(Intubate!) : Stag e Description GFR (Ml/min/1.73
(Intubate!) : Stag e Description GFR (Ml/min/1.73
(Intubate!) : Stag e Description GFR (Ml/min/1.73
Weight = 40 kg • Pericarditis
ABG Interpretation Na Deficit = 10 × 40 × 0.6 Dressler’s Signs of • Pneumonitis
Hyponatremi Na Deficit = 10 ÷ 12 × = 240 meqs Post-Myocardial Infarction • Pleuritis
a TBW …using PNS 1L Pericarditis • Pyrexia
FiO2 FM 240 meqs ÷ 154 meqs/L = 1.6 • Pain
RA = 0.21 5-6 = 40% L
I (FiO2 × 713) – pCO2 NP = Lpm × 4 + 20 6-7 = 50% 1600 ml/24 hrs = 67 cc/hr
0.8 FM = Lpm × 10 -10 7-8 = 60%
RB = Lpm × 10 Bacteremia Bacteria in the Blood (positive Blood Culture)
II PaO2 VR = 100% TP Water Deficit = (Actual Na – 140) × TBW
I AB = 80 6 = 40% 140
CPAP = Lpm × 4 + 20 7 = 70% Hypernatrem Septicemia Presence of Microbes & their Toxins in the
III Target FiO2 + pCO2 8 = 80% ia TBW Males = Weight (kg) × 0.6 Blood
II 0.8 Target FiO2 9 = 90% TBW Females = Weight (kg) × 0.5
× 100 < 60 yo = 80 10 = 100% Requires ≥ 2 of the Following:
713 > 60 yo = 80 – (age – • Temperature > 38°C or < 36° C
60) Systemic Inflammatory • Respiratory Rate > 24 breaths/minute
COPD = 60 Serum Normal 280-300 Response Syndrome • Cardiac Rate > 90 beats/minute
Expected PF = Age × 5 Osmolalit [2 (Corrected Na + K)] + RBS (SIRS) • White Blood Cell Count > 12000 or < 4000
y (mOsm/ (mmol/L) DKA 300-320 • > 10% Bands
L)
[H+] = 24 × pCO2 < 0.3 Chronic Renal Failure HHS 330-380 Sepsis SIRS with proven/suspected Microbial etiology
Delta H HCO3 0.3-0.7 Acute Renal Failure on Urine Specific Gravity – 1 × 40000 Sepsis with ≥ 1 Signs of Organ Dysfunction
top of Chronic Renal Osmolalit • Cardiovascular: SBP < 90 mmHg or MAP ≤
!H = [H+] – 40 Failure y 70 mmHg responding to IV administration
pCO2 – 40 • Renal: UO < 0.5 ml/kg/hr for 1 hr despite
adequate fluid resuscitation
> 0.7 Acute Renal Failure • Respiratory: PaO2/FIO2 < 250 or if the
(Intubate!) Mean Arterial SBP + (2 × Normal: 70-110 mmHg Severe Sepsis Lung is the only Dysfunctional Organ ≤ 200
Pressure DBP) 60 mmHg is enough to sustain (Sepsis Syndrome) • Hematologic: Platelet Count < 80000 µl or
3 organs 50% decrease in Platelet from highest
recorded over the previous 3 days
[Weight (kg) × 0.4] × [Desired HCO3 – Actual Desired HCO3 • Unexplained Metabolic Acidosis (pH ≤ 7.3
HCO3 HCO3] Normal = 20 Cerebral Normal: 70-90 mmHg
Perfusion MAP – ICP > 90 = Increased ICP or Base Deficit ≥ 50 meq/L & Plasma
Deficit CRF = 15 Lactate > 1.5x upper limit of normal
**Give only ¼ of the computed deficit Pressure < 70 = Ischemia
• Adequate Fluid Resuscitation (PAWP ≥ 12
1 amp = 44 meq NaHCO3 mmHg or CVP ≥ 8 mmHg)
Normal 80-120
Obese ≥ 30 Multi-Organ Dysfunction Dysfunction of > 1 Organ requiring intervention
Estimated Syndrome (MODS) to maintain Homeostasis
Creatinin Renal Impairment 50-80
e
Clearance IBW × 35 cal/kg = Total cal/ CHO 60% ÷ 4
Chronic Renal Injury 20-50
(ECC) Diabeti day Pre-Renal Renal Failure Post-Renal
c Diet Failure Failure
CHON 20% ÷ 4
Chronic Renal Failure 5-20 IBW = [Height (in) × 2.54 –
150] Urine > 500 < 350 < 350
(– 10% if female) Fats 20% ÷ 9
End-Stage Renal Disease <5 Osmolality
I Kidney Damage with Normal ≥ 90 D5W 50 -- -- -- -- -- U/P Crea Ratio > 40 < 20 --
or Increased GFR
D10W 100 -- -- -- -- -- Urine Na+ < 20 > 40 > 40
II Kidney Damage with Mild 60-90
Decreased GFR BUN/Creatinine > 20 < 15 > 15
0.9 NSS (PNSS) -- 154 154 -- -- --
Differential Count > 50% Lymphocytes > 50% PMN Motor Neuron Lesions
E Confined to Bed/Chair
Cholesterol < 45 mg/dl > 45 mg/dl Character Upper Motor Neuron Lower Motor Neuron
• Stable Oxygenation (PaO2/FiO2 > 200, PEEP ≤ 5
Light’s Criteria – EXUDATE if any of the following: Tone Hypertonic Clonus Hypotonic Clonus
cmH2O) • Pleural/Serum Protein > 0.5
• Intact Cough & Airway Reflexes • Pleural/Serum LDH > 0.6
• No Vasopressor Agents being Administered Fasciculations (-) (+)
• Pleural LDH > 2/3 the Upper Limit of Normal Serum LDH
Indications FAILURE Wasting (-) (+)
for Weaning • Respiratory Rate ≥ 35 breaths/minute for 5 minutes
• O2 Saturation < 90% De Bakey Classification of Stanford Classification of
• Cardiac Rate > 140 beats/minute (20% increase/ Aortic Aneurysms Aortic Aneurysms Reflexes Exaggerated (-)
decrease from baseline)
• Systolic Blood Pressure < 90/> 180 mmHg
Type I Ascending Aorta & Beyond Type A Ascending Aorta
• Increased Anxiety Diaphoresis
Neurologic Localizations
Type II Ascending Aorta Type B Descending
SUCCESSFUL: Aorta • Limb/Truncal Ataxia
Breathing Ratio of Respiratory Rate to Total Volume in Lung Cerebellum • Intent Tremors
< 105 • Dysmetria & Dysdiadokinesia
Type Aorta Distal to Subclavian --
III Artery
• Prominent Cranial Nerve Deficit (CN III-XII)
• Respiratory Rate > 28 breaths/minute Brainstem • Ipsilateral CN Deficits with Contralateral Limb
• Blood Pressure < 90 mmHg or 30 mmHg below Motor/Sensory Deficits
Criteria for baseline Murmur Grading • Cerebellar Signs
Admission for • New onset confusion or altered consciousness
Community- • Hypoxemia (PO2 < 60 while breathing Room Air Grade I Faint • Disturbed Higher Intellectual Functions
Acquired or O2 Saturation < 90%) Cerebrum • Emotional & Behavioral Disturbances
Pneumonia • Unstable Co-Morbid Conditions • Speech Disturbances & Seizures
• Multi-Lobular Infiltrates Grade II Audible by Stethoscope
• Pleural Effusion
Grade III Moderately Loud • Involuntary Movement
Basal Ganglia • Rigidity
• Bradykinesia
Kilips Classification of Acute MI with Expected Hospital Mortality Rate Grade IV Loud with a Palpable Thrill
• Upper/Lower Motor Neuron Disturbances
Class I No signs of Pulmonary/Venous Congestion 0-5% Grade V Very Loud & Audible with Stethoscope partly off the Chest Spinal Cord • Sensory Disturbances
• Autonomic Disturbances
Moderate Heart Failure or (+) Bibasal Rales, S3 Grade VI Very Loud & Audible with Stethoscope removed from the
Class II Gallop, Tachypnea, or signs of Right-Sided Heart 10-20% Chest • Distal & Symmetric Lower Motor Neuron
Failure, Venous & Hepatic Congestion Peripheral Nerves Disturbances
• Sensory Disturbances
Class Severe Heart Failure, Rales > 50% of Lung Fields or 35-45%
• Autonomic Disturbances
• Impending Respiratory Failure, Apnea
III Pulmonary Edema • Respiratory Rate > 35 breaths/minute
• Inspiratory Force < 25 cmH2O Myoneural • Muscle Fatigability
• Tidal Volume < 3-5 ml/kg Junction • Proximal Weakness of Muscles
Shock with Systolic Blood Pressure of < 90 mmHg &
Class evidence of Peripheral Vasoconstriction, Peripheral 85-95%
• Vital Capacity < 10-15 cc/kg
IV Cyanosis, Mental Confusion, & Oliguria Indications for • PaO2 < 60 mmHg with FiO2 > 60% Muscles • Proximal & Symmetric Motor Disturbances
Mechanical • PaCO2 > 50 mmHg with pH < 7.35
Ventilation • Forced Expiratory Volume < 10 ml/kg
• VQ/VT > 0.6
Leads Cardiac Area • To Deliver High FIO2 Hepatic Encephalopathy
• pH < 7.35
• Absent Gag Reflex
I, aVL, V5, High Left Lateral Circumflex Artery Stag Mental Status Asterixi EEG
V6 Wall e a
• Tidal Volume = 500
• FiO2 = 100
II, III, aVF Inferior Wall Right Coronary Artery • Assist Control/Synchronized Intermittent 1 I Euphoria/Depression, Mild Confusion, (+)/(-) Normal
Ventilator Settings mV Mode Blurred Speech, Disorientation, Asleep
aVR Right Lateral Wall Right Coronary Artery • BUR = 16
• PF = 50 II Lethargy, Moderate Confusion (+) Abnorma
• PEEP = 5 cmH2O l
V1, V2 Septal Wal LAD • Pale = 6-20
V3, V4 Anterior Wall Left Coronary Artery, LAD III Marked Confusion, Incoherent Speech, (+) Abnorma
• Awake, Alert Sleeping, Arousable l
• PaCO2 > 60 mmHg with FIO2 < 50%
• PEEP < 5 cm IV Coma, Initially Responsive to Noxious (-) Abnorma
Small 10 ml • PaCO2 < pH Stimuli, Later Unresponsive l
Pericardial Effusion • Spontaneous TV < 5 ml
Indications for • Vital Capacity > 10 ml/kg
Moderate 10-20 ml Weaning • MIP > 25 cmH2O
• Respiratory Rate < 30 breaths/minute Criteria for Rheumatoid Arthritis
Large > 20 ml • Rapid Shallow Breathing Index < 100 (1987 American College of Rheumatology)
• Stable Vital Signs in 1-2 hours
5 Rheumatoid Nodules over Bony Prominences, Extensor Surfaces, or 10 Immunologic Disorder – (+) Lupus Erythematosus Cell Preparation, 1 Eyelids close but open to pain
Juxta-Articular Regions observed by the physician Anti-ds DNA, or Anti-SM Antibodies
Motor Response
7 Radiographic Changes on the posteroanterior hand & wrist (Erosions • (+) = 4 OF THESE CRITERIA
or Uniequivocal Bony Decalcification) adjacent to the involved joints • Some may present with 1-2 Criteria but still with SLE
• Rule out Drug-Induced SLE (Hydralazine, Isoniazid, Procainamide, 4 Thumbs Up, Fist, or Peace Sign
Criteria 1-4 must be present for AT LEAST 6 WEEKS Chlorpromazine) & other Vasculitides
Criteria 2-5 must be observed by the Physician 3 Localizes Pain
Approaching Patients in Coma • Hypercarbia (e.g. Pneumothorax, Pleural Effusion, 1 Breathing > Ventilation Rate
Atelectasis) with or without Hypoxemia
• Cortical – Thought Content • Alveolar Hyperventilation & inability to eliminate CO2
0 Breathing at Ventilation Rate, Apnea
Level of Consciousness • ARAS & Brainstem – Arousal & Wakefulness • Impaired CNS drive to breathe & impaired strength with
• Medullary – Waking & Sleeping Type II failure of Neuromuscular Function in the Respiratory Tract
• Drug Overdose, Brainstem Injury, Sleep Breathing Disorder Minimum Score = 0
• Respiratory Overload Maximum Score = 16
• Cheyne-Stoke – Diencephalon, Diffuse o **The lower the score, the greater the Coma**
Increased Resistive Load (Bronchospasm)
Respiratory Pattern Cervical o Reduced Lung Compliance (Alveolar Edema)
• Hyperventilation – Brainstem o Reduced Chest Wall Compliance (Pneumothorax)
• Apnea – Pons o Increased Minute Ventilation (Pulmonary Embolus)
• Ataxic Cluster – Medulla Muscle Strength
Color Colorless Turbid, Clear/Cloudy Xantochromi Grade I Fever, Non-Specific Symptoms (Anorexia, Vomiting, Abdominal
2 Opens to Pain ≤8 Severe
Greenish c Pain),
(Coma)
(+) Tourniquet Test
9-13 Moderate
Protein 15-45 mmHg Increased Mild Increase Mild 1 No Eye Opening 14-15 Mild
Increase Grade II Grade I + Spontaneous Bleeding
Verbal Response (V)
Pressur 30-180 200-500 Normal to Normal to Grade III Grade II + Severe Bleeding + Circulatory Failure
e mmH2O mmH2O Mild Increase Mild 5 Oriented
Increase Grade IV Grade III + Irreversible Shock + Massive Bleeding
4 Confused/Disoriented
Glucose 45-70 mg/dl Decreased Normal Decreased
Solumedrol 2g + D5W 500cc x Somatostatin 250mcg IV bolus then (+) Babinski Reflex (-) Babinski Reflex
RHD Prophylaxis Ampicillin 2 g + Gentamycin 2 mg/kg
20 µgtts/min 2amps (3mg/amp) + PNSS 1L x 24H
for 5 days w/o interruption Paralysis of Lower Face Facial Paralysis of Affected Side
Prednisone Tapering
Terbutaline (Bicanyl) Drip Streptokinase Drip Contralateral Tongue Deviation Ipsilateral Tongue Deviation
1 tab after Breakfast & Lunch for 3 days
Prednisone 20 1 tab after Breakfast, ½ Tab after Lunch for 3 days
mg/tab 1 tab after Breakfast for 3 days (-) Fasciculations (+) Fasciculations
D5W 250cc + Bricanyl 5amps Streptokinase 1.5M units + D5W Discontinue
x 10-30 µgtts/min 90cc x 100cc/H (1H running rate)
via soluset
Level
Thiamine Drip Give prior: Benadryl 50mg ivtt Framingham Criteria for Diagnosis of Congestive Heart Failure 3 L’s of Neurologic Lesion
Solucortef 250mg ivtt Assessment
Lateralize
• Paroxysmal Nocturnal Dyspnea
50-100mg IV (for 40-50 y.o.) APTT monitoring q6H • Neck Vein Distention Localize
• Rales
Major Criteria • Cardiomegaly
• Acute Pulmonary Edema
Toradol Drip • S3 Gallop Siriraj Stroke Score
• Increased Venous Pressure (> 16 cmH2O)
• (+) Hepatojugular Reflux
Toradol 30mg + PNSS 80cc via Clinical Features Scor
soluset x 8H e
• Extremity Edema
Toradol 100mg + PNSS 80cc x • Night Cough
10cc/H Consciousness Alert 0
• Dyspnea on Exertion
Minor Criteria • Hepatomegaly
Tramadol Drip Zantac Drip • Pleural Effusion Drowsy, Stupor 2.5
• Vital Capacity Reduced by 1/3 from Normal
• Tachycardia (> 120 beats/minute) Semi-Coma, Coma 5
Tramadol 100 mg + PNSS 80 Zantac 5 amps in D5W 500 cc x 16H
cc x 10 µgtts/min Major/Minor • Weight Loss > 4.5 kg over 5 days of Treatment
Vomiting No 0
Criteria
Stage IV Late Capsule Formation (≥ Day 14), Thickened Capsule 37.2-37.7 5 Moderately High Risk > 2 Risk Factors < 100 mg/dl
Thermoregulat (10-Year Risk 10-20%)
ory Dysfunction 37.8-38.2 10
(°C) Moderate Risk > Risk Factors < 130 mg/dl
Metabolic Syndrome Criteria (≥ 3)
(10-Year Risk < 10%)
38.3-38.8 15
Central Obesity Waist Circumference > 102 cm (Males) or > 88 cm
(Females) Low Risk 0-1 Risk Factors < 160 mg/dl
38.9-39.3 20
Prinzmetal Angina Ischemic Pain at rest but not with exertion; ST 130-139 20
Segment Elevation, Transient Epicardial Coronary ECG Intervals
Artery Focal Spasm > 140 25
P Wave 0.6-0.10 seconds
Absent 0
5 Medications to Treat Myocardial Infarction Cardiac PR Interval 0.12-0.20 seconds
Dysfunction Mild (Pedal Edema) 5
Nitrates Vasodilation & Analgesia QRS Complex 0.8-0.10 seconds
Moderate (Bibasal Rales) 10
Beta Blockers Decreased Myocardial Contraction, Decreased Heart QT Interval 0.35-0.42 seconds
Workload Severe (Pulmonary 15
Edema)
Statins Pleomorphic Effect Right Atrial Abnormality
Arrhythmia Absent 0 P-Wave Prominent Peaked P-Waves in Lead II (> 2.5 mm high)
Clopidogrel Anti-Thrombotic (Atrial Fibrillation) Configuratio
Present 10 ns Left Atrial Abnormality
Aspirin Anti-Thrombotic M-Shaped, Widened P-Waves in Lead II (> 0.1 seconds long)
Precipitant Negative 0
History
Positive 10 Right Ventricular Hypertrophy
Community Acquired Pneumonia
QRS Tall R Waves in Leads V1 & V2, Deep S Waves in Leads V5 &
Interpretation: Complex V6
• T = > 36°C or < 40°C, PR = < 125 bpm, RR = < 30 Configuratio
cpm, BP > 90/60 mmHg
• < 25 Storm Unlikely
• 25-44 Impending Storm ns
• No Acute Altered Mental State, No Suspected Left Ventricular Hypertrophy
Aspiration, Stable or No Comorbidities
• > 45 Highly Suggestive of Storm Tall R Waves in Leads V5 & V6, Deep S Waves in Leads V1 &
• Localized Infiltrates, No Pleural Effusions or V2
Low-Risk Abscess
• OUTPATIENT
TIMI Score
Treatment
• Detection of Rise &/or Fall of Cardiac
• Previously Healthy = Amoxicillin or Extended Age > 65 years old 1 1 5% Risk Biomarkers with at least 1 value above normal
Macrolide Criteria for Acute • Pathologic Q-Wave
• Stable Comorbidities = ß-Lactam/ß-Lactamase Myocardial • Imaging Evidence of new loss of Viable
> 3 CAD Risk Factors 1 2 8% Risk Infarction Myocardiardial or new regional wall motion
Inhibitor Combination or 2nd Gen Cephalosporin +
Extended Macrolide abnormality
• Alternative: 3rd Gen Cephalosporin + Extended Known CAD (> 50% Stenosis) 1 3 13% Risk • Sudden unexpected Cardiac Death
Macrolide
• For Percutaneous Coronary Intervention (PCI) or
Coronary Artery Bypass Graft (CABG)
Aspirin Use in the past 7 Days 1 4 20% Risk • Increased Biomarkers > 3x 99th Percentile
• T = < 36°C or > 40°C, PR = > 125 bpm, RR = > 30 • Pathological Findings of Myocardial Infarction
cpm, BP = < 90/60 mmHg Severe Angina in the last 24 Hours 1 5 26% Risk
Moderate-Risk • Altered Mental State, Aspiration Suspected, • Type I – Ischemia due to primary Coronary event
Decompensated Comorbid Conditions
Elevated Cardiac Markers 1 6 41% Risk • Type II – Ischemia due to increased O2 demand
• Multilobar Infiltrates, Pleural Effusions, Abscesses
or decreased O2 supply
• WARD ADMISSION
ST Deviation > 0.5 mm 1 7 50% Risk Classification of • Type III – Sudden Unexpected Cardiac Death
Myocardial (New ST Elevation/New Left Bundle Branch
Treatment
Infarction Block)
• IV Non-Antipseudomonal ß-Lactam (BLIC, • Type IVa – associated with PCI
Cephalosporin, or Carbapenems) + Extended
Hypertension Classification Systolic (mmHg) Diastolic (mmHg) • Type IVb – associated with Stent Thrombosis
Macrolide • Type IVc – associated with CABG
• IV Non-Antipseudomonal ß-Lactam + Respiratory
Fluoroquinolones Normal < 120 < 80
Troponin
ST Elevation > 0.1 mV = • 100 Large Acute MI
Pre-Hypertension 120-139 80-89
Reinfatrction • 10 Medium MI
• 1 Small MI
Stage I Hypertension 140-150 90-99
III Marked Confusion, Incoherent Speech, (+) Abnorma Risk Serum Creatinine > 1.5x < 0.5 ml/kg/h × 6 hours
Sleeping, Arousable l 1997 AJCC Nodal GFR decreased > 25%
Classification
• Level I – Submental &
IV Coma, Initially Responsive to Noxious (-) Abnorma Injury Serum Creatinine > 2x < 0.5 ml/kg/h × 12 hours
Stimuli (later Unresponsive l Submandibular
• Level II – Upper Jugular GFR decreased > 50%
• Level III – Middle Jugular
• Level IV – Lower Jugular Failure Serum Creatinine > 3x (> 4 mg/ < 0.3 ml/kg/h × 24 hours
Criteria for • Blood Glucose = ≥ 11.1 mmol/L (200 mg/dl) • Level V – Post Triangle dl; Acute Rise > 0.5 mg/dl) (Oliguria)
Diabetes • Fasting Plasma Glucose = 7 mmol/L (126 mg/dl) • Level VI –Hyoid Bone to GFR decreased > 75% Anuria × 12 hours
Mellitus • 2-Hour Plasma Glucose = > 11.1 mmol/L (200 mg/ Suprasternal Notch
dl) • Level VII – inferior to
Loss Persistent ARF: Complete Kidney Function Loss > 4 weeks
Suprasternal Notch
CHADS2 Scoring
Aspirin Daily/Warfarin
Acute Hepatitis A
Hypertension 1 1 2.8% (Raise INR to 2-3) or
+ + - - Superimposed on
other Oral Anti-
Chronic Hepatitis B
Coagulants