First Line Treatments - Pharm Flashcards
(254 cards)
1
Q
Tx of Ischemic Priapism?
A
Terbutaline 5-10mg PO
or 0.25-0.5 SQ or pseudoephedrine 60mg PO
2
Q
Tx of Epididymitis w/ STD suspected (<35 yrs old)?
A
Doxycycline 100mg PO BID x10-14 days
AND
AZITHROMYCIN
3
Q
Tx of Epididymitis w/ STD suspected (but PCN allergy)?
A
Doxycycline 100mg PO BID x10-14 days
AND
Azithromycin 2gm x1
4
Q
Tx of Epididymitis without suspicion for STD (>35 yrs old)?
A
Ciprofloxacin 500mg BID x10-14 days
OR Levofloxacin 750mg PO QD x10-14 days
5
Q
Tx of Appendage Torsion?
A
NSAIDs, will self resolve in 1-2 weeks
6
Q
Tx of Fournier’s Gangrene?
A
Ciprofloxacin 400mg IV
AND
Clindamycin 1.2gm IV
+/- Vancomycin 1gm IV
7
Q
Tx of Orchitis?
A
NSAIDs, ice, scrotal support
8
Q
Tx of Uncomplicated UTI?
A
Nitrofurantoin 100mg BID x5 days
(aka Macrobid)
**unless creatinine clearance <30 mL/min
9
Q
Tx of Complicated UTI?
A
Ciprofloxacin 500mg BID x5-14 days
OR
Ceftriaxone 1gm IV daily
10
Q
Tx of Complicated UTI and critically ill or septic?
A
Imipenem 500mg IV q6h
AND
Vancomycin 15-20 mg/kg q8-12 hours with or without loading dose
11
Q
Tx of Vaginal bleeding in pregnant woman?
A
If Rh(-), RhoGAM 300mcg IM
12
Q
What are the contraindications to administering Methotrexate in ectopic pregnancy?
A
- unstable or ruptured
- quant HCG >15,000 IU/L
- fetal cardiac activity
- free fluid on US
- gestational sac >3.5 cm
- liver or renal disease
- patient is breastfeeding
- patient with unreliable follow up
13
Q
Seizure prevention in preeclampsia?
A
Mg 2-4g IV load over 30 minutes, then 1g/hr
14
Q
Seizure abortive in eclampsia?
A
Mg 2-4g IV q5-10 min
Diazepam 5mg IV q 5 min OR Phenytoin 15-20mg/kg IV once
15
Q
What medication should be used for BP control in preeclampsia/eclampsia
A
Labetalol 10-20mg IV once, then double dose q10 min up to 80 mg to max 200 mg
And Hydralazine 5-10mg IV q20min as needed
16
Q
In preeclampsia/eclampsia, what is the goal BP?
A
Don’t drop BP more than 25% in first 30 min. Goal BP 140-155/90-105 within the first several hours
17
Q
When giving magnesium, what do you need to be sure to monitor?
A
Magnesium toxicity:
- diminished deep tendon reflexes
- somnolence
- dilated pupils
- decreased respiratory drive
- hypotension
- bradycardia
18
Q
In addition to hydration and correcting metabolic derangements, what is the treatment for hyperemesis gravidarumcausing hypovolemia?
A
Ondansetron (or metoclopramide)
19
Q
What is the treatment for nausea and vomiting in pregnancy that is not causing hypovolemia?
A
Prophylaxis (at night):
Doxylamine Succinate 10mg
AND Pyridoxine(B6) 10mg
(separate or combo pill)
20
Q
What is the tx for vaginitis caused by suspected herpes?
A
Acyclovir 400mg TID
21
Q
What is the tx for suspected GCC or PID?
A
Ceftriaxone 250mg IM x1
AND Doxycycline 100mg BID
22
Q
What is the tx for vaginitis caused by Trichomoniasis?
A
Metronidazole 500mg BID x7days
23
Q
What is the tx for bacterial vaginosis?
A
Metronidazole 500mg BID x7-14 days, and partner should seek treatment
24
Q
What is the treatment for uncomplicated vaginal candidiasis?
A
Fluconazole 150mg PO x1
25
What is the treatment for complicated vaginal Candidiasis (DM or recurrent infections)?
Fluconazole 150mg PO x2 (days 0 and 3)
26
What is the treatment for vaginal candidiasis in a pregnant patient?
topical cream i.e. miconazole x7days
27
What is the treatment for diverticulitis?
10-14 days PO abx:
- Cipro 500mg BID + Metro 500mg TID x 14 days
plus clear diet x2-3 days and slowly advance diet
28
What is the treatment for mild c. diff?
Metronidazole 500mg PO q8h x10 days
29
What is the treatment for severe c. diff?
Vanc 125-500mg PO q6h x10 days
30
What is the treatment for severe c. diff with complications?
Vanc 125-500 PO q6h x10 days
AND Metro 500mg IV q8h
plus surgical consultation
31
What is the treatment for abdominal pain plus nausea/vomiting?
Ondansetron 4 mg IV q8h
32
What is the 2nd line treatment for abd pain plus n/v?
Metoclopramide 10 mg PO/IV q6h
Prochlorperazine 10 mg PO/IV 6h/25 mg PR x1
Diphenhydramine 25-50 mg PO/IV q6h
33
What is the treatment for Appendicitis pain?
Morphine 0.05-0.1 mg/kg
34
What is the treatment for appendicitis nausea?
Ondansetron 4 mg IV
35
What is the treatment for uncomplicated (non-perforated) appendicitis undergoing surgery?
```
Start within ONE HOUR of surgery
- Cefoxitin 2g IV QID
or
- Ciprofloxacin 400 mg IV Q12h
PLUS Metro 500 mg IV q6h
```
36
What is the treatment for perforated appendicitis undergoing surgery?
```
Immediately start:
- Cefoxitin 2g IV QID
or
- Ciprofloxacin 400 mg IV Q12h
PLUS Metro 500 mg IV q6h
```
37
What is the treatment for perforated appendicitis undergoing surgery that is high risk?
```
Cefepime 2 g IV q12h
+ Metro 500 mg IV q8h
OR
Pip/Tazo (Zosyn) 4.5 g IV QID
OR
Imipenem 500 mg q6h
```
38
What is the treatment for acute pancreatitis?
LR 250-500 mL/hr
or LR 5-10 mL/kg/hr
given over first 24 hours
39
What is the treatment for pancreatic necrosis?
Imipenem 500 mg IV q6h
| b/c known to penetrate
40
What is the treatment for status epilepticus?
Benzos: Midazolam, Lorazepam, Diazepam
If refractory --> Fosphenytoin IV
41
What is the treatment for an agitated patient? (oral medication)
Haloperidol 5 mg PO, 0.5-1 mg PO if elderly
or Olanzanzapine 5-10 mg PO
or Lorazepam 1-2 mg PO
42
What is the treatment for an agitated patient? (injectable)
Benzos:
Lorazepam 1-2 mg IV/IM
Haloperidol 0.5-10 mg IV/IM
Ziprasidone 10-25 mg IM
43
What is the treatment for extrapyramidal symptoms?
Diphenhydramine 25-50 mg PO/IV/IM
or Benztropine 1 mg PO/IV/IM
Check EKG if on antipsychotics
44
What is the treatment for EtOH withdrawal with seizures?
Benzos:
Lorazepam - start with 2mg IV/PO q2h
up to 6-8mg IV q15-60min
45
What is the treatment for EtOH withdrawal hallucinations?
Haloperidol
or Ziprasidone
or Dexmedetomidate
Load 1mcg/kg IV over 10 min
then infusion 0.2-0.7 mcg/kg/hr
46
What is the treatment for Ibuprofen overdose (>/= 400 mg/kg)?
one dose activated charcoal
| more doses would not help
47
What is the treatment for methanol & ethylene glycol overdose/poisoning?
Fomepizole 15 mg/kg IV load then 10 mg/kg q12h
plus thiamine 100 mg IV q6h x 2 days
plus pyridoxine 50 mg IV q6h x 2 days
48
What is the treatment for methanol & ethylene glycol overdose/poisoning is pH < 7.3?
sodium bicarb to promote urinary excretion
49
What is the treatment for isopropyl alcohol poisoning?
supportive
| NO fomepizole
50
What is the treatment for peripheral vertigo?
```
Meclizine 25 mg PO
or benadryl 25 mg PO or IV
or valium 5mg IV
or ondansetron 4 mg IV
PLUS IV fluids
```
51
What is the treatment for hepatic encephalopathy?
Lactulose 30-60 grams PO, NGT or 300 grams PR
| second line: Rifamixin 400 mg TID
52
What is the treatment for hyperkalemia?
Calcium then Insulin 10 units + 1 amp D50
53
What is the treatment for Spontaneous Bacterial Peritonitis?
Third Gen Cephalosporin
- Cefotaxime 2g IV q8h
- Ceftriaxone 2g IV q24 h
54
What is the treatment for Spontaneous Bacterial Peritonitis if the patient has a penicillin allergy?
Levofloxacin 750 mg IV q24h
Ciprofloxacin 400mg IV BID
Pip/Tazo 4.5 g IV TID
55
What is the treatment for DKA and K+<3.3?
20-30 mEq/hr IV K+
56
What is the fluid treatment for DKA in adults?
1-2 L NS Bolus over 1-2 hours
57
What is the fluid treatment for DKA in pediatric patients?
20 mL/kg NS over first hour, then 250-500 mL/hr
58
What is the treatment for ongoing seizure?
Lorazepam (Ativan) 2-4 mg IV/IM, repeat PRN
| max of 0.1 mg/kg
59
What is the treatment for ongoing seizure refractory to Lorazepam after 5 minutes?
Fosphenytoin 20-30 PE/kg at 150 PE/min IV
or
Levetiracetem 20 mg/kg IV to max 60 mg/kg
or
Valproic Acid 20-40 mg/kg @ 7.5 mg/min IV
or
Phenobarbital 20 mg/kg IV at 50-100 mg/min
60
What is the dosing of Lorazepam for acute seizure?
2-4 mg IV/IM, repeat PRN
| max of 0.1 mg/kg
61
What is the dosing of Fosphenytoin for acute seizure?
20-30 PE/kg at 150 PE/min IV
62
What is the dosing of Leviteracetem for acute seizure?
20 mg/kg IV to max 60 mg/kg
63
What is the dosing of Valproic Acid for acute seizure?
20-40 mg/kg @ 7.5 mg/min IV
64
What is the dosing of Phenobarbital for acute seizure?
20 mg/kg IV at 50-100 mg/min
65
What is medication and dose for Nephrolithiasis pain control?
Morphine 0.1mg/kg or 4 mg IV
| and Ketorolac 30 mg IV if no CKD
66
What is medication and dose for Nephrolithiasis nausea control?
Zofran 4 mg IV
67
What is the treatment for nephrolithiasis plus UTI?
Ciprofloxacin or 3rd gen cephalosporin
68
What is the antibiotic for epidural abscess with possible MRSA?
Vanc 15-30 mg/kg IV
PLUS Metronidazole 500 mg IV
PLUS Cefotaxime 2 g IV
69
What is the antibiotic for epidural abscess without concerns for MRSA?
Nafcillin 2 g IV
or
Oxacillin 2 g IV
PLUS Metronidazole 500 mg IV
PLUS Cefotaxime 2 g IV
70
What is the treatment for epistaxis refractory to pressure?
topical vasoconstrictor -- oxymetazolone or phenylephrine
intranasal spray or cotton pledgets soaked in vasoconstrictor and anesthetic -- viscous lidocaine 2% or lidocaine 4% topical solution with 0.5% phenylephrine
leave in place for five minutes
71
What is the treatment for ITP?
steroids, IVIG, or anti-D immunoglobulin
| avoid NSAIDs
72
What is the treatment for TTP?
FFP and plasma exchange with stat hematology consult
73
What is the treatment for DIC?
if severe bleeding --> transfuse
if clotting --> heparin
FFP for prolonged coagulation and bleeding
Cryoprecipitate for fibrinogen <100 despite FFP
Platelets if <50k and bleeding
Platelets if <20k and no bleeding
pRBCs PRN for anemia
74
What is the treatment for HIT?
stop heparin
75
What is the treatment for GI bleeding if the patient has known ascites/liver failure?
Rocephin (Ceftriaxone) or Azithromycin
76
Activated charcoal does not absorb ..?
1. acids or alkalis
2. alcohols
3. metals or ionic compounds (eg iron potassium lithium)
4. hydrocarbons
*** must have normal GCS and maintaining own airway
77
What is the dose of activated charcoal?
1 g/kg
78
What are really the only toxicities that whole bowel irrigation is used for?
iron (>60 mg/kg elemental iron)
slow release calcium channel blockers
slow-release potassium chloride
79
What is the substance/dose used for whole bowel irrigation?
polyethylene glycol - 30 mL/kg/h
80
For which ingestions would you consider multi-dose activated charcoal administration and what is the dose?
carbamazepine
phenobaritone
quinine
theophylline
dose is 1 g/kg activated charcoal four hourly
81
For alkalinization of the urine during treatment of salicylate toxicity, what is the dose of sodium bicarb?
1-2 mmol/kg NaHCO3 stat
| then you can infuse further doses over the next 1-2 hours, aiming for a urinary pH >7.5
82
What amount of iron would have to be ingested to be considered significant?
>40 mg/kg
83
What is the treatment for iron overdose?
whole bowel irrigation if significant ingestion and confirmed with xray
84
When should deferoxamine be considered in iron overdose?
serum iron concentrations >90 micromol/L
| or if 60-90, visible on xray, and patient is symptomatic
85
What is the dose of deferoxamine for acute iron ingestion?
15 mg/kg/hr IV, then reduce rate after 4-6 hours so that the total IV dose dose not exceed 80 mg/kg/24 hrs
86
When can you stop treatment for iron ingestion?
until the child is asymptomatic, the anion-gap acidosis is resolved, and the serum iron concentration is <60 micromol/L
87
What is the treatment for hypertension related to toxic injection?
calcium-channel blocking agents, phentolamine, labetalol, or nitroprusside
88
What is the first line treatment for patient with ventricular tachycardia in the context of intoxication, specifically drugs with drug with sodium-channel blocking properties (eg, tricyclic antidepressants, carbamazepine, cocaine)?
Sodium bicarb
Types IA (eg, procainamide), IC, and III antiarrhythmic agents are not recommended and are potentially dangerous since they may further impair cardiac conduction.
89
What anti-epileptic medication is contraindicated in treatment of seizures due to intoxication?
Phenytoin
| also Keppra is unlikely to help --> use benzos instead
90
What is the treatment for hyperthermia related to drug toxicity?
possibly ice water immersion
| do not use antipyretics like acetaminophen or ibuprofen
91
What is the antidote for Acetaminophen toxicity?
N-acetylcysteine (NAC) IV 150 mg/kg over 1 hr
then infuse 12.5 mg/kg/hr x 4 hrs
then 6.25 mg/kg/hr x 16 hrs
92
What is the antidote for anticholinergic toxicity?
Physostigmine
93
What is the antidote for arsenic toxicity?
dimercaprol/BAL
94
What is the antidote for beta blocker toxicity?
glucagon
95
What is the antidote for copper toxicity?
penicillamine
96
What is the antidote for cyanide toxicity?
thiosulfate, hydrocobalamine
97
What is the antidote for digoxin toxicity?
digoxin specific immune Fab fragments
98
What is the antidote for ethylene glycol toxicity?
Fomepizole
99
What is the antidote for glypizide toxicity?
glucose, octrotide
100
What is the antidote for heparin toxicity?
protamine
101
What is the antidote for hydrofluoric acid toxicity?
calcium
102
What is the antidote for isoniazid toxicity?
pyridoxime
103
What is the antidote for lead toxicity?
dimercaprol
104
What is the antidote for lidocaine toxicity?
lipid emulsion (aka intralipid) and sodium bicarb)
105
What is the antidote for magnesium toxicity?
calcium
106
What is the antidote for MAOI or SSRI toxicity?
cyproheptadine or benzos for serotonin syndrome
107
What is the antidote for methemoglobinemia?
methylene blue
108
What is the antidote for methotrexate toxicity?
folic acid, leucovorin
109
What is the antidote for mercury toxicity?
dimercaprol (BAL), EDTA or DMSA
110
What is the antidote for opioid toxicity?
naloxone
111
What is the treatment for warfarin overdose?
vitamin K
112
What is the treatment for salicylate toxicity?
alkalinization of the blood to 7.5 or higher with:
1 AMPS/100 mEq NaHCO3
followed by D5W with 150 mEq NaHCO3/L at 200-250 mL/hr
+/- hemodialysis
+ IV potassium repletion
ADMIT
113
What is the treatment for acute digoxin toxicity?
10 vials Digoxin immune Fab
(effects within 30-120 min)
Atropine for bradydysrhythmias
Magnesium for VT/VF
114
What is the treatment for opioid overdose?
0.4 mg Naloxone IV in adults
If no effect, increase dose q2-3 min
2mg --> 4 mg --> 10mg -->15mg
(0.1 mg/kg in kids -- max2mg)
Monitor for 4-6 hrs back to baseline
If require 2 or more doses of Naloxone --> admit
115
What is the treatment for opioid withdrawal?
Clonidine 0.1mg PO
- can repeat dose every 30-60 min
Monitor BP closely!
116
What is the method for decontamination/elimination in TCA overdose?
```
IV intralipid (central administration preferred)
1 ml/kg to 1.5 ml/kg bolus q3-5 min to a total of 3 ml/kg
IV drip started at 0.25 mL/kg/min-0.5ml/kg/min for 1 hr or until max dose of 8 ml/kg delivered
```
117
What is the tx for arrhythmia due to TCA overdose?
Sodium Bicarb
Bolus 100mEq for QRS>100, repeat q5min until QRS narrows
QRS<100, start drip (150mEq/1L of D5W, infusing at 150/hr) until goal pH 7.45-7.55 on ABG
118
What is the preferred method for BP support in TCA overdose?
Start with IV fluids -- fill the tank
- consider hypertonic saline (3%) to saturate Na channels
May need to add pressors --> neosynephrine or norepi preferred to overcome alpha blockade
119
What labs and imaging should be ordered for suspected hyperthermia/heat stroke?
1. EKG
2. CXR (pulm edema common in heat stroke)
3. Labs: CBC and coags, BMP, Mg/Phos/Ca, and CPK (acute renal failure, rhabdomyolysis), liver enzymes (acute liver failure), +/- tox screen
120
What empiric abx should be given to infants 0-28 days with fever?
```
Ampicillin 100mg/kg/24 hrs divided q6h
PLUS either
Gentamicin 5 mg/kg/24hrs divided q8h
or
Cefotaxime 150 mg/kg/24 hrs divided q8h
```
(avoid ceftriaxone in infants <28 days due to possibly inducing acute bilirubin encephalopathy)
121
If pressor is required during sepsis, what is first line and its dose?
Norepinephrine:
- initial starting dose: 8-12mcg/min
- Weight based dosing: 0.01-3mcg/kg/min
(Increases BP and HR)
122
What are two second line pressors for sepsis and their associated dose?
Epinephrine & Vasopressin
Epinephrine:
- Initial starting dose: 5-35 mcg/min
- weight based dosing: 0.1-0.5 mcg/kg/min
(increases BP and HR)
Vasopressin:
- fixed dosing at 0.04 units/min
123
If patient is septic and only have peripheral IV access, what pressor can be used (although not first line)?
Phenylephrine
- initial starting dose: 25-180 mcg/min
- weight based dosing: 0.5mcg/kg/min
(can cause reflex bradycardia)
124
What abx are used for outpatient tx of community acquired pneumonia in previously healthy people?
Azithromycin 500 mg PO x1 and 250mg PO QD x4days
OR
Doxycycline 100 mg PO BID x7 days
125
What abx are used for outpatient tx of community acquired pneumonia in patients with co-morbidities or recent abx?
Levofloxacin 750 mg PO QD x5days
OR
Cefpodoxine 200mg PO BID + Azithromycin 500 mg PO QD x7days
126
For outpatient tx of CAP, if aspiration is suspected, which abx should be added?
Clindamycin or Metronidazole
127
What is inpatient abx tx for CAP?
Levofloxacin 750mg PO/IV
OR
Ceftriaxone 1 g IV q12h PLUS Azithromycin 500 mg PO/IV
128
What additional abx should be added for inpatient abx tx of CAP if patient requiring ICU?
Vancomycin
129
What is inpatient abx tx for HCAP, HAP, or VAP?
```
Cefepime 2g IV q12h
+
Levofloxacin 750 mg IV qd
+
Vancomycin 1g IV q12h
```
130
What is abx tx for presumed PCP pneumonia?
Trimethoprim/Sulfamethoxazole 240/1200mg IV q6h
| consider steroids
131
In patients with pneumonia, what 2 risk stratification tools help determine need for admission?
CURB-65
| Pneumonia Severity Index
132
What absolute neutrophil count defines neutropenia?
ANC < 500 cells/microL
ANC = WBC x (%neutrophils+%bands)
133
What are the empiric abx for suspected meningitis in pediatrics <1 month old?
```
Ampicillin 50 mg/kg QID
+
Gentamicin 2.5mg/kg IV TID
+
Cefotaxime 50mg/kg IV QID
```
134
What are the empiric abx for suspected meningitis in pediatrics >1 month old?
Ampicillin 50 mg/kg QID
+
Cefotaxime 100mg/kg IV TID
OR
Ceftriaxone 50mg/kg IV BID
+
Vancomycin 15 mg/kg IV QID
135
What are the empiric abx for suspected meningitis in adults?
```
Ceftriaxone 2g IV BID
OR
Cefotaxime 2g q4h
+
Vancomycin 15-20 mg/kg IV BID
+
If >50y/o: Ampicillin 2q q4h (covers Listeria)
```
136
What are the empiric abx for suspected healthcare-associated meningitis?
```
Vancomycin 15-20mg/kg IV BID
+
Cefepime 2g IV TID
OR
Merepenem 2g IV TID
```
137
What is the empiric tx for suspected HSV meningitis?
Acyclovir 10mg/kg IV TID
138
What is the empiric tx for suspected cryptococcal meningitis?
Amphotericin B 0.7-1mg/kg IV QD
AND
Flucytosine 25 mg/kg PO QID
139
What is the empiric tx for suspected TB meningitis?
Isoniazid 300 mg PO QD,
Rifampin 600mg QD,
Pyrazinamide 2g PO QD,
Ethambutol 1.6g PO QD
140
What is the acronym for the quick differential for headaches?
BITE ME
Bleed, Infection, Thrombosis, Eye, Mass, Environmental
141
What is normal opening pressure during LP?
9-18 cm H2O
142
What is the first line treatment for a low-risk, mild headache?
Ibuprofen 800mg
Acetaminophen 1000mg
and/or
Caffeine 200mg
(all PO)
143
What is first line for a low-risk, moderate-severe headache?
Ketorolac 30 mg IV (unless Ibuprofen already given)
+
Prochlorperazine 10mg IV (or Metoclopramide 10mg IV)
+
IV fluids
144
What is the treatment for a cluster headache?
(unilateral, assoc with scleral injection, lacrimation, congestion, rhinorrhea, facial sweating, miosis, ptosis, or eyelid edema)
Oxygen 6-10L and sumatriptan 6mg SQ
145
What are contraindications to triptan administration?
HTN, CAD, peripheral vascular disease, arrhythmias, recent MAOi, SSRI, or triptan use (serotonin syndrome)
146
What are potential side effects of prochlorperazine?
```
dystonic reaction (treat with benadryl)
QTc prolongation
```
147
How is warfarin reversed?
Vitamin K 5-10mg IV over 10 minutes (INR corrected in 6-24 hrs)
PLUS either:
FFP or PCC
FFP (3-6 hrs to infuse, INR corrected in ~12 hrs)
PCC (INR corrected 15 min after 1 hr infusion, dosing is weight-based)
148
How is aspirin reversed?
Platelet transfusion
149
How is Heparin reversed?
Protamine Sulfate -- call pharmacy for dosing, bc dependent on dose of heparin, route given, and time of last dose
150
How is Dabigatran reversed?
No antidote. Half-life is 12 hours in patients with normal renal function.
One third is protein bound with 60% removed after 2-3 hrs of hemodialysis.
151
What is the BP goal in patients with hemorrhagic stroke?
If presents with SBP 150-200, goal is <140
| Otherwise aim for 25% reduction
152
For BP control in intracranial hemorrhage patients, what is the first line medication and dose?
Nicardipine
- initial rate of 5 mg/hr IV
(can increase by 2.5 mg q15min until desired BP or max rate of 15 mg/hr.)
Once goal BP achieved titrate down to 3 mg/hr
- use cautiously in patients with heart failure who are already taking beta blockers
153
For BP control in ICH, what is the dose of labetalol?
10-20mgIV q10min (max dose 80mg/dose)
154
When is labetalol contraindicated?
Bradycardia, heart failure, severe COPD
155
For BP control in ICH, what is the dosing for Hydralazine?
10-20 mg IV q4-6h
(max dose 40mg/dose)
BP response may be delayed and unpredictable. Typically only for patients with contraindication to labetalol
156
If patient begins to show signs of herniation in ICH, what is the treatment? (discuss with neurosurg)
Mannitol 1g/kg IV infusion with goal of serum osmolality of 300-310
- side effects include hypovolemia from diuresis
Hypertonic Saline dose is typically 30 mL of 23.4% saline over 20 mins
- requires infusion through a central line (3% saline does not)
157
What is the goal cerebral perfusion pressure (CPP) in ICH?
Goal CPP is 50-70 mm Hg
| CPP = MAP-ICP
158
What is the goal BP in SAH?
<140 mmHg
(use nicardipine, labetalol, or hydralazine)
- prevents delayed vasospasm that leads to secondary ischemia
159
What labs are diagnostic of temporal arteritis?
ESR>50, elevated CRP, and CBC, which may show normochromic anemia
160
What medication should be given as soon as temporal arteritis is suspected?
60mg of Prednisone PO daily for 2 weeks
| start immediately; will not affect biopsy results in the first 48 hrs
161
If temporal arteritis patient has vision loss, what is the medication that should be given & dose?
1000mg methylprednisone IV daily for 3 days, then maintenance dose
+
ASA 81 mg/daily -- reduce risk of visual loss, TIA, or stroke
Add PPI while on steroids to reduce risk of peptic ulcer
162
What labs and imaging should be ordered if venous sinus thrombosis is suspected?
Labs: CBC, BMP, Coags, HCG
Imaging: CT-venography or MRI/MR venography
163
What is the treatment of venous sinus thrombosis?
Anticoagulation with heparin or LMWH, even in the presence of hemorrhagic infarction
164
How is hypertensive emergency defined?
Hypertension that causes acute end organ damage (ie, CHF or increased Creatinine)
generally BP >180/120 (though rate is more important)
165
How is hypertensive urgency defined?
Hypertension without the associated end organ damage
166
What labs are important to obtain when evaluating hypertensive urgency/emergency?
Labs: CBC, BMP, UA, troponin, BNP;
| and EKG -- assess for LV hypertrophy or acute ST or T wave changes
167
What is the goal BP reduction timeline in hypertensive emergencies?
1-2 hrs: max reduction in MAP 20-25%
| 2-6 hrs: Goal BP 160/100
168
What are potential antihypertensive medications to be used in hypertensive emergencies?
1. Nitroglycerin 5-100 ug/min
2. Labetalol 20-80mg IV bolus then 0.5-2 mg/min (Caution in bradycardia)
3. Nicardipine 5-15mg/hr
4. Hydralazine 5-20 mg q20-30min
In a true hypertensive emergency, use short-acting, titratable medications and place an A line to monitor BP closely
169
For hypertensive urgency, rapid administration of antihypertensive therapy is unwarranted, what is the tx instead?
If patient has missed home med, start there.
Otherwise, initiate a maintenance dose of an oral medication before discharge in patients with SBP ?/= 200mg, or DBP >/=120 mm Hg;
this is optional in patients with lower BP
Asymptomatic patients may be discharged home.
170
What is the treatment for carotid/vertebral dissection -- extracranial dissection WITH ischemic neurologic symptoms?
Anticoagulation w/ unfractionated heparin (goal of PTT 45-60 sec) or LMWH (enoxaparin 1mg/kg BID or Dalteparin 100 U/kg BID)
- this will usually either be followed by either warfarin or antiplatelet therapy (consult or inpatient team will decide this) bridge to outpatient therapy.
171
What is the treatment for carotid/vertebral dissection -- extracranial dissection WITHOUT ischemic neurologic symptoms?
antiplatelet therapy, NO anticoagulation
172
What labs should be ordered if carbon monoxide poisoning is suspected?
1. Carboxyhemoglobin level
- baseline COHb in nonsmokers 3%, smokers 10-15%
2. ABG (to evaluate acid-base status)
3. Cardiac biomarkers if cardiac sx or risk factors
4. CN (cyanide) level in patients with smoke inhalation injury
and EKG!
173
What is the tx for CO poisioning?
100% O2 on nonrebreather for 90 min?
174
If CN toxicity suspected/smoke inhalation injury, what is the tx?
```
Sodium thiosulfate (25%) 1.65 mL/kg IV (max dose 12.5 g)
or
Hydroxycobalamin 70mg/kg IV (5g is the standard adult dose)
```
175
What labs should EVERY joint pain patient get?
UA
ESR/CRP
CBC
BMP
176
What antibiotics should be ordered for open fractures?
Cephalexin +/- Gentamicin if contaminated
177
What is a normal compartment pressure? What is abnormal and what indicates need for emergent fasciotomy?
Normal <12 mmHg
Elevated >20 mmHg
Need for Fasciotomy >30 mmHg
Can also use PULSE pressure (= diastolic pressure - compartment pressure) where <30mmHg indicates inadequate perfusion
178
What labs should be sent on arthrocentesis fluid?
```
Gram stain and culture
fluid cell count
crystals
synovial lactate
(glucose and protein are rarely helpful but can be sent)
```
Serum:
Consider serum lyme titer if suspicious
ESR and CRP will often be requested by consult services. CBC, BMP
179
What should be on the differential for a painful joint?
```
Septic arthritis
Gout
Pseudogout
Lyme Disease
Rheumatoid Arthritis
Cellulitis
Septic bursitis
osteoarthritis
```
180
What is the treatment for septic joint with Gonococcus/Gram negative bacteria on gram stain?
Ceftriaxone 1g IV daily
+
OR washout
181
What is the treatment for septic joint with Gam positives on gram stain, and not immunocompromised?
Vancomycin by total body weight
+
OR washout
182
What is the treatment for septic joint with Gam positives on gram stain, and immunocompromised or IV drug user?
Vancomycin + Cefepime 2g QD
+
OR washout
183
What is the treatment for septic joint with human or animal bite inoculation of wound?
Ampicillin + Sulbactam
+
OR washout
184
How do you diagnose acute limb ischemia?
Doppler pulses --
normal if 1-1.4
borderline if 0.91-0.99
abnormal if <0.9
then arteriography, CT angiography, or MR angiography per hospital protocol or consultant preference.
185
How do you manage acute limb ischemia?
Immediate IV heparin and aspirin followed by continuous heparin infusion
Vasc surg consult for revascularization +/-embolectomy, bypass graft
186
How do you treat gout?
NSAIDs (Naproxen 500mg BID, Indomethacin 50mg TID, ibuprofen 800mg QID) --> high initial dose, then taper
- If contraindication to NSAIDs (bleed, renal failure), then consider steroids
Colchicine: low dose course of 1.2 mg followed 1 hr later by 0.6 mg for 1.8mg total dose.
- warn pts of GI upset side effects
DONT use allopurinol or probenacid during acute exacerbations.
187
What type of splint should be applied for a scaphoid/lunate fracture?
thumb spica
188
What type of splint should be applied for a First Metacarpal fx?
thumb spica
189
What type of splint should be applied for De Quervain's tenosynovitis?
thumb spica
190
What type of splint should be applied for a ulnar styloid fracture?
ulnar gutter
191
What type of splint should be applied for a 4th and 5th metacarpal fx?
ulnar gutter
192
What type of splint should be applied for a 4th and 5th phalanges fx?
ulnar gutter
193
What type of splint should be applied for a Distal Radius fx?
Sugar tong
194
What type of splint should be applied for a Distal Ulnar fx?
Sugar tong
195
What type of splint should be applied for wrist sprains?
Volar splint
196
What type of splint should be applied for a metacarpal fx?
Volar splint
197
What type of splint should be applied for distal humerus fx?
Posterior long arm
198
What type of splint should be applied for a proximal humerus fx?
posterior long arm
199
What type of splint should be applied for a radial head or neck fx?
posterior long arm
200
What type of splint should be applied for olecranon fx?
posterior long arm
201
What type of splint should be applied for severe ligamentous injuries of the elbow?
posterior long arm
202
What type of splint should be applied for unstable ankle fractures?
Posterior leg/ Posterior Sugar tong
203
What type of splint should be applied for a distal tib/fib fx?
Posterior leg/ Posterior Sugar tong
204
What type of splint should be applied for midfoot fx (metatarsal/tarsal)?
Posterior leg/ Posterior Sugar tong
205
What type of splint should be applied for proximal tib/fib fx?
long leg posterior
206
What type of splint should be applied for unstable knee fx?
long leg posterior
207
What type of splint should be applied for femur fx?
long leg posterior
208
What is the treatment for status asthmaticus?
albuterol and ipratropium nebs and steroids
If in extremis, consider magnesium and IV epinephrine
209
What size ET tube will work for most adults?
7.5
210
What agents and doses should be used for the average expected uncomplicated intubation? (according to EMRA book)
20mg etomidate
| 120mg succinylcholine
211
What are two pre-treatment agents that can be used in intubation and their doses?
Lidocaine 1.5 mg/kg (100mg)
| Fentanyl 3mcg/kg (200mcg)
212
Which two induction agents have little to no effect on BP?
Etomidate
| Ketamine
213
What is the dose for Etomidate when used as an induction agent?
0.3 mg/kg (20mg)
214
What is the dose for Versed (Midazolam) + Fentanyl when used as an induction agent?
0.3 mg/kg (20mg)
| 3mcg/k (200mg)
215
What is the dose for Propofol when used as an induction agent?
1.5 mg/kg (100 mg)
216
What is the dose for Ketamine when used as an induction agent?
1.5 mg/kg (120mg adult)
217
What is the dose for Succinylcholine when used as a paralytic agent? Onset/Duration?
1.5 mg/kg (120 mg)
| Onset <1 min, Short duration (4-6 min)
218
What is the dose for Rocuronium when used as a paralytic agent? Onset/Duration?
1 mg/kg (80 mg) of IDEAL BODY WEIGHT
| Onset <2 min, Medium duration (30-60 min)
219
What is the dose for Vecuronium when used as a paralytic agent? Onset/Duration?
0.08-0.1 mg/kg (10 mg)
| Onset 2-3 min, Medium duration (25-40 min)
220
What is the dose for Pancuronium when used as a paralytic agent? Onset/Duration?
0.1 mg/kg
| Onset 2-3 min, Long duration (60-100 min)
221
What are absolute contraindications to the use of succinylcholine?
1. History of malignant hyperthermia
2. Burns >5 days old until they are healed
3. Spinal cord injury
4. Stroke that occurred between 5 days and 6 months
5. Neuromuscular disease
222
What is the albuterol/ipatropium dose for acute asthma exacerbation?
Albuterol 4-8 puffs or 2.5-5mg q15-30min x1hr then q30min
| Ipatroprium Bromide MDI 2 puffs or Neb: 0.5 mL of 0.02% onset 30+min, lasts up to 6 hrs
223
In a patient with severe acute asthma exacerbation, what steroid/dose should be administered? what other med can be given?
PO: Prednisone 40-60mg
IV: Methylprednisolone 125mg IV
Magnesium 2-4g IV over 10-15 min
224
What peak flow (FEV1) may be indicative of exacerbation?
FEV1 >70% : mild exacerbation
FEV1 >/=40%: mild-mod severity
FEV1 <40% or unable to obtain d/t clinical status: severe
225
If patient with acute asthma exacerbation cannot tolerate inhaled therapy, what medication can be given?
```
Terbutaline 0.25-0.5mg SQ q30min to max dose of 5mg over 4 hrs
or
Epinephrine (1:1000) 0.2-0.5 mL SC Q20-30 min x3 doses
```
226
If patients receive steroids in ED for acute asthma exacerbation, discharge on burst PO regiment, which is what?
Prednisone 40-60mg PO daily x3-7 days
If concern for poor compliance, alternative: Solumedrol 160mg IM x1 dose
227
What antibiotic should be prescribed in UNCOMPLICATED moderate to severe COPD exacerbations?
Uncomplicated:
- Age <65
- no comorbidities
- FEV1>50
- <3exacerbations per year
```
Azithromycin (Z pack)
or
Cefpodoxime
or
Doxy
or
Bactrim
for 5 days
```
228
What is the dose of epinephrine in anaphylaxis?
```
IM epi (1:1000): 0.3-0.5mL q5min PRN, titrate to effect
(EpiPen=0.3mL)
Inject into anterolateral thigh
```
229
What 3 medications can/should be given for patients with angioedema?
1. Steroid: methylprednisolone 125mg IV or dexamethasone 10mg IV
2. H1 blocker: Diphenhydramine 50mg IV
3. H2 blocker: Famotidine 40mg IV or Ranitidine 50 mg IV
230
What NT-proBNP and BNP levels are indicative of ADHF?
NT-proBNP >1000
BNP>400
(but these vary with age)
if age>75, cutoff of BNP>800pg/mL
231
What are the signs/sx of flash pulmonary edema?
Rales, crackles
SBP >180 mmHg
Tachycardia
Usually history of poorly controlled hypertension
232
What are the two initial mainstays of treatment for flash pulmonary edema?
BiPAP with a PEEP of 5-8 and titrate up
| Nitroglycerin drip-- start BIG >25mcg/min and titrate up
233
If patient is in ADHF and bradycardic, what med?
Atropine or external pacing
234
If patient is in ADHF and is hypotensive, what med should be administered?
Norepinephrine
| If norepi unavailable, can give dopamine
235
What 2 medications can be given in ADHF to increase inotropy?
Milrinone, Dobutamine
236
If ADHF is refractory to medical treatment, consult cardiology for what intervention?
Placement of an intraaortic balloon pump (IABP)
237
If patient is in ADHF and is fluid overloaded, what medication should be ordered?
Furosemide for diuresis
Give total daily home PO dose as IV dose
Ex: 40 mg PO --> 40 mg IV
Furosemide IV to PO conversion is 1:2
20mg IV = 40mg PO
238
What is the dose of nitroglycerin in flash pulmonary edema/acute heart failure?
0.4mg of sublingual spray or tab for immediate relief
Start 0.3-0.5 mcg/kg/min (typical starting dose is 25 mcg/min) Titrate up q3min
If no IV access, can place 0.5 to 1 inch of nitro paste
239
What is a side effect of Nitroglycerin administration?
decrease in BP, so very efficacious in HTN
| However, do not use if BP <95-100
240
What 3 patient populations should not receive nitroglycerin?
1. taking phosphodiesterase inhibitors
2. with severe aortic stenosis
3. with right sided MI
241
What are side effects of Lasix/Furosemide?
Can cause electrolyte abnormalities (hypokalemia, hypocalcemia, hypochloremia)
Peak diuresis 30 min
242
What is the Furosemide (Lasix), Torsemide, Bumex conversion?
furosemide 40 mg = Torsemide 20mg = Bumex 1mg
243
What is the dose for milrinone?
Bolus 50mcg/kg IV over 10 min then start 0.375 mcg/kg/min IV and titrate up
244
What are possible side effects of milrinone?
can cause hypotension and cardiac arrhythmias.
| Obtain cardiology consult
245
What DDimer is generally considered abnormal?
>500 ng/mL
246
What things can artificially elevate ddimer?
```
advanced age (beginning age 40)
active malignancy
pregnancy
recent operation
rheumatologic disease
sickle cell disease
```
247
In the case of pulmonary embolism, what is the dosing of unfractionated heparin?
80 units/kg IV bolus
followed by
18 units/kg/hr IV infusion (goal PTT 60-85 sec)
If no weight available, 5000u bolus, 1000u/hr drip in average sized patient.
248
In the case of pulmonary embolism, what is the dosing of fractionated heparin (LMWH)?
Enoxaparin: 1mg/kg SC q12h
Dalteparin: 100 units/kg SC q12h or 150 units/kg SC q24 hrs
249
What are contraindications to fractionated heparin (LMWH)
renal insufficiency (CrCl <30), HIT, weight <50 kg or >100kg, recent or planned procedure
250
In the case of pulmonary embolism, what is the dosing of Fondaparinux (Factor Xa inhibitor)?
5-10 mg SQ injection (dose depends on body mass), safe in patients with HIT
251
In the case of pulmonary embolism, what is the dosing of Rivaroxaban Factor Xa inhibitor?
15 mg PO BID
252
In the case of pulmonary embolism, what is the dosing of Argatroban (Direct thombin inhibitor)?
2mcg/kg/min IV --> If hepatic dysfunction 0.5 mcg/kg/min
| CALL HEMATOLOGY before administering given dosing variability. Effects are NONREVERSIBLE.
253
In the case of pulmonary embolism, what is the dosing of Warfarin (Vit K antagonist)?
Do not start warfarin prior to starting short-term anticoagulation given increased risk of recurrent DVT/PE
Should be overlapped with short-term anticoagulation for a minimum of 5 days AND until INR is therapeutic (INR 2-3) for 24 hrs
Typical initial dose is 5mg PO for the first 2 days then adjusted according to INR.
MANY meds interact with warfarin. be sure to review med list.
254
In massive PE, what is thrombolytic dosing?
Alteplase (tPA): 15 mg IV bolus followed by 2 hr infusion of 100 mg.
Discontinue heparin during infusion.
If pulseless 50 mg IV bolus over 2-3 min, additional 50 mg IV bolus can be given 30 min later.
