ICU
UCSD ICU Guide
CCM Tutorial
Chicago Medicine ICU Guide
Common ICU Rx
ABG Ninja Practice ; Acid Base Tutorial; Winters Formula; Review combined BMP + ABG problems

#. Vasopressors
Alnajjars equation of life: 1.34 x O2 sat x CO (SVxHR) x Hgb
CO: preload - contractility - afterload: fluids/lasix - inotropes (epi) - hydralazine (arterial), pressors
septic shock: preload down, ctx increase, afterload down
CHF: preload inc, ctx decreased, afterload increased

V; VI; I - types of rx for shock
inotropes: dobutamine, primacore
pressors: epi -> NE -> dopamine; vessels
vasopressin / phenylprine - vasopressor
epi/NE -> V-ctx
primacore, dobutamine -> ctx

#. Ventilation

#. Procedures / Calculations

#. ABGs: (pH 7.35-7.45)(PaO2 80-100)(PaCO2 35-45)(HCO3 22-26)(BXs ---)
Winters Formula
Al’Najjars:


#. Acid-Base

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#. Neuro
- haldol
- risperidol

#. CV:
- hydralazine: 10mg IVP PRN / TID
- labetalol:

#. Pulm
- Duonebs q4 w/ albuterol q2
- Prednisone 50mg qd x5 days PO; Decadron IV
- RSI rx:

#. GI
- Colace
- GI cocktail

#. Renal:
- UOP 0.5-1cc/kg/hr
- lasix w/ response

#. Pain

#. Tox
- Opiates : Narcan
- Benzos : flumazenil


#. PPx.
- lovenox , heparin
- H2 / PPI: prevent stress ulcers: intubated, or home regimen

#. FEN
- IVF : 1/2 D5 NS w/ 20 KCl; 40+20+10
- Na / K
- Nutrition:

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Respiratory Distress
• 1. ABG, accucheck
• 2.
• Indications for intubation: Respiratory Failure (Hypoxic or Hypercapneic) or impending.
• Try first: BiPAP vs CPAP
• After intubation: (order set; ex. fentanyl + propofol order set), CXR (placement).


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BP Management

HTN
-

Hypotension / Shock
- Happy value? goals: SBP >90; MAP >65.
- Pressors
-

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Etoh Withdrawal
- CIWA protocol : paired ativan dose to assessment
- Withdrawal peaks at 48-72hrs after last drink (key!) : agitation, anxiety, tremor, hallucinations, HA, sweats.
- IVF: bolus 1-2L then D5 1/2 NS + 20KCl at maintenance+50cc/hr + banana bag.
- Ativan 2mg IV q1hr PRN
- Szr precautions.
- SEVERE withdrawal: librium 50-100mg PO q1hr PRN; last resort = ICU precedex
- Check Mg / electrolytes - MVI (?)
- ? haldol : NO -> lowers seizure threshold, worse outcomes.

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Insulin Management
Why manage it? 40% admits w/ hyperglycemia -> poor immune response, inc infxns, thrombosis, inc CV events. Home BS goals vs inpatient? 80-110 vs 140-180/200 BS. Glucose >200-220 increasing M/M. <140 increase M/M (hypoglycemia).
Write the order?
Insulin: Long (lantus 24, NPH 12) vs Short (lispro, regular)
24hr dose - 1/2 - 1/3 as long acting --> rest as daily short acting.
1. Wt based: 0.4 U / kg /hr x 24hr. +/- 0.1U/kg
2. IV insulin /hr extrapolated. ex. 2U/hr x4hr = 12U/24hr
3. Home dose - correlate w/ home BS.
4. SSI - <40 = low; 40-100 = mid; >100 = high
Transition: lantus IM -> cont IV insulin x4hr then dc. ; run ~meal time.
Monitoring: TID + qHS - goals
Pearls > When pt goes NPO or skips meal, do you dc insulin? cont long, skip short.
> Insulin 1U drops BS 10. > A1C 6% = ~130. Each 1% inc = ~+30
> Drivers of hyperglycemia? CS (iatrogenic, stress), infection, skip DM rx, surgery/trauma
> Hypoglycemia? Insulin, NPO for procedures, poor appetite, improved diet (!) > Daily titrating up - inc 10% /day is typical. > DC metformin, PO rx
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CVA
Px: exact time onset? RFs (afib, carotids, smoking, HTN/DM, hx CVA)
DDx: seizures, migraine, tumor, metabolic
Initial w/u: CT head non-con
Ischemic (85%; 2/2 distal emboli) vs Hemorrhagic (15%) vs TIA (<24 hr; typically <15 min resolution; neg CT)

1. Figure out issue: CT head non-con; possible MRI/MRA 24 hrs later. 

- w/u: trops/CKMB; EKG; UDS; CBC/CMP; 
2. Treatment the CVA
- tPA: ischemic <3hr (up to <4.5hr) and CT neg bleed and bring BP <185/110; (c/i: INR>1.7/PTT>40, heparin within 48hr, 3 mo hx 
CVA/hemorrhage, recent surgery CNS/spine). Time window may be increased if at large-vessel lesions w/ very poor prognosis. 
     > tPA dose: 0.9mg/kg (max 90mg) 10% bolus + 90%/hr. 
- anti-platelet: ASA 325 (+dipyramidole = aggrenox) within 24-48hrs. 
- no AC within 24 hrs; after 24 hrs is ok!
- BP: permissive HTN <220/120 or sx. 
- fluids: isotonic. mannitol if w/ edema.
- NO heparin/AC; NO hypothermia evidence. 
- neurosurg / IR: endovascular (lysis/thrombectomy) not better than IV tpa?
3. Secondary Prevention
- Etio w/u: carotid US, 2D echo, tele/holter monitor, lipid panel, TSH, A1C,counseling. 
- antiplatelet: ASA (dec mortality, recur) - 325mg then 81mg qd. 
     > ASA + dipyrimadole > ASA alone, plavix > ASA alone. cilostazole > ASA . ASA + plavix = ASA.
- AC: not routine. only if afib; hold off 2-4 wks if large CVA. 
- BP goals: <120-140 SBP
- statin: reduce recurrrence: LDL goal <70. atorvastatin 80mg qd .
- fluoxetine: ?improved motor after 3 mo. 


CVA Admit order-set
#. NIH Stroke Scale: on admit
#. Dysphagia screen prior to PO: on admit
#. VTE/DVT PPx (by end hospital day 2): MUST be prior to MN day 2; meds/SCDs - docutment c/i.
#. *Anti-thrombotic Tx (by end hospital day 2): by MN day 2; PR ok .
#. *AC Tx (if Afib/Aflutter): current or w/ hx. document c/i.
#. *Lipid panel: within 48hrs; or documented lipid panel within past 30 days
#. PT/OT/ST
#. Smoking Cessation: document it.
#. Stroke Education: must include 5 RFs (risk factors, si/sx CVA, call 911 if w/ sx, f/u MD, information all rx)
#. *DC on anti-thrombotic
#. *DC on AC (afib/aflutter)
#. *DC on statin (if LDL>100)
#. *DC on intensive statin tx: lipitor 80; crestor 40; zocor 80; vytorin 10/80 qd.
* = not for hemorrhagic CVA.

Hemorrhagic CVA: 

Etio: HTN, tumor, trauma, AVM/aneurysm, etc. 
50% mortality. neurosurgery consult. 
SBP goal: <140. 
Management
- Coagulopathies: Vit K / FFP; keep INR <1.4, plates >100k. 
- HOB 30-45 deg. 
- BP control : IV nicardipine or labetalol gtt.
- SAH: surgical clip v coil. 
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CHF: acute decompensation HF
. px: dyspnea (at rest, worsen), rales, hx CAD/ACS
. trigger: ACS, afib, PE, PNA/infxn, xs Na intake, rx noncompliance, anemia, HTN urgency
. w/u: (CXR, BNP) trop/ekg, BUN/Cr/UOP
. monitor: VS, daily wts, tele 24-48 hrs, I/Os, BMP w/ K + Mg
. tx: hypoxia (O2 mask high-flow), diurese (lasix 40 or 2x home dose, bumex; goal 1-1.5L or kg out/day; fx IV=PO), vasodilation (nitrates IV 5-10 mcg/min); vasodilation faster to reduce sx, then diurese out; ADHF no BB (or 1/2 dose), no ACEi - risk hypoTN; if hypoTN (inotrope, pressers; short-term maintain perfusion); daily Na 2g + fluids 2L limit; seated; ø morphine (inc M/M, low ab
. monitor: fluid status (daily wts, I/Os), daily K + Mg (cuz lasix), telemetry x24-48hrs
. tx goals acute (sx, hemodynamics, O2 sat) vs chronic (M/M, sx = ACEi,BB)
. when stable: BB, ACEi (improve long-term M/M), advanced NYHA (III-IV) spironolactone, Na limit, f/u BMP
. dc criteria: address trigger, ok volume status, document LVEF% (low EF = ACEi, BB), PT/OT ADLs, PO diuresis; main reason for re-admit is inadequate diuresis

ACS/CAD
• CP: 1. substernal CP appropriate quality + duration, 2. w/ exertion/stress, 3. relief rest +/- nitro;
• Typical (3/3) vs. atypical (2/3) vs. noncardiac (0-1/3)
• CAD equiv: CKD, DM, atherosclerosis (carotid, peripheral aa, AAA)
• CAD RFs: M, HTN, HLD, obesity, fhx (M<50, F<60)
• w/u: troponins x3 q4-6hr, ekg s; CXR/CT; TIMI Score
• cardiac ddx: angina vs unstable angina / NSTEMI vs STEMI; r/o AAA, aortic dissection, pulm, demand ischemia
• STEMI: Door-2-balloon 120 min, window <12hr
• UA/NSTEMI: anti-ischemic/plates/coag; (hep-stat-ASP-BB!)
     - anti-ischemic: morphine, O2, nitro SL, metoprolol 25-50mg (if c/i- CCB)
     - anti-platelets: ASA 325 -> 81, plavix 300-600 -> 75
     - anti-coagulation: UFH 60U/kg IVB (max 4k U) -> 12 U/kg/h x48hr; lovenox 1mg/kg SC BID (qd if CrCl <30) x2-8 days
     - other: statins
     - exceptions: R-MI (c/i nitro, IVF pre-load), bronchospasms / brady / heart blocks (c/i BB)
• Dc: manage RFs, see cards recs; see UA/NSTEMI low risk vs high risk algo. 
• ASCVD score: ACS event risk /10 yr; gender, total Chol, HDL, smoker, SBP, +/- antiHTN rx.

Afib w/ RVR
• Trigger: PIRATES (PNA/PE, infxn, rheumatic fvr, anemia, thyrotoxicosis, etoh, sepsis)
• Goal is rate control: target <110 (very strict control ?inc M/M)
• w/u: EKG/trop/CXR, etoh, TSH, CBC, echo, d-dimer
• Tx: RATE + RHYTHM + ANTI-coagulation
#1= diltiazem, #2= metoprolol
- diltiazem 0.25mg/kg IV over 2min then 10-15 mg/hr drip (titrate w/ BP and HR); convert to PO 120-360 mg when stable
- metoprolol 5 mg/2 min - repeat q5min x3 (mild c/i if asthma)
- digoxin (must have cards, attending around) 0.25 mg q2hr (can take hrs to work!)
• Anti-coagulation : CHADSVASC2 (CHF,HTN,>75yo <2pt>,DM,CVA/TIA hx <2pt), vasc dz , 65-76yo, Sex F)
- 0 (low; ø - but still risk - option ASA 81), 1 (mod; ASA81 - warfarin INR 2-3), >2 (warfarin, rivaroxaban, dabigatran, apixaban)
• If recurrent and sx fib, can cardiovert (need 48hr..?) / rx convert.

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Sepsis Shock
• Surviving Sepsis Guidelines
• SIRS / Sepsis / Severe / Shock / MODS: MS, CV instability, ARDS, GI peritonitis/ischemic, shock liver, AKI, subclinical DIC
• SIRS ddx: trauma, burns, pancreatitis, etc.
• 6o min: Sepsis Six: IVF, blood cx, IV abx, O2, UOP, CBC / lactate. 
• Labs: CBC/CMP; lactic acid (hypo perfusion); blood cx x2; all >48hr lines dc + cx; ß-D-glucan / manna (candida); procalcitonin (guide de-escalation); 
• Abx: typically 7-10 days (empiric 3-5 days); vanc+zosyn (vanc+imipenam/meropenam)(vanc+levo/cipro+clinda)
- special cases: neutropenia (<500), splenectomy, IV drug use, HIV/AIDS - look-up causes 
• CV rx: vasopressors (NE; epi, vasopressin) or inotropes (dobutamine 20 mcg/kg/min - CF/hypoperfusion); CS is last line (hydrocortisone 200mg/day — only in septic shock/ICU). 
• Ventilation: sepsis ARDS: TV 6cc/kg (lower than nl 12cc/kg), +PEEP; minimize IVFs. 
• Sepsis source: 50% pulm; UTI, GI
• IVFs: NS/LR - 30cc/kg/hr bolus; have d/c time in mind - 2-5L total
- goals: MAP>65 mmHG, UOP >0.5cc/kg/hr, lactate to nl
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HTN: 
Clonidine TID is great if pt compliant; danger is from rebound HTN. Other option is clonidine patch Catapres tts2
PRN rx: labetalol, hydralazine
Amlodipine: 
BB: metoprolol cardio-centric - no effect on BPs really; can use atenolol, nadolol instead
Metoprolol and ASA really reduce M/M in patients in long-term. Nice thing about metoprolol is that it will reduce M/M in CAD/ACS pts

HTN Emergency
• Danger si: CP/back pain (MI, dissection), SOB (pulm edema), HA, vision, n/v, MS (subarachnoid bleed, HTN encephalopathy), oliguria/ARF
• Tx: goal reduce MAP by 10% in 1st hr, then 15% q 2-3 hr
• Agents: 
- Hydralazine: 5-10 mg IVP (onset 10 min, 1-4 hr)
- Labetalol: 20-80mg IVP q10 min (onset 5-10min, 3-6hr)
- others: - Nitroglycerin, Na nitroprusside, enalaprilat (vasotec), esmolol


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COPD
• Exacerbation: inc sputum, inc cough, inc dyspnea; inc O2 need, ?hx intubation
• Risks: age, comorbidities (cardiac), GERD, pulm HTN, sputum
• Single best predictor: previous exac
• GOLD Scoring:
• Trigger: #1 = infection, others: environmental, medical non-compliance, cardiac (CHF)
• W/u: CXR (r/o other etios), EKG/trop, ?BNP, ?ABG
• BOCS Mg: B-agonist, O2, CS, Mg, ipratropium. 
• Tx: O2 (88-92%; if not rapidly help - consider other etios ex. PE)
- systemic CS: prednisone 40-60mg x5-14 days (or IV solumedrol); IV = PO
- #1: SABA +/- ipratropium; albuterol 2.5mg / atrovent 0.5mg inhaler q1-2hrs
- Abx: levaquin 750mg qday x 7 days. 
- Mg bolus + gtt as 2nd line. 
- Pneumovax, fluvax
• Decompensation? (words#, RR>25, - if PacO2 inc, PaO2 dec (<55) -> BiPAP - ?intubation)