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Operations- Ross
- Provide discharge instructions that coincide with chief complaints, as well as put chief complaints that are relevant.
- If you have a code aorta (ascending aortic dissection) dial 8008 and select code aorta, don’t page cardiothoracic surgery etc.
- Descending aortic dissections managed by vascular here at ULH
- Cerner Camera Capture
- 2 phones available (1 in room 9, 1 at attending desk)
- Log into cerner on phone using “Cerner Camera Capture” app
- Put in MRN
- Put in location folder
- Will find picture in multimedia manager on left hand menu list
- Code Green
- Imminent Delivery
- Road Rash
- If truly severe consider calling trauma and/or burn nurse to help get wound care managed
- Can write for more than 3 days of opioid pain meds if medically justified
- New Kasper
- When in patient chart click on ED provider view
- Click on Kasper within white menu list on the left
- Dispo Times
- NES if waiting for recommendations for multiple hours consider discussing with ED attending about escalating to NES attending.
- Ortho should put in bedslip within approx. 2 hours
PEM Endocrine- Kopp
- DKA in Peds
- 45kg child slow fluid resuscitation
- 1.5x maintenance fluid rate
- 45kg fast fluid resuscitation
- 2x maintenance fluid rate
- With resuscitation, if K is greater than 5 do not include K in initial fluid resuscitation
- Add in dextrose when there is a decrease in glucose of >100 in 1 hour
- Keep in mind to continue to check glucose every hour
- Bicarb administration not recommended… except for life-threatening hyperkalemia or acidosis with pH <6.9 with evidence of compromised cardiac contractility
- Avoid intubation
- Increased CO2 > decreased pH CSF > cerebral vasodilation > cerebral edema
- Make sure you match RR if you do intubate, and be quick to bag during RSI, 45 sec of apnea can be drastic
- Hypoglycemia
- Rule of 50
- 50/D50=1ml/kg
- 50/D25=2ml/kg
- 50/D10=5ml/kg
- 50/D5=10ml/kg
- Recommend D10 or D5 fluids for correcting hypoglycemia
- D50/D25 > will blow small IVs which is most peripheral IVs in kids
- Rule of 50
- Inborn errors of metabolism
- Most will have a cheat sheet
- D10 45% NS with electrolytes run at 1.5x maintenance fluid
- Dextrose fluids is mainstay
- Adrenal insufficiency
- Stress dose steroids
- 3x base dose steroids
- Hydrocortisone (IV or IM)
- 0-3: 25mg (Can pick kid up with 1 arm)
- 3-12: 50mg (Can pick kid up with 2 arms)
- >12: 100mg (Too big to pick up)
- Stress dose steroids
- Diabetes insipidus
- DDAVP IN, IV, SubQ
- Goal of lowering Na
Pharm Lectures
- Magnesium
- Normal level 1.7-2.3
- Hypomagnesia (<1.5)
- Causes: poor nutrition chronic EtOH, excessive GI or renal loss, medications (thiazides etc.
- Symptoms
- Cramps
- Fatigue
- Vertical nystagmus
- Ataxia
- Seizures
- Dysrhythmias, QTc prolongation
- Tx: Mag oxide 300mg tablet, Mag sulfate 1-4G IV
- Torsades de pointes> 2G IV over 15 min
- V fib > Mag 2G IV over 2-5 min
- Hypermagnesemia (>4)
- Cause: overuse of mag supplements/laxatives
- Symptoms
- Muscle weakness
- Absence of deep tendon reflexes
- Mag Pearls
- Predominantly intracellularà when serum levels are low= intracellular is likely very depleted
- Potassium and magnesium levels are linkedà if difficulty repleting potassium check a magnesium level and replace
- Potassium
- Normal Range 3.5-5.0 (Cards patients 4.5 goal)
- Physiologic function
- Action potential regulation
- Muscle contraction
- Hyperkalemia: K > 5.5 mEq/L
- Causes:
- Renal dysfunction (ESRD/AKI)/rhabdomyolysis;
- Medications (ACE inhibitors, ARB’s, potassium sparing diuretics, immunosuppression (cyclosporine, tacrolimus), trimethoprim-sulfamethoxazole (Bactrim®)
- Symptoms: EKG changes, arrhythmias
- Causes:
- Hypokalemia: K < 3.5 mEq/L
- Causes: GI losses, medications (diuretics, insulin, albuterol)
- Symptoms: Cramping, weakness, myalgias, malaise, arrhythmias
- EKG changes
-
- Hyperkalemia treatment
- Cardiac stabilization
- Calcium gluconate
- Shift K
- Regular Insulin + Dextrose, Albuterol
- Targeted Elimination
- Dialysis
- Loop diuretics
- Cation Exchange Resins/Polymer
- Cardiac stabilization
- Hypokalemia treatment
- Check and replete Mag
- 3.2-3.5 mMol/L
- 40 mEq KCl PO or per tube
- KCl IV over 1 hour x 4 doses
- 2.7-3.1 mMol/L
- 40 mEq KCl PO or per tube x 2 doses 4 hours apart
- KCl IV over 1 hour x 4-8 doses
- < 2.6 mMol/L
- 10 mEq KCl over 1 hour x 8 doses
- Phosphorus
- Normal: 2.5-4.5
- Hypophosphatemia
- Causes: Refeeding syndrome, chronic alcohol abuse, hyperparathyroidism, vitamin D deficiency, diabetic ketoacidosis (DKA) chronic diarrhea, antacids, hungry bone syndrome
| Serum Phosphorus | Replacement | Recheck Level |
| 2.1-2.5 mg/dL | 1-2 packets PhosNaK2-4 times daily15 mMolNaPhosin D5W over 2 hours | With AM labs |
| 1.6-2.0 mg/dL | 30 mMolNaPhosin D5W over 4 hours | With AM labs |
| < 1.6 mg/dL | 45 mMolNaPhosin D5W over 6 hours | Recheck 4 hours after infusion |
- Symptoms: Loss of appetite, Bone pain/fragile bones, Irregular breathing, Irritability, Fatigue/Weakness, Encephalopathy, Seizures
- Hyperphosphatemia
- Causes: Abnormal renal function (AKI/CKD), rhabdomyolysis, tumor lysis syndrome, hypoparathyroidism, hypothyroidism, phosphate containing laxatives, vitamin D toxicity, bisphosphonates, fosphenytoin.
- Treatment:
- Phosphate restricted diet (800 – 1000 mg/dL)
- Fluid resuscitation to euvolemia
- Forced diuresis (acetazolamide +/- furosemide)
- Phosphate binders: Bind phosphate in the gastrointestinal track (dosed 3 x daily with meals) à several drug interactions
- Calcium
- Normal: 8.8 – 10.4 mg/dl
- 1.10-1.30 mmol/l (ionized)
- Hypocalcemia
- Muscular
- Hyperflexia
- Fasciculations
- Cramping, myalgias
- Neuro
- Anxiety, delirium, coma
- Paresthesias
- Seizure
- Cardiovascular
- Hypotension
- Vtach
- Bradycardia, heart block
- Indications for treatment:
- QT prolongation
- Seizure, delirium, coma
- Severe Muscle cramping
- Pre-emptive in blood product transfusion
- Caution: EG toxicity, severe increase in phosphate
- Muscular
- Hypercalcemia
- Signs and Symptoms: Muscle weakness, hyporeflexia, GI (constipation, ileus, n/v), hypertension, Delirium, coma, Paresthesia
- Normal: 8.8 – 10.4 mg/dl
- Sodium
| Hyponatremia | |
| Moderate(125-130 mEq/L)Nausea / vomitingHeadache, fatigueMuscle cramps | Severe(< 120-125 mEq/L)Altered mental statusSeizuresComa |
| Hypernatremia | |
| Moderate(145 – 155 mEq/L)ThirstIrritabilityRestlessness | Severe(> 160 mEq/L)HyperreflexiaSeizuresComa |
- Hyponatremia
- Treatment for Hypotonic Hyponatremia (Serum Na <135, Serum Osm (<280 mOsm/kg)
- Hypervolemic
- Fluid restriction
- Diuresis
- Euvolemic
- Fluid restriction
- Stop offending medication
- Hypovolemic
- Stop offending medication
- Isotonic crystalloid (Saline)
- Causative meds
- SSRIs, TCAs, Antipsychotics, antineoplastics, NSAIDs, AEDs
- Hypervolemic
- Hypertonic Saline
- Indications for hypertonic Saline
- Seizure
- Confusion (use with caution and consider other etiologies first)
- Gait instability
- Coma or cerebral herniation
- Initial management
- 3% NaCl infusion 2ml/kg over 5-10 min
- If no clinical improvement > Repeat 3% bolus
- Ensure correction does not exceed 6 mEq/L in 24 hours
- What if no 3% NaCl at your facility?
- Hypertonic sodium bicarb can be used
- Push slow over 3-5 min, 2amps ~ 200 mL 3% Saline
- Hypertonic sodium bicarb can be used
- Indications for hypertonic Saline
- Hypernatremia
- Initial Labs
- BMP
- Mg, Phos
- Urine Na
- Urine Osm and/or Urine SG
- Treatment
- Hypovolemia with hypotension
- Isotonic fluids are recommended
- Normotensive Hypovolemia
- D5W or 0.45 % NaCl
- Na Correction
- Goal: restore sodium balance
- Lower Na: <10-12 mEq/L per 24hr
- Free Water Deficit
- Correct first half within 24 hours
- Correct remainder over 72 hours
- Hypovolemia with hypotension
- Diabetes insipidus
- Labs
- Serum Na > 145 mEq/L
- UOP > 200 mL/hr (sustained)
- Urine SG < 1.005
- Urine Osm < 300 mOsm/kg
- Serum Osm > 300 mOsm/kg
- Treatment
- Hemodynamically Stable:
- DDAVP (desmopressin) 1 mcg IV q8hr
- May be administered subcutaneously*
- DDAVP (desmopressin) 1 mcg IV q8hr
- Hemodynamically Unstable:
- Vasopressin continuous infusion
- Goal of Therapy:
- Maintain UOP < 200 mL/hr
- Hemodynamically Stable:
- Labs
- Initial Labs
- Treatment for Hypotonic Hyponatremia (Serum Na <135, Serum Osm (<280 mOsm/kg)