"
"
Anticoagulant Overdose
Unfractionated Heparin Overdose:
1.Discontinue heparin infusion.
2.Protamine sulfate, 1 mg IV for every 100 units of
heparin infused in preceding hour, dilute in 25 mL
fluid, and give IV over 10 min (max 50 mg in 10
min period).
Low-Molecular-Weight Heparin (Enoxaparin)
Overdose:
-Protamine sulfate 1 mg IV for each 1 mg of
enoxaparin given. Repeat protamine 0.5 mg IV for
each 1 mg of enoxaparin, if bleeding continues
after 2-4 hours. Measure factor Xa.
Warfarin (Coumadin) Overdose:
-Gastric lavage with normal saline until clear fluid
and activated charcoal if recent oral ingestion.
Discontinue coumadin and heparin, and
monitor hematocrit q2h.
Partial Reversal:
-Vitamin K (Phytonadione), 0.5-1.0 mg IV/SQ.
Check INR in 24 hours, and repeat vitamin K
dose if INR remains elevated.
Minor Bleeds:
-Vitamin K (Phytonadione), 5-10 mg IV/SQ q12h,
titrated to desired INR.
Serious Bleeds:
-Vitamin K (Phytonadione), 10-20 mg in 50-100 mL
fluid IV over 30-60 min (check INR q6h until
corrected) AND
-Fresh frozen plasma 2-4 units x 1.
-Type and cross match for 2 units of PRBC, and
transfuse wide open.
-Cryoprecipitate 10 U x 1 if fibrinogen is less than
100 mg/dL.
Labs: CBC, platelets, PTT, INR.
Deep Venous Thrombosis
1.Admit to:
2.Diagnosis: Deep vein thrombosis
3.Condition:
4.Vital Signs: q shift. Call physician if BP systolic >160,
<90 diastolic, >90, <60; P >120, <50; R>25, <10; T
>38.5 C.
5.Activity: Bed rest with legs elevated; bedside
commode.
6.Nursing: Guaiac stools, warm packs to leg prn;
measure calf and thigh circumference qd; no
intramuscular injections.
7.Diet: Regular
8. IV Fluids: D5W at TKO
9. Special Medications:
Anticoagulation:
-Heparin (unfractionated) 80 U/kg IVP, then 18
U/kg/hr IV infusion. Check PTT 6 hours after initial
bolus; adjust q6h until PTT 1.5-2.0 times control
(50-80 sec). Overlap heparin and warfarin
(Coumadin) for at least 4 days and discontinue
heparin when INR has been 2.0-3.0 for two
consecutive days OR
-Enoxaparin (Lovenox) outpatient: 1 mg/kg SQ q12h
for DVT without pulmonary embolism. Overlap
enoxaparin and warfarin for 4-5 days until INR is 2-
3.
-Enoxaparin (Lovenox) inpatient: 1 mg/kg SQ q12h or
1.5 mg/kg SQ q24 h for DVT with or without
pulmonary embolism. Overlap enoxaparin and
warfarin (Coumadin) for at least 4 days and
discontinue heparin when INR has been 2.0-3.0 for
two consecutive days.
-Warfarin (Coumadin) 5-10 mg PO qd x 2-3 d;
maintain INR 2.0-3.0. Coumadin is initiated on the
first or second day only if the PTT is 1.5-2.0 times
control [tab 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 mg].
10. Symptomatic Medications:
-Propoxyphene/acetaminophen (Darvocet N100) 1-2
tab PO q3-4h prn pain OR
-Hydrocodone/acetaminophen (Vicodin), 1-2 tab q4-
6h PO prn pain.
-Docusate sodium (Colace) 100 mg PO qhs.
-Famotidine (Pepcid) 20 mg IV/PO q12h OR
-Lansoprazole (Prevacid) 30 mg qd.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
11. Extras: CXR PA and LAT, ECG; Doppler scan of
legs. V/Q scan, chest CT scan.
12. Labs: CBC, INR/PTT, SMA 7. Protein C, protein S,
antithrombin III, anticardiolipin antibody. UA with
-Zileuton (Zyflo) 600 mg PO qid.
Acute Bronchitis
-Ampicillin/sulbactam (Unasyn) 1.5 gm IV q6h OR
-Cefuroxime (Zinacef) 750 mg IV q8h OR
-Cefuroxime axetil (Ceftin) 250-500 mg PO bid OR
-Trimethoprim/sulfamethoxazole (Bactrim DS), 1 tab
PO bid OR
-Levofloxacin (Levaquin) 500 mg PO/IV PO qd [250,
500 mg].
-Amoxicillin 875 mg/clavulanate 125 mg (Augmentin
875) 1 tab PO bid.
10. Symptomatic Medications:
-Docusate sodium (Colace) 100 mg PO qhs.
-Famotidine (Pepcid) 20 mg IV/PO q12h OR
-Lansoprazole (Prevacid) 30 mg qd.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
headache.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
11. Extras: Portable CXR, ECG, pulmonary function
tests before and after bronchodilators; pulmonary
rehabilitation; impedance cardiography,
echocardiogram.
12. Labs: ABG, CBC with eosinophil count, SMA7, B-
type natriuretic peptide (BNP). Theophylline level stat
and after 24h of infusion. Sputum Gram stain, C&S.
Chronic Obstructive Pulmonary
Disease
1.Admit to:
2.Diagnosis: Exacerbation of COPD
3.Condition:
4.Vital Signs: q4h. Call physician if P >130; R >30,
<10; T >38.5 C; O
saturation <90%.
2
5.Activity: Up as tolerated; bedside commode.
6.Nursing: Pulse oximeter. Measure peak flow with
portable peak flow meter bid and chart with vital signs.
No sedatives.
7.Diet: No added salt, no caffeine. Push fluids.
8.IV Fluids: D5 1/2 NS with 20 mEq KCL/L at 125 cc/h.
9.Special Medications:
-Oxygen 1-2 L/min by NC or 24-35% by Venturi mask,
keep O
saturation 90-91%.
2
Beta-Agonists, Acute Treatment:
-Albuterol (Ventolin) 0.5 mg and ipratropium
(Atrovent) 0.5 mg in 2.5 mL NS q1-2h until peak
flow meter 200-250 L/min, then q4h prn OR
-Levalbuterol (Xopenex) 0.63-1.25 mg by
nebulization q6-8h prn.
-Albuterol (Ventolin) MDI 2-4 puffs q4-6h.
-Albuterol/Ipratropium (Combivent) 2-4 puffs qid.
Maintenance Corticosteroids and Anticholinergics:
-Methylprednisolone (Solu-Medrol) 60-125 mg IV q6h
or 30-60 mg PO qd. Followed by:
-Prednisone 20-60 mg PO qd.
-Triamcinolone (Azmacort) MDI 2 puffs qid or 4 puffs
bid.
-Beclomethasone (Beclovent) MDI 4-8 puffs bid with
spacer, followed by gargling with water OR
-Flunisolide (AeroBid) MDI 2-4 puffs bid OR
-Ipratropium (Atrovent) MDI 2 puffs tid-qid OR
-Fluticasone (Flovent) 2-4 puffs bid (44 or 110
mcg/puff).
Aminophylline and Theophylline (second line
therapy):
-Aminophylline loading dose, 5.6 mg/kg total body
weight over 20 min (if not already on theophylline);
then 0.5-0.6 mg/kg ideal body weight/hr (500 mg in
250 mL of D5W); reduce if elderly, or heart or liver
disease (0.2-0.4 mg/kg/hr). Reduce loading to 50-
75% if already taking theophylline (1 mg/kg of
aminophylline will raise levels by 2 mcg/mL) OR
-Theophylline IV solution loading dose, 4.5 mg/kg
total body weight, then 0.4-0.5 mg/kg ideal body
weight/hr.
-Theophylline long acting (Theo-Dur) 100-400 mg PO
bid-tid (3 mg/kg q8h); 80% of daily IV aminophylline
in 2-3 doses.
Acute Bronchitis
-Trimethoprim/sulfamethoxazole (Septra DS) 160/800
mg PO bid or 160/800 mg IV q12h (10-15 mL in 100
cc D5W tid) OR
-Cefuroxime (Zinacef) 750 mg IV q8h OR
-Ampicillin/sulbactam (Unasyn) 1.5 gm IV q6h OR
-Doxycycline (Vibra-tabs) 100 mg PO/IV bid OR
-Azithromycin (Zithromax) 500 mg x 1, then 250 mg
PO qd x 4 or 500 mg IV q24h OR
-Clarithromycin (Biaxin) 250-500 mg PO bid OR
-Levofloxacin (Levaquin) 500 mg PO/IV qd [250, 500
mg].
10. Symptomatic Medications:
-Docusate sodium (Colace) 100 mg PO qhs.
-Famotidine (Pepcid) 20 mg IV/PO bid OR
-Lansoprazole (Prevacid) 30 mg qd.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
headache.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
11. Extras: Portable CXR, PFTs with bronchodilators,
ECG, impedance cardiography, echocardiogram.
12. Labs: ABG, CBC, SMA7, UA. Theophylline level stat
and after 12-24h of infusion. Sputum Gram stain and
C&S, alpha 1 antitrypsin level.
Hemoptysis
1.Admit to: Intensive care unit
2.Diagnosis: Hemoptysis
3.Condition:
4.Vital Signs: q1-6h. Orthostatic BP and pulse bid. Call
physician if BP >160/90, <90/60; P >130, <50; R>25,
sat <90%.
<10; T >38.5 C; O
2
5.Activity: Bed rest with bedside commode. Keep pat-
ient in lateral decubitus, Trendelenburg’s position,
bleeding side down.
6.Nursing: Quantify all sputum and expectorated blood,
suction prn. O
at 100% by mask, pulse oximeter. Dis-
2
continue narcotics and sedatives. Have double lumen
endotracheal tube available for use. Foley to closed
drainage.
7.Diet: NPO
8.IV Fluids: 1 L of NS wide open ( 6 gauge), then
transfuse PRBC. Then infuse D5 1/2 NS at 125 cc/h.
9.Special Medications:
-Transfuse 2-4 U PRBC wide open.
-Promethazine/codeine (Phenergan with codeine) 5
cc PO q4-6h prn cough. Contraindicated in massive
hemoptysis.
-Initiate empiric antibiotics if bronchitis or infection is
present.
10. Extras: CXR PA, LAT, ECG, VQ scan, contrast CT,
bronchoscopy. PPD, pulmonary and thoracic surgery
consults.
11. Labs: Type and cross 2-4 U PRBC. ABG, CBC,
platelets, SMA7 and 12, ESR. Anti-glomerular
basement antibody, rheumatoid factor, complement,
anti-nuclear cytoplasmic antibody. Sputum Gram
stain, C&S, AFB, fungal culture, and cytology qAM for
3 days. UA, INR/PTT, von Willebrand Factor. Repeat
CBC q6h.
Anaphylaxis
1.Admit to:
2.Diagnosis: Anaphylaxis
3.Condition:
4.Vital Signs: q1-4h; call physician if BP systolic >160,
<90; diastolic >90, <60; P >120, <50; R>25, <10; T
>38.5 C
5.Activity: Bedrest
6.Nursing: O
at 6 L/min by NC or mask. Keep patient
2
in Trendelenburg's position, No. 4 or 5 endotracheal
tube at bedside. Foley to closed drainage.
7.Diet: NPO
8.IV Fluids: 2 IV lines. Normal saline or LR 1 L over 1-
2h, then D5 ½ NS at 125 cc/h.
9.Special Medications:
Gastrointestinal Decontamination:
-Gastric lavage with normal saline until clear fluid if
indicated for recent oral ingestion.
-Activated charcoal 50-100 gm, followed by
magnesium citrate 6% solution 150-300 mL PO.
Bronchodilators:
-Epinephrine (1:1000) 0.3-0.5 mL SQ or IM q10min or
1-4 mcg/min IV OR in severe life-threatening
reactions, give 0.5 mg (5.0 mL of 1: 10,000
solution) IV q5-10min prn. Epinephrine, 0.3 mg of
1:1000 solution, may be injected SQ at site of
allergen injection OR
-Albuterol (Ventolin) 0.5%, 0.5 mL in 2.5 mL NS
q30min by nebulizer prn OR
-Aerosolized 2% racemic epinephrine, 0.5-0.75 mL in
2-3 mL saline nebulized q1-6h.
Corticosteroids:
-Methylprednisolone (Solu-Medrol) 250 mg IV x 1,
then 125 mg IV q6h OR
-Hydrocortisone sodium succinate 200 mg IV x 1,
then 100 mg q6h, followed by oral prednisone 60
mg PO qd, tapered over 5 days.
Antihistamines:
-Diphenhydramine (Benadryl) 25-50 mg PO/IV q4-6h
OR
-Hydroxyzine (Vistaril) 25-50 mg IM or PO q2-4h.
-Cetrizine (Zyrtec) 5-10 mg PO qd.
-Cimetadine (Tagamet) 300 mg PO/IV q6-8h.
Pressors and Other Agents:
-Norepinephrine (Levophed) 8-12 mcg/min IV, titrate
to systolic 100 mm Hg (8 mg in 500 mL D5W) OR
-Dopamine (Intropin) 5-20 mcg/kg/min IV.
10. Extras: Portable CXR, ECG, allergy consult.
11. Labs: CBC, SMA 7&12.
Pleural Effusion
1.Admit to:
2.Diagnosis: Pleural effusion
3.Condition:
4.Vital Signs: q shift. Call physician if BP >160/90,
<90/60; P>120, <50; R>25, <10; T >38.5 C
5.Activity:
6.Diet: Regular.
7.IV Fluids: D5W at TKO
8.Extras: CXR PA and LAT, repeat after thoracentesis;
left and right lateral decubitus x-rays, ECG, ul-
trasound, PPD; pulmonary consult.
9. Labs: CBC, SMA 7&12, protein, albumin, amylase,
ANA, ESR, INR/PTT, UA. Cryptococcal antigen,
histoplasma antigen, fungal culture.
Thoracentesis:
Tube 1: LDH, protein, amylase, triglyceride, glucose
(10 mL).
Tube 2: Gram stain, C&S, AFB, fungal C&S (20-60
mL, heparinized).
Tube 3: Cell count and differential (5-10 mL, EDTA).
Syringe: pH (2 mL collected anaerobically,
heparinized on ice).
Bag or Bottle: Cytology.
Unfractionated Heparin Overdose:
1.Discontinue heparin infusion.
2.Protamine sulfate, 1 mg IV for every 100 units of
heparin infused in preceding hour, dilute in 25 mL
fluid, and give IV over 10 min (max 50 mg in 10
min period).
Low-Molecular-Weight Heparin (Enoxaparin)
Overdose:
-Protamine sulfate 1 mg IV for each 1 mg of
enoxaparin given. Repeat protamine 0.5 mg IV for
each 1 mg of enoxaparin, if bleeding continues
after 2-4 hours. Measure factor Xa.
Warfarin (Coumadin) Overdose:
-Gastric lavage with normal saline until clear fluid
and activated charcoal if recent oral ingestion.
Discontinue coumadin and heparin, and
monitor hematocrit q2h.
Partial Reversal:
-Vitamin K (Phytonadione), 0.5-1.0 mg IV/SQ.
Check INR in 24 hours, and repeat vitamin K
dose if INR remains elevated.
Minor Bleeds:
-Vitamin K (Phytonadione), 5-10 mg IV/SQ q12h,
titrated to desired INR.
Serious Bleeds:
-Vitamin K (Phytonadione), 10-20 mg in 50-100 mL
fluid IV over 30-60 min (check INR q6h until
corrected) AND
-Fresh frozen plasma 2-4 units x 1.
-Type and cross match for 2 units of PRBC, and
transfuse wide open.
-Cryoprecipitate 10 U x 1 if fibrinogen is less than
100 mg/dL.
Labs: CBC, platelets, PTT, INR.
Deep Venous Thrombosis
1.Admit to:
2.Diagnosis: Deep vein thrombosis
3.Condition:
4.Vital Signs: q shift. Call physician if BP systolic >160,
<90 diastolic, >90, <60; P >120, <50; R>25, <10; T
>38.5 C.
5.Activity: Bed rest with legs elevated; bedside
commode.
6.Nursing: Guaiac stools, warm packs to leg prn;
measure calf and thigh circumference qd; no
intramuscular injections.
7.Diet: Regular
8. IV Fluids: D5W at TKO
9. Special Medications:
Anticoagulation:
-Heparin (unfractionated) 80 U/kg IVP, then 18
U/kg/hr IV infusion. Check PTT 6 hours after initial
bolus; adjust q6h until PTT 1.5-2.0 times control
(50-80 sec). Overlap heparin and warfarin
(Coumadin) for at least 4 days and discontinue
heparin when INR has been 2.0-3.0 for two
consecutive days OR
-Enoxaparin (Lovenox) outpatient: 1 mg/kg SQ q12h
for DVT without pulmonary embolism. Overlap
enoxaparin and warfarin for 4-5 days until INR is 2-
3.
-Enoxaparin (Lovenox) inpatient: 1 mg/kg SQ q12h or
1.5 mg/kg SQ q24 h for DVT with or without
pulmonary embolism. Overlap enoxaparin and
warfarin (Coumadin) for at least 4 days and
discontinue heparin when INR has been 2.0-3.0 for
two consecutive days.
-Warfarin (Coumadin) 5-10 mg PO qd x 2-3 d;
maintain INR 2.0-3.0. Coumadin is initiated on the
first or second day only if the PTT is 1.5-2.0 times
control [tab 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 mg].
10. Symptomatic Medications:
-Propoxyphene/acetaminophen (Darvocet N100) 1-2
tab PO q3-4h prn pain OR
-Hydrocodone/acetaminophen (Vicodin), 1-2 tab q4-
6h PO prn pain.
-Docusate sodium (Colace) 100 mg PO qhs.
-Famotidine (Pepcid) 20 mg IV/PO q12h OR
-Lansoprazole (Prevacid) 30 mg qd.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
11. Extras: CXR PA and LAT, ECG; Doppler scan of
legs. V/Q scan, chest CT scan.
12. Labs: CBC, INR/PTT, SMA 7. Protein C, protein S,
antithrombin III, anticardiolipin antibody. UA with
-Zileuton (Zyflo) 600 mg PO qid.
Acute Bronchitis
-Ampicillin/sulbactam (Unasyn) 1.5 gm IV q6h OR
-Cefuroxime (Zinacef) 750 mg IV q8h OR
-Cefuroxime axetil (Ceftin) 250-500 mg PO bid OR
-Trimethoprim/sulfamethoxazole (Bactrim DS), 1 tab
PO bid OR
-Levofloxacin (Levaquin) 500 mg PO/IV PO qd [250,
500 mg].
-Amoxicillin 875 mg/clavulanate 125 mg (Augmentin
875) 1 tab PO bid.
10. Symptomatic Medications:
-Docusate sodium (Colace) 100 mg PO qhs.
-Famotidine (Pepcid) 20 mg IV/PO q12h OR
-Lansoprazole (Prevacid) 30 mg qd.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
headache.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
11. Extras: Portable CXR, ECG, pulmonary function
tests before and after bronchodilators; pulmonary
rehabilitation; impedance cardiography,
echocardiogram.
12. Labs: ABG, CBC with eosinophil count, SMA7, B-
type natriuretic peptide (BNP). Theophylline level stat
and after 24h of infusion. Sputum Gram stain, C&S.
Chronic Obstructive Pulmonary
Disease
1.Admit to:
2.Diagnosis: Exacerbation of COPD
3.Condition:
4.Vital Signs: q4h. Call physician if P >130; R >30,
<10; T >38.5 C; O
saturation <90%.
2
5.Activity: Up as tolerated; bedside commode.
6.Nursing: Pulse oximeter. Measure peak flow with
portable peak flow meter bid and chart with vital signs.
No sedatives.
7.Diet: No added salt, no caffeine. Push fluids.
8.IV Fluids: D5 1/2 NS with 20 mEq KCL/L at 125 cc/h.
9.Special Medications:
-Oxygen 1-2 L/min by NC or 24-35% by Venturi mask,
keep O
saturation 90-91%.
2
Beta-Agonists, Acute Treatment:
-Albuterol (Ventolin) 0.5 mg and ipratropium
(Atrovent) 0.5 mg in 2.5 mL NS q1-2h until peak
flow meter 200-250 L/min, then q4h prn OR
-Levalbuterol (Xopenex) 0.63-1.25 mg by
nebulization q6-8h prn.
-Albuterol (Ventolin) MDI 2-4 puffs q4-6h.
-Albuterol/Ipratropium (Combivent) 2-4 puffs qid.
Maintenance Corticosteroids and Anticholinergics:
-Methylprednisolone (Solu-Medrol) 60-125 mg IV q6h
or 30-60 mg PO qd. Followed by:
-Prednisone 20-60 mg PO qd.
-Triamcinolone (Azmacort) MDI 2 puffs qid or 4 puffs
bid.
-Beclomethasone (Beclovent) MDI 4-8 puffs bid with
spacer, followed by gargling with water OR
-Flunisolide (AeroBid) MDI 2-4 puffs bid OR
-Ipratropium (Atrovent) MDI 2 puffs tid-qid OR
-Fluticasone (Flovent) 2-4 puffs bid (44 or 110
mcg/puff).
Aminophylline and Theophylline (second line
therapy):
-Aminophylline loading dose, 5.6 mg/kg total body
weight over 20 min (if not already on theophylline);
then 0.5-0.6 mg/kg ideal body weight/hr (500 mg in
250 mL of D5W); reduce if elderly, or heart or liver
disease (0.2-0.4 mg/kg/hr). Reduce loading to 50-
75% if already taking theophylline (1 mg/kg of
aminophylline will raise levels by 2 mcg/mL) OR
-Theophylline IV solution loading dose, 4.5 mg/kg
total body weight, then 0.4-0.5 mg/kg ideal body
weight/hr.
-Theophylline long acting (Theo-Dur) 100-400 mg PO
bid-tid (3 mg/kg q8h); 80% of daily IV aminophylline
in 2-3 doses.
Acute Bronchitis
-Trimethoprim/sulfamethoxazole (Septra DS) 160/800
mg PO bid or 160/800 mg IV q12h (10-15 mL in 100
cc D5W tid) OR
-Cefuroxime (Zinacef) 750 mg IV q8h OR
-Ampicillin/sulbactam (Unasyn) 1.5 gm IV q6h OR
-Doxycycline (Vibra-tabs) 100 mg PO/IV bid OR
-Azithromycin (Zithromax) 500 mg x 1, then 250 mg
PO qd x 4 or 500 mg IV q24h OR
-Clarithromycin (Biaxin) 250-500 mg PO bid OR
-Levofloxacin (Levaquin) 500 mg PO/IV qd [250, 500
mg].
10. Symptomatic Medications:
-Docusate sodium (Colace) 100 mg PO qhs.
-Famotidine (Pepcid) 20 mg IV/PO bid OR
-Lansoprazole (Prevacid) 30 mg qd.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
headache.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
11. Extras: Portable CXR, PFTs with bronchodilators,
ECG, impedance cardiography, echocardiogram.
12. Labs: ABG, CBC, SMA7, UA. Theophylline level stat
and after 12-24h of infusion. Sputum Gram stain and
C&S, alpha 1 antitrypsin level.
Hemoptysis
1.Admit to: Intensive care unit
2.Diagnosis: Hemoptysis
3.Condition:
4.Vital Signs: q1-6h. Orthostatic BP and pulse bid. Call
physician if BP >160/90, <90/60; P >130, <50; R>25,
sat <90%.
<10; T >38.5 C; O
2
5.Activity: Bed rest with bedside commode. Keep pat-
ient in lateral decubitus, Trendelenburg’s position,
bleeding side down.
6.Nursing: Quantify all sputum and expectorated blood,
suction prn. O
at 100% by mask, pulse oximeter. Dis-
2
continue narcotics and sedatives. Have double lumen
endotracheal tube available for use. Foley to closed
drainage.
7.Diet: NPO
8.IV Fluids: 1 L of NS wide open ( 6 gauge), then
transfuse PRBC. Then infuse D5 1/2 NS at 125 cc/h.
9.Special Medications:
-Transfuse 2-4 U PRBC wide open.
-Promethazine/codeine (Phenergan with codeine) 5
cc PO q4-6h prn cough. Contraindicated in massive
hemoptysis.
-Initiate empiric antibiotics if bronchitis or infection is
present.
10. Extras: CXR PA, LAT, ECG, VQ scan, contrast CT,
bronchoscopy. PPD, pulmonary and thoracic surgery
consults.
11. Labs: Type and cross 2-4 U PRBC. ABG, CBC,
platelets, SMA7 and 12, ESR. Anti-glomerular
basement antibody, rheumatoid factor, complement,
anti-nuclear cytoplasmic antibody. Sputum Gram
stain, C&S, AFB, fungal culture, and cytology qAM for
3 days. UA, INR/PTT, von Willebrand Factor. Repeat
CBC q6h.
Anaphylaxis
1.Admit to:
2.Diagnosis: Anaphylaxis
3.Condition:
4.Vital Signs: q1-4h; call physician if BP systolic >160,
<90; diastolic >90, <60; P >120, <50; R>25, <10; T
>38.5 C
5.Activity: Bedrest
6.Nursing: O
at 6 L/min by NC or mask. Keep patient
2
in Trendelenburg's position, No. 4 or 5 endotracheal
tube at bedside. Foley to closed drainage.
7.Diet: NPO
8.IV Fluids: 2 IV lines. Normal saline or LR 1 L over 1-
2h, then D5 ½ NS at 125 cc/h.
9.Special Medications:
Gastrointestinal Decontamination:
-Gastric lavage with normal saline until clear fluid if
indicated for recent oral ingestion.
-Activated charcoal 50-100 gm, followed by
magnesium citrate 6% solution 150-300 mL PO.
Bronchodilators:
-Epinephrine (1:1000) 0.3-0.5 mL SQ or IM q10min or
1-4 mcg/min IV OR in severe life-threatening
reactions, give 0.5 mg (5.0 mL of 1: 10,000
solution) IV q5-10min prn. Epinephrine, 0.3 mg of
1:1000 solution, may be injected SQ at site of
allergen injection OR
-Albuterol (Ventolin) 0.5%, 0.5 mL in 2.5 mL NS
q30min by nebulizer prn OR
-Aerosolized 2% racemic epinephrine, 0.5-0.75 mL in
2-3 mL saline nebulized q1-6h.
Corticosteroids:
-Methylprednisolone (Solu-Medrol) 250 mg IV x 1,
then 125 mg IV q6h OR
-Hydrocortisone sodium succinate 200 mg IV x 1,
then 100 mg q6h, followed by oral prednisone 60
mg PO qd, tapered over 5 days.
Antihistamines:
-Diphenhydramine (Benadryl) 25-50 mg PO/IV q4-6h
OR
-Hydroxyzine (Vistaril) 25-50 mg IM or PO q2-4h.
-Cetrizine (Zyrtec) 5-10 mg PO qd.
-Cimetadine (Tagamet) 300 mg PO/IV q6-8h.
Pressors and Other Agents:
-Norepinephrine (Levophed) 8-12 mcg/min IV, titrate
to systolic 100 mm Hg (8 mg in 500 mL D5W) OR
-Dopamine (Intropin) 5-20 mcg/kg/min IV.
10. Extras: Portable CXR, ECG, allergy consult.
11. Labs: CBC, SMA 7&12.
Pleural Effusion
1.Admit to:
2.Diagnosis: Pleural effusion
3.Condition:
4.Vital Signs: q shift. Call physician if BP >160/90,
<90/60; P>120, <50; R>25, <10; T >38.5 C
5.Activity:
6.Diet: Regular.
7.IV Fluids: D5W at TKO
8.Extras: CXR PA and LAT, repeat after thoracentesis;
left and right lateral decubitus x-rays, ECG, ul-
trasound, PPD; pulmonary consult.
9. Labs: CBC, SMA 7&12, protein, albumin, amylase,
ANA, ESR, INR/PTT, UA. Cryptococcal antigen,
histoplasma antigen, fungal culture.
Thoracentesis:
Tube 1: LDH, protein, amylase, triglyceride, glucose
(10 mL).
Tube 2: Gram stain, C&S, AFB, fungal C&S (20-60
mL, heparinized).
Tube 3: Cell count and differential (5-10 mL, EDTA).
Syringe: pH (2 mL collected anaerobically,
heparinized on ice).
Bag or Bottle: Cytology.
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