contraindication:digitalis resistant heart failure,asthma)

 

2.Low B.P.DC會降血壓的藥(Lasix, Valium, Propofol…),看heart rate urine output patient’s appearance

          Heart rate and urine output normal =>observation(physiologic)

          Cardiogenic shock=>DobutamineDopamine

          Non-cardiogenic shock heart rate increase and urine out put decrease(compensatory)=>fluid challenge(2-5 rule)
Colloid FFP
Dopamine
Levophed

    Fluid challenge 2-5 rule

CVP initial X

Challenge 200 mlCVP<X+2,再challenge 500 ml

X+2< CVP <X+5,則challenge 200 ml

CVP>X+5,則stop fluid challenge,改用Dopamine                                

    Neck CVP insertion(CVP level 才準,有ventilator者,要減掉PEEP,所以最好off ventilatorcheck,打完請照X-ray看位置(4th intercostal spacehilar)fluid level 要足夠,給升壓劑才有意義,否則會造成tachycardia and peripheral vasoconstriction,且效果不好。

    Dopamine用法:4 amp(800 mg)N/S(D5W) 500ml(double dose)

2 amp+ 500 ml(single dose)

2 amp250 ml.(二合一)常用

   Dobutamine用法:2 amp(500mg)+N/S(D5W) 500ml

   Start:3 µg/kg/min

   Titrate:20 µg/kg/min(因為dose太高會有降血壓效果,所以limit dose   

   20µg/kg/min,怕血壓會掉太多)

Dopaminenergic D R2-3 µg/kg/minincrease renal and splenic blood flow

    β1 R4-8 µg/kg/min

    α R:>8 µg/kg/min(才有升壓效果)

Ex:70 Kg3µg/kg/min,給8 drops(ml/hr),用等比級數調整劑量滴數

*常用dose:26.6×滴數 / B.W.µg/kg/min

>>__µg/kg/min*BW/26.6=滴數(用在400mg in 250ml)

*Single dose:13.3 ×滴數 / B.W.µg/kg/min

   >>同上

*Dobutamine dose:33.3 x滴數/BW=µg/kg/min

>>__µg/kg/min*BW/33.3=滴數(用在500mg in 250ml)

*Levophed(Norepinephrine) 8mg in 250 ml D5W

升壓效果較Dopamine,倘若掛了dopamine血壓還升不上,可加掛levophed

HR,可先將dopamine dose調低

*洗腎後血壓低,可先少量補水(200 c.c.),若仍低,可給Dopamine

* double dose 是因為若是CHF的病人需要dopamine or dobutamine給太多水反而會引起fluid overload,所以double dose可以在少量水份給高量濃度.

 

3.Oliguria

先排除obstructionOn foleyirrigation echoIf no obstructioncheck renal function and compared with previous dataavoid nephrotoxic drugs,血壓低時身體產生保護作用,自然無尿,已證實用利尿劑或是Dopamine renal dose對預後不會有幫助。

 

4.AsystolePEA(D/D:6H6T)

叫叫ABC(CPR)O2(on endo)IV(Atropine 1 ampBosmin 1 amp)monitor(EKGshow Torsades de PointesMgSO4 1 ampDC shock(360J)

 

5.Sodium Bicarbonate給法:

 check Blood Gas: PH7.2才給(因怕太酸造成hyperkalemia induced cardiac arrest),看BE負多少

ExBase Excess:16IV push 4 amp4 amp slow IV drip

 

6.Dyspnea:看pateint有無cyanosis,給O2,看O2 oximeter,作EKG,抽 blood gas to R/O CO2 retensionD/D CO2 retension or O2 saturation down

  Allergy: Bosmin 0.3 ml inhalationSC

bronchospasm

二合一:Atrovent+Berotec(Ventolin) inhalation or

三合一:Ventolin+Bosmin+Decadron( 1 amp) inhalation

Solucortef(hydrocortisone) 2 amp ST(excerbation of COPD0.5 amp50mg Q6H × 3 days),Methylprednisolone: 31.25 mg q6h

Aminophylline(2 amp + N/S 500 c.c(pump)keep 21 drops)controversialSE : tachycardia

Heart failure or ascities

Lasix 2 amp ST(if blood pressure is acceptable)

AMI(check EKGCKMBTroponin I q6h)

MONA therapy with Heparininform VS PTCA

Pulmonary emboli

完全無法排除,by clinical,如果查不到原因一定要考慮,尤其是EKGS1Q3T3 pattern,不過很少見,大部份以sinus tachycardia來表現,所以若有unexplained hypoxemiaD-D dimmer increaseCXRwedge shape,如果PE為唯一考量,vital sign unstable,就先用Heparin or LMWH(EnoxaparinClexane)60 mg SC q12h,但D-D dimerold age, infection, inflammation, pregnancy皆會上昇

 

7.Conscious change: D/Dfind cause and treat

  緊急狀況先排除:sugarABGEKGhemorrhage(non contrast brain CT)electrolytes, sepsis

 

8. Fever: find cause and treat

       obtain culture: S/C,U/R,blood cultures × 2bed sorecather related lumbar puncture, thoracentesis, abdominal tapping if necessary

       reduce temperature: scanol, keto if fever>38.3

       increase IV

Empiric antibiotics(看部位)

 

9.RI insulin pump for HHNKDKADM with poor control(Sugar>500 mg/dl,show high)

a. hydrationDKA100 ml/KgHHNK150 ml/kg

b. Plasma osmolarity : 2Na++ Glucose/18 + BUN/2.8

c. DKAif PH<7.1,再補Sodium Bicarbonate

d. ST RI 10-15 U(可給可不給)

e. RI pump(100U RI +N/S 100c.c.)

Ex: 70 kg100 U RI + N/S 100 c.c. drip(1 c.c.=1 U)(0.1 U/Kg/hr)

Blood sugar(mg/dl)

滴數

<200

DCIV改成5%glucose0.45N/S 500c.c.

200-250

1

250-300

2

300-350

3

350-400

4

400-450

5

450-500

6

>500

7

別忘了check sugar q2h-q4hcheck K+ q4h-q6hcheck Mg2+ initially

因為給RI會降低potassium(transcellular shift),所以

Potassium concentration 

Give? mEq over next hour

<3

40

3-4

30

4-5

20

5-6

10

>6

0

sugar stable and well intake,計算total dose of insulin/day四等份

multiple daily injection:RI__tid/acNPH__hscheck sugar qidac

 

10.200<sugar <500(sugar250)/10

 

11.Hypoglycemia: 50% glucose 2-4 amp

 

12.Hyperkalemia

   Calcium gluconate先打1 amp

   再給Humulin RI 8 U+D50W 4 amp(5 g sugar1 U)

   KayexalateKalimate 30 gm QID

   Sodium Bicarbonate:severe metabolic acidosis才用

   Thiazide

H/D if intractable hyperkalemia

 

13.Hypokalemia: KCl 1 amp AT or PO TID with meals(if water restriction)slow K

   deficiency,算TTKGA decrease of 1 mEq/L in the plasma K+ concentration may represent a total body K+ deficit of 200-400mEq

 

14.Hyponatremia:urine Naurine Osmblood OsmD/DR/O Adrenal insufficiency

   symptom: 0.9 %N/S

   symptom: 3% NaCl(不可補太快,否則會造成central pontine myelinolysis)

     Na+ <120: 3% NaCl

Ex:鈉缺少量=(135-現在data)×0.6(male)×body weight

                          0.5(female)

   3%NaCl 500 ml512 mEq

   70Kg male: Na+115         共缺(135115)×0.6×70840 mEq

   補鈉的速度不能超過1-2 mEq/L/hour24 hrs內不能超過8 Eq/L

   所以一天內只能補70×0.6×8336 Eq

336÷24÷0.51327 ml/hr(滴數)

   快速算法:24 hrs補一瓶3%NaCl 500 ml,所以20滴,之後再check

ps: Nahyperglycemia時會降低,correct Na=Na + 1.4×(sugar100),所以不要一見到Na低就補。

 

15.Hypernatremia:

  Water deficit:=(plasma Na140/140× 0.6(male)× body weight

                                    0.5(female)

  缺的水分分成2-3 days補充,IV0.45% NaCl, D5W

 

16.Hypercalcemia:

hydration fluid status 足夠後給lasix,但要注意同時補充potassium.

 

17.Seizurefind cause and treat

  1. Acute seizure attack: Valium, Ativan
  2. Dilantin: loading 10mg/kgmaintain dose 1 amp Q8H IVkeep Dilantin level 10-20 mg/dl,口服效果也不錯1# PO TID
  3. Luminal: loading 3 amp IM STmaintain dose:1 amp HS IM 

 

18. endo選號:adult: female:7.0-7.5male: 7.5-8.0,插完記的照X-ray, location carina 上方3-5 cm, fixed 22 cm first

 

19. Ventilator set

l          AC modeFiO2: 100%, RR: 10-15/min

l          Tidal volume: 10-12 L/kg, but 6-8 L/kg (ARDS)

l          PEEP: COPD: 3-5 cm H2O, Max < 15( adjust 3-5 cmH2O every time to achieve PaO2> 60and FiO260)ARDS: 10-15 cm H2O

l          Trigger sensitivity-1 to –2 cmH2O

l          Flow rate: 5-20 L/min

l          Flow sensitivity: 2 L/min

l          Inspiratory flow: 60 L/min

l          I/E ratio:

1:2 to 1:4 (COPD)

1:1 to 1:2ARDS

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