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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 189 TABLE 6-2: Diagnosis: Hypernatremia Disposition ?Unit/medical floor (depends on level of hypernatremia) Monitor Vitals Electrolyte monitoring Neuromonitoring Diet Regular; continue oral fluids Fluid See below for type of fluid to be used O 2 PRN Activity Bedrest Dx studies Labs BMP, calcium, Mg, PO4, LFT, UA, serum osmolality Urine specific gravity, Uosm, UNa+ and UK+, TSH Radiology and cardiac studies CXR (PA and lateral), ECG Prophylaxis ? Consults Nephrology Nursing I/O, daily weights Avoid When correcting hypernatremia, the rate of decline in PNa+ should not exceed 1 m Eq/L/ hr (can cause cerebral edema/herniation) Management See following page Etiologies: Hypernatremia Dehydration Diarrhea Obstructive uropathy Excess sodium bicarbonate (continued)

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190 ELECTROLYTE DISTURBANCE AND NEPHROLOGY TABLE 6-2: Diagnosis: Hypernatremia (Continued) Renal dysplasia Diabetes mellitus Diabetes insipidus (DI) Hypernatremia (>145) (See TBW Deficit) Hypovolemic hypernatremia Correct TBW deficit in 48-72 hrs Secondary to fluid loss treatment: replace deficit with D5W (see management below) Can give 5% albumin to rapidly restore intravascular volume Isovolemic hypernatremia If secondary to DI U osm <200; if secondary to central DI give vasopressin challenge, 5 mg IV, or Desmopressin: 4 mcg IV/SQ q12h (should ↑ Uosm by 50%; keep urine specific gravity >1. 010) If Uosm = 200-500 nephrogenic DI correct deficit with D5W Treatment: replace TBW in 48-72 hrs Hypervolemic hypernatremia Secondary to hypertonic saline solution/HCO 3 infusion/excessive salt ingestion Treatment: furosemide, 40-80 mg IV/PO daily-bid SPA (25%) 50-100 m L bid-tid Correction of Hypovolemic Hypernatremia 1. TBW in hypernatremia: male = 0. 5 × wt (kg); female = 0. 4 × wt (kg) 2. Current TBW = TBW × [140/PNa+] 3. TBW deficit = TBW-current TBW 4. X = replacement fluid Na+ (m Eq)/154 5. Replacement volume (L) = TBW deficit × [1/(1-X)] (continued)

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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 191 TABLE 6-2: Diagnosis: Hypernatremia (Continued) Example 1. A 70-kg male with PNa+ of 160 m Eq/L 2. TBW = (0. 5 × 70 kg) = 35 L 3. Current TBW = [35 × (140/160)] = 30. 6 L 4. TBW deficit = (35-30. 6) = 4. 4 L5. X = 75 (m Eq/L)/154 = 0. 496. Replacement volume (L) = 4. 4 (L) × [1/(1-0. 49)] = 8. 6 L (replace this deficit in 48-72 hrs) Note Replacement: Give one-half in first 24 hrs and next half in next 48 hrs Isotonic fluid (NS) should be used initially if symptomatic (shock, hypotension); corrected slowly over 48-72 hrs The serum sodium should fall by no more than 0. 5 m Eq/L/hr (12 m Eq/day) N a + concentration in IV fluids: NS = 154 m Eq/L; 1/2 NS = 75 m Eq/L

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192 ELECTROLYTE DISTURBANCE AND NEPHROLOGY TABLE 6-3: Diagnosis: Hypokalemia Disposition Monitor bed Monitor Vitals Cardiac monitoring Electrolyte monitoring Diet Regular Fluid Heplock (flush every shift) O 2 PRN Activity Bedrest Dx studies Labs BMP, Mg, PO4, calcium, CBC, UA, LFT Radiology and cardiac studies ECG Special tests U K+, UCr, urine electrolytes, Uosm, serum osmolality ?Renin; ?aldosterone; ?24-hr urine: K+, Na, and Cr; cortisol Prophylaxis ? Consults Nephrology Nursing I/O Avoid ? Management See below Transtubular Potassium Gradient (TTKG): Normal 8-9 (Can Be up to 12 in K+-Rich Diet) TTKG = (UK+ × Posm)/(PK+ × Uosm) In patient with hypokalemia without any disease, TTKG should be <3 In patient with hypokalemia without any disease and TTKG >3, renal loss of K+ (continued)

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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 193 TABLE 6-3: Diagnosis: Hypokalemia (Continued) In patient with hyperkalemia without any disease, TTKG should be >10 Patient with hyperkalemia and TTKG of <7 indicates hypoaldosteronism/renal tubular defect Note Hypoaldosteronism: administration of mineralocorticoid 9 α-fludrocortisone, 0. 05 mg, should cause TTKG to rise >7 If UK+ >15 m Eq/L or >30 m Eq/24 hrs or TTKG >7 renal loss If UK+ <15 m Eq/L or <25 m Eq/24 hrs or TTKG <3 extrarenal loss Common Etiologies of Hypokalemia Diarrhea-/vomiting-/laxative-induced Pyloric obstruction Alkalosis High renin state True hyperaldosteronism Chewing tobacco Carbenicillin Mineralocorticoid [fludrocortisone (Florinef)] Mg depletion Renal tubular acidosis (RTA) I and II Cushing's syndrome/disease Adrenal hyperplasia (11 β-and 17 α-hydroxylase deficiency) Licorice Amphotericin B Diuretic (thiazide, furosemide, ethacrynic acid) Bartter's syndrome and Gitelman syndrome (continued)

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194 ELECTROLYTE DISTURBANCE AND NEPHROLOGY TABLE 6-3: Diagnosis: Hypokalemia (Continued) Hypokalemia (<3. 5 m Eq) Check Mg level (if low, correct Mg level before correcting K+ level) Mg depletion impairs K+ reabsorption across the renal tubule K-Dur: 20 m Eq tablet PO bid-tid Micro K: 10 m Eq tablet PO bid-tid (max: 100 m Eq/day) KCl elixir: 1-3 tablespoons (20 m Eq in 1 tablespoon) 10 m Eq KCl in 100 m L can be given via peripheral line over 1 hr 20 m Eq KCl in 100 m L should be given via central line over 2 hrs Note 40-60 m Eq can ↑ K+ by 1-1. 5 m Eq/L but this ↑ may be transient Do not give >10 m Eq IV per hour via peripheral line or >20 m Eq IV per hour via central line

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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 195 TABLE 6-4: Diagnosis: Hyperkalemia Disposition Monitor bed Monitor Vitals Cardiac monitoring Electrolyte monitoring Diet Low-K + diet Fluid Heplock (flush every shift) O2 PRN Activity Bedrest Dx studies Labs BMP, calcium, Mg, PO4, LFT, CBC, serum osmolality Radiology and cardiac studies ECG Special tests U K+, UNa, urine electrolytes, UCr, Uosm ?Cortisol level, ?Cortrosyn stimulation test Prophylaxis ? Consults Nephrology Nursing I/O Avoid See below and following pages Management See following pages Common Etiologies: Hyperkalemia Metabolic or respiratory acidosis Adrenal insufficiency Heparin Insulin deficiency β-Blockers Arginine (continued)

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196 ELECTROLYTE DISTURBANCE AND NEPHROLOGY TABLE 6-4: Diagnosis: Hyperkalemia (Continued) Succinylcholine Digitalis toxicity Hemolyzed blood Renal failure Aldosterone antagonist Hypoaldosteronism Blood transfusion Thrombocytosis/leukocytosis Muscle necrosis TMP/SMX, K+-sparing diuretics, ACE inhibitors TTKG: Normal 8-9 (Can Be Up to 12 in K+-Rich Diet) TTKG = (UK+ × Posm)/(PK+ × Uosm) In patient with hypokalemia without any disease, TTKG should be <3 In patient with hypokalemia without any disease and TTKG >3, renal loss of K+ In patient with hyperkalemia without any disease, TTKG should be >10 Patient with hyperkalemia and TTKG of <7 indicates hypoaldosteronism/renal tubular defect Note Hypoaldosteronism: administration of mineralocorticoid 9 α-fludrocortisone, 0. 05 mg, should cause TTKG to rise >7 Causes of Hyperkalemia That Do Not Respond to Mineralocorticoid Challenge K+-sparing diuretics Amiloride (continued)

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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 197 TABLE 6-4: Diagnosis: Hyperkalemia (Continued) Spironolactone Triamterene Drugs Trimethoprim Pentamidine Tubular resistance to aldosterone Interstitial nephritis Sickle cell disease Urinary tract obstruction Pseudohypoaldosteronism type I ↑ Distal nephron K + reabsorption Hyperkalemia (Recheck K+ Level and Get ECG) If K+ >7, ECG Changes, or Symptomatic Consider Treatment Secondary to Transcellular shift: acidosis/myonecrosis Blood transfusion (1 unit of whole blood can ↑ K + by 0. 25 m Eq/ 24 hrs) Medications: ACE inhibitors, heparin, NSAIDs, digitalis, β-blockers, TMP/SMX, K+-sparing diuretics Check UK+ level If >30 m Eq/L suggests transcellular shift If <30 m Eq/L suggests impaired renal secretion Treatment Calcium gluconate: 10 m L of 10% (1 ampule); infuse slowly over 2-3 mins (onset 2-3 mins) Repeat dose in 5 min if ECG changes persist (continued)

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198 ELECTROLYTE DISTURBANCE AND NEPHROLOGY TABLE 6-4: Diagnosis: Hyperkalemia (Continued) Insulin (regular): 10 U + 50 m L of a 50% glucose solution IV (onset 15-20 mins) Bicarbonate: 45 m Eq (1 amp of 7. 5% Na HCO3) IV over 5 mins (onset 30 mins); effective only in setting of metabolic acidosis Albuterol: 10-20 mg in 4 m L saline by nasal inhalation over 10 mins (onset 30 mins) N a+ polystyrene (Kayexalate): 20-30 g with 100 m L of 20% sorbitol PO q4-6h To give Kayexalate as enema: 50 g in 50 m L of 70% sorbitol plus 150 m L tap water If no response to above treatment or severe hyperkalemia consider dialysis

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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 199 TABLE 6-5: Diagnosis: Hypomagnesemia Disposition Medical floor Monitor Vitals Cardiac monitoring Electrolyte monitoring Neuromonitoring Diet Regular Fluid Heplock (flush every shift) O 2 PRN Activity Bedrest Dx studies Labs BMP, Mg, calcium, PO4, CBC Radiology and cardiac studies ECG Special tests 24-hr urine Mg, urine Mg, urine electrolytes, U Cr Prophylaxis ? Consults ?Nephrology Nursing ? Avoid ? Management See Management: Hypomagnesemia (<1. 8 mg/d L) (continued)

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200 ELECTROLYTE DISTURBANCE AND NEPHROLOGY TABLE 6-5: Diagnosis: Hypomagnesemia (Continued) Etiologies: Hypomagnesemia (<1. 8 mg/d L) Urinary loss Intestinal loss Miscellaneous Hypercalcemia Malabsorption Alcoholism Hyperglycemia Laxative use Sepsis Hypophosphatemia Pancreatitis Malnutrition RTA Severe diarrhea Metabolic acidosis Bartter's syndrome and Gitelman syndrome Intestinal and biliary fistula Hungry bone syndrome Novel paracellin-1 mutation Thermal injury Medications Hyperthyroidism Aminoglycosides Digitalis Diabetes Amphotericin B Diuretics Hypoalbuminemia β-Agonist Foscarnet TPN Cisplatin Insulin Citrated blood product Catecholamine Pentamidine Cyclosporine Management: Hypomagnesemia (<1. 8 mg/d L) Mg deficit = 0. 2 × wt (kg) × desired ↑ in Mg concentration replace within 2-3 days Note: Monitor respiratory drive and tendon reflexes when replacing Mg Treatment Mg Ox: 400 or 600 mg PO (600 mg provides 35 m Eq) 1-2 tablets daily (continued)

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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 201 TABLE 6-5: Diagnosis: Hypomagnesemia (Continued) Mg Cl: 65-130 mg PO tid-qid (64 mg = 5. 3 m Eq/tablet) Severe (<1 mg/d L): Mg SO4, 1-6 g in 500 m L D5W at 1 g/hr Note: Sulfate can cause metabolic acidosis if used for a long period of time

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202 ELECTROLYTE DISTURBANCE AND NEPHROLOGY TABLE 6-6: Diagnosis: Hypermagnesemia Disposition Medical floor Monitor Vitals Cardiac monitoring Electrolyte monitoring Neuromonitoring Diet Regular Fluid Heplock (flush every shift) O 2 PRN Activity Bedrest Dx studies Labs BMP, Mg, calcium, PO4, CBC Radiology and cardiac studies ECG Special tests 24-hr urine Mg, urine Mg, urine electrolytes, U Cr Prophylaxis ? Consults ? Nursing ? Avoid ? Management See below Hypermagnesemia (>2. 3) Check ECG ( ↑ PR, ↑ QRS) Treatment Saline diuresis NS or 1/2 NS at 100-300 m L/hr Calcium chloride (Ca Cl): 1-3 g in IVF at 1 g/hr Furosemide: 20-40 mg IV q4-6 If Mg >9 stat hemodialysis

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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 203 TABLE 6-7: Diagnosis: Hypocalcemia Disposition ?Monitor bed/medical floor Monitor Vitals Cardiac monitoring Electrolyte monitoring Neuromonitoring Diet Regular (salt deficient) Fluid Heplock (flush every shift) O 2 PRN Activity Bedrest Dx studies Labs CBC, BMP, calcium, Mg, PO4, intact PTH, LFT Radiology and cardiac studies ECG, CXR (PA and lateral) Special tests ?24-hr urine calcium, Mg, PO 4, and K+ Prophylaxis ? Consults ? Nursing ? Avoid Caffeine Management See below Calcium (8. 8-10. 3 mg/d L; 4. 4-5. 2 m Eq/L; 2. 2-2. 6 mmol/L) ↓ Albumin 1 g = ↓ calcium 0. 8 mg/d L (0. 2 mmol/L) Corrected [calcium] = measured total [calcium] mg/d L + [0. 8 × (4 -[albumin] g/d L)] Etiologies: Hypocalcemia Hypoalbuminemia Hyperphosphatemia (continued)

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204 ELECTROLYTE DISTURBANCE AND NEPHROLOGY TABLE 6-7: Diagnosis: Hypocalcemia (Continued) Hypomagnesemia Recent use of MRI with gadolinium, which can lead to pseudohypocalcemia Excess fluoride Vitamin D deficiency Hypoparathyroidism Pancreatitis Drugs Ethylenediaminetetraacetic acid (EDTA)Bisphosphonate Cisplatin Foscarnet Leucovorin Cinacalcet Citrate Large volume of blood transfusion (citrate used as an anticoagulant chelates calcium) Symptoms: Hypocalcemia Paresthesia Hypotension Chvostek's sign Bradycardia Prolongation of QT interval Tetany Seizure Trousseau's sign Cardiac contractility Management: Hypocalcemia Acute treatment Ca Cl 10% (270 mg calcium/10 m L vial): give 5-10 m L over 10 mins Ca Cl 10% (270 mg calcium/10 m L vial): dilute in 50-100 m L D 5W over 20-30 mins (continued)

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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 205 TABLE 6-7: Diagnosis: Hypocalcemia (Continued) Calcium gluconate: 20 m L of 10% (2 vials): infuse over 10-15 mins followed by infusion of 60 m L in 500 m L of D5W at 0. 5-2 mg/kg/hr Chronic treatment Calcium carbonate (Oscal), 1-2 tablets PO tid; calcium citrate (Citracal), 1 tablet PO q8h Vitamin D 2 (ergocalciferol), 1 tablet PO daily; calcitriol, 0. 25 mcg PO daily, titrate up to 0. 5-2 mcg qid (in chronic kidney disease) Docusate sodium (Colace): 1 tablet PO bid

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206 ELECTROLYTE DISTURBANCE AND NEPHROLOGY TABLE 6-8: Diagnosis: Hypercalcemia Disposition ?Monitor bed/medical floor Monitor Vitals Cardiac monitoring Electrolyte monitoring Neuromonitoring Diet Regular (calcium restriction 400 mg/24 hrs) Fluid IVF hydration essential before starting diuresis O 2 PRN Activity Up ad lib Dx studies Labs Labs CBC, BMP, LFT, Mg, PO4, TSH, total ionized calcium Radiology and cardiac studies CXR, ECG, female: ?mammogram Special tests Intact PTH, 25-OH vitamin D, PTH-related protein, 24-hr calcium and PO 4, male: ?PSA Prophylaxis ? Consults ?Endocrine Nursing Seizure precaution, I/O, neuro check q2-6h Avoid ? Management See Management: Hypercalcemia Etiologies: Hypercalcemia ↑ Bone resorption Hyperparathyroidism (primary and secondary) Malignancy Hyperthyroidism (continued)

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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 207 TABLE 6-8: Diagnosis: Hypercalcemia (Continued) Paget's disease Tamoxifen Hypervitaminosis A ↑ Calcium absorption Milk alkali syndrome Hypervitaminosis D (lymphoma, sarcoidosis) Miscellaneous Lithium Thiazide diuretics Rhabdomyolysis Theophylline toxicity Adrenal insufficiency Familial hypocalciuric hypercalcemia Metaphyseal chondroplasia (very rare) Congenital lactase deficiency (very rare) Management: Hypercalcemia IVF: NS at 200-300 m L/hr, then adjust to maintain the urinary output to 100-150 m L/hr, followed by furosemide, 10-20 mg IV Zoledronic acid (Zometa): 4 mg IV over 15 mins Pamidronate (Aredia): 60-90 mg IV over 4 hrs q24h (if Ca + >13. 5 mg/d L) Etidronate: 7. 5 mg/kg/24h IV daily × 3 days or (alendronate: 5-10 mg PO qd or 70 mg PO weekly) Calcitonin: 4-8 IU/kg IM/SQ q6h if NS and Lasix not effective Hydrocortisone: 200 mg IV daily × 3 days Plicamycin (Mithracin): 25 mcg per kg per day IV over 6 hrs for 3-8 doses Gallium nitrate (Ganite): 100-200 mg per m2 IV over 24 hrs for 5 days Dialysis

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208 ELECTROLYTE DISTURBANCE AND NEPHROLOGY TABLE 6-9: Diagnosis: Hypophosphatemia Disposition Medical floor Monitor Vitals Electrolyte monitoring Diet Regular Fluid Heplock (flush every shift) O2 PRN Activity Up ad lib Dx studies Labs CBC, BMP, Mg, PO4, calcium, LFT, PTH, albumin Radiology and cardiac studies ECG, CXR Prophylaxis ? Consults ?Nephrology Nursing ? Avoid ? Management See Management: Hypophosphatemia (<2. 3 mg/d L) Etiologies: Hypophosphatemia Acute respiratory alkalosis Phosphate binders Hyperparathyroidism Primary renal phosphate wasting Malnutrition Fanconi's syndrome Vitamin D deficiency Hyperglycemia (continued)

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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 209 TABLE 6-9: Diagnosis: Hypophosphatemia (Continued) Management: Hypophosphatemia (<2. 3 mg/d L) If >1 Neutra-Phos capsule: 2 250-mg tablets PO bid or tid Phospho-Soda: 5 m L PO bid or tid (5 m L = 129 mg phosphorus) If <1 Na phosphate or K+ phosphate: 0. 08-0. 16 mmol/kg over 6 hrs until phosphorus level is 1. 5 mg/d L Na phosphate or K+ phosphate: 10 mmol in 250 m L NS or D5W over 8 hrs Note: Rapid replacement with phosphorus can cause hypocalcemia (monitor for signs: tetany)

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210 ELECTROLYTE DISTURBANCE AND NEPHROLOGY TABLE 6-10: Diagnosis: Hyperphosphatemia Disposition Medical floor Monitor Vitals Electrolyte monitoring Diet Regular (phosphorus-deficient) Fluid Heplock (flush every shift) O2 PRN Activity Up ad lib Dx studies Labs BMP, Mg, PO4, calcium, LFT, PTH, albumin Radiology and cardiac studies CXR (PA and lateral), ECG Prophylaxis ? Consults ?Nephrology Nursing ? Avoid Calcium citrate, aluminum-containing products Management See Management: Hyperphosphatemia (>4. 3 mg/d L) Etiologies: Hyperphosphatemia Ketoacidosis Lactic acidosis Tumor lysis syndrome Rhabdomyolysis Acromegaly Hypoparathyroidism Phosphate supplements (Fleet enema/bowel preparation laxatives with Na phosphate) (continued)

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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 211 TABLE 6-10: Diagnosis: Hyperphosphatemia (Continued) Management: Hyperphosphatemia (>4. 3 mg/d L) Mild to moderate Calcium carbonate: 1 g with each meal Calcium acetate (Phos Lo): 1-3 667-mg tablets with each meal Insulin and glucose (cell phosphate uptake) used when rapid ↓ in phosphate needed Aluminum hydroxide (Amphojel): 5-10 m L or 1-2 tablets PO ac tid Aluminum carbonate (Basaljel): 5-10 m L or 1-2 tablets PO ac tid Severe NS: 1-3 L over 1-3 hrs Acetazolamide (Diamox): 500 mg PO or IV q6h Dialysis

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212 ELECTROLYTE DISTURBANCE AND NEPHROLOGY TABLE 6-11: Diagnosis: Metabolic Acidosis (Gap or Non-Anion Gap) Disposition Monitor bed/?unit Monitor Vitals Cardiac monitoring Electrolyte monitoring Neuromonitoring Diet NPO Fluid Heplock (flush every shift) O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC with differential, BMP, Mg, calcium, PO4, LFT, plasma acetone, ETOH level Blood C&S, UA, ?urine C&S, serum/urine toxicology screen, plasma osmolality Radiology and cardiac studies CXR (PA and lateral) Special tests ?Methanol level, ?paraldehyde level, ?salicylate level, ?ethylene glycol level, lactic acid level (see Etiologies: Increased Lactic Acid Level), osmolal gap Prophylaxis ? Consults ? Nursing I/O, stool guaiac Management Treat underlying cause Avoid ? (continued)

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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 213 Note Think of MUD PILES:Methanol Uremia Diabetic ketoacidosis Paraldehyde Iron, isoniazid Lactic acid Ethanol, ethylene glycol Salicylates Anion gap may be normal in methanol or ethylene glycol intoxication if there is concurrent ETOH ingestion Anion gap (10-14 m Eq/L) = Na +-(Cl-+ HCO3-) Anion gap decreases 2. 5 m Eq per 1 g/d L albumin drop Etiologies: Increased Anion Gap Metabolic Acidosis Lactic acidosis Ketoacidosis Methanol Ethylene glycol Rhabdomyolysis ASA Toluene Paraldehyde/phenformin Renal failure (uremia) Iron/isoniazid (continued)TABLE 6-11: Diagnosis: Metabolic Acidosis (Gap or Non-Anion Gap) (Continued)

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214 ELECTROLYTE DISTURBANCE AND NEPHROLOGY TABLE 6-11: Diagnosis: Metabolic Acidosis (Gap or Non-Anion Gap) (Continued) Etiologies: Increased Lactic Acid Level Regional hypoperfusion Severe hypoxemia Diabetes Liver disease Sepsis Pheochromocytoma Shock (cardiogenic, septic, or hypovolemic) Severe anemia Carbon monoxide poisoning Malignancies Thiamine deficiency Osmolal Gap Osmolal gap = measured osmolality-calculated osmolality Calculated osmolality = [2 × (Na+) + (glucose/18) + (BUN/2. 8) + (ethanol/4. 6)] Increased osmolal gap in methanol and ethylene glycol Also increased in ethanol, sorbitol, isopropyl alcohol, and mannitol but patient not acidotic

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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 215 NEPHROLOGY TABLE 6-12: Diagnosis: Acute Renal Failure Disposition Medical floor Monitor Vitals Cardiac monitoring Electrolyte monitoring Neuromonitoring Diet Renal diet (not necessary if patient already on dialysis) Fluid Fluid challenge if prerenal azotemia suspected IVF should not contain K +, Mg+, or phosphate O2 PRN Activity Bedrest Dx studies Labs CBC with differential, BMP, calcium, Mg, PO4, UA, urine R&M, Cr Cl Urine C&S, LFT, uric acid; CPK level if rhabdomyolysis suspected Radiology and cardiac studies Renal US, CXR, ECG Special tests ?Urine electrolytes, U Cr, Uosm, urine eosinophils ?ESR, ?CRP, blood C&S?Inflammatory disorders: ANA, anti-DS DNA, ANCA, anti-GBM antibodies, complement level (continued)

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216 ELECTROLYTE DISTURBANCE AND NEPHROLOGY Cryoglobulin, rheumatoid factor (cryoglobulin screen), hepatitis C antibody ?Serum and urine electrophoresis, ?24-hr urine protein, Cr, and Na+ Prophylaxis ? Consults Nephrology, ?urology (if postrenal failure suspected) Nursing Foley catheter, I/O, stool guaiac, ?daily weight Avoid ACE inhibitors, ARBs, NSAIDs, contrast dye, Mg-containing products Drugs associated with interstitial nephritis (see Drugs Associated with Interstitial Nephritis) Management Treat etiology Note: Bacitracin can cause pseudo Cr elevation Etiologies: Acute Renal Failure Prerenal Postrenal Dehydration BPH Shock Prostate disease Low cardiac output Kidney stone Cirrhosis Pelvic malignancy Renal vascular disease ± ACE inhibitor/angiotensin-receptor blocker Intrarenal Prolonged renal ischemia (acute tubular necrosis) Medications: NSAIDs, amphotericin B, aminoglycosides (continued)TABLE 6-12: Diagnosis: Acute Renal Failure (Continued)

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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 217 TABLE 6-12: Diagnosis: Acute Renal Failure (Continued) Medications associated with interstitial nephritis (see Drugs Associated with Interstitial Nephritis) Contrast—AIN Rhabdomyolysis Hypercoagulable state Emboli Glomerulonephritis Drugs Associated with Interstitial Nephritis Allopurinol NSAIDs Captopril PCN Cephalothin Phenytoin Cimetidine Pantoprazole (Protonix) Ciprofloxacin Rifampin Furosemide/thiazides TMP/SMX Physical Examination Findings in Renal Failure Prerenal Intrarenal Postrenal Weight loss or gain Weight gain Enlarged prostate Poor skin turgor Mental status change Weight gain Orthostatic hypotension Hypotension/ hypertension Bladder distention Ascites Increased JVD Pelvic mass from bladder distention Edema Note: Signs and symptoms include malaise, anorexia, nausea (from uremia) (continued)

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218 ELECTROLYTE DISTURBANCE AND NEPHROLOGY TABLE 6-12: Diagnosis: Acute Renal Failure (Continued) Urine Electrolytes Prerenal Intrarenal UNa+ (m Eq/L) <20 >30 Fe Na <1 >2 U/P Cr >40 <20 Uosm >500 <35 BUN/Cr ratio >10:1 10:1Fe Na = (U Na+/PNa+)/(UCr/PCr) × 100 RTA Type I (Distal) II (Proximal) Hyperkalemic Problem Defect in H+ secretion Defect in HCO3 absorption Urine p H Usually >6; never <5. 3Usually >6; can be <5. 3Usually <6 PK+ Low Low High Urine NH4 Low Normal Low Treatment HCO3 Na HCO3/K+ citrate/thiazide Diuretic/low-K+ diet Plasma osmolarity (280-290) = 2 × (Na+) + (Glu/18) + (BUN/2. 8) Osmolal gap (<10) = measured plasma osmolarity by lab- calculated plasma osmolarity (continued)

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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 219 TABLE 6-12: Diagnosis: Acute Renal Failure (Continued) Urine Electrolytes UNa+ (0-300 m Eq/L) Urine chloride (0-300 m Eq /L) Needed in calculating Fe Na Useful in metabolic alkalosis Used in evaluation of oliguria Used in evaluation of volume status High in acute tubular necrosis (usually >40) UK+ (5-300 m Eq /L) Dehydration/ ↓ volume status (usually <20) Used to determine if kidney is the source of potassium loss Used in evaluation of hyponatremia Needed to calculate TTKG Urine osmolarity (50-1,400 Osmol/kg H2O)UCr (10-400 mg/d L or 0. 4-2. 5 g/day) Used in evaluation of hyponatremia Useful in calculating Cr Cl Used in evaluation of hyperkalemia Needed in calculating Fe Na Used in evaluation of volume status Needed to calculate TTKG Urine anion gap = [(Na+) + (K+)]-Cl- Indicated in hyperchloremic metabolic gap acidosis; negative in gastrointestinal HCO3 loss and positive in RTA Note: Urine electrolytes: Normal values vary widely because they are based on individual intake of water and solute

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220 ELECTROLYTE DISTURBANCE AND NEPHROLOGY TABLE 6-13: Diagnosis: Nephrolithiasis Disposition Medical floor Monitor Vitals Electrolyte monitoring Diet Regular, ?low oxalate Fluid Hydration is essential O2 PRN Activity Up ad lib Dx studies Labs CBC, BMP, calcium Mg, PO4, uric acid, LFT UA, urine R&M, urine C&S, urine p H Radiology and cardiac studies KUB; IVP; ?CT of abdomen; CT urogram; US of abdomen (useful in pregnancy) Special tests Recover stone for chemical analysis PTH if elevated calcium level?24-hr urine: uric acid, calcium, Cr, citrate, oxalate, cystine, Na +, PO4, Mg+ Prophylaxis ? Consults ?Urology Nursing Strain urine, I/O Avoid Triamterene, indinavir, acetazolamide For oxalate stones: avoid rhubarb, peanut, spinach, tea, chocolate, cola, berries For cystine stones: avoid methionine-containing diet (continued)

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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 221 Management Pain management Hydromorphone (Dilaudid): 2-4 mg PO q4-6h PRN or Meperidine (Demerol): 75-100 mg PO q2-4h PRN or Morphine: 1-2 mg (max: 15 mg) IM/SQ or slow IV q4h PRN or Hydrocodone plus acetaminophen (5/500) (Vicodin): 1-2 tablets PO q4-6h PRN or Oxycodone plus acetaminophen (2. 5/325) (Percocet): 1-2 tablets PO q6h PRN Calcium stones Hydrochlorothiazide: 25-50 mg PO bid (supplement with K + to avoid hypokalemia) or Chlorthalidone: 25-50 mg PO qd (supplement with K+ to avoid hypokalemia) or Indapamide: 2. 5 mg PO daily or Neutral phosphate: 500 mg PO tid-qid Uric acid stones Potassium citrate: 20 m Eq bid (maintain urine p H = 6-7) Allopurinol: 300 mg PO daily Cystine stones Potassium citrate to keep p H >7. 5 Tiopronin: 200-500 mg PO bid Penicillamine: 1-2 g PO daily Struvite stones Remove stone Antibiotic Acetohydroxamic acid: 250 mg PO tid-qid TABLE 6-13: Diagnosis: Nephrolithiasis (Continued)

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222 ELECTROLYTE DISTURBANCE AND NEPHROLOGY TABLE 6-14: Diagnosis: Rhabdomyolysis Disposition Medical floor Monitor Vitals Cardiac monitoring Electrolyte monitoring mainly K + Diet Regular Fluid Diuresis is essential to prevent renal failure O2 PRN Activity Bedrest Dx studies Labs CPK (usually >10,000 IU/L), troponin, UA, urine R&M, CBC with differential, TSH BMP, calcium, Mg, PO4 (can have ↑ potassium and phosphorus, ↓ calcium, bicarbonate, and uric acid are common with rhabdomyolysis) Radiology and cardiac studies ECG Prophylaxis ? Consults ?Nephrology Nursing I/O Avoid IVP dye, metformin Management See Management: Rhabdomyolysis Etiologies: Rhabdomyolysis Trauma or muscle compression ETOH Extreme exertion Heat loss Sickle cell trait Metabolic myopathies (continued)

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ELECTROLYTE DISTURBANCE AND NEPHROLOGY 223 TABLE 6-14: Diagnosis: Rhabdomyolysis (Continued) Malignant hyperthermia Endocrinopathies Seizure Dermatomyositis Polymyositis Medications causing rhabdomyolysis ETOH Cocaine Opioid Carbon monoxide Colchicine Statins Infections causing rhabdomyolysis Bacterial pyomyositis Influenza A and BCoxsackievirus EBV HSV Parainfluenza Adenovirus Echovirus HIV CMV Falciparum malaria Management: Rhabdomyolysis Treat underlying cause Fluid resuscitation with NS Forced mannitol-alkaline diuresis Keep p H >6 If compartment syndrome is suspected, compartment pressures should be measured and fasciotomy should be considered Dialysis

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225 7 Neurology OUTLINE 7-1. Coma/Brain Death 226 7-2. Guillain-Barré Syndrome (Acute Idiopathic Demyelinating Polyneuropathy)230 Meningitis (See Table 5-6) 7-3. Myasthenic Crisis 2337-4. Seizure 2367-5. Stroke (Brain Attack) 2397-6. Subarachnoid Hemorrhage 2487-7. TIA 250

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226 NEUROLOGY TABLE 7-1: Diagnosis: Coma/Brain Death Disposition Unit Monitor Vitals Cardiac monitoring Electrolyte monitoring Neuromonitoring/intracranial pressure monitoring if available Diet NPO, hyperalimentation, NG feeding Fluid MIVF O 2 Ventilator support Dx studies Labs CBC with differential, BMP, LFT, Mg, PO 4 , calcium, UA, ABG, serum/urine toxicology screen Serum acetaminophen and salicylate level, blood C&S, urine C&S Radiology and cardiac studies CXR (PA and lateral); ECG; CT of head, chest, abdomen, and pelvis; ?MRI of head, ?PET Special tests LP, CSF analysis (see below), amylase, lipase, EEG CSF and serum: ?neuron-specific enolase, glial protein S-100, creatine kinase, and lactate Prophylaxis DVT prophylaxis after ruling out intracerebral hemorrhage, GI prophylaxis if on ventilator Consults Ethics committee, neurology Nursing I/O, stool guaiac, aspiration precaution Avoid ? (continued)

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NEUROLOGY 227 Management Manage airway Assess circulation and treat with IVF or blood transfusion Give thiamine before giving patient glucose Treat underlying cause Medical Record Documentation 1. Etiology 2. Irreversibility of condition3. Absence of brainstem reflexes4. Absence of motor response to pain5. Absence of respiration with PCO 2 at least 60 6. Justification for confirmatory test and result7. Result of repeat examination in 6 hrs (optional) Glasgow Coma Scale Eye opening Verbal response Motor response 1 = No response 1 = No response 1 = No response to pain 2 = Opens with pain2 = Unintelligible sounds2 = Extension with pain (decerebrate) 3 = Opens with verbal stimuli3= Inappropriate responses3 = Flexion with pain (decorticate) 4 = Opens spontaneously4 = Converse but confused 4 = Withdraws from pain stimuli 5 = Alert and oriented5 = Localization of pain (pushes away) 6 = Responds to verbal commands (continued) TABLE 7-1: Diagnosis: Coma/Brain Death (Continued)

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228 NEUROLOGY TABLE 7-1: Diagnosis: Coma/Brain Death (Continued) Brainstem reflexes (to determine brainstem function) Corneal reflex Pupillary reflex Gag reflex Doll's eye reflex Cold caloric test (oculovestibular reflex) Brain Dead Criteria Special considerations 1. Cause known 2. Cause irreversible3. No severe overlying medical condition: electrolytes, acid-base disturbances, endocrine abnormalities 4. No drug intoxication or poisoning5. Core temperature at least 33°C (91°F) Clinical features 1. Unresponsiveness (no motor response to pain) 2. No grimacing to pain3. No brainstem reflexes a. No pupil response to lightb. No corneal reflexc. No oculocephalic reflex (doll's eye)d. No caloric vestibular reflex (50 m L water; allow 1 min each ear; allow 5 mins between ears) e. No gag or cough with suctionf. No ventilatory effort Apnea test 1. Temperature at least 36. 5°C (97°F) (continued)

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NEUROLOGY 229 TABLE 7-1: Diagnosis: Coma/Brain Death (Continued) 2. SBP at least 90 3. No diabetes insipidus or positive fluid balance in past 6 hrs4. Preoxygenate to get PO 2 at least 200 and PCO 2 to 40 or lower 5. Shut off vent for 8 mins; stop test if respiration seen or systolic BP <90 or PO 2 significant desaturation or cardiac arrhythmia. 6. Draw ABG: Test is positive if no respiratory effort and PCO 2 is at least 60 mm Hg or there is a 20 mm Hg ↑ over baseline. Optional confirmatory tests 1. EEG a. Minimum of eight scalp electrodes (interelectrode distance: 10 cm; interelectrode resistance of 100-10,000 ohms) b. Gains ↑ to 2 V/min c. Test integrity of recording system by deliberate creation of electrode artifact by manipulation d. Test for reactivity to pain, loud noises, or lighte. Recording by a qualified technician for 30 mins 2. Transcranial Doppler US: absence of diastolic or reverberating flow3. Technetium 99 HMPAO brain scan: no intracerebral uptake4. Somatosensory evoked potentials: no response of N20-P225. Repeat examination in 6 hrs LP and Tube Contents Tube number Test for 1 Cell count 2 Gram stain, bacteria, viral and fungus C&S, AFB, India ink 3 Glucose, protein, LDH, VDRL test 4 Cell count, RBCs, WBCs 5 Hold for other tests

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230 NEUROLOGY TABLE 7-2: Diagnosis: Guillain-Barré Syndrome (Acute Idiopathic Demyelinating Polyneuropathy) Disposition Unit Monitor Vitals Neuro check q1-4h Respiratory Diet NPO except medication if gag reflex intact Fluid Heplock (flush every shift) O 2 ≥ 2 L O 2 via NC; keep O 2 saturation >92% (monitor for respiratory depression) Activity Bedrest Dx studies Labs CBC with differential, BMP Radiology and cardiac studies CXR (AP/lateral) Special tests CSF analysis Prophylaxis DVT Consults Neurology, PT/OT Nursing Aspiration precaution Avoid Corticosteroids (may delay recovery) Management See Treatment Etiology: Guillain-Barré Syndrome Acute/subacute polyneuropathy that follows minor infective illnesses (“cold,” URI), inoculations, or surgical procedures; may also occur without obvious precipitants Preceding Campylobacter jejuni infection has been demonstrated in some cases (continued)

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NEUROLOGY 231 TABLE 7-2: Diagnosis: Guillain-Barré Syndrome (Acute Idiopathic Demyelinating Polyneuropathy) (Continued) Clinical features and diagnosis Progressive weakness of more than one limb, with symmetric deficits; usually begins in the legs, often more proximal than distal Distal areflexia Mild sensory involvement Autonomic dysfunction (tachycardia, labile BP, abnormal sweating, sphincter disturbances, paralytic ileus) Cranial neuropathies (VII palsy) No fever Increased CSF protein (after 1 week) CSF white blood cell count ≤ 10 Nerve conduction study: slowing of conduction (demyelination) Progression for up to 4 weeks Recovery within 4 weeks after progression stops Treatment Plasmapheresis: Three to five cycles Intravenous immunoglobulin: 400 mg/kg/day for 5 days Treatment otherwise symptomatic: Prevent respiratory failure or cardiovascular collapse: Patients severely affected need to be in ICU (may need elective intubation and mechanical ventilation) Avoid corticosteroids [may delay recovery (contraindicated)] PT/OT after acute phase Prognosis 70-75% recover completely (continued)

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232 NEUROLOGY TABLE 7-2: Diagnosis: Guillain-Barré Syndrome (Acute Idiopathic Demyelinating Polyneuropathy) (Continued) 25%: mild neurologic deficits 5% die (respiratory failure) Prognosis is worse when there is evidence of previous C. jejuni infection, advanced age, and need for ventilatory support

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NEUROLOGY 233 TABLE 7-3: Diagnosis: Myasthenic Crisis Disposition Unit Monitor Vitals Neuro check q1-4h Diet NPO except medication if gag reflex intact Fluid Heplock (flush every shift) O 2 ≥ 2 L O 2 via NC; keep O 2 saturation >92% (monitor for respiratory depression) Activity Bedrest Dx studies Labs CBC with differential, BMP, ABG Radiology and cardiac studies CXR (AP/lateral) Special tests Edrophonium (Tensilon) test, electromyography Acetylcholine receptor antibodies Prophylaxis ? Consults Neurology Nursing Aspiration precaution Avoid ? Management See Management: Myasthenic Crisis Signs and Symptoms: Myasthenic Crisis Clinical syndrome: work-related weakness Initially, ocular muscles: Ptosis and diplopia (approximately 40%). Ultimately 90% of patients have ocular involvement. Then, facial and oropharyngeal muscles: dysarthria, dysphagia and facial diplegia. Occasionally, swallowing is impaired before the ocular signs appear. Virtually all patients with myasthenia gravis have some involvement of oropharyngeal and ocular muscles at some time. (continued)

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234 NEUROLOGY TABLE 7-3: Diagnosis: Myasthenic Crisis (Continued) Last, diffuse muscle weakness, worse after exertion Electromyography Impaired neuromuscular transmission (decremental response with repetitive nerve stimulation or increased “jitter” and blocking of impulses with single-fiber electromyography) Edrophonium (Tensilon) test Weakness improves 15-30 mins after infusion in patients with ocular signs (ptosis and strabismus), but results are more difficult to assess in patients with limb weakness or respiratory failure alone Acetylcholine receptor antibodies Present in high titer in 90% of long-standing myasthenia gravis, but in only 50% of patients with ocular signs alone Exacerbation with generalized weakness that includes respiratory muscles to the point of ventilatory failure (myasthenic crisis) Clinically Restlessness, insomnia, anxiety, tachycardia, diaphoresis, and tachypnea. Later, headache, central cyanosis, hypotension, confusion and asterixis. ABGP O 2 <60 mm Hg or PCO2 >50 mm Hg demonstrates respiratory failure Vital capacity If vital capacity <15 m L/kg elective intubation is necessary to provide positive pressure ventilation Mechanical ventilation Pressure support is preferred. Consider tracheostomy if intubation is needed for >2 weeks. (continued)

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NEUROLOGY 235 TABLE 7-3: Diagnosis: Myasthenic Crisis (Continued) Management: Myasthenic Crisis Pharmacologic treatment Cholinergic drugs: Pyridostigmine (Mestinon), max dose of 120 mg every 3 hrs (by NG tube). When weaning from ventilator, restart cholinergic medications at one-half of previous dosage. Plasma exchange Three to five cycles (1. 5-2. 0 L per exchange) until pulmonary function reaches 80% of predicted normal value (short-term benefit only) Immunoglobulin infusion400 mg/kg per day for 4-5 days. Mechanism of action is not well known (binding of receptor antibodies by the infused immunoglobulin or blockade of phagocytes that destroy the receptors?). Anecdotal evidence of clinical improvement. High-dose steroids: Prednisone, 60-100 mg daily, may cause transient weakness. Watch carefully.

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236 NEUROLOGY TABLE 7-4: Diagnosis: Seizure Disposition Medical floor/unit if status epilepticus Monitor Vitals Cardiac monitoring Electrolyte monitoring Neuromonitoring q1-4h Diet NPO Fluid MIVF O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs BMP, Mg, calcium, PO4, LFT, CBC with differential, UA Serum/urine toxicology screen, ETOH level Prolactin if patient presents within 1-2 hrs of having seizure If fever: blood C&S, urine C&S, sputum C&S Radiology and cardiac studies CXR (PA and lateral), CT/MRI of head, ECG Special tests ABG, LP for CSF analysis (if suspected infection or subarachnoid hemorrhage), ?RPR/?VDRL EEG (awake, sleep-deprived, photic stimulation, hyperventilation) Antiseizure medication level if patient already on medication for seizure (continued)

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NEUROLOGY 237 Prophylaxis ? Consults ?Neurology Nursing Aspiration precaution, seizure precaution, low bed with rails Avoid Levofloxacin (Levaquin), bupropion (Wellbutrin), levothyroxine (Synthroid), amphetamine Management 1. Check blood glucose (fingerstick glucose); if low (<55) thiamine, 10 mg IV, plus 1 amp of D 50W (1 amp can ↑ glucose level by 100) 2. Management Bite block Diazepam: 5 mg/min IV [0. 2 mg/kg (max: 20 mg)] or Lorazepam (Ativan): 2 mg/min IV (0. 1 mg/kg) Fosphenytoin: 1,000-1,500 (15-20 mg/kg) IV in saline or dextrose solution at 150 mg/min or Phenytoin (Dilantin): 15-20 mg/kg in 100 m L NS; give loading dose of 25-50 mg/min (max: 1. 5 g) (Note: Do not mix phenytoin with dextrose solution; if hypotension, reduce infusion rate) If seizure persists start phenobarbital, 120-260 mg IV (10-20 mg/kg) If seizure continues induce coma (propofol, 1-2 mg/kg IV bolus, then 2-4 mg/kg infusion) or Phenobarbital: 10-15 mg/kg IV over 1-2 hrs, then 0. 5-4 mg/ kg/hr infusion or (continued)TABLE 7-4: Diagnosis: Seizure (Continued)

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238 NEUROLOGY Midazolam: 0. 2 mg/kg IV slowly followed by 0. 75-10 mcg/ kg/min infusion Patient needs intubation and ventilatory support; may need vasopressor for hypotension 3. Treat underlying cause4. Speak to patient about revoking his or her driver's license and informing department of motor vehicles if the license has not already been revoked Note Fosphenytoin loading dose for seizure: 15-20 mg/kg Phenytoin loading dose for seizure: 15-20 mg/kg Correct Dilantin for low albumin = (albumin × 0. 2) + 0. 1TABLE 7-4: Diagnosis: Seizure (Continued)

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NEUROLOGY 239 TABLE 7-5: Diagnosis: Stroke (Brain Attack) Disposition Unit Monitor Vitals Cardiac monitoring Neuro check q1-2h Diet NPO except medication if gag reflex intact (start diet after swallowing studies) Fluid MIVF (preferably without glucose) O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs Blood glucose, CBC with differential, BMP, Mg, PO4, LFT, PT/PTT/INR, UA ?Serum/urine toxicology screen, fasting lipid profile Radiology and cardiac studies Initially, stat noncontrast CT of head, CXR MRI with diffuse-weighted images; very sensitive for ischemic stroke, but not required if patient is candidate for r-TPA (may delay treatment) ?Swallowing studies, carotid duplex US, cardiac echo, ?Holter Special tests Lipid profile, ?ESR, ?VDRL, ?RPR, ?ANA, ?anticardiolipin antibodies ?Lupus anticoagulant?Hemoglobin electrophoresis, ?coagulation panel, protein C&S (continued)

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240 NEUROLOGY If patient on enoxaparin (Lovenox) ?check anti-factor Xa 4-6 hrs after first dose Prophylaxis DVT after ruling out intracerebral hemorrhage Consults Neurology, PT/OT, rehabilitation medicine, speech Nursing I/O, Foley catheter, above-the-knee elastic stocking, stool guaiac, aspiration precaution Elevate head of bed at 30-45 degrees, egg crate mattress Avoid ? Management See Management: Ischemic Stroke National Institutes of Health Stroke Scale Description Score Description Score Level of consciousness Motor upper extremity [arms outstretched at 90 degrees (sitting) or 45 de-grees (supine) × 10 secs] Alert and responsive 0 No drift 0Arousable to minor stimuli 1 Drift but does not fall to bed1 Arousable to only pain stimuli2 Some antigravity but cannot sustain 2 Unarousable/reflex responses3 No antigravity but some movement3 No movement 4 (continued)TABLE 7-5: Diagnosis: Stroke (Brain Attack) (Continued)

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NEUROLOGY 241 TABLE 7-5: Diagnosis: Stroke (Brain Attack) (Continued) Orientation Motor lower extremity [legs outstretched at 90 degrees (sitting) or 45 de-grees (supine) × 10 secs] Patient's name and current month0 No drift 0 Patient's name or current month1 Drift but does not fall to bed1 Unable to state name or month2 Some antigravity but cannot sustain 2 Commands No antigravity but some movement3 Open and close eyes and grip and release grip0 No movement 4 Either of the two commands1 Limb ataxia, finger to nose, and heel to shin Neither of the two commands2 No ataxia 0 Gaze (horizontal extraocular muscle by voluntary or doll's eye)Ataxia in arms or legs 1 Normal 0 Ataxia in arms and legs 2 Partial palsy 1 Sensory (test with sharp object) Forced eye deviation or total paresis2 Normal 0 Visual field Unilateral loss but aware of touch1 Normal 0 Total unilateral loss 2 Quadrantanopia 1 Bilateral loss 3 (continued)

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242 NEUROLOGY TABLE 7-5: Diagnosis: Stroke (Brain Attack) (Continued) Hemianopia 2 Language Blindness 3 Normal 0Facial palsy (if stuporous check grimace)Moderate aphasia 1 Normal 0 Severe aphasia 2 Flat nasolabial fold, asymmetric smile1 Mute 3 Lower face paralysis (partial)2 Dysarthria (read set of words) Complete paralysis 3 Normal 0Neglect (touch patient on both hands simulta-neously; show fingers in both visual fields)Mild to moderate slurring 1 No neglect 0 Unintelligible or mute 2 Partial neglect (neglect in any modality)1 Total neglect (more than 1 modality)2 National Institutes of Health Stroke Scale Score and Percent with Favorable Outcome Score Score Age <60 yrs% with favorable outcome Age 69-75 yrs% with favorable outcome 0-9 42% 0-9 54%10-14 18% 10-14 27%15-20 27% 15-20 0%>20 12% >20 0% (continued)

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NEUROLOGY 243 TABLE 7-5: Diagnosis: Stroke (Brain Attack) (Continued) Age 61-68 yrs% with favorable outcome Age >75 yrs% with favorable outcome 0-9 37% 0-9 36%10-14 25% 10-14 15%15-20 25% 15-20 6%>20 0% >20 0% Source: From NINDS t-PA stroke study group, National Institutes of Health. Management: Ischemic Stroke 1. Start ASA, 325 mg PO daily, ± clopidogrel (Plavix), 75 mg PO daily, if CT/MRI is negative for bleed (hemorrhagic stroke) ASA plus dipyridamole (Aggrenox), 1 tablet PO bid, has been shown to be more effective than ASA for prevention of CVA Alternative drug that can be used is ticlopidine, 250 mg bid, but the side effects are neutropenia, thrombocytopenia 2. Recombinant tissue plasminogen activator (rt-PA) can be used in nonhemorrhagic stroke and should present within 3 hrs, recommended by National Institute of Neurological Disorders and Stroke (see exclusion criteria below) rt-PA: 0. 9 mg/kg (max: 90 mg) 10% IV bolus, then give 90% over 1-hr infusion Do not give ASA, heparin, or warfarin during first 24 hrs if rt-PA is given 3. Heparin and warfarin use in atherosclerotic stroke is controversial 4. Heparin and warfarin are indicated in patients with cardiogenic emboli and atrial fibrillation (keep INR = 2-3, 2. 5-3. 5 in mechanical valve) (see exclusion criteria below for starting patient on heparin and warfarin) (continued)

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244 NEUROLOGY TABLE 7-5: Diagnosis: Stroke (Brain Attack) (Continued) 5. BP management: Lowering BP in acute cerebral infarction is contraindicated unless patient has the following: BP: systolic >230 or diastolic >120 Hypertensive encephalopathy is present Vital organs are compromised Cerebral ischemia secondary to aortic dissection 6. Treatment: labetalol, 10 mg IV over 1-2 mins, then repeat every 10 mins as needed, to a total dose of 150 mg (discontinue if hypotension, bradycardia, or bronchial spasm). Alternative: nicardipine IV at 5 mg/hr, ↑ by 2. 5 mg/hr q5-15min to max 15 mg/hr (discontinue if hypotension, bradycardia) 7. Docusate sodium, 100 mg PO qh, or bisacodyl, 10-15 mg PO qh 8. Acetaminophen (Tylenol): 650 mg PO/PR q4-6h PRN for headache or temperature >38°C 9. Consider statin for cholesterol management and ACE for BP management 10. Consider ACE inhibitor, thiazide diuretic, or both for BP management and secondary stroke prevention Note: Patient on Lovenox: may consider checking anti-factor Xa 4-6 hrs after the first dose rt-PA Inclusion Criteria in Patient with Stroke 1. Age >18 yrs (no studies in children) 2. Clinical evidence of ischemic stroke with neurologic deficit3. Time of onset <3 hrs; remember, “TIME is BRAIN”; the sooner the t-PA is given, the better the prognosis rt-PA Exclusion Criteria in Patient with Stroke Historical relevance 1. Stroke or head trauma within past 3 mos2. Prior history of intracranial hemorrhage (continued)

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NEUROLOGY 245 TABLE 7-5: Diagnosis: Stroke (Brain Attack) (Continued) 3. Any major surgery within past 14 days 4. GI or GU bleeding within past 21 days5. MI in past 3 mos6. Arterial puncture at noncompressible site within past 7 days7. LP within past 7 days Clinical relevance 8. Rapidly improving symptoms of stroke9. Isolated or minor neurologic signs 10. Seizure at onset of stroke with postictal residual impairments11. Symptoms suggestive of subarachnoid hemorrhage (with negative head CT) 12. Presentation consistent with acute MI or post-MI pericarditis13. Persistent BP: systolic >185, diastolic >110 14. Pregnancy/lactation15. Active bleeding Relevance of lab16. Platelets <100,000/mm 3 17. Glucose <50 mg/d L (2. 8 mmol/L) or >400 mg/d L (22. 3 mmol/L)18. INR >1. 7 if on warfarin19. Elevated PTT if on heparin Relevance of radiologic studies20. Head CT shows evidence of hemorrhage21. Head CT shows early infarct signs (diffuse swelling, parenchymal hypodensity, and/or effacement of >33% of middle cerebral artery territory) Source: Report of quality standard subcommittee of American Academy of Neurology, with permission. (continued)

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246 NEUROLOGY TABLE 7-5: Diagnosis: Stroke (Brain Attack) (Continued) Heparin and Warfarin Exclusion Criteria in Patient with Stroke 1. CT/MRI scan shows hemorrhage, tumor, abscess, epidural or subdural hematoma 2. Current bleeding3. History of GI bleeding, bleeding tendencies4. Large infarction noted on CT/MRI scan5. Neurologic deterioration secondary to severe cerebral edema6. Recent surgery past 14 days7. Severe uncontrolled HTN (BP >185/110) MRI Contraindications Absolute contraindications Relative contraindications Electronically, magnetically, and mechanically activated implants:Electronically, magnetically, and mechanically activated implants: other pacemakers, e. g., Cardiac pacemakers For the carotid sinus Cardiac defibrillators Insulin pumps and nerve stimulators Ferromagnetic or electronically operated stapedial implants Lead wires or similar wires Aneurysm clips Carotid artery vascular clamp Metallic splinters in orbit Hemostatic CNS clips Nonferromagnetic stapedial implants Cochlear implants Implanted bone growth/fusion stimulator (continued)

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NEUROLOGY 247 TABLE 7-5: Diagnosis: Stroke (Brain Attack) (Continued) Prosthetic heart valves (in high fields, if dehiscence is suspected) Hemostatic clips (body) CHF Pregnancy (claustrophobia)

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248 NEUROLOGY TABLE 7-6: Diagnosis: Subarachnoid Hemorrhage Disposition Unit Monitor Vitals Neuro check q1-4h Diet NPO except medication if gag reflex intact Fluid Heplock (flush every shift) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs BMP, Mg, calcium, CBC with differential, LFT, PT/PTT/INR, UA Radiology and cardiac studies Noncontrast CT of head, CXR, MRI (see contraindications below), ECG MRI/MRA: sensitive for acute ischemic lesions, presence of vascular aneurysms and vasospasm Cerebral angiography: detection of vascular aneurysms and vasospasm. Also, especially in posterior circulation, endovascular aneurysm coiling is effective ?Swallowing studies Special tests VDRL, ?CSF analysis Prophylaxis ? Consults Neurology, neurosurgery, ?rehabilitation, speech Nursing Seizure precaution I/O, stool guaiac, above the knee elastic stocking Elevate head of bed at 30-45 degrees, egg crate mattress Avoid ? (continued)

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NEUROLOGY 249 Management 1. Prevention of vasospasm: nimodipine, 60 mg q4h PO or via NG tube q4h (contraindication: hypotension; use lower dose in liver disease) 2. BP control: nitroprusside sodium, 0. 1-0. 5 mcg/kg/min (50 mg in 250 m L NS) Labetalol: 10-40 mg IV q30min 3. Seizure prophylaxis (controversial): phenytoin, 15 mg/kg IV in NS (max: 50 mg/min), then 300 mg PO/IV (4-6 mg/kg/day) 4. Morphine: 1-4 mg IV q2-6h (avoid oversedation)5. Docusate sodium, 100 mg PO qh, or bisacodyl, 10-15 mg PO qh TABLE 7-6: Diagnosis: Subarachnoid Hemorrhage (Continued)

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250 NEUROLOGY TABLE 7-7: Diagnosis: TIA Disposition Unit Monitor Vitals Cardiac monitoring Neuro check qh Diet NPO except medication if gag reflex intact (start diet after swallowing studies) Fluid MIVF (preferably without glucose) O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs Blood glucose, CBC with differential, BMP, LFT, PT/PTT/INR, stool guaiac, UA Fasting lipid profile, ?serum/urine toxicology screen Radiology and cardiac studies Noncontrast CT of head, CXR, ?MRI (see MRI Contraindications), ECG MRI (sensitive for ischemic, small stroke or stroke in brainstem) Carotid duplex US, cardiac echo, ?Holter, ?swallowing studies Special tests ?ESR, ?VDRL, ?RPR, ?ANA, ?anticardiolipin antibodies ?Lupus anticoagulant?Hemoglobin electrophoresis, ?coagulation panel, protein C and S If patient placed on Lovenox ?check anti-factor Xa 4-6 hrs after first dose Prophylaxis DVT prophylaxis after ruling out intracerebral hemorrhage (continued)

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NEUROLOGY 251 Consults Neurology, rehabilitation, speech Nursing I/O, Foley catheter, stool guaiac, above-the-knee elastic stocking, aspiration precaution, elevation of head of bed at 30-45 degrees, egg crate mattress Avoid ? Management 1. Start ASA, 325 mg PO daily, ± Plavix, 75 mg PO daily, if CT/ MRI is negative for bleed (hemorrhagic stroke) Aggrenox, 1 tablet PO bid, has been shown to be more effective than ASA for prevention of CVA Alternative drug that can be used is ticlopidine, 250 mg bid, but the side effects are neutropenia, thrombocytopenia 2. Heparin and warfarin use in atherosclerosis TIA is controversial3. Heparin and warfarin are indicated in patients with cardiogenic emboli from atrial fibrillation (keep INR = 2-3, 2. 5-3. 5 in mechanical valve) (see exclusion criteria below for starting patient on heparin and warfarin) 4. BP management: Lowering BP in acute cerebral infarction is contraindicated unless patient has the following: BP: systolic >230 or diastolic >120 Hypertensive encephalopathy is present Vital organs are compromised Cerebral ischemia secondary to aortic dissection 5. Labetalol, 10 mg IV over 1-2 mins, then repeat every 10 mins as needed, to a total dose of 150 mg (DC if hypotension, bradycardia, or bronchial spasm). Alternative: nicardipine IV at 5 mg/hr; ↑ by 2. 5 mg/hr q5-15min to max 15 mg/hr. (DC if hypotension, bradycardia) 6. Docusate sodium, 100 mg PO qh, or bisacodyl, 10-15 mg PO qh 7. Tylenol: 650 mg PO/PR q4-6h PRN for HA or temperature >38°C (continued)TABLE 7-7: Diagnosis: TIA (Continued)

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252 NEUROLOGY 8. Consider statin for cholesterol management and secondary stroke prevention; also ACE inhibitor, thiazide diuretic, or both for BP management and secondary stroke prevention Note: Patient on Lovenox: may consider checking anti-factor Xa 4-6 hrs after the first dose Heparin and Warfarin Exclusion Criteria in Patient with Stroke 1. CT/MRI scan shows: hemorrhage, tumor, abscess, epidural or subdural hematoma 2. Current bleeding3. History of GI bleeding, bleeding tendencies4. Large infarction noted on CT/MRI scan5. Neurologic deterioration secondary to severe cerebral edema6. Recent surgery past 14 days7. Severe uncontrolled HTN (BP >185/110) MRI Contraindications Absolute contraindications Relative contraindications Electronically, magnetically, and mechanically activated implants:Electronically, magnetically, and mechanically activated implants: other pacemakers, e. g., Cardiac pacemakers For the carotid sinus Cardiac defibrillators Insulin pumps and nerve stimulators Ferromagnetic or electronically operated stapedial implants Lead wires or similar wires Aneurysm clips Carotid artery vascular clamp Metallic splinters in orbit Hemostatic CNS clips Nonferromagnetic stapedial implants (continued)TABLE 7-7: Diagnosis: TIA (Continued)

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NEUROLOGY 253 TABLE 7-7: Diagnosis: TIA (Continued) Cochlear implants Implanted bone growth/fusion stimulator Prosthetic heart valves (in high fields, if dehiscence is suspected) Hemostatic clips (body) CHF Pregnancy (claustrophobia)

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255 8 Pulmonology OUTLINE 8-1. Asthma 256 8-2. COPD: Acute Exacerbation 2598-3. PE 2638-4. Tension Pneumothorax 2668-5. Pleural Effusion 2678-6. Hemoptysis 271

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256 PULMONOLOGY TABLE 8-1: Diagnosis: Asthma Disposition Medical floor/unit Monitor Vitals, pulse oximeter Respiratory monitoring: consider peak flow rate before and after bronchodilator treatment Diet Regular Fluid Heplock (flush every shift) O 2 ≥ 2 L O 2 via NC; keep O 2 saturation >92% Activity ?Bedrest Dx studies Labs ABG, CBC with differential and eosinophil, BMP, sputum Gram stain and C&S Radiology and cardiac studies CXR, ECG Special tests Peak flow rate pre-and post-breathing treatment Pulmonary function test before and after bronchodilator prior to discharge ?BNP if not sure whether it's CHF or asthma Prophylaxis Consider inhaled corticosteroids, DVT Consults ?Pulmonary Nursing Pulse oximeter, peak flow, smoking cessation Avoid β -Blocker in exacerbations Management 1. β 2 -agonist Mild to moderate Albuterol: 2. 5 mg via nebulizer q20min or 6-12 puffs via MDI (continued)

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PULMONOLOGY 257 Severe Albuterol, 2. 5-5 mg, with ipratropium, 0. 5 mg via nebulizer Albuterol: 10-15 mg nebulizer over 1 hr Note: If patient develops tachycardia/palpitation/tremors use levalbuterol (Xopenex), 0. 63-1. 25 mg q6-8h 2. Methylprednisolone, 2 mg/kg × 1 dose initially, then 1 mg/kg IV q6h, then change to PO prednisone, 1 mg/kg/24 hrs (give daily or divide bid) (max: 60 mg/24 hrs), then taper or 3. Prednisolone: 1-2 mg/kg/24 hrs PO (give daily or divide bid) (max: 60 mg/24 hrs) 4. If all above fails consider epinephrine, 0. 3 m L of a 1:1,000 SQ q20min × 3 doses Terbutaline: 0. 25 mg SQ q6-8h or Terbutaline loading dose: 2-10 mcg/kg IV, then maintenance 0. 08-6 mcg/kg/min Consider aminophylline loading dose, 5-6 mg/kg IV; give over 20-30 mins, then maintenance dose IV maintenance dose 1-10 yrs 1 mg/kg/hr 10-16 yrs 0. 75-0. 9 mg/kg/hr >16 yrs 0. 7 mg/kg/hr 5. Ipratropium and albuterol (Combivent): 2-4 puffs qid6. Fluticasone (Flovent): 88-220 mcg twice daily (max: 880 mcg twice daily) 7. Montelukast (Singulair): 5-10 mg PO qh8. Salmeterol (Serevent): 2 puffs bid (continued) TABLE 8-1: Diagnosis: Asthma (Continued)

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258 PULMONOLOGY 9. If infection suspected consider using antibiotics 10. ?Pulmonary rehabilitation TABLE 8-1: Diagnosis: Asthma (Continued)

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PULMONOLOGY 259 TABLE 8-2: Diagnosis: COPD: Acute Exacerbation Disposition Unit Monitor Vitals, pulse oximeter Respiratory monitoring: continuous O 2 saturation Diet Regular Fluid Heplock (flush every shift) O 2 ≤ 6 L to achieve O 2 saturation ≥ 90% (high oxygen content can suppress CO 2 drive) Activity ?Bedrest Dx studies Labs CBC with differential, BMP, Mg, ABG, troponin I, ?blood C&S Sputum Gram stain and C&S, UA Radiology and cardiac studies CXR (PA and lateral), ECG, peak expiratory flow rate Special tests ? α 1 -Antitrypsin level ?PFT with bronchodilator when stable Theophylline level if patient on theophylline Prophylaxis Consider inhaled corticosteroids, influenza (flu) and pneumococcal vaccine, DVT Consults Pulmonary, respiratory therapist (smoking cessation) Nursing Continuous O 2 saturation monitoring Avoid β -Blockers in acute settings Management See Management: COPD; also consider antibiotics (continued)

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260 PULMONOLOGY TABLE 8-2: Diagnosis: COPD: Acute Exacerbation (Continued) Global Initiative for Chronic Obstructive Lung Disease (GOLD) Criteria for Disease Severity in COPD Patient 0 (At risk) Normal spirometry Chronic symptoms (cough, sputum) I (Mild) Forced expiratory volume/forced vital capacity (FEV/FVC) <70% FEV >80% ≥ predicted with or without symptoms II (Moderate) FEV/FVC <70% FEV <80% or >50% predicted with or without chronic symptoms III (Severe) FEV/FVC <70% FEV <50% or >30% predicted with or without chronic symptoms IV (Very severe) FEV/FVC <70% FEV <30% predicted Treatment Modalities for Global Initiative for Chronic Obstructive Lung Disease (GOLD) Stages for Patient with COPD GOLD stages First line Second line 0-I ?Risk factor avoidance ?Short-acting bronchodilator PRN 1. Smoking cessation2. Influenza vaccine II ?As stage I + add long-acting bronchodilators, preferably inhaled?Pulmonary rehabilitation (continued)

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PULMONOLOGY 261 TABLE 8-2: Diagnosis: COPD: Acute Exacerbation (Continued) III ?As stage II + add long-acting inhaled corticosteroids?Pulmonary rehabilitation IV ?As stage III + add long-acting domiciliary oxygen?If respiratory failure surgery Source: From NIH, Global Initiative for Chronic Obstructive Lung Disease. Management: COPD 1. β 2 -agonist Mild to moderate Albuterol: 2. 5 mg via nebulizer q20min or 6-12 puffs via metered-dose inhaler Severe Albuterol, 2. 5-5 mg with ipratropium, 0. 5 mg via nebulizer Albuterol, 10-15 mg nebulizer over 1 hr Note: If patient develops tachycardia/palpitation/tremors use Xopenex, 0. 63-1. 25 mg q6-8h 2. Methylprednisolone, 2 mg/kg × 1 dose initially, then 1 mg/kg IV q6h, then change to PO prednisone, 1 mg/kg/24 hrs (give daily or divide bid) (max: 60 mg/24 hrs), then taper 3. Prednisolone: 1-2 mg/kg/24 hrs PO (give daily or divide bid), max: 60 mg/24 hrs, then taper 4. Consider aminophylline loading dose, 5-6 mg/kg IV; give over 20-30 mins, then maintenance dose IV maintenance dose 1-10 yrs 1 mg/kg/hr 10-16 yrs 0. 75-0. 9 mg/kg/hr >16 yrs 0. 7 mg/kg/hr (continued)

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262 PULMONOLOGY TABLE 8-2: Diagnosis: COPD: Acute Exacerbation (Continued) 5. Albuterol, metaproterenol, or terbutaline, 2-4 puffs q30-60min, then ↓ to 2-4 puffs q3-4h 6. Ipratropium: 4-6 puffs q4-6h7. Flovent: 88-220 mcg twice daily (max: 880 mcg twice daily)8. Serevent: 2 puffs bid 9. Guaifenesin: 100-400 mg PO q4-6h for cough and clearance of the secretion 10. Consider using antibiotics (see pneumonia protocols)11. Chest physiotherapy (controversial) Recommended Antibiotics in Acute Exacerbation of COPD Augmentin: 875 mg PO bid TMP/SMX DS: PO bid Amoxicillin: 500 mg PO bid Doxycycline: 100 mg PO bid Levofloxacin: 500 mg PO bid Ciprofloxacin: 500 mg PO bid Cefuroxime: 500 mg PO bid Cefprozil: 500 mg PO bid Cefpodoxime: 200 mg PO bid Loracarbef: 400 mg PO bid

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PULMONOLOGY 263 TABLE 8-3: Diagnosis: PE Disposition Unit Monitor Vitals Cardiac monitoring Neuromonitoring Diet Heart-healthy Fluid IV access O 2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC, BMP, Mg, PT/PTT/INR, ABG, troponin Radiology and cardiac studies CXR (PA and lateral), venous Doppler (lower extremity), ECG, spiral CT V-Q scan if contraindication to spiral CT or pregnancy, ?pulmonary angiography ?Impedance plethysmography (lower extremity) ?Quantitative D dimer in patient with low probability of having PE Special tests Protein C&S, antithrombin III, ?factor V Leiden, lupus anticoagulant ?Fibrinogen, anticardiolipin antibodies, ?hypercoagulable panel, ANA Prophylaxis ? Consults ?Vascular surgery for ?inferior vena cava (IVC) filter, ?hematology/oncology, ?pulmonary (continued)

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264 PULMONOLOGY Nursing Pulse oximeter, stool guaiac, SCD Avoid ? Management See Management: PE Wells' Criteria for PE (Modified) Score Clinical symptoms of DVT 3Other diagnosis less likely than PE 3Heart rate >100 1. 5Immobilization or surgery in past 4 weeks 1. 5Previous DVT/PE 1. 5Hemoptysis 1Malignancy 1 Score Probability of patient having PE <2 Low 2-6 Moderate >6 High Source: Reproduced from Dr. Philip Wells, M. D., Msc., with permission. Management: PE 1. If hemodynamic instability or extensive DVT consider pulmonary embolectomy or thrombolytics (t PA/streptokinase) (check fibrinogen before starting thrombolytics) t PA, 100 mg IV over 2 hrs then heparin infusion, 15 units/kg/ hr (keep PTT 1. 5-2. 0 control) or streptokinase, 250,000 units IV over 30 mins then 100,000 units/hr × 24-72 hrs then heparin infusion, 15 units/kg/hr (keep PTT 1. 5-2. 0 control) (continued)TABLE 8-3: Diagnosis: PE (Continued)

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PULMONOLOGY 265 TABLE 8-3: Diagnosis: PE (Continued) 2. If hemodynamically stable Heparin: bolus 80 units/kg IV then 18 units/kg/hr, √ PTT 6 hrs after starting infusion (keep PTT 1. 5-2. 0 control) or Enoxaparin (Lovenox): 1 mg/kg SQ q12h or 1. 5 mg/kg SQ daily 3. Start warfarin (Coumadin): 5-10 mg PO daily (maintain INR 2-3) when PTT becomes therapeutic 4. IVC filter (indicated in patient who has contraindication to anticoagulant or patients with recurrent PE or massive PE) 5. Pain management (see Chapter 12)6. Ranitidine: 150 mg PO bid PRN

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266 PULMONOLOGY TABLE 8-4: Diagnosis: Tension Pneumothorax Disposition Unit Monitor Vitals Cardiac monitoring Diet Regular Fluid Heplock (flush every shift) O2 100% O2 Activity Bedrest Dx studies Labs CBC with differential, ABG Radiology and cardiac studies Serial CXR (AP and lateral), ECG, ?CT of chest Prophylaxis ? Consults Pulmonary, ?cardiothoracic surgery Nursing Continuous O 2 saturation Avoid ? Management 1. Insert 16-to 19-gauge cannula at second intercostal space and midclavicular line over superior aspect of the rib and attach three-way stopcock and 100-m L syringe followed by thoracostomy tube 2. Thoracotomy tube (16-22 French): insert at fourth, fifth, or sixth intercostal space at midaxillary line and connect underwater seal 3. Treat recurrent pneumothorax with pleurodesis Intrapleural doxycycline, 5 mg/kg in 50 m L NS; premedicate patient with a benzodiazepine and infuse lidocaine, 4 mg/kg in 50 m L NS intrapleurally before doxycycline or Intrapleural talc, 5 g in 250 m L NS (respiratory depression has been reported)

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PULMONOLOGY 267 TABLE 8-5: Diagnosis: Pleural Effusion Disposition Medical floor Monitor Vitals Cardiac monitoring Diet Regular Fluid Heplock (flush every shift) O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs CBC with differential, BMP, calcium, Mg, LFT, amylase, lipase Rheumatoid factor, ANA, ESR Radiology and cardiac studies CXR (PA and lateral), thoracocentesis, spiral CT, bronchoscopy Special tests PT/PTT, pleural fluid analysis (see below) Suspicion of pancreatitis, esophageal rupture: amylase Chylous fluid: TG levels Cryptococcal and Histoplasma antigen Tumor markers: carcinoembryonic antigen; complement C3, C4; α 1-antitrypsin Suspicion of SLE: ANASuspicion of TB: PPD, Serum Quanti FERON-TB Test and Quanti FERON-TB Gold Test Quanti FERON-TB Test for latent TB infection Prophylaxis DVT (continued)

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268 PULMONOLOGY Consults Pulmonary Nursing Pulse oximeter, stool guaiac Avoid ? Management Chest drain; perform pleurodesis in recurrent cases Use any of the following when performing medical pleurodesis: tetracycline and bleomycin or doxycycline or minocycline or mepacrine Pleural Fluid Analysis Orders Tube 1 Tube 2 Tube 3 Tube 4 LDH Gram stain Cell count Cytology Protein C&S Differential p HGlucose Fungal C&S Adenosine deaminase (TB) Amylase AFBTG (continued)TABLE 8-5: Diagnosis: Pleural Effusion (Continued)

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269TABLE 8-5: Diagnosis: Pleural Effusion (Continued) Pleural Fluid Analysis Fluid Transudate Exudate Transudate Exudate Protein <3 g/d L >3 g/d L CHF PE, pulmonary infarction LDH <200 U/L >200 U/L Cirrhosis Infection/TBSpecific gravity <1. 016 >1. 016 Nephrotic syndrome Malignancy Fluid:serum protein ratio <0. 5 >0. 5 Hypoalbumin Collagen vascular disease Glomerulonephritis Esophageal rupture/trauma Fluid:serum LDH ratio <0. 6 >0. 6 Constrictive pericarditis Hypothyroidism Atelectasis Pancreatitis Note The following exudates can present as transudates: malignancy, PE, sarcoid The following transudate can present as an exudate: CHF Hemothorax: pleural fluid hematocrit:serum hematocrit ratio >0. 5 (50%) Chylothorax: TG >110 mg/d L If pleural fluid p H <7. 2 may have possible empyema (continued)

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270 PULMONOLOGY TABLE 8-5: Diagnosis: Pleural Effusion (Continued) Light's Criteria for Diagnosing Pleural Effusion Exudate (Yes to One Criterion Means It Is an Exudate), 98% Sensitive and 83% Specific Pleural total protein/serum total protein >0. 5 Pleural LDH/serum LDH >0. 6 Pleural LDH more than two-thirds of the upper limit of normal for serum LDH Note: With patient suspected of transudate but meeting Light's criteria (e. g., CHF patient recently diuresed), subtract serum albumin from pleural albumin. If it is <1. 2 mg/d L, then effusion is exudates. Source: From Light RW, Mac Gregor MI, Luchsinger PC, et al. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med 1972; 77:507-513, with permission.

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PULMONOLOGY 271 TABLE 8-6: Diagnosis: Hemoptysis Disposition Unit Monitor Vitals, check H&H q2-4h initially, then q4-8h Cardiac monitoring Diet NPO Fluid Initially resuscitate NS/LR (wide open to 125 m L/hr), then place on MIVF ?Blood transfusion O2 ≥2 L O2 via NC; keep O2 saturation >92% Activity Bedrest Dx studies Labs H&H q2-4h initially, then q4-8h, CBC, BMP, LFT, type and cross PRBC PT/PTT/INR, NG aspirate guaiac, fibrinogen, stool guaiac, PPD, ?BNP Sputum Gram stain and C&S sputum, AFB Cx, UA, 24-hr sputum production Radiology and cardiac studies EGD, CXR (PA and lateral), CT of chest Bronchoscopy when stable, bronchial arteriography Special tests Upper GI series with small bowel follow-through, ?colonoscopy, ?bronchoscopy ?V/Q scan, ?AFB, ?sputum fungal and cytology, ?ABG ?Anti-glomerular basement antibodies, ?rheumatoid factor, ?complement ?ANCA, hemosiderin-laden macrophage (continued)

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272 PULMONOLOGY Prophylaxis PPI Consults Pulmonary, GI, thoracic surgery Nursing NG tube (patient with hematochezia to evaluate upper GI bleeding); monitor urine output Avoid Heparin, Coumadin, NSAIDs, ASA Management Transfuse 2-4 units PBRC if profuse bleeding or low H&H Ranitidine, 50 mg IV q6-8h, or famotidine, 20 mg IV q12h, or pantoprazole (Protonix), 40 mg IV bid If high INR vitamin K, 10 mg IV/SQ daily, and have FFP, 2-4 units, ready Variceal bleed Octreotide IV bolus: 25-50 mcg followed by continuous IV infusion of 25-50 mcg/hr or Vasopressin: 20 units IV over 20-30 mins, then 0. 2-0. 3 unit/min for 30 mins, then ↑ by 0. 2 unit/min until bleeding stops or max: 0. 9 unit/min Nitroglycerin paste, 1 inch q6h off qh, or nitroglycerin, 10-30 mcg/min infusion (50 mg in 250 D 5W)TABLE 8-6: Diagnosis: Hemoptysis (Continued)

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273 9 Rheumatology OUTLINE 9-1. Gout/Pseudogout 274 9-2. Giant Cell Arteritis (Temporal Arteritis) 2779-3. SLE 279

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274 RHEUMATOLOGY TABLE 9-1: Diagnosis: Gout/Pseudogout Disposition Medical floor Monitor Vitals Diet Low-purine diet Fluid Heplock (flush every shift) O 2 PRN Activity Bedrest with BRP and OOB to chair Dx studies Labs Serum and urine uric acid level, CBC with differential, BMP, Mg, calcium, PO 4 , TSH UA, urine R&M, 24-hr urine collection for uric acid, LFT, ESR Ferritin, iron, transferrin Radiology and cardiac studies X-ray of joint involved (may show subcortical bone cyst) Special tests Aspirated synovial fluid analysis: Gram stain, cell count, glucose, light and polarized micrography for crystals, protein, C&S, 24-hr urine for uric acid Gout = monosodium urate monohydrate, negative birefringent crystals (needle shape) Pseudogout = calcium pyrophosphate crystals, weakly positive birefringent polymorphic crystal (rhomboidal shape) Prophylaxis ? Consults ?Rheumatology, ?surgery Nursing Elevate joint involved if possible (continued)

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RHEUMATOLOGY 275 Avoid Purine-containing products: meats, beans, peas, spinach, ETOH, liver, sweetbreads, diuretics, ASA, pyrazinamide, ethambutol, cyclosporin A Management See below Note: Urine uric acid <600 mg/24 hrs considered undersecretor Acute treatment options for gout and pseudogout 1. Indomethacin: 25-50 mg PO q6h × 2 days, then 50 mg tid × 2 days, then 25 mg tid or 2. Ketorolac (Toradol): 30-60 mg IM, then 15-30 mg IM q6h/10 mg PO tid-qid or 3. Ibuprofen: 800 mg, then 400-800 mg PO q4-6h or Note: Avoid NSAIDs in renal failure 4. Etoricoxib: 120 mg PO daily5. Methylprednisolone, 125 mg IV × 1 dose, then prednisone, 40-60 mg PO daily × 5 days, then taper Note: High-dose prednisone is usually tapered after 2-3 days 6. Colchicine: 0. 5-0. 6 mg PO 2 tablets followed by 1 tablet qh until relief (max dose of 9. 6 mg/24 hrs), then 0. 5-0. 6 PO daily-bid (not commonly used) 7. Pain management is essential Chronic management of hyperuricemia Overproducers: allopurinol, 300 mg PO daily, may ↑ to 100-300 mg bid-tid q2weeks (max: 3 g/day) (Side effects: rash, leukopenia, thrombocytopenia, diarrhea, drug fever) (continued) TABLE 9-1: Diagnosis: Gout/Pseudogout (Continued)

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276 RHEUMATOLOGY Underexcreters: Probenecid: 250 mg PO bid, ↑ 500 mg bid after 1 week, then ↑ by 500 mg q4weeks Sulfinpyrazone: 50 mg PO bid ↑ to 100-200 mg bid-tid q2weeks (max: 800 mg/day) Note: Ineffective for chronic tophaceous gout TABLE 9-1: Diagnosis: Gout/Pseudogout (Continued)

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RHEUMATOLOGY 277 TABLE 9-2: Diagnosis: Giant Cell Arteritis (Temporal Arteritis) Disposition Unit Monitor Vitals Neuromonitoring Diet Regular Fluid Heplock (flush every shift) O 2 PRN Activity Bedrest Dx studies Labs CBC with differential, ESR, CRP, LFT, ?fibrinogen Radiology and cardiac studies ?Temporal arteriography, ?color duplex ultrasonography of the temporal artery ?Head CT/MRI Special tests Temporal artery biopsy Prophylaxis ? Consults Rheumatology, surgery for biopsy Nursing ? Avoid ? Management Severe symptoms (e. g., vision loss): methylprednisolone, 250 mg IV q8h daily × 3-5 days Mild symptoms: prednisone, 1 mg/kg PO daily, then taper Consider using cyclosporine-azathioprine or cyclosporine-methotrexate combination as a steroid-sparing recipe for steroid-resistant cases (efficacy unproved) Low-dose ASA may be useful (continued)

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278 RHEUMATOLOGY Calcium and vitamin D supplement due to chronic use of steroid and risk of osteoporosis Giant Cell Arteritis History Headache Jaw/tongue claudication Arthralgia/arthritis Anorexia/weight loss Vision disturbance Myalgia Physical examination Temporal artery tenderness, erythema, swollen, and warm Vision disturbance TIA/stroke Scalp tenderness TABLE 9-2: Diagnosis: Giant Cell Arteritis (Temporal Arteritis) (Continued)

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RHEUMATOLOGY 279 TABLE 9-3: Diagnosis: SLE Disposition Medical floor Monitor Vitals ?Neuromonitoring Diet No salt and low-psoralen diet Fluid Heplock (flush every shift) O 2 PRN Activity Up ad lib, BRP, OOB to chair Dx studies Labs CBC with differential, BMP, Mg, PO 4 , calcium, LFT, PT/PTT/INR, ESR, CRP, UA, ANA Radiology and cardiac studies CXR (PA and lateral), ECG Special tests Complement CH50, C3, C4, lupus erythematosus cell preparation, Coombs' test, lupus anticoagulant Anticardiolipin antibody, antinuclear cytoplasmic antibody, DNA binding Rheumatoid factor, 24-hr urine for Cr Cl and protein If ANA positive check anti-DS DNA, anti-Sm, anti-Ro, anti-La, anti-U1-RNP If drug-induced SLE suspected check antihistone antibody Prophylaxis Influenza (flu) and pneumococcal vaccine Consults Rheumatology (continued)

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280 RHEUMATOLOGY Nursing ? Avoid Procainamide, quinidine Management See Management: SLE Classification Criteria for SLE At least four of the following 11 disorders must be present to diagnose patient with SLE: Malar rash Discoid rash Photosensitivity Oral ulcers Arthritis Serositis Renal disorder Neurologic disorder Hematologic disorder Immunologic disorder ANA Source: Adapted from Tan EM, Cohen AS, Fries JF, et al. The 1982 revised criteria for classification of systemic lupus erythematosus. Arthritis Rheum 1982; 25:1271-1277, with permission. Management: SLE Methylprednisolone, 500 mg IV q12h × 3-4 days, then prednisone, 50 mg PO daily or Prednisone: 80-100 mg PO daily ( ↑ up to 300 mg/day) Maintenance dose: 10-20 mg PO daily/20-40 mg every other day (continued)TABLE 9-3: Diagnosis: SLE (Continued)

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RHEUMATOLOGY 281 TABLE 9-3: Diagnosis: SLE (Continued) Mild disease associated with arthritis, dermatologic changes, and serositis Hydroxychloroquine: 200-600 mg PO daily Methotrexate Arthritis, arthralgia, and myalgia Ibuprofen: 400 mg PO qid Indomethacin: 25-50 mg PO tid-qid Mild nephritis Azathioprine (steroid-sparing agent) Severe nephritis, vasculitis, or CNS disease Cyclophosphamide Renal disease Cyclosporine Mycophenolate

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283 10 Toxicology OUTLINE 10-1. Poisoning 284 10-2. Acetaminophen Overdose 28610-3. ETOH Withdrawal 29210-4. Anticoagulant Overdose 29710-5. ASA (Salicylate) Overdose 29910-6. Benzodiazepine Overdose 30210-7. Carbon Monoxide Poisoning 30410-8. Cocaine Abuse 30610-9. Digoxin Toxicity 309 10-10. Ethylene Glycol Overdose 31210-11. Iron Overdose 31410-12. Lead Overdose 31610-13. Methanol Overdose 31810-14. Opioid Intoxication (Heroin, Morphine, Meperidine, Fentanyl)320 10-15. Opioid Withdrawal (Heroin, Morphine, Meperidine, Fentanyl)322 10-16. Organophosphate Intoxication 324 10-17. Theophylline Overdose 32610-18. TCA Overdose 32810-19. Toxins and Antidotes 330

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284 TOXICOLOGY TABLE 10-1: Diagnosis: Poisoning Life-threatening poisoning Hemodialysis can be useful with the following poisoning: Ethylene glycol Salicylate Lithium Theophylline Methanol Charcoal hemoperfusion can be useful with the following poisoning:Theophylline Salicylate Phenobarbital Paraquat Activated charcoal is ineffective for the following: ETOH Lithium Iron Absolute contraindications to charcoal is corrosives Poisoning (general management) 1. Stabilize patient (ABCs) 2. Consider elective intubation in comatose patient3. Call poison control 4. IVF if patient hypotensive5. Oxygen6. Thiamine7. Glucose8. Naloxone9. Monitor vital signs and mental status The following drug overdose requires level to determine severity of overdose and treatment options: Acetaminophen Ethylene glycol Methanol Arsenic Iron Salicylate Carbon monoxide Lead Theophylline (continued)

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TOXICOLOGY 285 Digoxin Lithium Poisoning toxidrome Stimulants Depressants Anticholinergics Antidepressants Amphetamines Cholinergics Cocaine Narcotics Sedative withdrawal Sedatives Signs and symptoms Agitation Miosis Fever Mydriasis Hyperreflexia Respiratory depression HTN Seizure Hyporeflexia Sweating Lethargy leading to coma Tachycardia TABLE 10-1: Diagnosis: Poisoning (Continued)

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286 TOXICOLOGY TABLE 10-2: Diagnosis: Acetaminophen Overdose Disposition Unit Monitor Vitals Cardiac monitoring Electrolyte monitoring Neuromonitoring Diet NPO Fluid Heplock (flush every shift) O 2 PRN Activity Bedrest Dx studies Labs Acetaminophen (Tylenol) level q4h until zero, PT/PTT/INR, BMP, calcium, Mg, PO 4 , LFT Amylase, lipase, CBC, ammonia, lactic acid Radiology and cardiac studies CXR (PA and lateral), ECG Special tests Serum/urine toxicology screen, serum ASA, ETOH level ?Charcoal hemoperfusion, ?hemodialysis Plot level on Rumack-Matthew nomogram to assess severity (see below) Prophylaxis ? Consults Poison control, nephrology for charcoal hemoperfusion, ?psychiatry Nursing I/O, aspiration precautions, seizure precaution, suicide observation, pulse oximeter (continued)

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TOXICOLOGY 287 NG tube with suction, gastric lavage Avoid Tylenol-containing products, liver-toxic agents (statins, anticonvulsants) Nephrotoxic agents (if acute renal failure), heparin, warfarin, ASA Management Gastric lavage: if ingestion <1 hr, insert NG tube, lavage with 150-200 m L of NS (if <5 yrs: 10 m L/kg) Activated charcoal with recent ingestion (1 g/kg PO or NG q2-4h); remove charcoal via NG suction before administering N -acetylcysteine (NAC) Indication of NAC administration Serum acetaminophen level greater than “hepatic toxicity” line of the Rumack-Matthew nomogram Single ingestion of >150 mg/kg (or 7. 5 g in an adult) by history and for whom results of a serum level will not be available within 8 hrs from the time of ingestion Unknown time of ingestion and a serum acetaminophen level >10 mcg/m L Laboratory evidence of hepatotoxicity (from mildly elevated aminotransferases to fulminant hepatic failure) and history of excessive acetaminophen ingestion NAC Dosing NAC using above nomogram (best if used within 8 hrs) Use NAC protocol for further management 1. 72-hr U. S. Food and Drug Administration-approved protocol: PO only 2. 48-hr IV bolus protocol3. 20-hr infusion protocol: IV (continued) TABLE 10-2: Diagnosis: Acetaminophen Overdose (Continued)

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288 TOXICOLOGY TABLE 10-2: Diagnosis: Acetaminophen Overdose (Continued) 72-hr NAC oral protocol 20-hr NAC IV protocol 140 mg/kg loading dose 150 mg/kg over 1 hr 70 mg/kg q4h × 68 hrs 50 mg/kg over 4 hrs or 12. 5 mg/kg/hr × 4 hrs 48-hr NAC IV protocol 100 mg/kg over 16 hrs or 6. 25 mg/kg/hr 140 mg/kg loading dose70 mg/kg q4h × 12 hrs If INR >1. 5 vitamin K, 5 mg PO/IM/SQ; if unresponsive consider FFP If INR >3 consider FFP, 2-4 units If nausea see Chapter 12 Source: From Prescott LF, Park J, Ballantyne A, Adriaenssensm P. Treatment of paracetamol with N-acetylcysteine. Lancet 1977;2:432-434, with permission; and Smilkstein MJ, Bronstein AC, Linden C, et al. Acetaminophen overdose: a 48-hour N-acetylcysteine treatment protocol. Ann Emerg Med 1991;20:1058-1063, with permission. Management of Adverse Reaction to IV NAC Reaction Treatment for adult Treatment for pediatric Flushing Continue NAC without treatment Continue NAC without treatment Urticaria Diphenhydramine, 50 mg IV1 mg/kg up to 50 mg Angioedema Discontinue (D/C) NAC diphenhydramine, 50 mg IV, and restart NAC at slower rate in 1 hr if symptoms resolve D/C NAC diphenhydramine 1 mg/kg up to 50 mg and restart NAC at slower rate in 1 hr if symptoms resolve (continued)

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