-1-

Heart failure Heart failure arrhythmia arrhythmia optimize preload, cardiac pumping, afterload preload Diuretic Furosemide Nitroglycerine, Morphine cardiac pumping acute heart failure dopamine dobutamine afterload Nitroprusside ACEI Hydralazine

Unstable angina/NSTEMI Unstable angina 1) New onset (< 2) 2) (Pain at rest) 3) Post MI angina NSTEMI Cardiac enzyme CK-MB Trop-T ( 0.03 ng/L 0.1 ng/L ) Admit ASA 81-300 mg stat Losec 1-2 cap /day Nitrate, Sedation, , , -Blocker ACEI HT CHF

Nitroglycerine iv drip Uncontrol pain Heart failure NTG 1:10 iv 10-15 microdrop/min 1-2 microdrop/min 15-30 1) 2) Heart rate 110 3) Mean arterial pressure 10%

Trop-T positive, CHF, Plavix 4 Plavix 1x1 Enoxaparin 0.4-0.6 ml sc q 12 hrs ( CrCL) Fondaparinux 2.5 mg sc OD () ( protocol )

-2-

STEMI STEMI ECG : Typical pattern (ST elevate) ECG criteria() J-point/T > 0.25, T/QRS > 75%, J-point > 0.3 mV EKG EKG 15 2-3 ST-segment admit CK MB 0 3 6 . Trop-T ( Onset) . 4, 10 STEMI 12 . Shock Intractable arrhythmia Streptokinase Enoxaparin 30 mg iv 15 ( 75 ) Enoxaparin 1 mg/kg sc q 12 hrs ( > 75 Enoxaparim 0.75 mg/kg sc q 12) ASA 81-300 mg stat Losec 1-2 cap /day Plavix 4 Plavix 1x1 Nitrate, Sedation, , , -Blocker ACEI HT CHF (UA/NSTEMI) Coronary reperfusion 1.ST Segment 50% 90 2.Early Peak Cardiac enzyme (60-min ratios T 60/T 0) CK > 4.0, CK-MB > 3.3, cTnI > 2.0 () 3. Chest Pain Streptokinase streptokinase Coronary reperfusion

Cardiac arrhythmia Ventricular premature contraction(PVC)

PVC Short run VT ( 30 ) PVC Hemodynamic stable 2 Xylocard amiodarone Xylocard 50 mg iv push 3:1 20 microdrop/min(1 mg/min) 1-4 mg/min

-3-

amiodarone loading 300 1 . 900 mg in 5%DW 500 ml iv drip 24 . loading oral() 1 tab tid 1 1 tab bid 1 maintenance 1 tab od -(2) ( Underlying Ischemic heart disease cardiomyopathy amiodarone long term treatment improve survival )

Ventricular Tachycardia(VT) VT Cardioversion 50-100J 100J Xylocard 50 mg Amiodarone 150 mg dilute iv 10-20 Cardioversion

Ventricular Fribrillation(VF) VF Cardioversion 100J Xylocard 50 mg Amiodarone 150 mg dilute iv 10-20 Cardioversion

SVT SVT Cardioversion Cardioversion 50-100J . 3 Adenosine 6 mg iv push 12-18 mg iv push Amiodarone 150 mg 30 150 mg 30 iv drip 30 mg/hrs sinus rhythm Verapramil 2.5-5 mg iv push 5-10 sinus rhythm ( Hypotension CHF Myocardial dysfunction (EF < 45%)

3 -blocker, Calcium channel blocker Digoxin

-4-

AF AF 2

Amiodarone 2 Heart rate Digoxin

Thromboembolism No Risk ASA(81-325 mg)/day, 1 Moderate ASA(81-325 mg)/day warfarin , > 1 moderate risk Risk Risk warfarin

High Risk Factor Prior Stroke, TIA, Systemic Embolism, Rheumatic Heart Moderate Risk Factor > 75, Hypertension, Heart failure, Lt Ventricular function < 35%, Diabetes Mellitus

Bradyarrhythmia Heart block sick sinus syndrome Heart block Inferior

wall MI sick sinus syndrome syncope Bradyarrhythmia Heart rate 55 Hemodynamic stable atropine 2 amp(1.2 mg) iv heart block mobitz II complete heart block Isoproterenol(0.5-5 microgram/min) iv drip Adrenaline iv drip refer temporary pacemaker

Acute Asthma Oxygen, Dexamethazone 4-6 mg iv q 6 hrs, Sabutamol nebulizer 6 . ( 20 Berodual aminophylline iv drip 0.5-0.9mg/kg/hr Terbutaline 2.5mg sc ) PaO2 < 60 mmHg / PaCO2 > 49 mmHg Oxygen Respirator

-5-

COPD with acute exacerbration

COPD with acute exacerbration precipitating Bacterial infection Heart failure Pneumothorax Pulmonary Embolism 50% Precipitating COPD with acute exacerbration antibiotic X-ray Pneumothorax Pneumonia EKG sign Heart failure Furosemide 20-40 mg iv Heart failure Bronchodilator anticholinergic B2-agonist Theophyline aminophylline (Impending respiratory failure) Dexamethazone Prednisolone Respiratory Failure Respirator asthma

Community Acquire Pneumonia

Sputum gram stain sputum film x-ray .. 50% Mellioidosis 20% Streptococcus Pneumonia 18% 12% antibiotic sputum gram stain underlying X-ray

Melioidosis X-ray Atypical Pneumonia multiple site infiltration location upper lobe Mellioidosis (Ceftazidime 6-8 gm/day +/- cotrimoxazole 2 3 Meronam 1 gm iv q 8 hrs Sulperazone 1 gm iv q 8 hrs + cotrimoxazole 2 3

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Risk Melioidosis Macrolides IV beta-lactam + (Doxy or Macrolide) Levofloxacin cardio-pulmonary disease iv beta-lactam + (Doxy or Macrolide) iv Levofloxacin

ICU iv beta-lactam + iv levofloxacin ( Major Criteria 1. 2.Septic shock Minor Criteria 1.

Systotlic BP < 90 mmHg 2. Multilobar Pneumonia 3. SpO2 < 90%(with o2 supplement) 1 Major 2 Minor)

Pneumotharax Pneumothorax 20% 20% Chest drain admit Oxygen, Bed rest Chest X-ray

Hemoptysis Hemoptysis Massive hemoptysis ( 200 ml/ 600 ml /) Massive hemoptysis Pneumonectomy Massive hemoptysis admit , Chest X-ray, Oxygen, Codeine, lesion , Record , Chest X-ray active TB TB

Diabetic ketoacidosis DKA 1.( BS > 250 mg%) 2. Acidosis (HCO3

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2) Insulin RI iv drip rate 10 unite/hr 10% . rate insulin 20 u/hr 200 mg% rate Insulin 1-5 u/hrs 2 u/hr 80-200 mg% insulin iv drip ketosis serum ketone negative ( Ketone ) 3) Potassium K Protocol Serum K < 3.3 add KCL 20-30 mEq Insulin K > 3.3 K 2 . , Serum K 3.3-5.3 add KCL 20-30 mEq, Serum K >5.3 KCL K 2 . Serum Electrolyte 4-6 .

Hyperosmolar Coma HHS 1.BS>600mg% 2.Serum OSM >350 3.Serum OSM >320 , Serum OSM = 2Na + BS/18 + BUN/2.8 Correct Na=((BS-100)/100 x 1.6) + Na

1.BS

-8-

Severe hyperthyroid Hyperthyroid Criteria Thyroid crisis Heart failure AF PTU Thyroid crisis 300-600 mg 6. , Dexamethazole 4 mg iv q 6 hrs

Renal failure Renal failure acute chronic chronic renal failure 1) 3 2) chronic anemia, renal osteodystrophy 3) kidney size

Acute Renal failure acute renal failure ATN systemic disease leptospirosis, malaria shock supportive dialysis BUN 100 Uremic symptom

CRF CRF 1) Infection UTI 2) obstruction stone BPH 3) Heart falure 4) Volume Volume Low protein diet, ACEI( Cr < 5 Cr < 2.5 DM), Phosphate binder CaCO3 Al(OH)3 acidosis NaHCO3

Infected CAPD 1. Gram stain 2. WBC > 100 PMN > 50% 3. 2 3 Gram stain Gram stain Gram positive Gram negative Gram positive Vancomycin 15-30 mg/kg IP (intraperitoneum) 5 Cefazolin 15 mg /kg IP OD Gram Negative Ceftazidime 1.5 gm IP OD Ceftriaxone 1 gm IP OD Cefotaxime 1 gm IP OD

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Hypernatremia

Hypernatremia (Na-140)/140 x BW x 0.6 litre 1 Meq/hrs Na 6-12 .

Hyponatremia Hyponatremia Na 125 3%NaCl BW ml/hrs( Na 1 Meq/hrs) Na 0.5-1 Meq/hrs Na 6-12 . 1) Volume Heart failure Cirrhosis Renal failure 2) Volume Tubulointerstitial disease, Diarrhea, 3) Volume SIADH, Hypothyroid, Adrenal insufficiency NaCl 2 Fluid Challenge test Restict fluid Na

Hyperkalemia Renal failure, Acidosis, Severe Injury ACEI EKG Peaked T wave, diminish R wave, wide QRS, prolong PR, P wave K 6.5 meq/litre 10% Calcium gluconate 10 ml iv push Insulin Glucose RI 2.5-5 U 50%Glucose 50 ml( 5-10 U), NaHCO3 2 Amp iv push, Kayexalate 15-30 gm manitol 50 ml 6 . Kayexalate 50 gm manitol 200 ml peritonial dialysis

-10-

Hypokalemia RTA, Periordic paralysis diarrhea K 2.5 meq/litre K K 40-60 meq iv fluid 1000 ml rate 80-100 ml/hrs Elixer KCL 30 ml 6 . 10-20 meq/hrs monitor EKG K 6-12 . K 2.5 Meq/litre Elixer KCL 15-30 ml meq 6 . K

UGIB UGIB BP, PR, Hct Hct 30%, BP 90/60 mmHg, Postural hypotension PR 100/min NG tube larvage active bleeding admit/consult surgery, Supportive iv fluid, Omeprazole 80 mg iv stat 40 mg iv 12 . High Risk 60 , Severe Comorbid , Active bleed(., NG tube irrigate ,) , Hypotensin, 6 U, Rebleed, Severe Coagulopathy (PT, PTT ASA NSAID) Esomeprazole(Nexium) 80mg iv stat iv drip 8mg/hrs(x 72.) Hct 6 . 30% Hemodynamic stable NPO Cirrhosis Somatostatin SB tube

Acute febrile Hemoculture admit CBC Malaria ( ) Doxycyclin 1 x 2 Rickettsia 3

Sepsis & Septic shock Infection, documented or suspected

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Systemic inflammatory response syndrome (SIRS) Fever > 38.3 C or Hypotermia < 36 C Tachypnea (Resp rate > 20) Heart rate > 90/min Leukocytosis > 12000 or Leukopenia < 4000 (Criteria 2 4)

Septic shock Organ Hypoperfusion 6 .: CVP 8-12 mmHg (11-16 cmH2O) MAP > 65 mmHg, Urine > 0.5ml/kg/hrs (2 .), Central venous oxygen sat > 65

500-1000 ml 30 Norepinephrine Dopamine Trop-T positive Norepinephrine Cutdown CVP Central Venous Oxygenation CVP 11 cmH2O 16 cmH2O MAP > 65 mmHg Central venous oxygen < 65 Dobutamine 2 . MAP < 65 mmHg adrenaline HCO3 Lactate 80-150 mg%

Malaria malaria 2 P. falciparum P. vivax P. falciparum Quinine 600 mg iv 8 hrs tetracyclin(250mg) 1 x 4 Doxycyclin 1 x 2 Renal failure Doxycyclin P. vivax Chloroquine 2 tab 8 hrs 2 tab OD 2 3 primaquine 2 tab OD 14 Mixed infection falciparum vivax Quinine primaquine

-12-

Elderly fatigue sepsis sepsis syndrome renal failure, arthritis, heart failure, hyperthyroid depression Hemoculture, UA, BUN, Cr, electrolyte ampicillin gentamicin 4-6 mg/kg/day cefotaxime 3-4 gm/day

Acute Abdomen sign peritonitis tender, guarding, rigidity rebound tenderness admit/consult surgery sign NPO antibiotic ampicillin 1 gm iv q 6 hrs gentamicin 4-6 mg/kg/day metronidazole 500mg iv q 8 hrs cefotaxime 3-4 gm/day metronidazole 500mg iv q 8 hrs acute cholecystitis restless NPO antibiotic ampicillin 1 gm iv q 6 hrs gentamicin 4-6 mg/kg/day cefotaxime 3-4 gm/day

CVA CT Scan infart CT ASA Gr V 1 x 1 Plavix 1x1 Emboli ( activity, AF, Infart main br. MCA Multiple infarct) Fraxiparin Enoxaparin 0.4-0.6 ml sc q 12 hrs Warfarin Large Infarct Fraxiparin Enoxaparin day 3, , Heart rate , BP manitol 250 ml iv drip 1 . Consult Neurosugery,

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Toxicology

NG tube larvage(, Hydrocarbon ) Activated charcoal 50 gm stat 1 dose Carbamazepine, dapsone, diazepam, digoxin, glutethimide, meprobamate, methotrexate, phenobarb, phenytoin, salicylate, theophylline, valproic acid 2-4 . MOM 15-30 ml q 4 . antidote 1) Organophosphate carbamate carbamate Atropine 2 amp(1.2mg) iv muscarinic effect , , bowel sound active, heart rate 15-30 organophosphate CNS nicotinic effect fasciculation, muscle weak respiratory failure 2-Pam Dose 1 gm 4-6 . CNS Nicotinic muscarinic Atropine 2amp(1.2mg) .15-30 muscarinic protocol 2) Paracetamol paracetamol . 30 20-30 20 antiodote N-Acetylcysteine(NAC) NAC oral activated charcoal NAC NAC 2

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2.1) 140 mg/kg 70 mg/kg 4 . 17 2.2) NAC 150 mg/kg 5%D/W 200 ml 15

50 mg/kg 5%D/W 500 ml 4 . 100 mg/kg 5%D/W 1000 ml 16 .

LFT N-Acetylcysteine . 1 100 mg 1 Amp 3 ml 300 mg 3) Benzodiazepine antidote Flumazenil . antidote Toxicology . (02)2468282

Snake bite 2 1) Hematotoxin 2) Neurotoxin 1) Hematotoxin 2 , platelet , Venous clotting time prolong (VCT) (30 ) clinical bleeding admit admit antivenom VCT prolong Clinical bleeding 40-60 ml 5%D/W 100 ml 30-60 6 . VCT VCT antibiotic PenV4 2 x 4 skin necrosis bleb bleb digital gangrene Skin Test Positive anti-venom antivenom 10 ml iv drip 1 . 40 ml iv drip 4 . 2) Neurotoxin

2.1) admit 12 . peak flow 150 L/min antivenom 100 ml

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2.2) admit 12. antivenom 50-100 ml 5%D/W 100 ml iv drip 30-60

2.3) antivenom antivenom

antibiotic PGS iv Augmentin Clindamycin Cefotaxime

-16-

Doctors Order for Acute Coronary Syndrome Progress Note Order for One Day Order for Continue

Date/Time Onset time .

PND Orthopnea DOE Chest pain score CXR EKG Diagnosis STEMI UA/NSTEMI Comorbid

Type 2 DM IHD Renal failure COPD

Cardiac enzyme MI CK-MB . 0, 3, 6 TropT . 4, 10 Coronary reperfusion 1.ST Segment 50% 90 2.Early Peak Cardiac enzyme (60-min ratios T 60/T 0) CK > 4.0 , CK-MB > 3.3 cTnI > 2.0 () 3. Chest Pain

Monitor EKG FBS Chol TG HDL CBC BUN Cr Electrolyte PT PTT DTX stat .mg%

( 180 mg% ) Trop T () 1........ 2 ........ CK MB () 1........ 2 ........ 3 .........

( Cardiac enzyme ECG uninterpreted Chest pain . 3, 6 SK 60 )

12 lead ECG if inferior wall add V3R V4R ( ECG uninterpreted ECG 15 x 2 ST segment change)

Repeat ECG 12 lead at () ........ , .......... Chest X-ray NSS 1000 ml iv ml/hrs ASA Gr V 1 tab Chew stat Clopidogrel (75) 4 tabs oral stat Enoxaparin 30 mg iv 15

( 75 ) Thrombolytic agent

SK 1.5 mu in NSS 100 ml in in 1 hr (if no contraindication)

If intractable chest pain start NTG 1: 5 in NSS 100 ml iv drip start 3 d/min titrace dose 3 d/min q 15 keep no chest pain, SBP > 100 mmHg

Record V/S q 1 hr, Notify if SBP > 180 or < 90 mmHg HR > 100 or < 50 /min RR > 25 or < 12 /min Intractable Chest pain or Bleeding

Admit ICU (NSTEMI, Complicated MI)

Low salt low fat soft diet I/O Retain foley cath Absolute bed rest Restrict oral fluid < ml/day Oxygen 2 litre/m

Medication Enoxaparin 40 mg sc q 12 hrs

( < 75 1 mg/kg; > 75 0.75 mg/kg)

ASA Gr V 1 tab tab oral OD PC Clopidogrel (75) 1 tab oral OD Isordil(10mg) 1 x 3 Propranolol(10mg) 1/2 x 2 Enalapril(5) 1 x 1 Simvastatin(10) 1 tab hs MOM 15 ml hs Omeprazole 1 x 1

Streptokinase 1. Hemorrhagic stoke 2.Ischemic stroke 6 3.Post Mafor operation 3 wk 4. Aortic dissection 5.Prolong CPR > 10 6.Pregnancy 7.Uncontrol HT (SBP > 180) 8. Streptokinase

-17-

ECG Criteria Diagnosis STEMI

ECG findings Lesion Sensitivity (%)

Specificity (%)

Positive predictive value (%)

Negative predictive value (%)

ST-segment elevation greater in lead III than in lead II plus ST-segment depression of > 1 mm in lead I, lead aVL, or both

Right coronary artery

90 71 94 70

Absence of the above findings plus ST-segment elevation in leads I, aVL, V5, and V6 and ST-segment depression in leads V1, V2, and V3

Left circumflex coronary artery

83 96 91 93

ST-segment elevation in leads V1, V2, and V3 plus any of the features below ST-segment elevation of > 2.5 mm in lead V1, right bundle branch block with Q wave, or both

Proximal LAD coronary artery

12 100 100 61

ST-segment depression of > 1 mm in leads II, III, and aVF

Proximal LAD coronary artery

34 98 93 68

ST-segment depression of 1 mm or ST-segment elevation in leads II, III, and aVF

Distal LAD coronary artery

66 73 78 62

J-point/T > 0.25, T/QRS > 75%, J-point > 0.3 mV

61.9 98 92.9 86.2

ST-segment Change > 1-2 mm

46 93 84

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Characteristics of Serum Cardiac Markers for the Diagnosis of Acute Myocardial Infarction*

Serum cardiac marker

Test first becomes positive (hours)

Peak level (hours)

Sensitivity (%)

Specificity (%)

Positive predictive value (%)

Negative predictive value (%)

CK Single assay 3 to 8 12 to 24 35 80 20 90

Serial assays 95 68 30 99

CK-MB Single assay 4 to 6 12 to 24 35 85 25 90

Serial assays 95 95 73 99

Troponin I and T Measured 4 hours after onset of chest pain

4 to 10 35 96 56 91

Measured 10 hours after onset of chest pain

8 to 28 89 95 72 98

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Doctors Order DKA Progress Note Order for One Day Order for Continue

DKA 1.( BS > 250 mg%) 2. Acidosis (HCO3 3.3 K 2 . Serum K 3.3-5.3 add KCL 20-30 mEq Serum K >5.3 KCL K 2 . Diagnosis 1 DM Type with DKA Comorbid

IHD Renal failure COPD

CBC UA BUN Cr HemoC/S x3 CXR EKG Serum ketone Electrolyte& Blood Sugar 4 . NSS 1000 ml x 1 1 . NSS 1000 ml + KCL mEq

iv rate ml.hrs (250-500 ml/hrs) DTX 1 . DTX < 200 mg% RI 100 U in NSS 100 ml

iv rate 10 d/min ( 10 u/hrs) Arterial blood gas pH < 6.9 NaHCO3 100 ml + KCL 20

mEq iv drip 2 pH 6.9-7 NaHCO3 50 ml + KCL 10

mEq iv drip 1 . ( NaHCO3 2 . pH > 7) DTX < 200 mg% 5%DNSS/2 1000 ml+KCl mEq

iv rate ml/hrs(150-250 ml/hrs) Isulin iv regimen

DTX 1 . RI 10 U in NSS 100 ml iv rate

DTX 100-150 RI rate 20 d/min (2 u/hrs) DTX 151-180 RI rate 30 d/min (3 u/hrs) DTX 180-200 RI rate 40 d/min (4 u/hrs) DTX >200 RI rate 50 d/min (5 u/hrs) DTX < 150 mg iv 5%DNSS -> ml/hrs (scale ) DTX > 200 mg iv 5%DNSS -> ml/hrs (scale ) Isulin sc regimen

DTX 2 . RI (0.1U/kg) sc 2 .

DTX 200

NPO Diabetic Diet I/O Retain foley cath Oxygen 2 litre/m

Medication

-20-

Doctors Order HHS Progress Note Order for One Day Order for Continue

HHS 1.BS>600mg% 2.Serum OSM >350 3.Serum OSM >320 Serum OSM = 2Na + BS/18 + BUN/2.8 Correct Na=((BS-100)/100 x 1.6) + Na 1.BS 5.3 KCL K 2 . Diagnosis 1 DM Type with HHS Comorbid

IHD Renal failure COPD

CBC UA BUN Cr HemoC/S x3 CXR EKG Serum ketone Electrolyte& Blood Sugar 4 . NSS 1000 ml x 1 1 . NSS+ KCL mEq

iv rate ml.hrs (250-500 ml/hrs) DTX 1 . DTX < 300 mg% RI 10 U iv stat RI 100 U in NSS 100 ml

iv rate 10 d/min ( 10 u/hrs) DTX < 300 mg%

5%DNSS/2 1000 ml+KCl mEq iv rate ml/hrs(150-250 ml/hrs) Isulin iv regimen

DTX 1 . RI 10 U in NSS 100 ml iv rate

DTX 100-250 RI rate 20 d/min (2 u/hrs) DTX 251-280 RI rate 30 d/min (3 u/hrs) DTX 280-300 RI rate 40 d/min (4 u/hrs) DTX >300 RI rate 50 d/min (5 u/hrs) DTX < 250 mg iv 5%DNSS -> ml/hrs (scale ) DTX > 300 mg iv 5%DNSS -> ml/hrs (scale )

NPO Diabetic Diet I/O Retain foley cath Oxygen 2 litre/m

Medication

-21-

Doctors Order Ischemic Stroke

Progress Note Order for One Day Order for Continue Date/Time Neurologic Exam GCS E M V Motor

Investigation CT brain Diagnosis CVA Thrombosis Emboli Comorbid

Type 2 DM IHD Renal failure COPD

CBC BUN Cr Electrolyte VDRL Chol TG HDL LDL FBS DTX stat .. mg%

( 180 mg% ) CXR EKG CT Brain E Record V/S q 4 hrs

SBP > 220 mmHg x 2 20 DBP > 120 mmHg x 2 20

Record Neurosign q 4 hrs GCS 2

NSS 1000 ml iv rate ml/hrs

NPO Soft Diet I/O Retain foley cath Oxygen 2 litre/m Fall Precaution Aspirate Precaution

Medication ASA Gr V 1 x 1 Omeprazole 40 mg iv q 12 Simvastatin(10) 1 tab hs

-22-

Doctors Order Hypertensive Emergency Progress Note Order for One Day Order for Continue

Diagnosis Hypertesive Crises Urgency Comorbid

Type 2 DM IHD Renal failure COPD

1. Hypertensive Crises TOD (Target organ dysfunction) Heart failure, Progressive Neurological deficit, Progressive impaire Kidney fuction IV ( 20%) 2. Hypersentive Urgency Systolic >220 diastolic >120 mm Hg admit admit

CBC UA BUN Cr Electrolyte Chol TG HDL CXR EKG LFT PT PTT DTX stat mg%

( 180 mg% ) Nitroprusside Nitroprusside

50mg in 5%DW 500 iv drip 8 d/min 5 d/min keep BP < mmHg ( 10-20%)

(0.25-10 mcg/kg/min)

Diltiazem 10 mg iv 1

50 mg in 5%DW 100 ml iv 30 d/min 5 d/min keep

BP < mmHg ( 10-20%) max 120 d/min

(0.25 mg/kg IV bolus (20 mg); may repeat 0.35-mg/kg bolus (25 mg) in 15 min; followed by 5-20 mg/h IV infusion)

Nicardipine (0.02% Nicardipine 24 ml 5% D/W NSS 100 ml) 30 ml/hrs 5 d/min keep BP < mmHg ( 10-20%)

NPO Soft Diet I/O Retain foley cath Oxygen 2 litre/m

Medication

-23-

Doctors Order SVT Progress Note Order for One Day Order for Continue

Diagnosis SVT Comorbid

Type 2 DM IHD Renal failure COPD

CBC UA BUN Cr Electrolyte Chol TG HDL CXR EKG DTX stat mg%

( 180 mg% )

NSS 1000 ml iv rate ml/hrs

On heparin lock Monitor EKG Adenosine 6 mg iv push

HR > 100 12 mg iv push HR > 100 12 mg iv push Dose 2 12 mg iv Dose 2 HR > 100 Adenosine push

Amiodarone 150 mg iv drip 30 150 mg iv drip 30 30 mg/hrs Heart rate < 100 EKG complete lead Sinus rhythms

Cardioversion 50-100 J Verapramil 2.5 mg iv push

5-10 sinus rhythm

NPO Soft Diet I/O Retain foley cath Oxygen 2 litre/m

Medication

-24-

Protocol Resuscitate Septic Shock Progress Note Order for One Day Order for Continue

Septic shock Organ Hypoperfusion 6 .: CVP 8-12 mmHg (11-16 cmH2O) MAP > 65, Urine > 0.5ml/kg/hrs (2 .), Central venous oxygen sat > 65 Severe Sepsis Hypotension, Urine < 0.5 ml/hrs , Hypoxemia PaO2/FiO2 < 250 < 200 ( (Pneumonia), Cr > 2, Bilirubin > 2 Platelet < 100,000, Coagulopathy (INR > 1.5) 500-1000 ml 30 Protocol step II Severe Sepsis Step III Cutdown CVP Central Venous Oxygenation Norepinephrine Dopamine CVP 11 cmH2O 16 cmH2O MAP > 65 mmHg Central venous oxygen < 65 Dobutamine HCO3 Lactate 80-150 mg% Insulin iv drip

Step I ER Acetar 1000 ml 500 ml iv 30 30 MAP > 65 mmHg Step II MAP < 65 mmHg Step III Step II

Admit Vital sign 1 .

stable 12 record vital sign Acetar 1000 ml x II

iv rate ... ml/hrs urine output < 30 ml/hrs

MAP < 65 mmHg Step III

Admit ICU, cutdown & insert CVP Vital sign , CVP 1 Arterial Blood gas Actetar 1000 ml x III

iv rate ml/hrs (rate 80-200) Dopamin 2:1 iv Keep BP > 90/60

15 d/min Max 30 d/min Norepinephrine 4 mg : 5%DW 100

3 d/min Max 45 d/min 2

Venous Blood gas (Central vein) Epinephrine 4 amp : 5%DW 100

3 d/min Max 100 d/min Dobutamin 2:1 iv ..... d/min (15-30) iv Protocol

NPO Soft Diet I/O Retain foley cath Oxygen 2 litre/m

Medication Ranithidine 50 mg iv q 8 hrs Hydrocortisone .. mg iv q

.. hrs ( 300 mg/day) Antibiotic ( antibiotic 1 .)

Unstable angina/NSTEMISTEMICardiac arrhythmiaSVT

Bradyarrhythmia Acute AsthmaCOPD with acute exacerbrationCommunity Acquire Pneumonia Pneumotharax

HemoptysisDiabetic ketoacidosisHyperosmolar ComaThyroid CrisisSevere hyperthyroidRenal failureAcute Renal failureCRFHypernatremiaHyponatremiaHyperkalemiaHypokalemiaUGIBAcute febrileSepsis & Septic shockMalariaElderly fatigueAcute AbdomenCVAToxicologySnake biteOrder for ContinueOrder for ContinueOrder for ContinueOrder for ContinueOrder for ContinueOrder for ContinueOrder for Continue