ELECTROLYTE SOLUTIONS ELECTROLYTES

IV Sol’n Glu Na Cl K Ca HCO3 a) Corrected Ca = (40-lbs) x 0.02 + serCa

D5W 5mg/L b) Corrected Na = Na + RBS mg% - 100 x 1.6 / 100
D10W 100mg/L c) Na Deficit = (140 – actual) (0.6 x BW)
0.9 NSS 154 154 d) K Deficit = (D-A) (0.4 x BW)
D5LR 130 109 4 3 28 D = 3.5 cardiac
D5NM 40 40 13 4.5 non-cardiac
H20 Deficit = 0.6 x kg BW
D5NR 140 98 5
D = 15 CKD
D5 0.9 50 mg/L
18 NCKD
NaCl
D5NMK 50 mg/L 40 40 30
Actual Na – Desired Na / Desired Na

Sol’n Na Cl K HCO3 Ca Mg
ECF 142 103 4 27 5 3
D5LR 130 109 4 28 5 CUSHING’S TRIAD
D5 0.45 77 77
3% NaCl 513 513 1) Increase systolic BP
0.9 NaCl 154 154 2) Widened pulse pressure
3) Bradycardia /AbN˚ respiratory pattern
D5W Osm = 278 a. Cheyne Stoke breathing
D5W Osm = 556
D5LR Osm = 130
NaHCO3 = 446 HEMORRHAGIC STROKE TRIAD

1) Papilledema
MECHANICAL VENTILATION 2) Headache
3) Vomiting
Indication for Intubation

1) Impending respiratory failure, apnea

2) RR >35
3) PaCO2 > 50 MEIG’S SYNDROME
4) PaO2 <60
5) TV < 3-5 ml/kg 1) Pleural Effusion
6) VC < 10-15 ml/kg 2) Polycystic Ovary / Fibromatosis
7) Inspiratory force < 25 cm H20 3) Hypoalbuminemia
8) FEV < 10 ml/kg
9) Vq / Vt > 0.6
10) To deliver high FIO2
11) Absent
12) pH <7.35

VENTILATOR SETTING GLASCOW COMA SCALE

1) TV: 6-8 ml/kg (ARDS) 8-10 ml/kg EYE RESPONSE

2) Pale: 6-20 a) Spontaneous eye opening 4
3) Mode: AC (Assist Control) b) Opens to verbal command 3
SIMV (Synchronized Intermittent 1 mV c) Responds to painful stimuli 2
4) FIO2 d) No response 1
5) PEEP 5cm H20
MOTOR
a) Obeys with command 6
INDICATIONS FOR WEANING b) Localizes pain 5
c) Flexion withdrawal 4
1) Mental status: Awake, Alery d) Decorticate / Flexion 3
2) PaCO2 > 60 mmHg w/ FIO2 < 50% e) Decerebrate / Extension 2
3) PEEP < 5 cm f) No response 1
4) PaCO2 < pH acceptable
5) Spontaneous TV < 5mL VERBAL
6) VC > 10 ml/kg a) Oriented 5
7) MIP > 25 cm H20 b) Disoriented 4
8) RR < 30/min c) Inappropriate 3
9) Rapid shallow breathing index < 100 (RBI) d) Incomprehensible 2
10) Stable vs. Ft a 1-2 hr e) No response 1

Spontaneous Trial
FIO2 room air 21%
O2 via nasal prong = # lpm x 0.4 x 20
 Desired FIO2 = 104 – (0.43 x age)
FOUR SCALE
- Full outline of responsiveness A. 713 x FIO2 – PCO2/0.8
B. pO2 / A
EYE RESPONSE C. 02 for age / B + pC02 / 0.8
a) Eyelids open, tracking, blinking to command 4 ________________________________
b) Eyelids open but not tracking 713
3
c) Eyelids close but open to loud voice 2 FIO2: 20 / 4 = L
d) Eyelids close but no pain 1
e) Eyelids close with pain 0

MOTOR RESPONSE DOPAMINE COMPUTATION

a) Thumbs up, fist or peace sign
4 Single strength = BW x desired dose / 13.3
b) Localizing to pain Double strength = BW x desired dose / 16.6
3 Single strength = BW x desired dose / 16.6
c) Flexion response to pain 2 Double strength = BW x desired dose / 33.2
d) Extension response to pain
1 Cardiac Dose = 5
e) No response to pain or generalized myoclonus 0 Renal Dose = 5-10

BRAINSTEM REFLEXES
a) Pupil and Corneal reflex 4
b) One pupil wide and fixed 3
c) Pupil or corneal reflex absent CT SCAN BLEED VOLUME
2
d) Pupil and corneal reflex absent Given: 58 mm ~ 5.8
1 23.3 mm ~ 2.3
e) Absent pupil, corneal and cough reflex
0 5.8 x 2.3 = 13.34 x 5 (constant) = 66.5 x 5.2 (constant) = 34.684 -(estimated
bleeding volume)
RESPIRATION
a) Not intubated, regular breathing pattern
4
b) Not intubated, cheyne-stoke breath pattern
3 DIAGNOSTIC THORACENTESIS DUE TO HEART FAILURE
c) Not intubated, irregular breathing 2
d) Breath above ventilation rate 1) If the effusion are not bilateral and comparable size
1 2) If the patient is febrile
e) Breath at ventilation rate, apnea 3) If the chest has a pleuritic chest pain
0 4) If effusion persist despite the diuretics therapy

DENGUE

GRADE I INDICATION FOR CHEST TUBE THORACOSTOMY

 Fever
 Non-specific symptoms 1) Pneumothorax
o Anorexia 2) Pleural effusion
o Vomiting 3) Chylothorax
o Abdominal pain 4) Empyema
 (+) Torniquet test 5) Hemathorax
6) Hydrothorax
GRADE II
 Grade I + spontaneous bleeding

GRADE III
 Grade II + severe bleeding + circulatory failure TIMING OF TUBE REMOVAL
 The timing of tube removal depends on clinical and
GRADE IV radiological evidence of complete expulsion of all contents of
 Grade III + irreversible shock + massive bleeding pleural cavity with complete expansion of the lung
 Minimal drainage should have occurred over the previous 24
hours (<25 ml/kg)
 When the patient coughs or performs the valsalva maneuver
ABG COMPUTATION no air leak should ensue
 The chest radiograph should confirmed complete expansion of
I. 713 (decimal FIO2) – PCO2/0.8 = I the lung
II. pO2/I = II  The s____ in the fluid in the tube in the underwater seal bottle
III. (Desired FIO2/II) + pCO2/0.8 should be minimal, relating to the normal negative pressured
________________________ x 100 in the chest during the phases of respiration
713
INDICATIONS FOR CTT RECOMMENDED DOSAGE FOR INITIAL TREATMENT OF TB
 Gross pus on thoracentesis
 Presence of organism on gram stain of the pleural fluid 1) Isoniazid = 5 mg/kg, max 300 mg
 Pleural fluid glucose < 50 mg / dL 2) Rifampicin = 10 mg/kg, max 600 mg
 Pleural fluid pH below 7.00 and 0.15 units lower than arter 3) Pyrazinamide = 20-25 mg/kg, max 2 g
4) Ethambutol = 15-20 mg/kg

LIGHT’S CRITERIA

1) Pleural fluid protein / serum protein > 0.5

2) Pleural fluid LDH / serum LDH > 0.6
3) Pleural fluid LDH > 2/3 the upper limit of normal serum LDH LOCATING MYOCARDIAL DAMAGE

Anterior = V2-V4 (L) coronary, LAD

TRANSUDATIVE VS EXUDATIVE FLUID
Anterolateral = I, qV1, V3 – V6, LAD, circumflexes
Transudative Exudative
Anteroseptal = V1-V4, LAD
SG < 1.012 > 1.020
Protein < 3 g/dL >3 g / dL Inferior = II, III, aVF, (R) coronary artery

FP / SP < 0.5 >0.5 Lateral = I, aVL, V5, V6, circumflex brance of (L) coronary artery
LDH <60% >60%
Posterior = V8 – V9 (R) coronary artery, circumflex artery
FLDH/SLDH <0.6 >0.6
(R) Ventricular = V4R, V5R, V6R, (R) coronary artery
Cholesterol <45 mg / dL >45 mg / dL

JONES CRITERIA OF RF
CLASSIFICATION OF PTB Major:
 Carditis
Class O  Polyarthritis
 NO PTB EXPOSURE  Chorea
 Not infected  Erythema marginatum
 Subcutaneous nodule
Class 1
 HISTORY OF EXPOSURE Minor:
 Neg. Skin test to tuberculin  Fever
 Polyarthralgia
Class 2  Lab: Inc. ESR / Leukocyte count
 TB INFECTION  ECG: Prolong P-R interval
 No disease  Elevated anti-streptolysin O, other strep antibody
 Positive reaction to tuberculin test  (+) throat culture
 No clinical, bacteriologic or radiographic evidence of TB  Rapid Ag test for Group A
 Strep / result: Scarlet Fever
Class 3
 TB CLINICALLY ACTIVE Criteria:
 Clinical, bacteriologic, or radiographic evidence of current  2 major/one minor and 2
disease  (+) evidence of preceding Group A strep infection

Class 4
 TB NOT CLINICALLY ACTIVE ACUTE RESPIRATORY FAILURE
 History of episode of TB
 Abnormal but stable radiographic findings TYPE I or Acute Hypoxemic Respiratory Failure
 No clinical or radiographic evidence of current disease  Occurs when alveolar flooding and subsequent intrapulmonary
shunt physiology occurs
Class 5  Alveolar flooding may be a consequence of pulmonary edema,
 TB SUSPECT pneumonia or alveolar hemorrhage
 Diagnosis pending  Low pressure pulmonary edema
 TB disease should be ruled out within 3 months  Defined by diffused bilateral airspace edema

Signs and Symptoms of TB TYPE II Respiratory Failure

 Fever  Occurs as a result of alveolar hyperventilation and results on
 Night sweats the inability to eliminate CO2 effectivity
 Weight loss  Mechanism by which this occurs are categorized by impaired
 Anorexia CNS drive to breath, impaired strength with failure of
 Weakness neuromuscular function in the respiratory ____
 General Malaise  Reason for diminished CNS drive to breath including drug
overdose, brainstem injury, sleep disordered breathing
Overload Respiratory System due to:
 Increase resistive loads (bronchospasms)
 Reduced lung compliance (alveolar edema)
 Reduced chest wall compliance (pneumothorax)
 Increase minute ventilation (pulmonary embolus)
TYPE III Respiratory Failure BRONCHIECTASIS
 Occurs as a result of lung atelectasis  Is an abnormal and permanent dilatation of bronchi
 Also called perioperative respiratory failure  Associated with destruction and inflammatory changes in the
 After general anesthesia, decreases in functional residual wall of the medium sized airways often at the level of
capacity of dependent lung units segmental or subsegmental bronchi
 The dilated airways frequently contain pools of thick purulent
TYPE IV Respiratory Failure material, while more peripheral airways are often occluded by
 Due to hypoperfusion of respiratory muscles in patients in secretions or obliterated and replaced by fibrous tissue
shock, due to pulmonary edema, lactic acidosis, anemic  As the result of inflammation it produces airway damage,
impaired clearance of microorganism resulting to vascularity of
the bronchial wall increases with associated enlargement of
DEFINITIONS USED TO DESCRIBE THE CONDITION OF SEPTIC PATIENTS the bronchial arteries and anastomoses between the bronchial
and pulmonary arterial circulation
Bacteremia
 Presence of bacteria in blood as evidenced by positive blood INDICATIONS FOR INITIATING HEMODIALYSIS
culture  Failure of conservative management
 Management to relieve
Septicemia a) Pulmonary congestion (unresponsive to high dose
 Presence of microbes and their toxins in the blood furosemide)
b) Severe metabolic acidosis
SIRS c) Severe hyperkalemia
 Systemic inflammatory response syndrome  BUN >100 mg/dL or creatinine >10mg/dL
 Two or more of the following conditions:  Note: For acute renal failure it is best to start dialysis early
o Fever (oral temp >38˚C) or hypothermia (<36˚C)
o Tachycardia (>90 bpm)
o Tachypnea (>24 bpm) RHEUMATIC ARTHRITIS
o Leukocytosis (>12,000/uL) or Leukopenia  Require 4 out of 2 criteria:
(<4,000/uL) or > 10% bands may have a non- o Morning stiffness
infectious etiology o Arteritis of 2 or more joints
Sepsis o Arteritis of hands and joints
 SIRS that has proven or suspected microbial etiology o Systemic arthritis
o Rheumatoid nodule
Severe Sepsis o Serum Rheumatoid factor
 Similar to sepsis “sepsis syndrome” o Radiographic changes
 Sepsis with one or more signs of organ dysfunction

Examples CHILD-PVGH CLASSIFICATION OF CIRRHOSIS

1) Cardiovascular: Arterial systolic blood pressure <90 mmHg or Factor Units 1 2 3

Mean Arterial Pressure ≤ 70 mmHg that responds to s. Bilirubin umol / L <34 34-51 >51
administration of IV mg / dL <2 2-3 >3
2) Renal: Urine output <0.5 ml/kg/hr for 1 hour despite adequate s. Albumin g/L >35 30-35 <30
fluid resuscitation g / dL >3.5 3.0-3.5 <3
3) Respiratory: PaO2/FIO2 <250 or if the lung is the only Protime sec 0-4 4-6 >6
dysfunctional organ ≤ 200 INR <1.7 1.7-2.3 >2.3
4) Hematologic: Platelet count <80,000/uL or 50% decrease in Ascites None Easily Poorly
platelet from highest value recorded over the previous 3 days controlled controlled
5) Unexplained metabolic acidosis: a pH ≤7.30 or a base deficit ≥
Hepatic None Minimal Advanced
5.0 meq/L and a plasma lactate level >1.5 times upper limit of
encephalopathy
normal for reporting
6) Adequate fluid resuscitation: Pulmonary artery wedge
 Calculated by adding the score of the 5 factor and can range
pressure ≥ 12 mmHg or Central Venous pressure ≥8 mmHg
from 5 – 15
Septic Shock
CHILD-PVGH Class is either:
 Sepsis with hypotension (arterial blood pressure of ≥ 90 mmHg
A. Score of 5 – 6
or MAP > 70 mmHg
B. Score of 7 – 9
C. Score of 10 or Above
Refractory Septic Shock
Decomposition
 Septic shock that last > 1 hour and does not respond to fluid or
 indicate cirrhosis
pressure administration
 N/A
 CHILD PVGH Score of 7 or more
Multi-organ Dysfunction Syndrome
 Dysfunction of more than 1 organ requiring intervention to
Class 8
maintain homeostasis
 Listing for liver transformation (accepted criteria)

Hepatic Fibrogenesis
 Stellate cell activation
 Collagen production
CLINICAL STAGE OF HEPATIC ENCEPHALOPATHY NEW YORK HEART ASSOCIATION FUNCTIONAL CLASSIFICATION

MS CLASS I
Stage I Euphoria, depression, mild confusion, slurred speech,  No limitation of physical activity
disturbance in sleep  No symptoms with ordinary exertion
Stage II Lethargy, moderate confusion
Stage III Marked confusion, incoherent speech, sleeping but CLASS II
arousable  Slight limitation of physical activity
Stage IV Coma, initially responsive to noxious stimuli, ____ response  Ordinary activity causes symptoms
COMPLICATIONS OF ERCP
CLASS III
1) Infection  Marked limitation of physical activity
2) Perforation  Less than ordinary activity causes symptoms
3) Pneumothorax  Asymptomatic at rest
4) Bleeding
CLASS IV
MUSCLE STRENGTH  Inability to carry out any physical activity without discomfort
 Symptomatic at rest
O – No muscular contraction
1 – Trace contraction
2 – Active movement with gravity eliminated
3 – Active movement against gravity FRAMINGHAM CIRTERIA FOR DIAGNOSIS OF CHF
4 – Active movement against gravity & slight resistance
5 – Against full resistance MAJOR CRITERIA
 Paroxysmal Nocturnal Dyspnea
 Neck vein distention
 Rales
IDEAL PEAK FLOW  Cardiomegaly
 Acute pulmonary edema
Ideal peak flow: Hg (m) – 100 x 5 (+) 175 (M) (+) 170 (F)  S3 gallop
 Increased venous pressure (>16 cmH20)
N ≥ 80%  Positive hepatojugular reflux
PEFR = Peak flow reading / Ideal peak flow x 100 = _____ %
MINOR CRITERIA
N ≤ 20%
 Extremity edema
PEFR variability: Highest reading – Lower x 100 = ______ %
 Night cough
Highest Reading
 Dyspnea on exertion
 Hepatomegaly
GRADING OF MURMURS  Pleural effusion
 Vital capacity reduced by one-third from normal
1 – Faint  Tachycardia (>120 bpm)
2 – Audible
3 – Moderately Loud MAJOR OR MINOR
4 – Loud with palpable thrill  Weight loss of >4.5 kg over 5 days treatment
5 – Loud with thrill, stet partially off
6 – Loud with thrill, w/o stet

BLOOD TRANSFUSION

 CP status assessed
 VS checked
 Please transfuse available _____ unit of patient’s blood type
after proper cross matching
 Run BT @ 5-10 gtts/min for 30 mins then to titrate @ 15-20
gtts/min with no BT reactions
 Mainline to KVO while on BT
 Monitor VS q15 mins while on BT
 Refer for any BT reactions such as fever, chills, dyspnea,
hypotension and pruritus
 Refer accordingly