Hosp/ICU Acute Care Pearls

1. 1st gen cephalosporins

2. coverage

1. cefazolin, cephalexin

2. gram +

1. 2nd gen cephalosporins

2. coverage

1. cefotetan, cefuroxime, cefoxitin, cefaclor

2. gram + and -

1. 3rd gen cephalosporins

2. coverage

1. ceftriaxone, cefotaxime, ceftazidime

2. more gram -

1. 4th gen cephalosporins

2. coverage

1. cefepime

2. pseudomonas

1. 5th gen cephalosporins

2. coverage

1. ceftaroline

2. MRSA

BROAD spectrum antibiotics

1. carbapenems*

2. augmentin

3. zosyn

4. ceftriaxone

5. FQNs

ADE associated with TCNs

1. skin hyperpigmentation

2. enamel hypoplasia

3. photosens

4. esophageal injury (take w water)

ADE associated with FQNs

1. tendon rupture

2. photosens

3. +QTc

Which antibiotic for tick borne bacteria?

doxycycline

Which antibiotic for VRE?

linezolid

Which antibiotic for surgical prophylaxis?

cefazolin

Which antibiotic for meningitis?

3rd gen ceph (ceftriaxone, cefotaxime)

Which antibiotic high risk of C diff?

clindamycin

Which antibiotics has a disulfiram-like reaction?

cefotetan, metronidazole

ADEs associated with aminoglycosides

1. nephrotox

2. ototox

ADEs associated with vancomycin

1. nephrotox

2. vancomycin infusion reaction

3. ototox

ADE associated with Bactrim (TMP/SMX)

hyperkalemia

ADE associated with linezolid

TC, SS

MENINGITIS empiric therapy

<1 month old

amp + cefotaxime or AG

MENINGITIS empiric therapy

1-23 months, 2-50 years old

vanc + 3rd gen ceph (ceftriaxone, cefotaxime)

MENINGITIS empiric therapy

>50 years old

vanc + amp + 3rd gen ceph (ceftriaxone, cefotaxime)

1. oseltamivir brand name

2. renal cut off

1. Tamiflu

2. 60

1. zanamivir brand name

2. AVOID in underlying ________

1. Relenza

2. resp disease, allergy to milk protein

Which flu medication is preferred in pregnancy and severe disease?

tamiflu

Common pathogen in pneumonia

Streptococcus pneumoniae

Inpatient CAP treatment

1. B-lactam choices

2. + _____ or ______

3. use ______ in QTc prolongation (>500s)

4. if MRSA risk → add

5. if Pseudomonas risk → replace B-lactam with

6. use antibiogram susceptibility ______

7. duration

8. duration (MRSA/pseudomonas)

1. unasyn, ceftriaxone, cefotaxime, ceftaroline

2. macrolide, levo/moxifloxacin

3. doxy

4. vanc, linezolid

5. zosyn, meropenem, imipenem/cilastatin, ceftazidime, cefepime

6. >80%

7. 5d

8. 7d

Inpatient HAP treatment

septic shock, IV abx (last 90d), antibiogram <90%

empiric therapy = mrsa + 2 anti-pseudomonal (diff classes)

1. MRSA =

2. anti-pseudomonal cell wall MOA =

3. anti-pseudomonal non cell wall MOA =

4. duration

1. vanc

2. zosyn, ceftazidime, cefepime, meropenem, primaxin, aztreonam

3. cipro, levo, amikacin, tobramycin

4. 7d

Diabetic foot infection MILD

empiric treatment

1. standard

2. recent ABx

3. high risk MRSA

4. duration

1. cephalexin

2. augmentin

3. +doxy or bactrim

4. 1-2w

Diabetic foot infection MOD/SEV

empiric treatment

1. standard

2. recent ABx

3. high risk MRSA

4. high risk anaerobes

5. high risk GNR/pseudomonas

6. duration

1. ceftriaxone

2. ceftriaxone

3. +vanc → open wounds, recent ABx

4. +metronidazole or zosyn → necrotic, gas form, ischemic limb

5. +cefepime or zosyn → water-soaked foot

6. 2-4 weeks

TUBERCULOSIS TREATMENT

1. RIPE =

2. duration =

1. rifampin + isoniazid + pyrazinamide + ethambutol

2. RIPE x2m → continue RI x4m → total 6m

TUBERCULOSIS TREATMENT

1. PRIM =

2. duration =

1. pyrazinamide + rifapentine + isoniazid + moxifloxacin

2. PRIM x2m → RIM x2m → total 4m

Main ADE with rifampin/rifapentine

red body secretions

Main ADE with isoniazid

PN (+vit B6/pyridoxine)

Main ADE with pyrazinamide

asymptomatic hyperuricemia

main ADE with ethambutol

optic neuritis, visual disturbances

complicated uti =

beyond bladder, T>/=100.4F

Urine Culture

1. Clean catch/voided: infection present > _______ CFU/mL WITH symptoms

2. Urinary catheter: infection present > _______ CFU/mL WITH symptoms

1. 100,000

2. 1,000

ASYMPTOMATIC bacteriuria

100,000 CFU/mL, do NOT treat unless:

1. -

2. -

1. pregnant

2. undergoing urinary procedure

Acute uncomplicated cystitis treatment options

1. 1st line options → 3

2. Alternative empiric →

1. nitrofurantoin, DS bactrim, fosfomycin

2. cipro, levo, PO B-lactams (cephalexin)

Acute COMPLICATED UTI (including pyelonephritis)

1. Septic shock → aim antibiogram

2. Sepsis w/o shock → aim antibiogram

3. Outpatient empiric options →

4. Inpatient empiric options →

5. History ESBL + B-lactamase →

1. 90%+

2. 80%+

3. cipro, levo, bactrim, PO B-lactams

4. ceftriaxone IV

5. ertapenem, meropenem, Primaxin

BITE WOUND outpatient =

augmentin

BITE WOUND inpatient =

unasyn

Nitrofurantoin renal cut off

30

Definitive therapy (bone, joint) for enterococcus

penicillin, cephalosporin

Definitive therapy (bone, joint) for enterobacteria (GNR)

ceftriaxone

Definitive therapy (bone, joint) for anaerobes

metronidazole, clindamycin

Mucosal/cutaneous candidiasis

oropharyngeal mild =

clotrimazole troches, nystatin susp

Mucosal/cutaneous candidiasis

oropharyngeal mod-sev =

fluconazole

Mucosal/cutaneous candidiasis

ESOPHAGEAL =

fluconazole

CANDIDEMIA

1. management =

2. duration = _____ after documented clearance (- blood culture)

1. echinocandins (-fungins)

2. 14 days

Histoplasmosis drug =

itraconazole

Aspergillosis drug =

voriconazole

Blastomycosis drug =

itraconazole

NS max rate = ____ mEq/L/day

10-12

HYPOkalemia

mild-mod treatment =

10-20 mEq PO BID-QID

HYPOkalemia

severe (serum K+ <3) or symptomatic treatment =

40 mEq IV/PO TID-QID

HYPOkalemia

Replace ____ first if also low

mg

HYPERKALEMIA treatment

cbigkdrop

1. calcium gluconate → ECG changes

2. Bicarb or b2 agonist → bicarb for MA, b2 adj to insulin+dex

3. insulin+dex → glucose >250 use just insulin

4. K+ binders → lokelma, kayexalate, veltessa

5. Drop → loop

HYPERmagnesemia chronic tx (normal renal) =

loop + NS

HYPERmagnesemia

1. Severe =

2. treatment =

1. >4

2. calcium gluconate

HYPOcalcemia treatment

correct hypomg → calc gluconate

HYPERcalcemia treatment

1. 1st line (normal renal)

2. EKG changes

3. malignancy-related

4. renal insufficiency / refractory bisphos

5. chronic hypercalcemia

1. NS bolus ± loop

2. calcitonin

3. IV bisphos

4. denosumab

5. cinacalcet

HYPOphosphatemia

acute treatment

1. K<3.5 = potassium phos

2. K>3.5 = sodium phos

HYPERphosphatemia

chronic treatment

1. 1st line

2. 2nd line

1. calcium (carbonate, acetate, citrate)

2. sevelamer, lanthanum

absolute contraindications to enteral nutrition (tube feed) →

1. mechanical obstruction

2. necrotizing enterocolitis

PARENTERAL NUTRITION

1g protein = ___ kcal

4

PARENTERAL NUTRITION

1g dextrose = ___ kcal

3.4

PARENTERAL NUTRITION

10% IVFE = ____ kcal/mL

1.1

Pharm agents used for sedation =

1. benzos

2. propofol

3. dexmedetomidine

Propofol related infusion syndrome (PRIS) risk with doses ____ mcg/kg/min and duration ______

severe MA, cardiovascular collapse, rhabdomyolysis,

>50, >48h

VTE PROPHYLAXIS

unfractionated heparin

1. dosing 1

2. dosing 2

3. monitoring

1. <50kg = 5000U SQ q12h

2. >100kg = 7500U SQ q8h

3. Hgb/Hct, plt, aPTT

VTE PROPHYLAXIS

LMWH heparin (enoxaparin/Lovenox)

1. dosing =

2. renal dosing =

3. monitoring =

1. 40 mg SQ qd

2. CrCL<30 → 30 mg SQ qd

3. Hgb/Hct, plt, peak anti Xa 0.2-0.4, renal fx

VTE PROPHYLAXIS

fondaparinux (Arixtra)

1. dosing =

2. renal dosing =

3. CONTRAINDICATIONS =

4. monitoring =

1. 2.5 mg SQ qd

2. CrCL 30-50 → -50% dose

3. <50kg, CrCL<30

4. Hgb/Hct, plt, renal fx

DELIRIUM

significant distress or agitation treatment =

haloperidol, atypical antipsychotics

DELIRIUM

mech vent where agitation is precluding weaning/extubation tx =

dexmedetomidine

Indications for stress ulcer prophylaxis → 5

1. mech vent >48h

2. coagulopathy

3. acute renal insuff/hepatic fail

4. sepsis

5. hypotension

PPI SIDE EFFECTS

1. +risk pneumonia, C diff

2. hypomg, hypoca

3. osteoporosis-related bone fractures

ICU GLUCOSE CONTROL RANGES

1. _____ mg/dL → most ICU

2. _____ mg/dL → cardiac surgery if can avoid hypoglycemia

3. _____ mg/dL → ELDERLY, END OF LIFE CARE

1. 140-180

2. 110-140

3. >180

Initiate insulin therapy when BG > ____ mg/dL

180

Decrease insulin therapy if BG <____ mg/dL

100

WHEN SWITCHING between SQ and IV insulin, overlap infusion for at least ____

2h

DKA vs HHS

(diabetic ketoacidosis vs hyperosmolar hyperglycemic state)

1. glucose

2. onset

3. pH

4. bicarb

1. DKA >200; HHS >600

2. DKA <24h; HHS days-weeks

3. DKA <7.3; HHS >7.3

4. DKA <18; HHS >15

DKA/HHS MANAGEMENT

1. Fluids →

2. Insulin → correct by _____ mg/dL/h → ____ U/kg/h infusion

3. Glucose goals →

4. Potassium → initiate ______ mEq KCl / L of IV fluid when …

5. DO NOT initiate ..

6. Phosphate →

7. Bicarbonate →

1. balanced crystalloid 500-1000 mL during first 2-4h

2. 50-75, 0.1

3. DKA 150-200; HHS 200-250

4. 20-30, K<5

5. NO INSULIN IF K<3.5

6. 20-30 mmol if phos<1, muscle weakness, cardiac/resp dysfx

7. 100 mEq q2h until pH>7

SEPSIS MANAGEMENT

1. antibiotics =

2. fluid resuscitation =

3. Target MAP > ___ mmHg

4. Vasopressors =

5. Inotropes =

6. If fluid resus and vasopressor fail =

1. MRSA + pseudomonas

2. 30 mL/kg w/in first 3h

3. 65

4. if fluid resus fails → 1st line NE

5. myocardial dysfx, ongoing hypoperfusion

6. steroid

balanced crystalloids =

use in sepsis, DKA/HHS

LR, plasmalyte

NOREPINEPHRINE

1. acts on

2. effect

3. top choice for

1. a1, b1

2. strong +BP, little +HR

3. septic shock

EPINEPHRINE

1. acts on

2. effect

3. top choice for

1. a1, b1, b2

2. +BP/HR

3. cardiac arrest, anaphylaxis

VASOPRESSIN

1. acts on

2. effect

3. top choice for

1. peripheral V1

2. +BP, no HR

3. add on low BP

DOPAMINE DOSE MOAs

mcg/kg/min

1. <2.5 = renal artery vasodilation

2. 2.5-10 = b1+b2 (HR/BP)

3. >10 = a1 (more BP)

ACLS: Bradycardia

1. treatment =

2. max cumulative dose =

3. if unresponsive =

1. atropine 1 mg q 3-5min

2. 3 mg

3. EP or DA infusion

ACLS: SVT (supraventricular tachycardia)

1. 1st line =

2. 2nd line =

1. vagal maneuvers

2. adenosine 6 mg IV push → repeat 12 mg IV push

ACLS: Torsades de Pointes

Treatment =

mg 1-2g IV/IO

QTc prolonging drugs/classes (7)

1. antiarrhythmics

2. serotonergics

3. FQNs, azoles, macrolides

4. antipsychotics

5. diphenhydramine

6. zofran

7. methadone

CARDIAC ARREST: SHOCKABLE

1. types =

2. management =

1. VF, pVT

2. CPR → defib/CPR → EP 1 mg IV/IO q 3-5min → amio/lido after 3rd shock → cont until ROSC

CARDIAC ARREST: NON-SHOCKABLE

1. types =

2. management =

1. PEA, asystole

2. CPR → EP 1 mg IV/IO q 3-5min → cont until ROSC

Cardiac arrest epinephrine dosing

1 mg IV/IO q 3-5min

Cardiac arrest amiodarone dosing

1. VF/pVT = 300 mg IV push → 150 mg IV push

2. tachy+pulse = 150 mg IV inf 10min → cont inf

Cardiac arrest lidocaine dosing

1. ______ IV bolus

2. followed by additional doses of ______ every ______

3. Max dose:

1. 1-1.5 mg/kg

2. 0.5-0.75 mg/kg, 5-10min

3. 3 mg/kg

ACLS: CALCIUM CHLORIDE

1. indications =

2. dosing =

1. hypoca, hyperk, CCB/BB tox, massive transfusion

2. 1g IV push

ACLS: DEXTROSE dosing

25-50 g IV push