Family Medicine
Family Medicine
Family Medicine
gies
Family Medicine
Year 2004 Edition
Paul D. Chan, MD
Christopher R. Winkle, MD
Peter J. Winkle, MD
Progress Notes
Daily progress notes should summarize developments in
a patient's hospital course, problems that remain
active, plans to treat those problems, and arrange-
ments for discharge. Progress notes should address
every element of the problem list.
Progress Note
Date/time:
Subjective: Any problems and symptoms of the
patient should be charted. Appetite, pain, head-
aches or insomnia may be included.
Objective:
General appearance.
Vitals, including highest temperature over past 24
hours. Fluid I/O (inputs and outputs), including
oral, parenteral, urine, and stool volumes.
Physical exam, including chest and abdomen, with
particular attention to active problems. Emphasize
changes from previous physical exams.
Labs: Include new test results and circle abnormal
values.
Current medications: List all medications and
dosages.
Assessment and Plan: This section should be
organized by problem. A separate assessment
and plan should be written for each problem.
Procedure Note
A procedure note should be written in the chart when a
procedure is performed. Procedure notes are brief
operative notes.
Procedure Note
Discharge Note
The discharge note should be written in the patient’s
chart prior to discharge.
Discharge Note
Date/time:
Diagnoses:
Treatment: Briefly describe treatment provided
during hospitalization, including surgical proce-
dures and antibiotic therapy.
Studies Performed: Electrocardiograms, CT
scans.
Discharge Medications:
Follow-up Arrangements:
Discharge Summary
Patient's Name and Medical Record Number:
Date of Admission:
Date of Discharge:
Admitting Diagnosis:
Discharge Diagnosis:
Attending or Ward Team Responsible for Patient:
Surgical Procedures, Diagnostic Tests, Invasive
Procedures:
Brief History, Pertinent Physical Examination, and
Laboratory Data: Describe the course of the patient's
disease up until the time that the patient came to the
hospital, including physical exam and laboratory data.
Hospital Course: Describe the course of the patient's
illness while in the hospital, including evaluation,
treatment, medications, and outcome of treatment.
Discharged Condition: Describe improvement or
deterioration in the patient's condition, and describe
present status of the patient.
Disposition: Describe the situation to which the patient
will be discharged (home, nursing home), and indicate
who will take care of patient.
Discharged Medications: List medications and instruc-
tions for patient on taking the medications.
Discharged Instructions and Follow-up Care: Date of
return for follow-up care at clinic; diet, exercise.
Problem List: List all active and past problems.
Copies: Send copies to attending, clinic, consultants.
Prescription Writing
• Patient’s name:
• Date:
• Drug name, dosage form, dose, route, frequency
(include concentration for oral liquids or mg strength
for oral solids): Amoxicillin 125mg/5mL 5 mL PO tid
• Quantity to dispense: mL for oral liquids, # of oral
solids
• Refills: If appropriate
• Signature
Cardiovascular Disorders
ST-Segment Elevation Myocardial
Infarction
1. Admit to: Coronary care unit
2. Diagnosis: Rule out myocardial infarction
3 Condition:
4. Vital Signs: q1h. Call physician if pulse >90,<60; BP
>150/90, <90/60; R>25, <12; T >38.5/C.
5. Activity: Bed rest with bedside commode.
7. Nursing: Guaiac stools. If patient has chest pain,
obtain 12-lead ECG and call physician.
8. Diet: Cardiac diet, 1-2 gm sodium, low fat, low choles-
terol diet. No caffeine or temperature extremes.
9. IV Fluids: D5W at TKO
10. Special Medications:
-Oxygen 2-4 L/min by NC.
-Aspirin 325 mg PO, chew and swallow, then aspirin
EC 162 mg PO qd OR Clopidogrel (Plavix) 75 mg
PO qd (if allergic to aspirin).
-Nitroglycerine 10 mcg/min infusion (50 mg in 250-500
mL D5W, 100-200 mcg/mL). Titrate to control
symptoms in 5-10 mcg/min steps, up to 200-300
mcg/min; maintain systolic BP >90 OR
-Nitroglycerine SL, 0.4 mg (0.15-0.6 mg) SL q5min
until pain free (up to 3 tabs) OR
-Nitroglycerin spray (0.4 mg/aerosol spray)1-2 sprays
under the tongue q 5min; may repeat x 2.
-Heparin 60 U/kg IV push, then 12 U/kg/hr by continu-
ous IV infusion for 48 hours to maintain aPTT of
50-70 seconds. Check aPTTq6h x 4, then qd.
Repeat aPTT 6 hours after each heparin dosage
change.
Thrombolytic Therapy
Absolute Contraindications to Thrombolytics: Active
internal bleeding, suspected aortic dissection, known
intracranial neoplasm, previous intracranial hemor-
rhagic stroke at any time, other strokes or
cerebrovascular events within 1 year, head trauma,
pregnancy, recent non-compressible vascular punc-
ture, uncontrolled hypertension (>180/110 mmHg).
Relative Contraindications to Thrombolytics: Absence
of ST-segment elevation, severe hypertension,
cerebrovascular disease, recent surgery (within 2
weeks), cardiopulmonary resuscitation.
A. Alteplase (tPA, tissue plasminogen activator,
Activase):
1. 15 mg IV push over 2 min, followed by 0.75 mg/kg
(max 50 mg) IV infusion over 30 min, followed by
0.5 mg/kg (max 35 mg) IV infusion over 60 min
(max total dose 100 mg).
2. Labs: INR/PTT, CBC, fibrinogen.
B. Reteplase (Retavase):
1. 10 U IV push over 2 min; repeat second 10 U IV
push after 30 min.
2. Labs: INR, aPTT, CBC, fibrinogen.
C. Tenecteplase (TNKase):
<60 kg 30 mg IVP
60-69 kg 35 mg IVP
70-79 kg 40 mg IVP
80-89 kg 45 mg IVP
$90 kg 50 mg IVP
C. Streptokinase (Streptase):
1. 1.5 million IU in 100 mL NS IV over 60 min.
Pretreat with diphenhydramine (Benadryl) 50 mg IV
push AND
Methylprednisolone (Soln-Medrol) 250 mg IV push.
2. Check fibrinogen level now and q6h for 24h until
level >100 mg/dL.
3. No IM or arterial punctures, watch IV for bleeding.
Angiotensin Converting Enzyme Inhibitor:
-Lisinopril (Zestril, Prinivil) 2.5-5 mg PO qd; titrate to
10-20 mg qd.
Long-acting Nitrates:
-Nitroglycerin patch 0.2 mg/hr qd. Allow for nitrate-free
period to prevent tachyphylaxis.
-Isosorbide dinitrate (Isordil) 10-60 mg PO tid [5,10,20,
30,40 mg] OR
-Isosorbide mononitrate (Imdur) 30-60 mg PO qd.
Beta-Blockers: Contraindicated in cardiogenic shock.
-Metoprolol (Lopressor) 5 mg IV q2-5min x 3 doses;
then 25 mg PO q6h for 48h, then 100 mg PO q12h;
hold if heart rate <60/min or systolic BP <100
mmHg OR
-Atenolol (Tenormin), 5 mg IV, repeated in 5 minutes,
followed by 50-100 mg PO qd OR
-Esmolol hydrochloride (Brevibloc) 500 mcg/kg IV over
1 min, then 50 mcg/kg/min IV infusion, titrated to
heart rate >60 bpm (max 300 mcg/kg/min).
Statins:
-Atorvastatin (Lipitor) 10 mg PO qhs OR
-Pravastatin (Pravachol) 40 mg PO qhs OR
-Simvastatin (Zocor) 20 mg PO qhs OR
-Lovastatin (Mevacor) 20 mg PO qhs OR
-Fluvastatin (Lescol)10-20 mg PO qhs.
11. Symptomatic Medications:
-Morphine sulfate 2-4 mg IV push prn chest pain.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
headache.
-Lorazepam (Ativan) 1-2 mg PO tid-qid prn anxiety
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
-Docusate (Colace) 100 mg PO bid.
-Dimenhydrinate (Dramamine) 25-50 mg IV over 2-5
min q4-6h or 50 mg PO q4-6h prn nausea.
-Famotidine (Pepcid) 20 mg IV/PO bid.
12. Extras: ECG stat and in 12h and in AM, portable
CXR, impedance cardiography, echocardiogram.
Cardiology consult.
13. Labs: SMA7 and 12, magnesium. Cardiac enzymes:
CPK-MB, troponin T, myoglobin STAT and q6h for
24h. CBC, INR/PTT, UA.
Ventricular Arrhythmias
1. Ventricular Fibrillation and Tachycardia:
-If unstable (see ACLS protocol): Defibrillate with
unsynchronized 200 J, then 300 J.
-Oxygen 100% by mask.
-Lidocaine (Xylocaine) loading dose 75-100 mg IV,
then 2-4 mg/min IV OR
-Amiodarone (Cordarone) 300 mg in 100 mL of D5W,
IV infusion over 10 min, then 900 mg in 500 mL of
D5W, at 1 mg/min for 6 hrs, then at 0.5 mg/min
thereafter; or 400 mg PO q8h x 14 days, then 200-
400 mg qd.
-Also see "other antiarrhythmics" below.
2. Torsades De Pointes Ventricular Tachycardia:
-Correct underlying cause and consider discontinuing
quinidine, procainamide, disopyramide, moricizine,
amiodarone, sotalol, Ibutilide, phenothiazine,
haloperidol, tricyclic and tetracyclic antidepres-
sants, ketoconazole, itraconazole, bepridil,
hypokalemia, and hypomagnesemia.
-Magnesium sulfate 1-4 gm in IV bolus over 5-15 min
or infuse 3-20 mg/min for 7-48h until QTc interval
<440 msec.
-Isoproterenol (Isuprel), 2-20 mcg/min (2 mg in 500 mL
D5W, 4 mcg/mL).
-Consider ventricular pacing and/or cardioversion.
3. Other Antiarrhythmics:
Class I:
-Moricizine (Ethmozine) 200-300 mg PO q8h, max 900
mg/d [200, 250, 300 mg].
Class Ia:
-Quinidine gluconate (Quinaglute) 324-648 mg PO q8-
12h [324 mg].
-Procainamide (Procan, Procanbid)
IV: 15 mg/kg IV loading dose at 20 mg/min, fol-
lowed by 2-4 mg/min continuous IV infusion.
PO: 500 mg (nonsustained release) PO q2h x 2
doses, then Procanbid 1-2 gm PO q12h [500, 1000
mg].
-Disopyramide (Nor-pace, Norpace CR) 100-300 mg
PO q6-8h [100, 150, mg] or disopyramide CR 100-
150 mg PO bid [100, 150 mg].
Class Ib:
-Lidocaine (Xylocaine) 75-100 mg IV, then 2-4 mg/min
IV
-Mexiletine (Mexitil) 100-200 mg PO q8h, max 1200
mg/d [150, 200, 250 mg].
-Tocainide (Tonocard) loading 400-600 mg PO, then
400-600 mg PO q8-12h (1200-1800 mg/d) PO in
divided doses q8-12h [400, 600 mg].
-Phenytoin (Dilantin), loading dose 100-300 mg IV
given as 50 mg in NS over 10 min IV q5min, then
100 mg IV q5min prn.
Class Ic:
-Flecainide (Tambocor) 50-100 mg PO q12h, max 400
mg/d [50, 100, 150 mg].
-Propafenone (Rythmol) 150-300 mg PO q8h, max
1200 mg/d [150, 225, 300 mg].
Class II:
-Propranolol (Inderal) 1-3 mg IV in NS (max 0.15
mg/kg) or 20-80 mg PO tid-qid [10, 20, 40, 60, 80
mg]; propranolol-LA (Inderal-LA), 80-120 mg PO qd
[60, 80, 120, 160 mg]
-Esmolol (Brevibloc) loading dose 500 mcg/kg over 1
min, then 50-200 mcg/kg/min IV infusion
-Atenolol (Tenormin) 50-100 mg/d PO [25, 50, 100
mg].
-Nadolol (Corgard) 40-100 mg PO qd-bid [20, 40, 80,
120, 160 mg].
-Metoprolol (Lopressor) 50-100 mg PO bid-tid [50, 100
mg], or metoprolol XL (Toprol-XL) 50-200 mg PO
qd [50, 100, 200 mg].
Class III:
-Amiodarone (Cordarone), PO loading 400-1200 mg/d
in divided doses for 2-4 weeks, then 200-400 mg
PO qd (5-10 mg/kg) [200 mg] or amiodarone
(Cordarone) 300 mg in 100 mL of D5W, IV infusion
over 10-20 min, then 900 mg in 500 mL of D5W, at
1 mg/min for 6 hrs, then at 0.5 mg/min thereafter.
-Sotalol (Betapace) 40-80 mg PO bid, max 320 mg/d
in 2-3 divided doses [80, 160 mg].
4. Extras: CXR, ECG, Holter monitor, signal averaged
ECG, cardiology consult.
5. Labs: SMA 7&12, Mg, calcium, CBC, drug levels. UA.
Hypertensive Emergency
1. Admit to:
2. Diagnosis: Hypertensive emergency
3. Condition:
4. Vital Signs: q30min until BP controlled, then q4h.
5. Activity: Bed rest
6. Nursing: Intra-arterial BP monitoring, daily weights,
inputs and outputs.
7. Diet: Clear liquids.
8. IV Fluids: D5W at TKO.
9. Special Medications:
-Nitroprusside sodium 0.25-10 mcg/kg/min IV (50 mg
in 250 mL of D5W), titrate to desired BP
-Labetalol (Trandate, Normodyne) 20 mg IV bolus
(0.25 mg/kg), then 20-80 mg boluses IV q10-15min
titrate to desired BP or continuous IV infusion of
1.0-2.0 mg/min titrate to desired BP. Ideal in pa-
tients with an aortic aneurysm.
-Fenoldopam (Corlopam) 0.01mcg/kg/min IV infusion.
Adjust dose by 0.025-0.05 mcg/kg/min q15min to
max 0.3 mcg/kg/min. [10 mg in 250 mL D5W].
-Nicardipine (Cardene IV) 5 mg/hr IV infusion, increase
rate by 2.5 mg/hr every 15 min up to 15 mg/hr (25
mg in D5W 250 mL).
-Enalaprilat (Vasotec IV) 1.25- 5.0 mg IV q6h. Do not
use in presence of AMI.
-Esmolol (Brevibloc) 500 mcg/kg/min IV infusion for 1
minute, then 50 mcg/kg/min; titrate by 50
mcg/kg/min increments to 300 mcg/kg/min (2.5 gm
in D5W 250 mL).
-Clonidine (Catapres), initial 0.1-0.2 mg PO followed
by 0.05-0.1 mg per hour until DBP <115 (max total
dose of 0.8 mg).
-Phentolamine (pheochromocytoma), 5-10 mg IV,
repeated as needed up to 20 mg.
-Trimethaphan camsylate (Arfonad)(dissecting aneu-
rysm) 2-4 mg/min IV infusion (500 mg in 500 mL of
D5W).
10. Symptomatic Medications:
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
headache.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
-Docusate sodium (Colace) 100-200 mg PO qhs.
11. Extras: Portable CXR, ECG, impedance cardiogra-
phy, echocardiogram.
12. Labs: CBC, SMA 7, UA with micro. TSH, free T4, 24h
urine for metanephrine. Plasma catecholamines, urine
drug screen.
Hypertension
I. Initial Diagnostic Evaluation of Hypertension
A. 15 Lead electrocardiography may document
evidence of ischemic heart disease, rhythm and
conduction disturbances, or left ventricular hyper-
trophy.
B. Screening labs include a complete blood count,
glucose, potassium, calcium, creatinine, BUN, uric
acid, and fasting lipid panel.
C. Urinalysis. Dipstick testing should include glucose,
protein, and hemoglobin.
D. Selected patients may require plasma renin activity,
24 hour urine catecholamines, or renal function
testing (glomerular filtration rate and blood flow).
II. Antihypertensive Drugs
A. Thiazide Diuretics
1. Hydrochlorothiazide (HCTZ, HydroDiuril),
12.5-25 mg qd [25 mg].
2. Chlorothiazide (Diuril) 250 mg qd [250, 500
mg].
3. Thiazide/Potassium Sparing Diuretic Combi-
nations
a. Maxzide (hydrochlorothiazide 50/triamterene
75 mg) 1 tab qd.
b. Moduretic (hyd r o c h l o r othiazide 50
mg/amiloride 5 mg) 1 tab qd.
c. D y a z i d e ( h y d r o c h l o r o t h i a z i d e 2 5
mg/triamterene 37.5) 1 cap qd.
B. Beta-Adrenergic Blockers
1. Cardioselective Beta-Blockers
a. Atenolol (Tenormin) initial dose 50 mg qd,
then 50-100 mg qd, max 200 mg/d [25, 50,
100 mg].
b. Metoprolol XL (Toprol XL) 100-200 mg qd
[50, 100, 200 mg tab ER].
c. Bisoprolol (Zebeta) 2.5-10 mg qd; max 20
mg qd [5,10 mg].
2. Non-Cardioselective Beta-Blockers
a. Propranolol LA (Inderal LA), 80-160 mg qd
[60, 80, 120, 160 mg].
b. Nadolol (Corgard) 40-80 mg qd, max 320
mg/d [20, 40, 80, 120, 160 mg].
c. Pindolol (Visken) 5-20 mg qd, max 60 mg/d
[5, 10 mg].
d. Carteolol (Cartrol) 2.5-10 mg qd [2.5, 5 mg].
C. Angiotensin-Converting Enzyme (ACE) Inhibi-
tors
1. Ramipril (Altace) 2.5-10 mg qd, max 20 mg/day
[1.25, 2.5, 5, 10 mg].
2. Quinapril (Accupril) 20-80 mg qd [5, 10, 20, 40
mg].
3. Lisinopril (Zestril, Prinivil) 10-40 mg qd [2.5, 5,
10, 20, 40 mg].
4. Benazepril (Lotensin) 10-40 mg qd, max 80
mg/day [5, 10, 20, 40 mg].
5. Fosinopril (Monopril) 10-40 mg qd [10, 20 mg].
6. Enalapril (Vasotec) 5-40 mg qd, max 40 mg/day
[2.5, 5, 10, 20 mg].
7. Moexipril (Univasc) 7.5-15 mg qd [7.5 mg].
D. Angiotensin Receptor Blockers
1. Losartan (Cozaar) 25-50 mg bid [25, 50 mg].
2. Valsartan (Diovan) 80-160 mg qd; max 320 mg
qd [80, 160 mg].
3. Irbesartan (Avapro) 150 mg qd; max 300 mg qd
[75, 150, 300 mg].
4. Candesartan (Atacand) 8-16 mg qd-bid [4, 8,
16, 32 mg].
5. Telmisartan (Micardis) 40-80 mg qd [40, 80
mg].
E. Calcium Entry Blockers
1. Diltiazem SR (Cardizem SR) 60-120 mg bid
[60, 90, 120 mg] or Cardizem CD 180-360 mg
qd [120, 180, 240, 300 mg].
2. Nifedipine XL (Procardia-XL, Adalat-CC) 30-
90 mg qd [30, 60, 90 mg].
3. Verapamil SR (Calan SR, Covera-HS) 120-240
mg qd [120, 180, 240 mg].
4. Amlodipine (Norvasc) 2.5-10 mg qd [2.5, 5, 10
mg].
5. Felodipine (Plendil) 5-10 mg qd [2.5, 5, 10 mg].
Syncope
1. Admit to: Monitored ward
2. Diagnosis: Syncope
3. Condition:
4. Vital Signs: q1h, postural BP and pulse q12h. Call
physician if BP >160/90, <90/60; P >120, <50; R>25,
<10
5. Activity: Bed rest.
6. Nursing: Fingerstick glucose.
7. Diet: Regular
8. IV Fluids: Normal saline at TKO.
9. Special medications:
High-grade AV Block with Syncope:
-Atropine 1 mg IV x 2.
-Isoproterenol 0.5-1 mcg/min initially, then slowly titrate
to 10 mcg/min IV infusion (1 mg in 250 mL NS).
-Transthoracic pacing.
Drug-induced Syncope:
-Discontinue vasodilators, centrally acting hypotensive
agents, tranquilizers, antidepressants, and alcohol
use.
Vasovagal Syncope:
-Scopolamine 1.5 mg transdermal patch q3 days.
Postural Syncope:
-Midodrine (ProAmatine) 2.5 mg PO tid, then increase
to 5-10 mg PO tid [2.5, 5 mg]; contraindicated in
coronary artery disease.
-Fludrocortisone 0.1-1.0 mg PO qd.
10. Symptomatic Medications:
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
headache.
-Docusate sodium (Colace) 100-200 mg PO qhs.
11. Extras: CXR, ECG, 24h Holter monitor,
electrophysiologic study, tilt test, CT/MRI, EEG, imped-
ance cardiography, echocardiogram.
12. Labs: CBC, SMA 7&12, CK-MB, troponin T, Mg,
calcium, drug levels. UA, urine drug screen.
Pulmonary Disorders
Asthma
1. Admit to:
2. Diagnosis: Exacerbation of asthma
3. Condition:
4. Vital Signs: q6h. Call physician if P >140; R >30, <10;
T >38.5°C; pulse oximeter <90%
5. Activity: Up as tolerated.
6. Nursing: Pulse oximeter, bedside peak flow rate
before and after bronchodilator treatments.
7. Diet: Regular, no caffeine.
8. IV Fluids: D5 ½ NS at 125 cc/h.
9. Special Medications:
-Oxygen 2 L/min by NC. Keep O2 sat >90%.
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 and sat $90%, then q4h OR
-Albuterol (Ventolin) MDI 3-8 puffs, then 2 puffs q3-6h
prn, or powder 200 mcg/capsule inhaled qid.
-Albuterol/Ipratropium (Combivent) 2-4 puffs qid.
Systemic Corticosteroids:
-Methylprednisolone (Solu-Medrol) 60-125 mg IV q6h;
then 30-60 mg PO qd. OR
-Prednisone 20-60 mg PO qAM.
Aminophylline and Theophylline (second-line ther-
apy):
-Aminophylline load dose: 5.6 mg/kg total body weight
in 100 mL D5W IV over 20min. Maintenance of 0.5-
0.6 mg/kg ideal body weight/h (500 mg in 250 mL
D5W); reduce if elderly, heart/liver failure (0.2-0.4
mg/kg/hr). Reduce load 50-75% if taking theophyl-
line (1 mg/kg of aminophylline will raise levels 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 (Theo-Dur) 100-400 mg PO bid (3 mg/kg
q8h); 80% of total daily IV aminophylline in 2-3
doses.
Inhaled Corticosteroids (adjunct therapy):
-Beclomethasone (Beclovent) MDI 4-8 puffs bid, with
spacer 5 min after bronchodilator, followed by
gargling with water
-Triamcinolone (Azmacort) MDI 2 puffs tid-qid or 4
puffs bid.
-Flunisolide (AeroBid) MDI 2-4 puffs bid.
-Fluticasone (Flovent) 2-4 puffs bid (44 or 110
mcg/puff); requires 1-2 weeks for full effect.
Maintenance Treatment:
-Salmeterol (Serevent) 2 puffs bid; not effective for
acute asthma because of delayed onset of action.
-Pirbuterol (Maxair) MDI 2 puffs q4-6h prn.
-Bitolterol (Tornalate) MDI 2-3 puffs q1-3min, then 2-3
puffs q4-8h prn.
-Fenoterol (Berotec) MDI 3 puffs, then 2 bid-qid.
-Ipratropium (Atrovent) MDI 2-3 puffs tid-qid.
Prevention and Prophylaxis:
-Cromolyn (Intal) 2-4 puffs tid-qid.
-Nedocromil (Tilade) 2-4 puffs bid-qid.
-Montelukast (Singulair) 10 mg PO qd.
-Zafirlukast (Accolate) 20 mg PO bid.
-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.
-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.
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,
<10; T >38.5°C; O2 sat <90%.
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. O2 at 100% by mask, pulse oximeter. Dis-
continue narcotics and sedatives. Have double lumen
endotracheal tube available for use.
7. Diet:
8. IV Fluids: 1 L of NS wide open ($6 gauge), then
transfuse PRBC, Foley to gravity.
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 con-
sults.
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: O2 at 6 L/min by NC or mask. Keep patient
in Trendelenburg's position, No. 4 or 5 endotracheal
tube at bedside.
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. Foley to closed drain-
age.
9. Special Medications:
Gastrointestinal Decontamination:
-Gastric lavage if indicated for recent oral ingestion.
-Activated charcoal 50-100 gm, followed by cathartic.
Bronchodilators:
-Epinephrine (1:1000) 0.3-0.5 mL SQ or IM q10min or
1-4 mcg/min IV OR in severe life threatening reac-
tions, give 0.5 mg (5.0 mL of 1: 10,000 sln) IV q5-
10min prn. Epinephrine, 0.3 mg of 1:1000 sln 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.
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 IV q4-6h OR
-Hydroxyzine (Vistaril) 25-50 mg IM or PO q2-4h.
-Famotidine (Pepcid) 20 mg IV/PO bid.
Pressors and other Agents:
-Norepinephrine (Levophed) 8-12 mcg/min IV, titrate to
systolic 100 mmHg (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, ultrasound,
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.
Hematologic Disorders
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 IV over 10 min (max 50 mg in 10 min period).
Low Molecular Weight Heparin (Enoxaparin) Over-
dose:
-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 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 than100
mg/dL.
Labs: CBC, platelets, PTT, INR.
Pulmonary Embolism
1. Admit to:
2. Diagnosis: Pulmonary embolism
3. Condition:
4. Vital Signs: q1-4h. Call physician if BP >160/90,
<90/60; P >120, <50; R >30, <10; T >38.5°C; O2 sat <
90%
5. Activity: Bedrest with bedside commode
6. Nursing: Pulse oximeter, guaiac stools, O2 at 2 L by
NC. Antiembolism stockings. No intramuscular injec-
tions.
7. Diet: Regular
8. IV Fluids: D5W at TKO.
9. Special Medications:
Anticoagulation:
-Heparin IV bolus 5000-10,000 Units (100 U/kg) IVP,
then 1000-1500 U/h IV infusion (20 U/kg/h) [25,000
U in 500 mL D5W (50 U/mL)]. Check PTT 6 hours
after initial bolus; adjust q6h until PTT 1.5-2 times
control (60-80 sec). Overlap heparin and Coumadin
for at least 4 days and discontinue heparin when INR
has been 2.0-3.0 for two consecutive days.
-Enoxaparin (Lovenox) 1 mg/kg sq q12h for 5 days for
uncomplicated pulmonary embolism. Overlap warfa-
rin as outlined above.
-Warfarin (Coumadin) 5-10 mg PO qd for 2-3 d, then 2-
5 mg PO qd. Maintain INR of 2.0-3.0. Coumadin is
initiated on second day if the PTT is 1.5-2.0 times
control. Check INR at initiation of warfarin and qd
[tab 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 mg].
Thrombolytics (indicated if hemodynamic compro-
mise):
Baseline Labs: CBC, INR/PTT, fibrinogen q6h.
Alteplase (recombinant tissue plasminogen activa-
tor, Activase): 100 mg IV infusion over 2 hours,
followed by heparin infusion at 15 U/kg/h to maintain
PTT 1.5-2.5 x control OR
Streptokinase (Streptase): P r e t reat with
methylprednisolone 250 mg IV push and
diphenhydramine (Benadryl) 50 mg IV push. Then
give streptokinase, 250,000 units IV over 30 min,
then 100,000 units/h for 24-72 hours. Initiate heparin
infusion at 10 U/kg/hour; maintain PTT 1.5-2.5 x
control.
10. Symptomatic Medications:
-Meperidine (Demerol) 25-100 mg IV prn pain.
-Docusate sodium (Colace) 100 mg PO qhs.
-Famotidine (Pepcid) 20 mg IV/PO q12h.
11. Extras: CXR PA and LAT, ECG, VQ scan; chest CT
scan, pulmonary angiography; Doppler scan of lower
extremities, impedance cardiography.
12. Labs: CBC, INR/PTT, SMA7, ABG, cardiac enzymes.
Protein C, protein S, antithrombin III, anticardiolipin
antibody. UA . PTT 6 hours after bolus and q4-6h. INR at
initiation of warfarin and qd.
Infective Endocarditis
1. Admit to:
2. Diagnosis: Infective endocarditis
3. Condition:
4. Vital Signs: q4h. Call physician if BP systolic >160/90,
<90/60; P >120, <50; R>25, <10; T >38.5°C
5. Activity: Up ad lib
6. Diet: Regular
7. IV Fluids: Heparin lock with flush q shift.
8. Special Medications:
Subacute Bacterial Endocarditis Empiric Therapy:
-Penicillin G 3-5 million U IV q4h or ampicillin 2 gm IV
q4h AND
Gentamicin 1-1.5/mg/kg IV q8h.
Acute Bacterial Endocarditis Empiric Therapy
-Gentamicin 2 mg/kg IV; then 1-1.5 mg/kg IV q8h AND
Nafcillin or oxacillin 2 gm IV q4h OR
Vancomycin 1 gm IV q12h (1 gm in 250 mL of D5W
over 1h).
Streptococci viridans/bovis:
-Penicillin G 3-5 million U IV q4h for 4 weeks OR
Vancomycin 1 gm IV q12h for 4 weeks AND
Gentamicin 1 mg/kg q8h for first 2 weeks.
Enterococcus:
-Gentamicin 1 mg/kg IV q8h for 4-6 weeks AND
Ampicillin 2 gm IV q4h for 4-6 weeks OR
Vancomycin 1 gm IV q12h for 4-6 weeks.
Staphylococcus aureus (methicillin sensitive, native
valve):
-Nafcillin or Oxacillin 2 gm IV q4h for 4-6 weeks OR
Vancomycin 1 gm IV q12h for 4-6 weeks AND
Gentamicin 1 mg/kg IV q8h for first 3-5 days.
Methicillin resistant Staphylococcus aureus (native
valve):
-Vancomycin 1 gm IV q12h (1 gm in 250 mL D5W over
1h) for 4-6 weeks AND
Gentamicin 1 mg/kg IV q8h for 3-5 days.
Methicillin resistant Staph aureus or epidermidis
(prosthetic valve):
-Vancomycin 1 gm IV q12h for 6 weeks AND
Rifampin 600 mg PO q8h for 6 weeks AND
Gentamicin 1 mg/kg IV q8h for 2 weeks.
Culture Negative Endocarditis:
-Penicillin G 3-5 million U IV q4h for 4-6 weeks OR
Ampicillin 2 gm IV q4h for 4-6 weeks AND
Gentamicin 1.5 mg/kg q8h for 2 weeks (or nafcillin, 2
gm IV q4h, and gentamicin if Staph aureus sus-
pected in drug abuser or prosthetic valve).
Fungal Endocarditis:
-Amphotericin B 0.5 mg/kg/d IV plus flucytosine (5-FC)
150 mg/kg/d PO.
9. Symptomatic Medications:
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
temp >39N C.
-Docusate sodium 100-200 mg PO qhs.
10. Extras: CXR PA and LAT, echocardiogram, ECG.
11. Labs: CBC with differential, SMA 7&12. Blood C&S
x 3-4 over 24h, serum cidal titers, minimum inhibitory
concentration, minimum bactericidal concentration.
Repeat C&S in 48h, then once a week. Antibiotic levels
peak and trough at 3rd dose. UA, urine C&S.
Pneumonia
1. Admit to:
2. Diagnosis: Pneumonia
3. Condition:
4. Vital Signs: q4-8h. Call physician if BP >160/90,
<90/60; P >120, <50; R>25, <10; T >38.5°C or O2
saturation <90%.
5. Activity:
6. Nursing: Pulse oximeter, inputs and outputs,
nasotracheal suctioning prn, incentive spirometry.
7. Diet: Regular.
8. IV Fluids: IV D5 ½ NS at 125 cc/hr.
9. Special Medications:
-Oxygen by NC at 2-4 L/min, or 24-50% by Ventimask,
or 100% by non-rebreather (reservoir) to maintain O2
saturation >90%.
Moderately ill Patients Without Underlying Lung
Disease from the Community:
-Cefuroxime (Zinacef) 0.75-1.5 gm IV q8h OR
Ampicillin/sulbactam (Unasyn) 1.5 gm IV q6h AND
EITHER
-Erythromycin 500 mg IV/PO q6h OR
Clarithromycin (Biaxin) 500 mg PO bid OR
Azithromycin (Zithromax) 500 mg PO x 1, then 250 mg
PO qd x 4 OR
Doxycycline (Vibramycin) 100 mg IV/PO q12h.
Moderately ill Patients With Recent Hospitalization or
Debilitated Nursing Home Patient:
-Ceftazidime (Fortaz) 1-2 gm IV q8h OR
Cefepime (Maxipime) 1-2 gm IV q12h AND EITHER
Gentamicin 1.5-2 mg/kg IV, then 1.0-1.5 mg/kg IV q8h
or 7 mg/kg in 50 mL of D5W over 60 min IV q24h OR
-Ciprofloxacin (Cipro) 400 mg IV q12h or 500 mg PO
q12h.
Critically ill Patients:
-Initial treatment should consist of a macrolide with 2
antipseudomonal agents for synergistic activity:
-Erythromycin 0.5-1.0 gm IV q6h AND EITHER
-Ceftazidime 1-2 gm q8h OR
Piperacillin/tazobactam (Zosyn) 3.75-4.50 gm IV q6h
OR
Ticarcillin/clavulanate (Timentin) 3.1 gm IV q6h OR
Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6h AND
EITHER
-Levofloxacin (Levaquin) 500 mg IV q24h OR
Ciprofloxacin (Cipro) 400 mg IV q12h OR
Tobramycin 2.0 mg/kg IV, then 1.5 mg/kg IV q8h or 7
mg/kg IV q24h.
Aspiration Pneumonia (community acquired):
-Clindamycin (Cleocin) 600-900 mg IV q8h (with or
without gentamicin or 3rd gen cephalosporin) OR
-Ampicillin/sulbactam (Unasyn) 1.5-3 gm IV q6h (with
or without gentamicin or 3rd gen cephalosporin)
Aspiration Pneumonia (nosocomial):
-Tobramycin 2 mg/kg IV then 1.5 mg/kg IV q8h or 7
mg/kg in 50 mL of D5W over 60 min IV q24h OR
Ceftazidime (Fortaz) 1-2 gm IV q8h AND EITHER
-Clindamycin (Cleocin) 600-900 mg IV q8h OR
Ampicillin/sulbactam or ticarcillin/clavulanate, or
piperacillin/tazobactam or imipenem/cilastatin (see
above) OR
Metronidazole (Flagyl) 500 mg IV q8h.
10. Symptomatic Medications:
-Acetaminophen (Tylenol) 650 mg 2 tab PO q4-6h prn
temp >38/C or pain.
-Docusate sodium (Colace) 100 mg PO qhs.
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Heparin 5000 U SQ q12h or pneumatic compression
stockings.
11. Extras: CXR PA and LAT, ECG, PPD.
12. Labs: CBC with differential, SMA 7&12, ABG. Blood
C&S x 2. Sputum Gram stain, C&S. Methenamine
silver sputum stain (PCP); AFB smear/culture.
Aminoglycoside levels peak and trough at 3rd dose.
UA, urine culture.
Septic Arthritis
1. Admit to:
2. Diagnosis: Septic arthritis
3. Condition:
4. Vital Signs: q shift
5. Activity: Up in chair as tolerated. Bedside commode
with assistance.
6. Nursing: Warm compresses prn, keep joint immobi-
lized. Passive range of motion exercises of the af-
fected joint bid.
7. Diet: Regular diet.
8. IV Fluids: Heparin lock
9. Special Medications:
Empiric Therapy for Adults without Gonorrhea Con-
tact:
-Nafcillin or oxacillin 2 gm IV q4h AND
Ceftizoxime (Cefizox) 1 gm IV q8h or ceftazidime 1
gm IV q8h or ciprofloxacin 400 mg IV q12h if Gram
stain indicates presence of Gram negative organ-
isms.
Empiric Therapy for Adults with Gonorrhea:
-Ceftriaxone (Rocephin) 1 gm IV q12h OR
-Ceftizoxime (Cefizox) 1 gm IV q8h OR
-Ciprofloxacin (Cipro) 400 mg IV q12h.
-Complete course of therapy with cefuroxime axetil
(Ceftin) 400 mg PO bid.
10. Symptomatic Medications:
-Acetaminophen and codeine (Tylenol 3) 1-2 PO q4-6h
prn pain.
-Heparin 5000 U SQ bid.
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
-Docusate sodium 100-200 mg PO qhs.
11. Extras: X-ray views of joint (AP and lateral), CXR.
Synovial fluid culture. Physical therapy consult for exer-
cise program.
12. Labs: CBC, SMA 7&12, blood C&S x 2, VDRL, UA.
Gonorrhea cultures of urethra, cervix, urine, throat,
sputum, skin, rectum. Antibiotic levels. Blood cultures x 2
for gonorrhea.
Synovial fluid:
Tube 1 - Glucose, protein, lactate, pH.
Tube 2 - Gram stain, C&S.
Tube 3 - Cell count.
Septic Shock
1. Admit to:
2. Diagnosis: Sepsis
3. Condition:
4. Vital Signs: q1h; Call physician if BP >160/90, <90/60;
P >120, <50; R>25, <10; T >38.5°C; urine output < 25
cc/hr for 4h, O2 saturation <90%.
5. Activity: Bed rest.
6. Nursing: Inputs and outputs, pulse oximeter. Foley
catheter to closed drainage.
7. Diet: NPO
8. IV Fluids: 1 liter of normal saline wide open, then D5
½ NS at 125 cc/h
9. Special Medications:
-Oxygen at 2-5 L/min by NC or mask.
Antibiotic Therapy
A. Initial treatment of life-threatening sepsis should
include a third-generation cephalosporin
(ce f t a z i d i m e , c e f o t a xi m e , c eftiz oxime or
ceftriaxone), or piperacillin/tazobactam, or
ticarcillin/clavulanic acid or imipenem, each with an
aminoglycoside (gentamicin, tobramycin or
amikacin). If Enterobacter aerogenes or cloacae is
s u s pecte d , t r e a t m e n t s h o u l d b e g i n wi t h
meropenem, or imipenem with an aminoglycoside.
B. Intra-abdominal or pelvic infections, likely to
involve anaerobes, should be treated with ampicillin,
gentamicin and metronidaz ole; or either
ticarcillin/clavulanic acid, ampicillin/sulbactam,
piperacillin/tazobactam, imipenem, cefoxitin or
cefotetan, each with an aminoglycoside.
C. Febrile neutropenic patients with neutrophil
counts <500/mm 3 should be treated with
vancomycin and ceftazidime, or
piperacillin/tazobactam and tobramycin or imipenem
and tobramycin.
D. Dosages for Antibiotics Used in Sepsis
-Ampicillin 1-2 gm IV q4h.
-Cefotaxime (Claforan) 2 gm q4-6h.
-Ceftizoxime (Cefizox) 1-2 gm IV q8h.
-Ceftriaxone (Rocephin) 1-2 gm IV q12h (max 4
gm/d).
-Cefoxitin (Mefoxin) 1-2 gm q6h.
-Cefotetan (Cefotan) 1-2 gm IV q12h.
-Ceftazidime (Fortaz) 1-2 g IV q8h.
-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q4-6h
(200-300 mg/kg/d).
-Ampicillin/sulbactam (Unasyn) 1.5-3.0 gm IV q6h.
-Piperacillin/tazobactam (Zosyn) 3.375-4.5 gm IV
q6h.
-Piperacillin or ticarcillin 3 gm IV q4-6h.
-Imipenem/cilastatin (Primaxin) 1.0 gm IV q6h.
-Meropenem (Merrem) 05-1.0 gm IV q8h.
-Gentamicin, tobramycin 100-120 mg (1.5 mg/kg)
IV, then 80 mg IV q8h (1 mg/kg) or 7 mg/kg in 50
mL of D5W over 60 min IV q24h.
-Amikacin (Amikin) 7.5 mg/kg IV loading dose; then
5 mg/kg IV q8h.
-Vancomycin 1 gm IV q12h.
-Metronidazole (Flagyl) 500 mg (7.5 mg/kg) IV q6-
8h.
-Clindamycin (Cleocin) 900 mg IV q8h.
-Aztreonam (Azactam) 1-2 gm IV q6-8h; max 8
g/day.
Nosocomial sepsis with IV catheter or IV drug abuse
-Nafcillin or oxacillin 2 gm IV q4h OR
-Vancomycin 1 gm q12h (1 gm in 250 cc D5W over 60
min) AND
Gentamicin or tobramycin as above AND EITHER
Ceftazidime (Fortaz) or ceftizoxime 1-2 gm IV q8h OR
Piperacillin, ticarcillin or mezlocillin 3 gm IV q4-6h.
Recombinant human activated protein C
-Drotrecogin alfa, (Xigris), 24 mg/kg/h IV infusion for 96
hours.
Blood Pressure Support
-Dopamine 4-20 mcg/kg/min (400 mg in 250 cc D5W,
1600 mcg/mL).
-Norepinephrine 2-8 mcg/min IV infusion (8 mg in 250
mL D5W).
-Albumin 25 gm IV (100 mL of 25% sln) OR
-Hetastarch (Hespan) 500-1000 cc over 30-60 min
(max 1500 cc/d).
-Dobutamine 5 mcg/kg/min, and titrate to bp keep
systolic BP >90 mmHg; max 10 mcg/kg/min.
10. Symptomatic Medications:
-Acetaminophen (Tylenol) 650 mg PR q4-6h prn temp
>39°C.
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Heparin 5000 U SQ q12h or pneumatic compression
stockings.
-Docusate sodium 100-200 mg PO qhs.
11. Extras: CXR, KUB, ECG. Ultrasound, lumbar punc-
ture.
12. Labs: CBC with differential, SMA 7&12, blood C&S x
3, T&C for 3-6 units PRBC, INR/PTT, drug levels peak
and trough at 3rd dose. UA. Cultures of urine, sputum,
wound, IV catheters, decubitus ulcers, pleural fluid.
Peritonitis
1. Admit to:
2. Diagnosis: Peritonitis
3. Condition:
4. Vital Signs: q1-6h. Call physician if BP >160/90, <90-
/60; P >120, <50; R>25, <10; T >38.5°C.
5. Activity: Bed rest.
6. Nursing: Guaiac stools.
7. Diet: NPO
8. IV Fluids: D5 ½ NS at 125 cc/h.
9. Special Medications:
Primary Bacterial Peritonitis -- Spontaneous:
Option 1:
-Ampicillin 1-2 gm IV q 4-6h (vancomycin 1 gm IV
q12h if penicillin allergic) AND EITHER
Cefotaxime (Claforan) 1-2 gm IV q6h OR
Ceftizoxime (Cefizox) 1-2 gm IV q8h OR
Gentamicin or tobramycin 1.5 mg/kg IV, then 1 mg/kg
q8h or 7 mg/kg in 50 mL of D5W over 60 min IV
q24h.
Option 2:
-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q6h OR
-Piperacillin/tazobactam (Zosyn) 3.375 gm IV q6h OR
-Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6h OR
-Meropenem (Merrem) 500-1000 mg IV q8h.
Secondary Bacterial Peritonitis – Abdominal Perfora-
tion or Rupture:
Option 1:
-Ampicillin 1-2 gm IV q4-6h AND
Gentamicin or tobramycin as above AND
Metronidazole (Flagyl) 500 mg IV q8h OR
Cefoxitin (Mefoxin) 1-2 gm IV q6h OR
Cefotetan (Cefotan) 1-2 gm IV q12h.
Option 2:
-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q4-6h
(200-300 mg/kg/d) with an aminoglycoside as
above OR
-Piperacillin/tazobactam (Zosyn) 3.375 gm IV q6h with
an aminoglycoside as above OR
-Ampicillin/sulbactam (Unasyn) 1.5-3.0 gm IV q6h with
aminoglycoside as above OR
-Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6-8h
OR
-Meropenem (Merrem) 500-1000 mg IV q8h.
Fungal Peritonitis:
-Amphotericin B peritoneal dialysis, 2 mg/L of dialysis
fluid over the first 24 hours, then 1.5 mg in each
liter OR
-Fluconazole (Diflucan) 200 mg IV x 1, then 100 mg IV
qd.
10. Symptomatic Medications:
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Acetaminophen (Tylenol) 325 mg PO/PR q4-6h prn
temp >38.5°C.
-Heparin 5000 U SQ q12h.
11. Extras: Plain film, upright abdomen, lateral decubitus,
CXR PA and LAT; surgery consult; ECG, abdominal ultra-
sound. CT scan.
12. Labs: CBC with differential, SMA 7&12, amylase,
lactate, INR/PTT, UA with micro, C&S; drug levels peak
and trough 3rd dose.
Paracentesis Tube 1: Cell count and differential (1-2 mL,
EDTA purple top tube)
Tube 2: Gram stain of sediment; inject 10-20 mL into an-
aerobic and aerobic culture bottle; AFB, fungal C&S
(3-4 mL).
Tube 3: Glucose, protein, albumin, LDH, triglycerides,
specific gravity, bilirubin, amylase (2-3 mL, red top
tube).
Syringe: pH, lactate (3 mL).
Diverticulitis
1. Admit to:
2. Diagnosis: Diverticulitis
3. Condition:
4. Vital Signs: qid. Call physician if BP systolic >160/90,
<90/60; P >120, <50; R>25, <10; T >38.5°C
5. Activity: Up ad lib.
6. Nursing: Inputs and outputs.
7. Diet: NPO. Advance to clear liquids as tolerated.
8. IV Fluids: 0.5-2 L NS over 1-2 hr then, D5 ½ NS at
125 cc/hr. NG tube at low intermittent suction (if
obstructed).
9. Special Medications:
Regimen 1:
-Gentamicin or tobramycin 100-120 mg IV (1.5-2
mg/kg), then 80 mg IV q8h (5 mg/kg/d) or 7 mg/kg
in 50 mL of D5W over 60 min IV q24h AND EI-
THER
Cefoxitin (Mefoxin) 2 gm IV q6-8h OR
Clindamycin (Cleocin) 600-900 mg IV q8h.
Regimen 2:
-Metronidazole (Flagyl) 500 mg q8h AND
Ciprofloxacin (Cipro) 250-500 mg PO bid or 200-300
mg IV q12h.
Outpatient Regimen:
-Metronidazole (Flagyl) 500 mg PO q6h AND EITHER
Ciprofloxacin (Cipro) 500 mg PO bid OR
Trimethoprim/SMX (Bactrim) 1 DS tab PO bid.
10. Symptomatic Medications:
-Meperidine (Demerol) 50-100 mg IM or IV q3-4h prn
pain.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
11. Extras: Acute abdomen series, CXR PA and LAT,
ECG, CT scan of abdomen, ultrasound, surgery and GI
consults.
12. Labs: CBC with differential, SMA 7&12, amylase,
lipase, blood cultures x 2, drug levels peak and trough 3rd
dose. UA, C&S.
Pyelonephritis
1. Admit to:
2. Diagnosis: Pyelonephritis
3. Condition:
4. Vital Signs: tid. Call physician if BP <90/60; >160/90;
R >30, <10; P >120, <50; T >38.5°C
5. Activity:
6. Nursing: Inputs and outputs.
7. Diet: Regular
8. IV Fluids: D5 ½ NS at 125 cc/h.
9. Special Medications:
-Trimethoprim-sulfamethoxazole (Septra) 160/800 mg
(10 mL in 100 mL D5W IV over 2 hours) q12h or 1
double strength tab PO bid.
-Ciprofloxacin (Cipro) 500 mg PO bid or 400 mg IV
q12h.
-Norfloxacin (Noroxin) 400 mg PO bid
-Ofloxacin (Floxin) 400 mg PO or IV bid.
-Levofloxacin (Levaquin) 500 mg PO/IV q24h.
-In more severely ill patients, treatment with an IV
third-generation cephalosporin, or
ticarcillin/clavulanic acid, or piperacillin/tazobactam
or imipenem is recommended with an
aminoglycoside.
-Ceftizoxime (Cefizox) 1 gm IV q8h.
-Ceftazidime (Fortaz) 1 gm IV q8h.
-Ticarcillin/clavulanate (Timentin) 3.1 gm IV q6h.
-Piperacillin/tazobactam (Zosyn) 3.375 gm IV/PB q6h.
-Imipenem/cilastatin (Primaxin) 0.5-1.0 gm IV q6-8h.
-Gentamicin or tobramycin, 2 mg/kg IV, then 1.5 mg/kg
q8h or 7 mg/kg in 50 mL of D5W over 60 min IV
q24h.
10. Symptomatic Medications:
-Phenazopyridine (Pyridium) 100 mg PO tid.
-Meperidine (Demerol) 50-100 mg IM q4-6h prn pain.
-Docusate sodium (Colace) 100 mg PO qhs.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
temp >39N C.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
11. Extras: Renal ultrasound, KUB.
12. Labs: CBC with differential, SMA 7. UA with micro,
urine Gram stain, C&S; blood C&S x 2. Drug levels peak
and trough third dose third dose.
Osteomyelitis
1. Admit to:
2. Diagnosis: Osteomyelitis
3. Condition:
4. Vital Signs: qid. Call physician if BP <90/60; T
>38.5°C
5. Activity: Bed rest with bathroom privileges.
6. Nursing: Keep involved extremity elevated. Range of
motion exercises tid.
7. Diet: Regular, high fiber.
8. IV Fluids: Heparin lock with flush q shift.
9. Special Medications:
Adult Empiric Therapy:
-Nafcillin or oxacillin 2 gm IV q4h OR
-Cefazolin (Ancef) 1-2 gm IV q8h OR
-Vancomycin 1 gm IV q12h (1 gm in 250 cc D5W over
1h).
-Add 3rd generation cephalosporin if gram negative
bacilli on Gram stain. Treat for 4-6 weeks.
Post-Operative or Post-Trauma:
-Vancomycin 1 gm IV q12h AND ceftazidime (Fortaz)
1-2 gm IV q8h.
-Imipenem/cilastatin (Primaxin)(single-drug treat-
ment) 0.5-1.0 gm IV q6-8h.
-Ticarcillin/clavulanate (Timentin)(single-drug treat-
ment) 3.1 gm IV q4-6h.
-Ciprofloxacin (Cipro) 500-750 mg PO bid or 400 mg IV
q12h AND
Rifampin 600 mg PO qd.
Osteomyelitis with Decubitus Ulcer:
-Cefoxitin (Mefoxin), 2 gm IV q6-8h.
-Ciprofloxacin (Cipro) and metronidazole 500 mg IV
q8h.
-Imipenem/cilastatin (Primaxin), see dosage above.
-Nafcillin, gentamicin and clindamycin; see dosage
above.
10. Symptomatic Medications:
-Meperidine (Demerol) 50-100 mg IM q3-4h prn pain.
-Docusate sodium (Colace) 100 mg PO qhs.
-Heparin 5000 U SQ bid.
11. Extras: Technetium/gallium bone scans, multiple X-
ray views, CT/MRI.
12. Labs: CBC with differential, SMA 7, blood C&S x 3,
MIC, MBC, UA with micro, C&S. Needle biopsy of bone
for C&S. Trough antibiotic levels.
Cellulitis
1. Admit to:
2. Diagnosis: Cellulitis
3. Condition:
4. Vital Signs: tid. Call physician if BP <90/60; T >38.5°C
5. Activity: Up ad lib.
6. Nursing: Keep affected extremity elevated; warm com-
presses prn.
7. Diet: Regular, encourage fluids.
8. IV Fluids: Heparin lock with flush q shift.
9. Special Medications:
Empiric Therapy Cellulitis
-Nafcillin or oxacillin 1-2 gm IV q4-6h OR
-Cefazolin (Ancef) 1-2 gm IV q8h OR
-Vancomycin 1 gm q12h (1 gm in 250 cc D5W over 1h)
OR
-Erythromycin 500 IV/PO q6h OR
-Dicloxacillin 500 mg PO qid; may add penicillin VK,
500 mg PO qid, to increase coverage for strepto-
coccus OR
-Cephalexin (Keflex) 500 mg PO qid.
Immunosuppressed, Diabetic Patients, or Ulcerated
Lesions:
-Nafcillin or cefazolin and gentamicin or aztreonam.
Add clindamycin or metronidazole if septic.
-Cefazolin (Ancef) 1-2 gm IV q8h.
-Cefoxitin (Mefoxin) 1-2 gm IV q6-8h.
-Gentamicin 2 mg/kg, then 1.5 mg/kg IV q8h or 7
mg/kg in 50 mL of D5W over 60 min IV q24h OR
aztreonam (Azactam) 1-2 gm IV q6h PLUS
-Metronidazole (Flagyl) 500 mg IV q8h or clindamycin
900 mg IV q8h.
-Ticarcillin/clavulanate (Timentin) (single-drug treat-
ment) 3.1 gm IV q4-6h.
-Ampicillin/Sulbactam (Unasyn) (single-drug therapy)
1.5-3.0 gm IV q6h.
-Imipenem/cilastatin (Primaxin) (single-drug therapy)
0.5-1 mg IV q6-8h.
10. Symptomatic Medications:
-Acetaminophen/codeine (Tylenol #3) 1-2 PO q4-6h
prn pain.
-Docusate sodium (Colace) 100 mg PO qhs.
-Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
temp >39N C.
-Zolpidem (Ambien) 5-10 mg qhs prn insomnia.
11. Extras: Technetium/Gallium scans, Doppler study
(ankle-brachial indices).
12. Labs: CBC, SMA 7, blood C&S x 2. Leading edge
aspirate for Gram stain, C&S; UA, antibiotic levels.
Pelvic Inflammatory Disease
1. Admit to:
2. Diagnosis: Pelvic Inflammatory Disease
3. Condition:
4. Vital Signs: q8h. Call physician if BP >160/90, <90/60;
P >120, <50; R>25, <10; T >38.5°C
5. Activity:
6. Nursing: Inputs and outputs.
7. Diet: Regular
8. IV Fluids: D5 ½ NS at 100-125 cc/hr.
9. Special Medications:
-Cefoxitin (Mefoxin) 2 gm IV q6h OR cefotetan
(Cefotan) 1-2 gm IV q12h; AND doxycycline
(Vibramycin) 100 mg IV q12h (IV for 4 days and
48h after afebrile, then complete 10-14 days of
doxycycline 100 mg PO bid) OR
-Clindamycin 900 mg IV q8h AND Gentamicin 2
mg/kg IV, then 1.5 mg/kg IV q8h or 7 mg/kg in 50
mL of D5W over 60 min IV q24h, then complete 10-
14 d of Clindamycin 300 mg PO qid or Doxycycline
100 mg PO bid OR
-Ceftriaxone (Rocephin) 250 mg IM x 1 and
doxycycline 100 mg PO bid for 14 days OR
-Ofloxacin (Floxin) 400 mg PO bid for 14 days.
AND EITHER
-Clindamycin 300 mg PO qid for 14 days OR
-Metronidazole (Flagyl) 500 mg PO bid for 14 days.
10. Symptomatic Medications:
-Acetaminophen (Tylenol) 1-2 tabs PO q4-6h prn pain
or temperature >38.5°C.
-Meperidine (Demerol) 25-100 mg IM q4-6h prn pain.
-Zolpidem (Ambien) 10 mg PO qhs prn insomnia.
11. Labs: CBC, SMA 7&12, ESR. GC culture, chlamydia
direct fluorescent antibody stain. UA with micro, C&S,
VDRL, HIV, blood cultures x 2. Pelvic ultrasound.
Gastrointestinal Disorders
Gastroesophageal Reflux Disease
1. Admit to:
2. Diagnosis: Gastroesophageal reflux disease.
3. Condition:
4. Vital Signs: q4h. Call physician if BP >160/90, <90/60;
P >120, <50; T >38.5°C
5. Activity: Up ad lib. Elevate the head of the bed by 6 to
8 inches.
6. Nursing: Guaiac stools.
7. Diet: Low-fat diet; no cola, citrus juices, or tomato
products; avoid the supine position after meals; no
eating within 3 hours of bedtime.
8. IV Fluids: D5 ½ NS with 20 mEq KCL at TKO.
9. Special Medications:
-Pantoprazole (Protonix) 40 mg PO/IV q24h OR
-Nizatidine (Axid) 300 mg PO qhs OR
-Omeprazole (Prilosec) 20 mg PO bid (30 minutes
prior to meals) OR
-Lansoprazole (Prevacid) 15-30 mg PO qd prior to
breakfast [15, 30 mg caps] OR
-Esomeprazole (Nexium) 20 or 40 mg PO qd OR
-Rabeprazole (Aciphex) 20 mg delayed-release tablet
PO qd OR
-Ranitidine (Zantac) 50 mg IV bolus, then continuous
infusion at 12.5 mg/h (300 mg in 250 mL D5W at 11
mL/h over 24h) or 50 mg IV q8h OR
-Cimetidine (Tagamet) 300 mg IV bolus, then continu-
ous infusion at 50 mg/h (1200 mg in 250 mL D5W
over 24h) or 300 mg IV q6-8h OR
-Famotidine (Pepcid) 20 mg IV q12h.
10. Symptomatic Medications:
-Trimethobenzamide (Tigan) 100-250 mg PO or 100-
200 mg IM/PR q6h prn nausea OR
-Prochlorperazine (Compazine) 5-10 mg IM/IV/PO q4-
6h or 25 mg PR q4-6h prn nausea.
11. Extras: Upright abdomen, KUB, CXR, ECG, endos-
copy. GI consult, surgery consult.
12. Labs: CBC, SMA 7&12, amylase, lipase, LDH. UA.
Gastrointestinal Bleeding
1. Admit to:
2. Diagnosis: Upper/lower GI bleed
3. Condition:
4. Vital Signs: q30min. Call physician if BP >160/90,
<90/60; P >120, <50; R>25, <10; T >38.5°C; urine
output <15 mL/hr for 4h.
5. Activity: Bed rest
6. Nursing: Place nasogastric tube, then lavage with 2 L
of room temperature normal saline, then connect to
low intermittent suction. Repeat lavage q1h. Record
volume and character of lavage. Foley to closed drain-
age; inputs and outputs.
7. Diet: NPO
8. IV Fluids: Two 16 gauge IV lines. 1-2 L NS wide open;
transfuse 2-6 units PRBC to run as fast as possible,
then repeat CBC.
9. Special Medications:
-Oxygen 2 L by NC.
-Ranitidine (Zantac) 50 mg IV bolus, then continuous
infusion at 12.5 mg/h [300 mg in 250 mL D5W over
24h (11 cc/h)], or 50 mg IV q6-8h OR
-Famotidine (Pepcid) 20 mg IV q12h.
-Vitamin K (Phytonadione) 10 mg IV/SQ qd for 3 days
(if INR is elevated).
Esophageal Variceal Bleeds:
-Somatostatin (Octreotide) 50 mcg IV bolus, followed
by 25-50 mcg/h IV infusion (1200 mcg in 250 mL of
D5W at 11 mL/h).
Vasopressin/Nitroglycerine Paste Therapy:
-Vasopressin (Pitressin) 20 U IV over 20-30 min-
utes, then 0.2-0.3 U/min [100 U in 250 mL of
D5W (0.4 U/mL)] for 30 min, followed by in-
creases of 0.2 U/min until bleeding stops or max
of 0.9 U/min. If bleeding stops, taper over 24-
48h AND
-Nitroglycerine paste 1 inch q6h OR nitroglycerin IV
at 10-30 mcg/min continuous infusion (50 mg in
250 mL of D5W).
10. Extras: Portable CXR, upright abdomen, ECG.
Surgery and GI consults.
Upper GI Bleeds: Esophagogastroduodenoscopy with
coagulation or sclerotherapy; Linton-Nachlas tube for
tamponade of esophageal varices.
Lower GI Bleeds: Sigmoidoscopy/colonoscopy (after a
GoLytely purge 6-8 L over 4-6h), technetium 99m RBC
scan, angiography with embolization.
11. Labs: Repeat hematocrit q2h; CBC with platelets
q12-24h. Repeat INR in 6 hours. SMA 7&12, ALT, AST,
alkaline phosphatase, INR/PTT, type and cross for 3-6 U
PRBC and 2-4 U FFP.
Viral Hepatitis
1. Admit to:
2. Diagnosis: Hepatitis
3. Condition:
4. Vital Signs: qid. Call physician if BP <90/60; T
>38.5°C
5. Activity:
6. Nursing: Stool isolation.
7. Diet: Clear liquid (if nausea), low fat (if diarrhea).
8. Special Medications:
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Vitamin K 10 mg SQ qd for 3d.
-Multivitamin PO qd.
9. Symptomatic Medications:
-Meperidine (Demerol) 50-100 mg IM q4-6h prn pain.
-Trimethobenzamide (Tigan) 250 mg PO q6-8h prn
pruritus or nausea q6-8h prn.
-Hydroxyzine (Vistaril) 25 mg IM/PO q4-6h prn pruritus
or nausea.
-Diphenhydramine (Benadryl) 25-50 mg PO/IV q4-6h
prn pruritus.
10. Extras: Ultrasound, GI consult.
11. Labs: CBC, SMA 7&12, GGT, LDH, amylase, lipase,
INR/PTT, IgM anti-HAV, IgM anti-HBc, HBsAg, anti-HCV;
alpha-1-antitrypsin, ANA, ferritin, ceruloplasmin, urine
copper.
Acute Pancreatitis
1. Admit to:
2. Diagnosis: Acute pancreatitis
3. Condition:
4. Vital Signs: q1-4h, call physician if BP >160/90,
<90/60; P >120, <50; R>25, <10; T >38.5°C; urine
output < 25 cc/hr for more than 4 hours.
5. Activity: Bed rest with bedside commode.
6. Nursing: Inputs and outputs, fingerstick glucose qid,
guaiac stools. Foley to closed drainage.
7. Diet: NPO
8. IV Fluids: 1-4 L NS over 1-3h, then D5 ½ NS with 20
mEq KCL/L at 125 cc/hr. NG tube at low constant
suction (if obstruction).
9. Special Medications:
-Ranitidine (Zantac) 6.25 mg/h (150 mg in 250 mL
D5W at 11 mL/h) IV or 50 mg IV q6-8h OR
Famotidine (Pepcid) 20 mg IV q12h.
-Ticarcillin/clavulanate (Timentin) 3.1 gm IV, or
ampicillin/sulbactam (Unasyn) 3.0 gm IV q6h or
imipenem (Primaxin) 0.5-1.0 gm IV q6h.
-Antibiotics are indicated for infected pancreatic
pseudocysts or for abscess. Uncomplicated pancre-
atitis does not require antibiotics.
-Heparin 5000 U SQ q12h.
-Total parenteral nutrition should be provided until the
amylase and lipase are normal and symptoms have
resolved.
10. Symptomatic Medications:
-Meperidine 50-100 mg IM/IV q3-4h prn pain.
11. Extras: Upright abdomen, portable CXR, ECG, ultra-
sound, CT with contrast. Surgery and GI consults.
12. Labs: CBC, platelets, SMA 7&12, calcium, triglycer-
ides, amylase, lipase, LDH, AST, ALT; blood C&S x 2,
hepatitis B surface antigen, INR/PTT, type and hold 4-6
U PRBC and 2-4 U FFP. UA.
Acute Diarrhea
1. Admit to:
2. Diagnosis: Acute Diarrhea
3. Condition:
4. Vital Signs: q6h; call physician if BP >160/90, <80/60;
P >120; R>25; T >38.5°C
5. Activity: Up ad lib
6. Nursing: Daily weights, inputs and outputs.
7. Diet: NPO except ice chips for 24h, then low residual
elemental diet; no milk products.
8. IV Fluids: 1-2 L NS over 1-2 hours; then D5 ½ NS with
40 mEq KCL/L at 125 cc/h.
9. Special Medications:
Febrile or gross blood in stool or neutrophils on
microscopic exam or prior travel:
-Ciprofloxacin (Cipro) 500 mg PO bid OR
-Levofloxacin (Levaquin) 500 mg PO qd OR
-Trimethoprim/SMX (Bactrim DS) (160/800 mg) one
DS tab PO bid.
11. Extras: Upright abdomen. GI consult.
12. Labs: SMA7 and 12, CBC with differential, UA, blood
culture x 2.
Stool studies: Wright's stain for fecal leukocytes, ova
and parasites x 3, clostridium difficile toxin, culture for
enteric pathogens, E coli 0157:H7 culture.
Ulcerative Colitis
1. Admit to:
2. Diagnosis: Ulcerative colitis
3. Condition:
4. Vital Signs: q4-6h. Call physician if BP >160/90,
<90/60; P >120, <50; R>25, <10; T >38.5°C
5. Activity: Up ad lib in room.
6. Nursing: Inputs and outputs.
7. Diet: NPO except for ice chips for 48h, then low
residue or elemental diet, no milk products.
8. IV Fluids: 1-2 L NS over 1-2h, then D5 ½ NS with 40
mEq KCL/L at 125 cc/hr.
9. Special Medications:
-Mesalamine (Asacol) 400-800 mg PO tid OR
-5-aminosalicylate (Mesalamine) 400-800 mg PO tid or
1 gm PO qid or enema 4 gm/60 mL PR qhs OR
-Sulfasalazine (Azulfidine) 0.5-1 gm PO bid, increase
over 10 days as tolerated to 0.5-1.0 gm PO qid OR
-Olsalazine (Dipentum) 500 mg PO bid OR
-Hydrocortisone retention enema, 100 mg in 120 mL
saline bid.
-Methylprednisolone (Solu-Medrol) 10-20 mg IV q6h
OR
-Hydrocortisone 100 mg IV q6h OR
-Prednisone 40-60 mg/d PO in divided doses.
-B12, 100 mcg IM for 5d then 100-200 mcg IM q
month.
-Multivitamin PO qAM or 1 ampule IV qAM.
-Folate 1 mg PO qd.
10. Symptomatic Medications:
-Loperamide (Imodium) 2-4 mg PO tid-qid prn, max 16
mg/d OR
-Kaopectate 60-90 mL PO qid prn.
11. Extras: Upright abdomen. CXR, colonoscopy, GI
consult.
12. Labs: CBC, SMA 7&12, Mg, ionized calcium, liver
panel, blood C&S x 2; stool Wright's stain, stool for ova
and parasites x 3, culture for enteric pathogens;
Clostridium difficile antigen assay, UA.
Parenteral Nutrition
General Considerations: Daily weights, inputs and
outputs. Finger stick glucose q6h.
Central Parenteral Nutrition:
-Infuse 40-50 mL/h of amino acid-dextrose solution in
the first 24h; increase daily by 40 mL/hr increments
until providing 1.3-2 x basal energy requirement
and 1.2-1.7 gm protein/kg/d (see formula page 97).
Standard solution:
Amino acid sln (Aminosyn) 7-10% . . . . 500 mL
Dextrose 40-70% . . . . . . . . . . . . . . . . . 500 mL
Sodium . . . . . . . . . . . . . . . . . . . . . . . . 35 mEq
Potassium . . . . . . . . . . . . . . . . . . . . . . . 36 mEq
Chloride . . . . . . . . . . . . . . . . . . . . . . . . 35 mEq
Calcium . . . . . . . . . . . . . . . . . . . . . . . . 4.5 mEq
Phosphate . . . . . . . . . . . . . . . . . . . . . . 9 mmol
Magnesium . . . . . . . . . . . . . . . . . . . . . . 8.0 mEq
Acetate . . . . . . . . . . . . . . . . . . . . . . . . . 82-104 mEq
Multi-trace element formula . . . . . . . . . 1 mL/d
(zinc, copper, manganese, chromium)
Regular insulin (if indicated) . . . . . . . . . 10-60 U/L
Multivitamin(12)(2 amp) . . . . . . . . . . . . 10 mL/d
Vitamin K (in solution, SQ, IM) . . . . . . . 10 mg/week
Vitamin B12 . . . . . . . . . . . . . . . . . . . . . 1000 mcg/week
Selenium (after 20 days of continuous T PN)
80 mcg/d
Intralipid 20%, 500 mL/d IVPB; infuse in parallel with
standard solution at 1 mL/min for 15 min; if no ad-
verse reactions, increase to 100 mL/hr once daily or
20 mg/hr continuously. Obtain serum triglyceride 6h
after end of infusion (maintain <250 mg/dL).
Cyclic Total Parenteral Nutrition:
-12h night schedule; taper continuous infusion in
morning by reducing rate to half of original rate
for 1 hour. Further reduce rate by half for an
additional hour, then discontinue. Finger stick
glucose q4-6h; restart TPN in afternoon. Taper at
beginning and end of cycle. Final rate of 185
mL/hr for 9-10 h and 2 hours of taper at each end
for total of 2000 mL.
Peripheral Parenteral Supplementation:
-3% amino acid sln (ProCalamine) up to 3 L/d at 125
cc/h OR
-Combine 500 mL amino acid solution 7% or 10%
(Aminosyn) and 500 mL 20% dextrose and
electrolyte additive. Infuse at up to 100 cc/hr in
parallel with:
-Intralipid 10% or 20% at 1 mL/min for 15 min (test
dose); if no adverse reactions, infuse 500 mL/d at
21 mL/h over 24h, or up to 100 mL/h over 5 hours
daily.
-Draw triglyceride level 6h after end of Intralipid infu-
sion.
7. Special Medications:
-Famotidine 20 mg IV q12h or 40 mg/day in TPN OR
-Ranitidine (Zantac) 50 mg IV q8h or 150 mg/day in
TPN.
8. Extras: Nutrition consult.
9. Labs:
Daily labs: SMA7, osmolality, CBC, cholesterol,
triglyceride, urine glucose and specific gravity.
Twice weekly Labs: Calcium, phosphate, SMA-12,
magnesium
Weekly Labs: Serum albumin and protein, pre-albu-
min, ferritin, INR/PTT, zinc, copper, B12, folate,
24h urine nitrogen and creatinine.
Enteral Nutrition
General Considerations: Daily weights, inputs and
outputs, nasoduodenal feeding tube. Head-of-bed at 30°
while enteral feeding and 2 hours after completion.
Enteral Bolus Feeding: Give 50-100 mL of enteral
solution (Pulmocare, Jevity, Vivonex, Osmolite, Vital
HN) q3h. Increase amount in 50 mL steps to max of
250-300 mL q3-4h; 30 kcal of nonprotein calories/kg/d
and 1.5 gm protein/kg/d. Before each feeding measure
residual volume, and delay feeding by 1h if >100 mL.
Flush tube with 100 cc of water after each bolus.
Continuous enteral infusion: Initial enteral solution
(Pulmocare, Jevity, Vivonex, Osmolite) 30 mL/hr.
Measure residual volume q1h for 12h then tid; hold
feeding for 1h if >100 mL. Increase rate by 25-50
mL/hr at 24 hr intervals as tolerated until final rate of
50-100 mL/hr. Three tablespoonfuls of protein powder
(Promix) may be added to each 500 cc of solution.
Flush tube with 100 cc water q8h.
Special Medications:
-Metoclopramide (Reglan) 10-20 mg IV/NG OR
-Erythromycin 125 mg IV or via nasogastric tube q8h.
-Famotidine (Pepcid) 20 mg IV/PO q12h OR
-Ranitidine (Zantac 150 mg NG bid.
Symptomatic Medications:
-Loperamide (Imodium) 2-4 mg NG/J-tube q6h prn,
max 16 mg/d OR
-Diphenoxylate/atropine (Lomotil) 1-2 tabs or 5-10 mL
(2.5 mg/5 mL) PO/J-tube q4-6h prn, max 12
tabs/d OR
-Kaopectate 30 cc NG or in J-tube q8h.
Extras: CXR, plain abdominal x-ray for tube placement,
nutrition consult.
Labs:
Daily labs: SMA7, osmolality, CBC, cholesterol,
triglyceride. SMA-12
Weekly labs when indicated: Protein, Mg, INR/PTT,
24h urine nitrogen and creatinine. Pre-albumin,
retinol-binding protein.
Hepatic Encephalopathy
1. Admit to:
2. Diagnosis: Hepatic encephalopathy
3. Condition:
4. Vital Signs: q1-4h, neurochecks q4h. Call physician if
BP >160/90,<90/60; P >120,<50; R>25,<10; T
>38.5°C.
5. Allergies: Avoid sedatives, NSAIDS or hepatotoxic
drugs.
6. Activity: Bed rest.
7. Nursing: Keep head-of-bed at 40 degrees, guaiac
stools; turn patient q2h while awake, chart stools.
Seizure precautions, egg crate mattress, soft restraints
prn. Record inputs and outputs.
8. Diet: NPO for 8 hours, then low-protein nasogastric
enteral feedings (Hepatic-Aid II) at 30 mL/hr. Increase
rate by 25-50 mL/hr at 24 hr intervals as tolerated until
final rate of 50-100 mL/hr as tolerated.
9. IV Fluids: D5W at TKO, Foley to closed drainage.
10.Special Medications:
-Sorbitol 70% solution, 30-60 gm PO now.
-Lactulose 30-45 mL PO q1h for 3 doses, then 15-45
mL PO bid-qid, titrate to produce 3 soft stools/d OR
-Lactulose enema 300 mL added to 700 mL of tap wa-
ter; instill 200-250 mL per rectal tube bid-qid AND
-Neomycin 1 gm PO q6h (4-12 g/d) OR
-Metronidazole (Flagyl) 250 mg PO q6h.
-Ranitidine (Zantac) 50 mg IV q8h or 150 mg PO bid
OR
-Famotidine (Pepcid) 20 mg IV/PO q12h.
-Flumazenil (Romazicon) 0.2 mg (2 mL) IV over 30
seconds q1min until a total dose of 3 mg; if a partial
response occurs, continue 0.5 mg doses until a total
of 5 mg. Flumazenil may help reverse hepatic
encephalopathy, even in the absence of benzodiaz-
epine use.
-Multivitamin PO qAM or 1 ampule IV qAM.
-Folic acid 1 mg PO/IV qd.
-Thiamine 100 mg PO/IV qd.
-Vitamin K 10 mg SQ qd for 3 days if elevated INR.
11. Extras: CXR, ECG; GI and dietetics consults.
12. Labs: Ammonia, CBC, platelets, SMA 7&12, AST,
ALT, GGT, LDH, alkaline phosphatase, protein, albumin,
bilirubin, INR/PTT, ABG, blood C&S x 2, hepatitis B
surface antibody. UA.
Alcohol Withdrawal
1. Admit to:
2. Diagnosis: Alcohol withdrawals/delirium tremens.
3. Condition:
4. Vital Signs: q4-6h. Call physician if BP >160/90, <90-
/60; P >130, <50; R>25, <10; T >38.5°C; or increase in
agitation.
5. Activity:
6. Nursing: Seizure precautions. Soft restraints prn.
7. Diet: Regular, push fluids.
8. IV Fluids: Heparin lock or D5 ½ NS at 100-125 cc/h.
9. Special Medications:
Withdrawal syndrome:
-Chlordiazepoxide (Librium) 50-100 mg PO/IV q6h for
3 days OR
-Lorazepam (Ativan) 1 mg PO tid-qid.
Delirium tremens:
-Chlordiazepoxide (Librium) 100 mg slow IV push or
PO, repeat q4-6h prn agitation or tremor for 24h;
max 500 mg/d. Then give 50-100 mg PO q6h prn
agitation or tremor OR
-Diazepam (Valium) 5 mg slow IV push, repeat q6h
until calm, then 5-10 mg PO q4-6h.
Seizures:
-Thiamine 100 mg IV push AND
-Dextrose water 50%, 50 mL IV push.
-Lorazepam (Ativan) 0.1 mg/kg IV at 2 mg/min; may
repeat x 1 if seizures continue.
Wernicke-Korsakoff Syndrome:
-Thiamine 100 mg IV stat, then 100 mg IV qd.
10. Symptomatic Medications:
-Multivitamin 1 amp IV, then 1 tab PO qd.
-Folate 1 mg PO qd.
-Thiamine 100 mg PO qd.
-Acetaminophen (Tylenol) 1-2 PO q4-6h prn headache.
11. Extras: CXR, ECG. Alcohol rehabilitation and social
work consult.
12. Labs: CBC, SMA 7&12, Mg, amylase, lipase, liver
panel, urine drug screen. UA, INR/PTT.
Toxicology
Poisoning and Drug Overdose
Decontamination:
-Gastric Lavage: Place patient left side down, place
nasogastric tube, and check position by injecting air
and auscultating. Lavage with normal saline until
clear fluid, then leave activated charcoal or other
antidote. Gastric lavage is contraindicated for corro-
sives.
-Cathartics:
-Magnesium citrate 6% sln 150-300 mL PO
-Magnesium sulfate 10% solution 150-300 mL PO.
-Activated Charcoal: 50 gm PO (first dose should be
given using product containing sorbitol). Repeat q2-
6h for large ingestions.
-Hemodialysis is indicated for isopropanol, methanol,
ethylene glycol, severe salicylate intoxication (>100
mg/dL), lithium, or theophylline (if neurotoxicity,
seizures, or coma).
Antidotes:
Narcotic Overdose:
-Naloxone (Narcan) 0.4 mg IV/ET/IM/SC, may
repeat q2min.
Methanol Ingestion:
-Ethanol (10% in D5W) 7.5 mL/kg load, then 1.4
mL/kg/hr IV infusion until methanol level <20
mg/dL. Maintain ethanol level of 100-150 mg/100
mL.
Ethylene Glycol Ingestion:
-Fomepizole (Antizol) 15 mg/kg IV over 30 min, then
10 mg/kg IV q12h x 4 doses, then 15 mg/kg IV
q12h until ethylene glycol level is less than 20
mg/dL AND
-Pyridoxine 100 mg IV q6h for 2 days and thiamine
100 mg IV q6h for 2 days.
Carbon Monoxide Intoxication:
-Hyperbaric oxygen therapy or 100% oxygen by
mask if hyperbaric oxygen not available.
Tricyclic Antidepressants Overdose:
-Gastric lavage
-Magnesium citrate 300 mg PO/NG x1
-Activated charcoal premixed with sorbitol 50 gm
NG q4-6h until level is less than the toxic range.
Benzodiazepine Overdose:
-Flumazenil (Romazicon) 0.2 mg (2 mL) IV over 30
seconds q1min until a total dose of 3 mg; if a
partial response occurs, repeat 0.5 mg doses
until a total of 5 mg. If sedation persists, repeat
the above regimen or start a continuous IV infu-
sion of 0.1-0.5 mg/h.
Labs: Drug screen (serum, gastric, urine); blood levels,
SMA 7, fingerstick glucose, CBC, LFTs, ECG.
Acetaminophen Overdose
1. Admit to: Medical intensive care unit.
2. Diagnosis: Acetaminophen overdose
3. Condition:
4. Vital Signs: q1h with neurochecks. Call physician if
BP >160/90, <90/60; P >130, <50 <50; R>25, <10;
urine output <20 cc/h for 3 hours.
5. Activity: Bed rest with bedside commode.
6. Nursing: Inputs and outputs, aspiration and seizure
precautions. Place large bore (Ewald) NG tube, then
lavage with 2 L of NS.
7. Diet: NPO
8. IV Fluids:
9. Special Medications:
-Activated charcoal 30-100 gm doses, remove via NG
suction prior to acetylcysteine.
-Acetylcysteine (Mucomyst, NAC) 5% solution loading
dose 140 mg/kg via NG tube, then 70 mg/kg via NG
tube q4h x 17 doses OR acetylcysteine 150 mg/kg
IV in 200 mL D5W over 15 min, followed by 50
mg/kg in 500 mL D5W, infused over 4h, followed by
100 mg/kg in 1000 mL of D5W over next 16h.
Complete all NAC doses even if acetaminophen
levels fall below toxic range.
-Phytonadione 5 mg IV/IM/SQ (if INR increased).
-Fresh frozen plasma 2-4 U (if INR is unresponsive to
phytonadione).
-Trimethobenzamide (Tigan) 100-200 mg IM/PR q6h
prn nausea
10. Extras: ECG. Nephrology consult for hemodialysis or
charcoal hemoperfusion.
11. Labs: CBC, SMA 7&12, LFTs, INR/PTT, acet-
aminophen level now and in 4h. UA.
Theophylline Overdose
1. Admit to: Medical intensive care unit.
2. Diagnosis: Theophylline overdose
3. Condition:
4. Vital Signs: Neurochecks q2h. Call physician if BP
>160/90, <90/60; P >130; <50; R >25, <10.
5. Activity: Bed rest
6. Nursing: ECG monitoring until level <20 mcg/mL,
aspiration and seizure precautions. Insert single lumen
NG tube and lavage with normal saline if recent
ingestion.
7. Diet: NPO
8. IV Fluids: D5 ½ NS at 125 cc/h
9. Special Medications:
-Activated charcoal 50 gm PO q4-6h, with sorbitol
cathartic, until theophylline level <20 mcg/mL.
Maintain head-of-bed at 30-45 degrees to prevent
aspiration of charcoal.
-Charcoal hemoperfusion is indicated if the serum level
is >60 mcg/mL or if signs of neurotoxicity, seizure,
coma are present.
-Seizure: Lorazepam (Ativan) 0.1 mg/kg IV at 2
mg/min; may repeat x 1 if seizures continue.
10. Extras: ECG.
11. Labs: CBC, SMA 7&12, theophylline level now and in
q6-8h; INR/PTT, liver panel. UA.
Subarachnoid Hemorrhage
1. Admit to:
2. Diagnosis: Subarachnoid hemorrhage
3. Condition:
4. Vital Signs: Vital signs and neurochecks q1-6h. Call
physician if BP >185/105, <110/60; P >120, <50;
R>24, <10; T >38.5°C; or change in neurologic status.
5. Activity: Bedrest.
6. Nursing: Head-of-bed at 30 degrees, turn q2h when
awake. Foley catheter, eggcrate mattress. Guaiac
stools, inputs and outputs's.
Bleeding precautions: check puncture sites for bleed-
ing or hematomas. Apply digital pressure or pressure
dressing to active compressible bleeding sites.
7. Diet: NPO except medications.
8. IV Fluids and Oxygen: 0.45% normal saline at 100
cc/h. Oxygen at 2 L per minute by nasal cannula.
-Keep room dark and quiet; strict bedrest. Neurologic
checks q1h for 12 hours, then q2h for 12 hours, then
q4h. Call physician if abrupt change in neurologic
status.
-Restrict total fluids to 1000 mL/day; diet as tolerated.
9. Special Medications:
-Nimodipine (Nimotop) 60 mg PO or via NG tube q4h
for 21d, must start within 96 hours.
-Phenytoin (seizures) load 15 mg/kg IV in NS (infuse at
max 50 mg/min), then 300 mg PO/IV qAM (4-6
mg/kg/d).
Hypertension:
-Nitroprusside sodium, 0.1-0.5 mcg/kg/min (50 mg in
250 mL NS), titrate to control blood pressure.
10. Extras: CXR, ECG, CT without contrast; MRI an-
giogram; cerebral angiogram. Neurology, neurosurgery
consults.
11. Labs: CBC, SMA 7&12, VDRL, UA.
Nephrolithiasis
1. Admit to:
2. Diagnosis: Nephrolithiasis
3. Condition:
4. Vital Signs: q8h. Call physician if urine output <30
cc/hr; BP >160/90, <90/60; T >38.5°C
5. Activity: Up ad lib.
6. Nursing: Strain urine, measure inputs and outputs.
Place Foley if no urine for 4 hours.
7. Diet: Regular, push oral fluids.
8. IV Fluids: IV D5 ½ NS at 100-125 cc/hr (maintain
urine output of 80 mL/h).
9. Special Medications:
-Cefazolin (Ancef) 1-2 gm IV q8h
-Meperidine (Demerol) 75-100 mg and hydroxyzine 25
mg IM/IV q2-4h prn pain OR
-Butorphanol (Stadol) 0.5-2 mg IV q3-4h.
-Hydrocodone/acetaminophen (Vicodin), 1-2 tab q4-6h
PO prn pain OR
-Oxycodone/acetaminophen (Percocet) 1 tab q6h prn
pain OR
-Acetaminophen with codeine (Tylenol 3) 1-2 tabs PO
q3-4h prn pain.
-Ketorolac (Toradol) 10 mg PO q4-6h prn pain, or 30-
60 mg IV/IM then 15-30 mg IV/IM q6h (max 5 days).
-Zolpidem (Ambien) 10 mg PO qhs prn insomnia.
11. Extras: Intravenous pyelogram, KUB, CXR, ECG.
12. Labs: CBC, SMA 6 and 12, calcium, uric acid,
phosphorous, UA with micro, urine C&S, urine pH,
INR/PTT. Urine cystine (nitroprusside test), send stones
for X-ray crystallography. 24 hour urine collection for uric
acid, calcium, creatinine.
Hypercalcemia
1. Admit to:
2. Diagnosis: Hypercalcemia
3. Condition:
4. Vital Signs: q4h. Call physician if BP >160/90, <90/60;
P >120, <50; R>25, <10; T >38.5°C; or tetany or any
abnormal mental status.
5. Activity: Encourage ambulation; up in chair at other
times.
6. Nursing: Seizure precautions, measure inputs and
outputs.
7. Diet: Restrict dietary calcium to 400 mg/d, push PO
fluids.
8. Special Medications:
-1-2 L of 0.9% saline over 1-4 hours until no longer
hypotensive, then saline diuresis with 0.9% saline
infused at 125 cc/h AND
-Furosemide (Lasix) 20-80 mg IV q4-12h. Maintain
urine output of 200 mL/h; monitor serum sodium,
potassium, magnesium.
-Calcitonin (Calcimar) 4-8 IV kg IM q12h or SQ q6-
12h.
-Etidronate (Didronel) 7.5 mg/kg/day in 250 mL of
normal saline IV infusion over 2 hours. Repeat on 3
days.
-Pamidronate (Aredia) 60 mg in 1 liter of NS infused
over 4 hours or 90 mg in 1 liter of NS infused over
24 hours x one dose.
9. Extras: CXR, ECG, mammogram.
10. Labs: Total and ionized calcium, parathyroid hor-
mone, SMA 7&12, phosphate, Mg, alkaline phosphatase,
prostate specific antigen and carcinoembryonic antigen.
24h urine calcium, phosphate.
Hypocalcemia
1. Admit to:
2. Diagnosis: Hypocalcemia
3. Condition:
4. Vital Signs: q4h. Call physician if BP >160/90, <90/60;
P >120, <50; R>25, <10; T >38.5°C; or any abnormal
mental status.
5. Activity: Up ad lib
6. Nursing: I and O.
7. Diet: No added salt diet.
8. Special Medications:
Symptomatic Hypocalcemia:
-Calcium chloride, 10% (270 mg calcium/10 mL vial)
give 5-10 mL slowly over 10 min or dilute in 50-100
mL of D5W and infuse over 20 min, repeat q20-30
min if symptomatic, or hourly if asymptomatic.
Correct hyperphosphatemia before hypocalcemia
OR
-Calcium gluconate, 20 mL of 10% solution IV (2
vials)(90 mg elemental calcium/10 mL vial) infused
over 10-15 min, followed by infusion of 60 mL of
calcium gluconate in 500 cc of D5W (1 mg/mL) at
0.5-2.0 mg/kg/h.
Chronic Hypocalcemia:
-Calcium carbonate with vitamin D (Oscal-D) 1-2 tab
PO tid OR
-Calcium carbonate (Oscal) 1-2 tab PO tid OR
-Calcium citrate (Citracal) 1 tab PO q8h or Extra
strength Tums 1-2 PO with meals.
-Vitamin D2 (Ergocalciferol) 1 tab PO qd.
-Calcitriol (Rocaltrol) 0.25 mcg PO qd, titrate up to 0.5-
2.0 mcg qid.
-Docusate sodium (Colace) 1 tab PO bid.
9. Extras: CXR, ECG.
10. Labs: SMA 7&12, phosphate, Mg. 24h urine calcium,
potassium, phosphate, magnesium.
Hyperkalemia
1. Admit to:
2. Diagnosis: Hyperkalemia
3. Condition:
4. Vital Signs: q4h. Call physician if QRS complex >0.14
sec or BP >160/90, <90/60; P >120, <50; R>25, <10;
T >38.5°C.
5. Activity: Bed rest; up in chair as tolerated.
6. Nursing: Inputs and outputs. Chart QRS complex
width q1h.
7. Diet: Regular, no salt substitutes.
8. IV Fluids: D5NS at 125 cc/h
9. Special Medications:
-Consider discontinuing ACE inhibitors, angiotensin II
receptor blockers, beta-blockers, potassium sparing
diuretics.
-Calcium gluconate (10% sln) 10-30 mL IV over 2-5
min; second dose may be given in 5 min. Contrain-
dicated if digoxin toxicity is suspected. Keep 10 mL
vial of calcium gluconate at bedside for emergent
use.
-Sodium bicarbonate 1 amp (50 mEq) IV over 5 min
(give after calcium in separate IV).
-Regular insulin 10 units IV push with 1 ampule of 50%
glucose IV push.
-Kayexalate 30-45 gm premixed in sorbitol solution
PO/NG/PR now and in q3-4h prn.
-Furosemide 40-80 mg IV, repeat prn.
-Consider emergent dialysis if cardiac complications or
renal failure.
10. Extras: ECG.
11. Labs: CBC, platelets, SMA7, magnesium, calcium,
SMA-12. UA, urine specific gravity, urine sodium, pH, 24h
urine potassium, creatinine.
Hypokalemia
1. Admit to:
2. Diagnosis: Hypokalemia
3. Condition:
4. Vital Signs: Vitals, urine output q4h. Call physician if
BP >160/90, <90/60; P>120, <50; R>25, <10; T
>38.5°C.
5. Activity: Bed rest; up in chair as tolerated.
6. Nursing: Inputs and outputs
7. Diet: Regular
8. Special Medications:
Acute Therapy:
-KCL 20-40 mEq in 100 cc saline infused IVPB over 2
hours; or add 40-80 mEq to 1 liter of IV fluid and
infuse over 4-8 hours.
-KCL elixir 40 mEq PO tid (in addition to IV); max total
dose 100-200 mEq/d (3 mEq/kg/d).
Chronic Therapy:
-Micro-K 10 mEq tabs 2-3 tabs PO tid after meals (40-
100 mEq/d) OR
-K-Dur 20 mEq tabs 1 PO bid-tid.
Hypokalemia with metabolic acidosis:
-Potassium citrate 15-30 mL in juice PO qid after
meals (1 mEq/mL).
-Potassium gluconate 15 mL in juice PO qid after
meals (20 mEq/15 mL).
9. Extras: ECG, dietetics consult.
10. Labs: CBC, magnesium, SMA 7&12. UA, urine Na,
pH, 24h urine for K, creatinine.
Hypermagnesemia
1. Admit to:
2. Diagnosis: Hypermagnesemia
3. Condition:
4. Vital Signs: q6h. Call physician if QRS >0.14 sec.
5. Activity: Up ad lib
6. Nursing: Inputs and outputs, daily weights.
7. Diet: Regular
8. Special Medications:
-Saline diuresis 0.9% saline infused at 100-200 cc/h to
replace urine loss AND
-Calcium chloride, 1-3 gm added to saline (10% sln; 1
gm per 10 mL amp) to run at 1 gm/hr AND
-Furosemide (Lasix) 20-40 mg IV q4-6h as needed.
-Magnesium of >9.0 requires stat hemodialysis be-
cause of risk of respiratory failure.
9. Extras: ECG
10. Labs: Magnesium, calcium, SMA 7&12, creatinine. 24
hour urine magnesium, creatinine.
Hypomagnesemia
1. Admit to:
2. Diagnosis: Hypomagnesemia
3. Condition:
4. Vital Signs: q6h
5. Activity: Up ad lib
6. Diet: Regular
7. Special Medications:
-Magnesium sulfate 4-6 gm in 500 mL D5W IV at 1
gm/hr. Hold if no patellar reflex. (Estimation of Mg
deficit = 0.2 x kg weight x desired increase in Mg
concentration; give deficit over 2-3d) OR
-Magnesium sulfate (severe hypomagnesemia <1.0) 1-
2 gm (2-4 mL of 50% sln) IV over 15 min, OR
-Magnesium chloride (Slow-Mag) 65-130 mg (1-2 tabs)
PO tid-qid (64 mg or 5.3 mEq/tab) OR
-Milk of magnesia 5 mL PO qd-qid.
8. Extras: ECG
9. Labs: Magnesium, calcium, SMA 7&12. Urine Mg,
electrolytes, 24h urine magnesium, creatinine.
Hypernatremia
1. Admit to:
2. Diagnosis: Hypernatremia
3. Condition:
4. Vital Signs: q2-8h. Call physician if BP >160/90, <7-
0/50; P >140, <50; R>25, <10; T >38.5°C.
5. Activity: Bed rest; up in chair as tolerated.
6. Nursing: Inputs and outputs, daily weights.
7. Diet: No added salt.
8. Special Medications:
Hypernatremia with Hypovolemia:
If volume depleted, give 1-2 L NS IV over 1-3 hours
until not orthostatic, then give D5W IV or PO to
replace half of body water deficit over first
24hours (attempt to correct sodium at 1 mEq/L/h),
then remaining deficit over next 1-2 days.
Body water deficit (L) = 0.6(weight kg)([Na serum]-
140)
140
Hypernatremia with ECF Volume Excess:
-Furosemide 40-80 mg IV or PO qd-bid.
-Salt poor albumin (25%) 50-100 mL bid-tid x 48-72 h.
Hypernatremia with Diabetes Insipidus:
-D5W to correct body water deficit (see above).
-Pitressin 5-10 U IM/IV q6h or desmopressin
(DDAVP) 4 mcg IV/SQ q12h; keep urine specific
gravity >1.010.
9. Extras: CXR, ECG.
10. Labs: SMA 7&12, serum osmolality, liver panel, ADH,
plasma renin activity. UA, urine specific gravity. Urine
osmolality, Na, 24h urine K, creatinine.
Hyponatremia
1. Admit to:
2. Diagnosis: Hyponatremia
3. Condition:
4. Vital Signs: q4h. Call physician if BP >160/90, <70/50;
P >140, <50; R>25, <10; T >38.5°C.
5. Activity: Up in chair as tolerated.
6. Nursing: Inputs and outputs, daily weights.
7. Diet: Regular diet.
8. Special Medications:
Hyponatremia with Hypervolemia and Edema (low
osmolality <280, UNa <10 mmol/L: nephrosis, heart
failure, cirrhosis):
-Water restrict to 0.5-1.0 L/d.
-Furosemide 40-80 mg IV or PO qd-bid.
Hyponatremia with Normal Volume Status (low
osmolality <280, UNa <10 mmol: water intoxication;
UNa >20: SIADH, diuretic-induced):
-Water restrict to 0.5-1.5 L/d.
Hyponatremia with Hypovolemia (low osmolality <280)
UNa <10 mmol/L: vomiting, diarrhea, third
space/respiratory/skin loss; UNa >20 mmol/L: diuretics,
renal injury, RTA, adrenal insufficiency, partial obstruc-
tion, salt wasting:
-If volume depleted, give 0.5-2 L of 0.9% saline over 1-
2 hours until no longer hypotensive, then 0.9%
saline at 125 mL/h or 100-500 mL 3% hypertonic
saline over 4h.
Severe Symptomatic Hyponatremia:
If volume depleted, give 1-2 L of 0.9% saline (154
mEq/L) over 1-2 hours until no longer orthostatic.
Determine volume of 3% hypertonic saline (513
mEq/L) to be infused:
Na (mEq) deficit = 0.6 x (wt kg)x(desired [Na] - actual
[Na])
Hyperphosphatemia
1. Admit to:
2. Diagnosis: Hyperphosphatemia
3. Condition:
4. Vital Signs: qid
5. Activity: Up ad lib
6. Nursing: Inputs and outputs
7. Diet: Low phosphorus diet with 0.7-1 gm/d
8. Special Medications:
Moderate Hyperphosphatemia:
-Restrict dietary phosphate to 0.7-1.0 gm/d.
-Calcium acetate (PhosLo) 1-3 tabs PO tid with meals,
OR
-Aluminum hydroxide (Amphojel) 5-10 mL or 1-2
tablets PO before meals tid.
Severe Hyperphosphatemia:
-Volume expansion with 0.9% saline 1-2 L over 1-2h.
-Acetazolamide (Diamox) 500 mg PO or IV q6h.
-Consider dialysis.
9. Extras: CXR PA and LAT, ECG.
10. Labs: Phosphate, SMA 7&12, magnesium, calcium.
UA, parathyroid hormone.
Hypophosphatemia
1. Admit to:
2. Diagnosis: Hypophosphatemia
3. Condition:
4. Vital Signs: qid
5. Activity: Up ad lib
6. Nursing: Inputs and outputs.
7. Diet: Regular diet.
8. Special Medications:
Mild to Moderate Hypophosphatemia (1.0-2.2 mg/dL):
-Sodium or potassium phosphate 0.25 mMoles/kg in
150-250 mL of NS or D5W at 10 mMoles/h.
-Neutral phosphate (Nutra-Phos), 2 tab PO bid (250
mg elemental phosphorus/tab) OR
-Phospho-Soda 5 mL (129 mg phosphorus) PO bid-tid.
Severe Hypophosphatemia (<1.0 mg/dL):
-Na or K phosphate 0.5 mMoles/kg in 250 mL D5W or
NS, IV infusion at 10 mMoles/hr OR
-Add potassium phosphate to IV solution in place of
maintenance KCL; max IV dose 7.5 mg phospho-
rus/kg/6h.
9. Extras: CXR PA and LAT, ECG.
10. Labs: Phosphate, SMA 7&12, Mg, calcium, UA.
Rheumatologic Disorders
Systemic Lupus Erythematosus
1. Admit to:
2. Diagnosis: Systemic Lupus Erythematosus
3. Condition:
4. Vital Signs: tid
5. Allergies:
6. Activity: Up as tolerated with bathroom privileges
7. Nursing:
8. Diet: No added salt, low psoralen diet.
9. Special Medications:
-Ibuprofen (Motrin) 400 mg PO qid (max 2.4 g/d) OR
-Indomethacin (Indocin) 25-50 mg tid-qid.
-Hydroxychloroquine (Plaquenil) 200-600 mg/d PO
-Prednisone 60-100 mg PO qd, may increase to 200-
300 mg/d. Maintenance 10-20 mg PO qd or 20-40
mg PO qOD OR
-Methylprednisolone (pulse therapy) 500 mg IV over
30 min q12h for 3-5d, then prednisone 50 mg PO
qd.
-Betamethasone dipropionate (Diprolene) 0.05%
ointment applied bid.
10. Extras: CXR PA, LAT, ECG. Rheumatology consult.
11. Labs: CBC, platelets, SMA 7&12, INR/PTT, ESR,
complement CH-50, C3, C4, C-reactive protein, LE prep,
Coombs test, VDRL, rheumatoid factor, ANA, DNA
binding, lupus anticoagulant, anticardiolipin, antinuclear
cytoplasmic antibody. UA.
General Pediatrics
Pediatric History and Physical Exam-
ination
History
Progress Notes
Daily progress notes should summarize developments in
a patient's hospital course, problems that remain active,
plans to treat those problems, and arrangements for
discharge. Progress notes should address every element
of the problem list.
Date/time:
Identify Discipline and Level of Education: e.g.
Pediatric resident PL-3
Subjective: Any problems and symptoms of the
patient should be charted. Appetite, pain, or fussi-
ness may be included.
Objective:
General appearance.
Vitals, including highest temperature (Tmax) over
past 24 hours. Feedings, fluid inputs and out-
puts (I/O), including oral and parenteral intake
and urine and stool volume output.
Physical exam, including chest and abdomen,
with particular attention to active problems. Em-
phasize changes from previous physical exams.
Labs: Include new test results and flag abnormal
values.
Current Medications: List all medications and
dosages.
Assessment and Plan: This section should be
organized by problem. A separate assessment and
plan should be written for each problem.
Discharge Note
The discharge note should be written in the patient’s chart
prior to discharge.
Discharge Note
Date/time:
Diagnoses:
Treatment: Briefly describe treatment provided
during hospitalization, including surgical procedures
and antibiotic therapy.
Studies Performed: Electrocardiograms, CT
scans.
Discharge Medications:
Follow-up Arrangements:
Prescription Writing
• Patient’s name:
• Date:
• Drug name, dosage form, dose, route, frequency
(include concentration for oral liquids or mg strength for
oral solids): Amoxicillin 125mg/5mL 5 mL PO tid
• Quantity to dispense: mL for oral liquids, # of oral
solids
• Refills: If appropriate
• Signature
Procedure Note
A procedure note should be written in the chart after a
procedure is performed (e.g. lumbar puncture).
Procedure Note
Developmental Milestones
Age Milestones
Immunizations
Immunization Schedule for Infants and Children
Age Immuniza- Comments
tions
4 mo DTaP, Hib,
IPV, PCV
Interval
after
1st visit DTaP, HBV Second dose of Hib is
1 month indicated only if first
DTaP, Hib, dose was received when
2 months IPV, (PCV) <15 months. Second
DTaP, HBV, dose of PCV 6-8 weeks
>8 months IPV after first dose (if criteria
met above).
Interval
after First
visit HBV, IPV, Td, If child is >13 years
2 months VAR, MMR old, a second varicella
HBV, Td, IPV vaccine dose is
8-14 needed 4-8 weeks af-
months ter the first dose.
Haemophilus Immunization
H influenzae type b Vaccination in Children
Immunized Beginning at 2 to 6 Months of Age
Influenza Immunization
Indications for Influenza Vaccination
A. Targeted high-risk children and adolescents (eg,
chronic pulmonary disease including asthma, sickle
cell anemia, HIV infection).
B. Other high-risk children and adolescents (eg,
diabetes mellitus, chronic renal disease, chronic
metabolic disease).
C. Close contacts of high risk patients.
D. Foreign travel if exposure is likely.
Vaccine Administration. Administer in the Fall, usually
October 1 - November 15, before the start of the influ-
enza season.
Antiemetics
-Chlorpromazine (Thorazine)
0.25-1 mg/kg/dose slow IV over 20 min/IM/PO q4-8h
prn, max 50 mg/dose
[inj: 25 mg/mL,; oral concentrate 30 mg/mL; supp:
25,100 mg; syrup: 10 mg/5 mL; tabs: 10, 25, 50,
100, 200 mg].
-Diphenhydramine (Benadryl)
1 mg/kg/dose IM/IV/PO q6h prn, max 50 mg/dose
[caps: 25, 50 mg; inj: 10 mg/mL, 50 mg/mL; liquid:
12.5 mg/5 mL; tabs: 25, 50 mg].
-Dimenhydrinate (Dramamine)
>12 yrs: 5 mg/kg/day IM/IV/PO q6h prn, max 300
mg/day
Not recommended in <12y due to high incidence of
extrapyramidal side effects.
[cap: 50 mg; inj: 50 mg/mL; liquid 12.5 mg/4 mL; tab:
50 mg; tab, chew: 50mg].
-Prochlorperazine (Compazine)
>12 yrs: 0.1-0.15 mg/kg/dose IM, max 10 mg/dose
or 5-10 mg PO q6-8h, max 40 mg/day OR 5-25 mg
PR q12h, max 50 mg/day
Not recommended in <12y due to high incidence of
extrapyramidal side effects
[caps, SR: 10, 15, 30 mg; inj: 5 mg/mL; supp: 2.5, 5,
25 mg; syrup: 5 mg/5 mL; tabs: 5, 10, 25 mg].
-Promethazine (Phenergan)
0.25-1 mg/kg/dose PO/IM/IV over 20 min or PR q4-
6h prn, max 50 mg/dose
[inj: 25,50 mg/mL; supp: 12.5, 25, 50 mg;syrup 6.25
mg/5 mL, 25 mg/5 mL; tabs: 12.5, 25, 50 mg].
-Trimethobenzamide (Tigan)
15 mg/kg/day IM/PO/PR q6-8h, max 100 mg/dose if
<13.6 kg or 200 mg/dose if 13.6-41kg.
[caps: 100, 250 mg; inj: 100 mg/mL; supp: 100, 200
mg].
Post-Operative Nausea and Vomiting:
-Ondansetron (Zofran) 0.1 mg/kg IV x 1, max 4 mg.
-Droperidol (Inapsine) 0.01-0.05 mg/kg IV/IM q4-6h
prn, max 5 mg [inj: 2.5 mg/mL].
Chemotherapy-Induced Nausea:
-Dexamethasone
10 mg/m2/dose (max 20 mg) IV x 1, then 5
mg/m2/dose (max 10 mg) IV q6h prn
[inj: 4 mg/mL, 10 mg/mL]
-Dronabinol (Marinol)
5 mg/m2/dose PO 1-3 hrs prior to chemotherapy,
then q4h prn afterwards. May titrate up in 2.5
mg/m2/dose increments to max of 15 mg/m2/dose.
[cap: 2.5, 5, 10 mg]
-Granisetron (Kytril)
10-20 mcg/kg IV given just prior to chemotherapy
(single dose) [inj: 1 mg/mL]
Adults (oral) 1 mg PO bid or 2 mg PO qd [tab: 1 mg]
-Metoclopramide (Reglan)
0.5-1 mg/kg/dose IV q6h prn.
Pretreatment with diphenhydramine 1 mg/kg IV is
recommended to decrease the risk of extrapyramidal
reactions.
[inj: 5 mg/mL]
-Ondansetron (Zofran)
0.15 mg/kg/dose IV 30 minutes before chemother-
apy and repeated 4 hr and 8 hr later (total of 3
doses) OR
0.3 mg/kg/dose IV x 1 30 minutes before chemother-
apy OR
0.45 mg/kg/day as a continuous IV infusion OR
Oral:
<0.3 m2: 1 mg PO three times daily
0.3-0.6 m2: 2 mg PO three times daily
0.6-1 m2: 3 mg PO three times daily
>1 m2: 4 mg PO three times daily OR
4-11 yr: 4 mg PO three times daily
>11 yr: 8 mg PO three times daily
[inj: 2 mg/mL; oral soln: 4mg/5 mL; tab: 4, 8, 24 mg;
tab, orally disintegrating: 4, 8 mg]
Cardiovascular Disorders
Pediatric Advanced Life Support
I. Cardiopulmonary assessment
A.Airway (A) assessment. The airway should be
assessed and cleared.
B.Breathing (B) assessment determines the respira-
tory rate, respiratory effort, breath sounds (air entry)
and skin color. A respiratory rate of less than 10 or
greater than 60 is a sign of impending respiratory
failure.
C.Circulation (C) assessment should quantify the
heart rate and pulse. In infants, chest compressions
should be initiated if the heart rate is less than 80
beats/minute (bpm). In children, chest compressions
should be initiated if the heart rate is less than 60
bpm.
II. Respiratory failure
A.An open airway should be established. Bag-valve-
mask ventilation should be initiated if the respiratory
rate is less than 10. Intubation is performed if pro-
longed ventilation is required. Matching the
endotracheal tube to the size of the nares or fifth
finger provides an estimate of tube size.
Intubation
Premature 2.0-2.5 0 8
Newborn 3.0-3.5 1 10
>2 kg 3.5-4.0 1 10
Infant 4.0-4.5 1.5 12
12 mo 4.5-5.0 2 12-14
36 mo 5.0-5.5 2 14-16
6 yr 6.0-6.5 2 16-18
10 yr .0-7.5 3 18-20
Adolescent 7.5-8.0 3 20
Adult
Intravenous
Agent dosage Indications
V. Dysrhythmias
A. Bradycardia
1. Bradycardia is the most common dysrhythmia in
children. Initial management is ventilation and
oxygenation. Chest compressions should be
initiated if the heart rate is <60 bpm in a child or
<80 bpm in an infant.
2. If these measures do not restore the heart rate,
epinephrine is administered. Intravenous or
intraosseous epinephrine is given in a dose of
0.1 mL/kg of the 1:10,000 concentration (0.01
mg/kg). Endotracheal tube epinephrine is given
as a dose of 0.1 mL/kg of the 1:1,000 concen-
tration (0.1 mg/kg) diluted to a final volume of 3-
5 mL in normal saline. This dose may be re-
peated every three to five minutes.
3. Atropine may be tried if multiple doses of epi-
nephrine are unsuccessful. Atropine is given in
a dose of 0.2 mL/kg IV/IO/ET of the 1:10,000
concentration (0.02 mg/kg. The minimum dose
is 0.1 mg; the maximum single dose is 0.5 mg
for a child and 1 mg for an adolescent.
Endotracheal tube administration of atropine
should be further diluted to a final volume of 3-5
mL in normal saline.
4. Pacing may be attempted if drug therapy has
failed.
B. Asystole
1. Epinephrine is the drug of choice for asystole.
The initial dose of intravenous or intraosseous
epinephrine is given in a dose of 0.1 mL/kg of
the 1:10,000 concentration of epinephrine (0.01
mg/kg). Endotracheal tube administration of
epinephrine is given as a dose of 0.1 mL/kg of
the 1:1,000 concentration of epinephrine (0.1
mg/kg), further diluted to a final volume of 3-5
mL in normal saline.
2. Subsequent doses of epinephrine are adminis-
tered every three to five minutes at 0.1 mL/kg
IV/IO/ET of the 1:1,000 concentration (0.1
mg/kg).
C. Supraventricular tachycardia
1. Supraventricular tachycardia presents with a
heart rate >220 beats/minute in infants and
>180 beats/minute in children. Supraventricular
tachycardia is the most common dysrhythmia in
the first year of life.
2. Stable children with no signs of respiratory
compromise or shock and a normal blood
pressure
a. Initiate 100% oxygen and cardiac monitoring,
and obtain pediatric cardiology consultation.
b. Administer adenosine 0.1 mg/kg (max 6 mg)
by rapid intravenous push. The dose of
adenosine may be doubled to 0.2 mg/kg
(max 12 mg) and repeated if supraventricular
tachycardia is not converted.
c. Verapamil (Calan) may be used; however, it
is contraindicated under one year; in conges-
tive heart failure or myocardial depression; in
children receiving beta- adrenergic blockers;
and in the presence of a possible bypass
tract (ie, Wolff-Parkinson-White syndrome).
Dose is 0.1-0.3 mg/kg/dose (max 5 mg) IV;
may repeat dose in 30 minutes prn (max 10
mg).
3. Supraventricular tachycardia in unstable
child with signs of shock: Administer synchro-
nized cardioversion at 0.5 joules (J)/kg. If
supraventricular tachycardia persists, cardiover-
sion is repeated at double the dose: 1.0 J/kg.
D. Ventricular tachycardia with palpable pulse
1. A palpable pulse with heart rate >120 bpm with
a wide QRS (>0.08 seconds) is present. Initiate
cardiac monitoring, administer oxygen and
ventilate.
2. If vascular access is available, administer a
lidocaine bolus of 1 mg/kg; if successful, begin
lidocaine infusion at 20-50 µg/kg/minute.
3. If ventricular tachycardia persists, perform
synchronized cardioversion using 0.5 J/kg.
4. If ventricular tachycardia persists, repeat syn-
chronized cardioversion using 1.0 J/kg.
5. If ventricular tachycardia persists, administer a
lidocaine bolus of 1.0 mg/kg, and begin
lidocaine infusion at 20-50 µg/kg/min.
6. Repeat synchronized cardioversion as indi-
cated.
E. Ventricular fibrillation and pulseless ventricular
tachycardia
1. Apply cardiac monitor, administer oxygen, and
ventilate.
2. Perform defibrillation using 2 J/kg. Do not delay
defibrillation.
3. If ventricular fibrillation persists, perform
defibrillation using 4 J/kg.
4. If ventricular fibrillation persists, perform
defibrillation using 4 J/kg.
5. If ventricular fibrillation persists, perform
intubation, continue CPR, and obtain vascular
access. Administer epinephrine, 0.1 mL/kg of
1:10,000 IV or IO (0.01 mg/kg); or 0.1 mL/kg of
1:1000 ET (0.1 mg/kg).
6. If ventricular fibrillation persists, perform
defibrillation using 4 J/kg.
7. If ventricular fibrillation persists, administer
lidocaine 1 mg/kg IV or IO, or 2 mg/kg ET.
8. If ventricular fibrillation persists, perform
defibrillation using 4 J/kg.
9. If ventricular fibrillation persists, continue epi-
nephrine, 0.1 mg/kg IV/IO/ET, 0.1 mL/kg of
1:1,000; administer every 3 to 5 minutes.
10. If ventricular fibrillation persists, alternate
defibrillation (4 J/kg) with lidocaine and epi-
nephrine. Consider bretylium 5 mg/kg IV first
dose, 10 mg/kg IV second dose.
F. Pulseless electrical activity is uncommon in
children. It usually occurs secondary to hypoxemia,
hypovolemia, hypothermia, hypoglycemia,
hyperkalemia, cardiac tamponade, tension
pneumothorax, severe acidosis or drug overdose.
Successful resuscitation depends on treatment of
the underlying etiology.
1. The initial dose of IV or IO epinephrine is given
in a dose of 0.1 mL/kg of the 1:10,000 concen-
tration (0.01 mg/kg). Endotracheal epinephrine
is given as a dose of 0.1 mL/kg of the 1:1,000
concentration (0.1 mg/kg) diluted to a final
volume of 3-5 mL in normal saline.
2. Subsequent doses are administered every three
to five minutes as 0.1 mL/kg of the 1:1,000
concentration IV/IO/ET (0.1 mg/kg).
VI. Serum glucose concentration should be determined
in all children undergoing resuscitation. Glucose
replacement is provided with 25% dextrose in water,
2 to 4 mL/kg (0.5 to 1 g/kg) IV over 20 to 30 minutes
for hypoglycemia. In neonates, 10% dextrose in water,
5 to 10 mL/kg (0.5 to 1 g/kg), is recommended.
Anaphylaxis
1. Admit to:
2. Diagnosis: Anaphylaxis
3. Condition:
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: Inputs and outputs, ECG monitoring, pulse
oximeter.
7. Diet:
8. IV Fluids: 2 IV lines. Normal saline or LR 10-20 mL/kg
rapidly over 1h, then D5 ½ NS at 1-1.5 times mainte-
nance.
9. Special Medications:
-O2 at 4 L/min by NC or mask.
-Epinephrine, 0.01 mg/kg [0.01 mL/kg of 1 mg/mL =
1:1000] (maximum 0.5 mL) subcutaneously, repeat
every 15-20 minutes prn. Usual dose for infants is
0.05-0.1mL, for children 0.1-0.3 mL, and for ado-
lescents 0.3-0.5 mL. If anaphylaxis is caused by an
insect sting or intramuscular injection, inject an
additional 0.1 mL of epinephrine at the site to slow
antigen absorption.
-Epinephrine racemic (if stridor is present), 2.25%
nebulized, 0.25-0.5 mL in 2.5 mL NS over 15 min
q30 min-4h.
-Albuterol (Ventolin) (0.5%, 5 mg/mL sln) nebulized
0.01-0.03 mL/kg (max 1 mL) in 2 mL NS q1-2h and
prn; may be used in addition to epinephrine if
necessary.
Corticosteroids:
-For severe symptoms, give hydrocortisone 5 mg/kg IV
q8h until stable, then change to oral prednisone. If
symptoms are mild, give prednisone: initially 2
mg/kg/day (max 40 mg) PO q12h, then taper the
dose over 4-5 days.
Antihistamines:
-Diphenhydramine (Benadryl) 1 mg/kg/dose
IV/IM/IO/PO q6h, max 50 mg/dose; antihistamines
are not a substitute for epinephrine OR
-Hydroxyzine (Vistaril) 0.5-1 mg/kg/dose IM/IV/PO q4-
6h, max 50 mg/dose.
10. Extras and X-rays: Portable CXR.
11. Labs: CBC, SMA 7, ABG.
Pleural Effusion
1. Admit to:
2. Diagnosis: Pleural effusion
3. Condition:
4. Vital signs: Call MD if:
5. Activity:
6. Diet:
7. IV Fluids:
8. Extras and X-rays: CXR PA and LAT, lateral de-
cubitus, ultrasound, sputum AFB. Pulmonary consult.
9. Labs: CBC with differential, SMA 7, protein, albumin,
ESR, UA.
Pleural fluid:
Tube 1 - LDH, protein, amylase, triglycerides, glucose,
specific gravity (10 mL red top).
Tube 2 - Gram stain, culture and sensitivity, AFB,
fungal culture (20-60 mL).
Tube 3 - Cell count and differential (5-10 mL, EDTA
purple top).
Tube 4 - Cytology (25-50 mL, heparinized).
Syringe - pH (2 mL, heparinized).
Transudate Exudate
Meningitis
1. Admit to:
2. Diagnosis: Meningitis.
3. Condition: Guarded.
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: Strict isolation precautions. Inputs and
outputs, daily weights; cooling measures prn temp
>38°C; consent for lumbar puncture. Monitor for signs
of increased intracranial pressure.
7. Diet:
8. IV Fluids: Isotonic fluids at maintenance rate.
9. Special Medications:
Term Newborns <1 months old (Group B strep, E
coli, gram negatives, Listeria):
-Ampicillin, 0-7 d: 150 mg/kg/day IV/IM q8h; >7d: 200
mg/kg/day IV/IM q6h AND
-Cefotaxime (Claforan): <7d: 100 mg/kg/day IV/IM
q12h; >7 days: 150 mg/kg/day q8h IV/IM.
Infants 1-3 months old (H. flu, strep pneumonia, N.
Meningitidis, group B strep, E coli):
-Cefotaxime (Claforan) 200 mg/kg/day IV/IM q6h OR
-Ceftriaxone (Rocephin) 100 mg/kg/day IV/IM q12-24h
AND
-Vancomycin (Vancocin) 40-60 mg/kg/day IV q6h.
-Dexamethasone 0.6 mg/kg/day IV q6h x 4 days.
Initiate before or with the first dose of parenteral
antibiotic.
Children 3 months to 18 years old (S pneumonia, H
flu, N. meningitidis):
-Cefotaxime (Claforan) 200 mg/kg/day IV/IM q6h, max
12 gm/day or ceftriaxone (Rocephin) 100
mg/kg/day IV/IM q12-24h, max 4 gm/day AND
-Vancomycin (Vancocin) 60 mg/kg/day IV q6h, max
4gm/day.
-Dexamethasone 0.6 mg/kg/day IV q6h x 4 days.
Initiate before or with the first dose of parenteral
antibiotic.
10. Symptomatic Medications:
-Ibuprofen (Advil) 5-10 mg/kg/dose PO q6-8h prn OR
-Acetaminophen (Tylenol) 15 mg/kg PO/PR q4h prn
temp >38°C or pain.
11. Extras and X-rays: CXR, MRI.
12. Labs: CBC, SMA 7. Blood culture and sensitivity x 2.
UA, urine culture and sensitivity; urine specific gravity.
Antibiotic levels. Urine and blood antigen testing.
Lumbar Puncture:
CSF Tube 1 - Gram stain, culture and sensitivity, bact-
erial antigen screen (1-2 mL).
CSF Tube 2 - Glucose, protein (1-2 mL).
CSF Tube 3 - Cell count and differential (1-2 mL).
Endocarditis Prophylaxis
Prophylactic Regimens for Dental, Oral, Respi-
ratory Tract, or Esophageal Procedures
Situation Drug Regimen Maximum
Dose
Standard Amoxicillin 50 mg/kg 2000 mg
general PO as a
prophylaxis single dose
1 hr before
procedure
Unable to Ampicillin 50 mg/kg 2000 mg
take oral IV/IM within
medication 30 minutes
before pro-
cedure
Allergic to Clindamy- 20 mg/kg 600 mg
penicillin cin PO as a
or single dose
1 hour be-
fore
procedure
Cephalexin 50 mg/kg 2000 mg
(Keflex) or PO as a
cefadroxil single dose
(Duricef) 1 hour be-
or fore
procedure
Azithromyci 15 mg/kg 500 mg
n PO as a
(Zithromax) single dose
or 1 hour be-
clarithromy fore proce-
cin (Biaxin) dure
Allergic to Clindamyci 20 mg/kg 600 mg
penicillin n IV 30 min-
and unable utes before
to take oral or procedure
medica-
tions Cefazolin 25 mg/kg 1000 mg
(Ancef) IV/IM within
30 minutes
before pro-
cedure
Prophylactic Regimens for Genitouri-
nary/Gastrointestinal Procedures
Situation Drug Regimen Maximum
Dose
Pneumonia
1. Admit to:
2. Diagnosis: Pneumonia
3. Condition:
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: Pulse oximeter, inputs and outputs. Bron-
chial clearance techniques, vibrating vest.
7. Diet:
8. IV Fluids:
9. Special Medications:
-Humidified O2 by NC at 2-4 L/min or 25-100% by
mask, adjust to keep saturation >92%
Term Neonates <1 month:
-Ampicillin 100 mg/kg/day IV/IM q6h AND
-Cefotaxime (Claforan) <1 wk: 100 mg/kg/day IV/IM
q12h; >1 wk: 150 mg/kg/day IV/IM q8h OR
-Gentamicin (Garamycin) 5 mg/kg/day IV/IM q12h.
Children 1 month-5 years old:
-Cefuroxime (Zinacef) 100-150 mg/kg/day IV/IM q8h
OR
-Ampicillin 100 mg/kg/day IV/IM q6h AND
-Gentamicin (Garamycin) or Tobramycin (Nebcin):
7.5 mg/kg/day IV/IM q8h (normal renal function).
-If chlamydia is strongly suspected, add erythromycin
40 mg/kg/day IV q6h.
Oral Therapy:
-Cefuroxime axetil (Ceftin)
tab: child: 125-250 mg PO bid; adult: 250-500 mg
PO bid
susp: 30 mg/kg/day PO q12h, max 1000 mg/day
[susp: 125 mg/5 mL; tabs: 125, 250,500 mg] OR
-Loracarbef (Lorabid)
30 mg/kg/day PO q12h, max 800 mg/day
[cap: 200, 400 mg; susp: 100 mg/5 mL, 200
mg/5mL]
-Cefpodoxime (Vantin)
10 mg/kg/day PO q12h, max 800 mg/day
[susp: 50 mg/5 mL, 100 mg/5 mL; tabs: 100, 200
mg]
-Cefprozil (Cefzil)
30 mg/kg/day PO q12h, max 1000 mg/day
[susp: 125 mg/5 mL, 250 mg/5 mL; tabs: 250, 500
mg].
-Cefixime (Suprax)
8 mg/kg/day PO qd-bid, max 400 mg/day
[susp: 100 mg/5 mL; tabs: 200, 400 mg].
-Clarithromycin (Biaxin)
15-30 mg/kg/day PO bid, max 1000 mg/day
[susp: 125 mg/5 mL, 250 mg/5 mL; tabs: 250, 500
mg].
-Azithromycin (Zithromax)
Children >2 yrs: 12 mg/kg/day PO qd x 5 days, max
500 mg/day
>16 yrs: 500 mg PO on day 1, 250 mg PO qd on
days 2-5
[cap: 250 mg; susp: 100 mg/5mL, 200 mg/5mL;
tabs: 250, 600 mg]
-Amoxicillin/clavulanate (Augmentin)
30-40 mg/kg/day of amoxicillin PO q8h , max 500
mg/dose
[elixir 125 mg/5 mL, 250 mg/5 mL; tabs: 250, 500
mg; tabs, chew: 125, 250 mg;]
-Amoxicillin/clavulanate (Augmentin BID)
30-40 mg/kg/day PO q12h, max 875 mg
(amoxicillin)/dose
[susp 200 mg/5 mL, 400 mg/5 mL; tab: 875 mg;
tabs, chew: 200, 400 mg]
Community Acquired Pneumonia 5-18 years old
(viral, Mycoplasma pneumoniae, chlamydia
pneumoniae, pneumococcus, legionella):
-Cefuroxime (Zinacef) 100-150 mg/kg/day IV/IM q8h,
max 9 gm/day OR
-Erythromycin estolate (Ilosone) 30-50 mg/kg/day PO
q8-12h, max 2 gm/day
[caps: 125, 250 mg; drops: 100 mg/mL; susp: 125
mg/5 mL, 250 mg/5 mL; tab: 500 mg; tabs, chew:
125,250 mg]
-Erythromycin ethylsuccinate (EryPed, EES)
30-50 mg/kg/day PO q6-8h, max 2gm/day
[susp: 200 mg/5 mL, 400 mg/5 mL; tab: 400 mg;
tab, chew: 200 mg]
-Erythromycin base (E-mycin, Ery-Tab, Eryc)
30-50 mg/kg/day PO q6-8h, max 2gm/day
[cap, DR: 250 mg; tabs: 250, 333, 500 mg]
-Erythromycin lactobionate
20-40 mg/kg/day IV q6h, max 4 gm/day
[inj: 500 mg, 1 gm]
-Clarithromycin (Biaxin)
15-30 mg/kg/day PO bid, max 1000 mg/day
[susp: 125 mg/5 mL, 250 mg/5 mL; tabs: 250, 500
mg]
Immunosuppressed, Neutropenic Pneumonia (S.
pneumoniae, group A strep, H flu, gram neg enterics,
Klebsiella, Mycoplasma Pneumonia, Legionella,
Chlamydia pneumoniae, S aureus):
-Tobramycin (Nebcin) (normal renal function):
<5 yr (except neonates): 7.5 mg/kg/day IV/IM q8h.
5-10 yr: 6.0 mg/kg/day IV/IM q8h.
>10 yr: 5.0 mg/kg/day IV/IM q8h OR
-Ceftazidime (Fortaz)150 mg/kg/day IV/IM q8h, max
12 gm/day AND
-Ticarcillin/clavulanate (Timentin) 200-300 mg/kg/day
of ticarcillin IV q6-8h, max 24 gm/day OR
-Nafcillin (Nafcil) or oxacillin (Bactocill, Prostaphlin)
150 mg/kg/day IV/IM q6h, max 12 gm/day OR
-Vancomycin (Vancocin) 40 mg/kg/day IV q6h, max 4
gm/day.
Cystic Fibrosis Exacerbation (Pseudomonas
aeruginosa):
-Ticarcillin/clavulanate (Timentin) 200-300 mg/kg/day
of ticarcillin IV q6-8h, max 24 gm/day OR
-Piperacillin/tazobactam (Zosyn) 300 mg/kg/day of
piperacillin IV q6-8h, max 12 gm/day OR
-Piperacillin (Pipracil) 200-300 mg/kg/day IV/IM q4-6h,
max 24 gm/day AND
-Tobramycin (Nebcin):
<5 yr (except neonates): 7.5 mg/kg/day IV/IM q8h.
5-10 yr: 6.0 mg/kg/day IV/IM q8h.
>10 yr: 5.0 mg/kg/day IV/IM q8h OR
-Ceftazidime (Fortaz) 150 mg/kg/day IV/IM q8h, max
12 gm/day OR
-Aztreonam (Azactam) 150-200 mg/kg/day IV/IM q6-
8h, max 8 gm/day OR
-Imipenem/Cilastatin (Primaxin) 60-100 mg/kg/day
imipenem component IV q6-8h, max 4 gm/day OR
-Meropenem (Merrem) 60-120 mg/kg/day IV q8h, max
6gm/day.
10. Symptomatic Medications:
-Acetaminophen (Tylenol) 10-15 mg/kg PO/PR q4h
prn temp >38°C or pain.
11. Extras and X-rays: CXR PA and LAT, PPD.
12. Labs: CBC, ABG, blood culture and sensitivity x 2.
Sputum gram stain, culture and sensitivity, AFB. Anti-
biotic levels. Nasopharyngeal washings for direct
fluorescent antibody (RSV, adenovirus, parainfluenza,
influenza virus, chlamydia) and cultures for respiratory
viruses. UA.
Specific Therapy for Pneumonia
Pneumococcal pneumonia:
-Erythromycin estolate (Ilosone)
30-50 mg/kg/day PO q8-12h, max 2 gm/day
[caps: 125, 250 mg; drops: 100 mg/mL; susp: 125
mg/5 mL, 250 mg/5 mL; tab: 500 mg; tabs, chew:
125,250 mg]
-Erythromycin ethylsuccinate (EryPed, EES)
30-50 mg/kg/day PO q6-8h, max 2gm/day
[susp: 200 mg/5 mL, 400 mg/5 mL; tab: 400 mg;
tab, chew: 200 mg]
-Erythromycin base (E-Mycin, Ery-Tab, Eryc)
30-50 mg/kg/day PO q6-8h, max 2gm/day
[tab: 250, 333, 500 mg]
-Erythromycin lactobionate
20-40 mg/kg/day IV q6h, max 4 gm/day
[inj: 500 mg, 1 g m] OR
-Vancomycin (Vancocin) 40 mg/kg/day IV q6h, max 4
gm/day OR
-Cefotaxime (Claforan) 100-150 mg/kg/day IV/IM q6h,
max 12 gm/day OR
-Penicillin G 150,000 U/kg/day IV/IM q4-6h, max 24
MU/day.
Staphylococcus aureus:
-Oxacillin (Bactocill, Prostaphlin) or Nafcillin (Nafcil)
150-200 mg/kg/day IV/IM q4-6h, max 12 gm/day
OR
-Vancomycin (Vancocin) 40 mg/kg/day IV q6h, max 4
gm/day
Haemophilus influenzae (<5 yr of age):
-Cefotaxime (Claforan) 100-150 mg/kg/day IV/IM q8h,
max 12 gm/day OR
-Cefuroxime (Zinacef) 100-150 mg/kg/day IV/IM q8h
(beta-lactamase pos), max 9 gm/day OR
-Ampicillin 100-200 mg/kg/day IV/IM q6h (beta-lactam-
ase negative), max 12 gm/day
Pseudomonas aeruginosa:
-Tobramycin (Nebcin):
<5 yr (except neonates): 7.5 mg/kg/day IV/IM q8h.
5-10 yr: 6.0 mg/kg/day IV/IM q8h.
>10 yr: 5.0 mg/kg/day IV/IM q8h AND
-Piperacillin (Pipracil) or ticarcillin (Ticar) 200-300
mg/kg/day IV/IM q4-6h, max 24 gm/day OR
-Ceftazidime (Fortaz) 150 mg/kg/day IV/IM q8h, max
12 gm/day.
Mycoplasma pneumoniae:
-Clarithromycin (Biaxin) 15-30 mg/kg/day PO q12h,
max 1 gm/day
[susp: 125 mg/5 mL, 250 mg/5 mL; tabs: 250, 500
mg].
-Erythromycin estolate (Ilosone)
30-50 mg/kg/day PO q8-12h, max 2 gm/day
[caps: 125, 250 mg; drops: 100 mg/mL; susp: 125
mg/5 mL, 250 mg/5 mL; tab: 500 mg; tabs, chew:
125,250 mg]
-Erythromycin ethylsuccinate (EryPed, EES)
30-50 mg/kg/day PO q6-8h, max 2gm/day
[susp: 200 mg/5 mL, 400 mg/5 mL; tab: 400 mg;
tab, chew: 200 mg]
-Erythromycin base (E-Mycin, Ery-Tab, Eryc)
30-50 mg/kg/day PO q6-8h, max 2gm/day
[cap, DR: 250 mg; tabs: 250, 333, 500 mg]
-Erythromycin lactobionate (Erythrocin)
20-40 mg/kg/day IV q6h, max 4 gm/day
[inj: 500 mg, 1 gm]
-Tetracycline (Achromycin)
>8 yrs only
25-50 mg/kg/day PO q6h, max 2 gm/day
[caps: 100, 250, 500 mg; susp: 125 mg/5 mL; tabs:
250, 500 mg]
Moraxella catarrhalis:
-Clarithromycin (Biaxin)
15 mg/kg/day PO q12h, max 1 gm/day
[susp: 125 mg/5 mL, 250 mg/5 mL; tabs: 250, 500
mg] OR
-Cefuroxime (Zinacef) 100-150 mg/kg/day IV/IM q8h,
max 9 gm/day OR
-Erythromycin estolate (Ilosone)
30-50 mg/kg/day PO q8-12h, max 2 gm/day
[caps: 125, 250 mg; drops: 100 mg/mL; susp: 125
mg/5 mL, 250 mg/5 mL; tab: 500 mg; tabs, chew:
125,250 mg]
-Erythromycin ethylsuccinate (EryPed, EES)
30-50 mg/kg/day PO q6-8h, max 2gm/day
[susp: 200 mg/5 mL, 400 mg/5 mL; tab: 400 mg;
tab, chew: 200 mg]
-Erythromycin base (E-Mycin, Ery-Tab, Eryc)
30-50 mg/kg/day PO q6-8h, max 2gm/day
[cap, DR: 250 mg; tabs: 250, 333, 500 mg]
-Erythromycin lactobionate (Erythrocin)
20-40 mg/kg/day IV q6h, max 4 gm/day
[inj: 500 mg, 1 gm] OR
-Trimethoprim/Sulfamethoxazole (Bactrim, Septra)
6-12 mg TMP/kg/day PO/IV q12h, max 320 mg
TMP/day
[inj per mL: TMP 16 mg/SMX 80 mg; susp per 5
mL: TMP 40 mg/SMX 200 mg; tab DS: TMP 160
mg/SMX 800 mg; tab SS: TMP 80mg/SMX 400 mg]
Chlamydia pneumoniae (TWAR), psittaci, tracho-
matous:
-Erythromycin estolate (Ilosone)
30-50 mg/kg/day PO q8-12h, max 2 gm/day
[caps: 125, 250 mg; drops: 100 mg/mL; susp: 125
mg/5 mL, 250 mg/5 mL; tab: 500 mg; tabs, chew:
125,250 mg]
-Erythromycin ethylsuccinate (EryPed, EES)
30-50 mg/kg/day PO q6-8h, max 2gm/day
[susp: 200 mg/5 mL, 400 mg/5 mL; tab: 400 mg;
tab, chew: 200 mg]
-Erythromycin base (E-Mycin, Ery-Tab, Eryc)
30-50 mg/kg/day PO q6-8h, max 2gm/day
[cap, DR: 250 mg; tabs: 250, 333, 500 mg]
-Erythromycin lactobionate (Erythrocin)
20-40 mg/kg/day IV q6h, max 4 gm/day
[inj: 500 mg, 1 gm ] OR
-Azithromycin (Zithromax)
children >2 yrs: 12 mg/kg/day PO qd x 5 days, max
500 mg/day
>16 yrs: 500 mg PO on day one, then 250 mg PO
qd on days 2-5
[cap: 250 mg; susp: 100 mg/5mL, 200 mg/5mL;
tabs: 250, 600 mg]
Influenza Virus:
-Oseltamivir (Tamiflu)
>1 yr and <15 kg: 30 mg PO bid
15-23 kg: 45 mg PO bid
>23 - 40 kg: 60 mg PO bid
>40 kg: 75 mg PO bid
>18 yr: 75 mg PO bid
[cap: 75 mg; susp: 12 mg/mL]
Approved for treatment of uncomplicated influenza
A or B when patient has been symptomatic no
longer than 48 hrs. OR
-Rimantadine (Flumadine)
<10 yr: 5 mg/kg/day PO qd, max 150 mg/day
>10 yr: 100 mg PO bid
[syrup: 50 mg/5 mL; tab: 100 mg].
Approved for treatment or prophylaxis of Influenza
A. Not effective against Influenza B. OR
-Amantadine (Symmetrel)
1-9 yr: 5 mg/kg/day PO qd-bid, max 150 mg/day
>9 yr: 5 mg/kg/day PO qd-bid, max 200 mg/day
[cap: 100 mg; syr: 50 mg/5 mL].
Approved for treatment or prophylaxis of Influenza
A. Not effective against Influenza B.
Bronchiolitis
1. Admit to:
2. Diagnosis: Bronchiolitis
3. Condition:
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: Pulse oximeter, peak flow rate. Respiratory
isolation.
7. Diet:
8. IV Fluids:
9. Special Medications:
-Oxygen, humidified 1-4 L/min by NC or 40-60% by
mask, keep sat >92%.
Nebulized Beta 2 Agonists:
-Albuterol (Ventolin, Proventil) (5 mg/mL sln) nebu-
lized 0.2-0.5 mL in 2 mL NS (0.10-0.15 mg/kg) q1-
4h prn.
Treatment of Respiratory Syncytial Virus (severe lung
disease or underlying cardiopulmonary disease):
-Ribavirin (Virazole) therapy should be considered in
high risk children <2 yrs with bronchopulmonary
dysplasia or with history of premature birth less
than 35 weeks gestational age. Ribavirin is admin-
istered as a 6 gm vial, aerosolized by SPAG
nebulizer over 18-20h qd x 3-5 days or 2 gm over
2 hrs q8h x 3-5 days.
Prophylaxis Against Respiratory Syncytial Virus:
-Recommended use in high risk children <2 yrs with
BPD who required medical management within the
past six months, or with history of premature birth
less than or equal to 28 weeks gestational age who
are less than one year of age at start of RSV
season, or with history of premature birth 29-32
weeks gestational age who are less than six
months of age at start of RSV season.
-Palivizumab (Synagis) 15 mg/kg IM once a month
throughout RSV season (usually October-March)
-RSV-IVIG (RespiGam) 750 mg/kg IV once a month
throughout RSV season (usually from October to
March).
Influenza A:
-Oseltamivir (Tamiflu)
>1 yr and <15 kg: 30 mg PO bid
15-23 kg: 45 mg PO bid
>23 - 40 kg: 60 mg PO bid
>40 kg: 75 mg PO bid
>18 yr: 75 mg PO bid
[cap: 75 mg; susp: 12 mg/mL]
Approved for treatment of uncomplicated influenza
A or B when patient has been symptomatic no
longer than 48 hrs. OR
-Rimantadine (Flumadine)
<10 yr: 5 mg/kg/day PO qd, max 150 mg/day
>10 yr: 100 mg PO bid
[syrup: 50 mg/5 mL; tab: 100 mg].
Approved for treatment or prophylaxis of Influenza
A. Not effective against Influenza B. OR
-Amantadine (Symmetrel)
1-9 yr: 5 mg/kg/day PO qd-bid, max 150 mg/day
>9 yr: 5 mg/kg/day PO qd-bid, max 200 mg/day
[cap: 100 mg; syr: 50 mg/5 mL].
Approved for treatment or prophylaxis of Influenza
A. Not effective against Influenza B.
Pertussis:
The estolate salt is preferred due to greater penetration.
-Erythromycin estolate 50 mg/kg/day PO q8-12h, max
2 gm/day
[caps: 125, 250 mg; drops: 100 mg/mL; susp: 125
mg/5 mL, 250 mg/5 mL; tab: 500 mg; tabs, chew:
125,250 mg]
-Erythromycin lactobionate (Erythrocin) 20-40
mg/kg/day IV q6h, max 4 gm/day
[inj: 500 mg, 1 gm].
Oral Beta 2 Agonists and Acetaminophen:
-Albuterol liquid (Proventil, Ventolin)
2-6 years: 0.1-0.2 mg/kg/dose PO q6-8h
6-12 years: 2 mg PO tid-qid
>12 years: 2-4 mg PO tid-qid
[soln: 2 mg/5 mL; tabs: 2,4 mg; tabs, SR: 4, 8 mg]
-Acetaminophen (Tylenol) 10-15 mg/kg PO/PR q4-6h
prn temp >38°.
10. Extras and X-rays: CXR.
11. Labs: CBC, SMA 7, CBG/ABG, UA. Urine antigen
screen. Nasopharyngeal washings for direct fluorescent
antibody (RSV, adenovirus, parainfluenza, influenza
virus, chlamydia), viral culture.
Septic Arthritis
1. Admit to:
2. Diagnosis: Septic arthritis
3. Condition:
4. Vital signs: Call MD if:
5. Activity: No weight bearing on infected joint.
6. Nursing: Warm compresses prn. Consent for
arthrocentesis. Age appropriate pain scale.
7. Diet:
8. IV Fluids:
9. Special Medications:
Empiric Therapy for Infants 1-6 months (strep, staph,
gram neg, gonococcus):
-Nafcillin (Nafcil) or oxacillin (Bactocill, Prostaphlin)
100 mg/kg/day IV/IM q6h AND
-Cefotaxime (Claforan) 100 mg/kg/day IV/IM q6h OR
-Gentamicin (Garamycin) or tobramycin (Nebcin)
(normal renal function): 7.5 mg/kg/day IV/IM q8h.
Empiric Therapy for Patients Age 6 months-4 yr (H
influenzae, streptococci, staphylococcus):
-Cefuroxime (Zinacef) 100-150 mg/kg/day IV/IM q8h
(preferred for H flu coverage until culture results
available) AND/OR
-Nafcillin (Nafcil) or oxacillin (Bactocill) 100-200
mg/kg/day IV/IM q6h.
Empiric Therapy for Children Older than 4 Years
(staph, strep):
-Nafcillin (Nafcil) or oxacillin (Bactocill, Prostaphlin)
150 mg/kg/day IV/IM q6h, max 12 gm/day OR
-Vancomycin (Vancocin) (MRSA) 40-60 mg/kg/day IV
q6-8h, max 4 gm/day.
10. Symptomatic Medications:
-Acetaminophen and codeine 0.5-1 mg co-
deine/kg/dose PO q4-6h prn pain [elixir per 5 mL:
codeine 12 mg, acetaminophen 120 mg].
-Ibuprofen (Children’s Advil) 5-10 mg/kg/dose PO q6-
8 hrs prn fever.
11. Extras and X-rays: X-ray views of joint, CXR.
Orthopedics and infectious disease consults. CT
scan.
12. Labs: CBC, blood culture and sensitivity x 2, PPD,
ESR, UA. Antibiotic levels. Urine antigen screen (H
flu).
Synovial fluid:
Tube 1 - Gram stain, culture and sensitivity.
Tube 2 - Glucose, protein, pH.
Tube 3 - Cell count.
Pyelonephritis
1. Admit to:
2. Diagnosis: Pyelonephritis
3.Condition:
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: Inputs and outputs, daily weights
7. Diet:
8.IV Fluids:
9. Special Medications:
-If less than 1 week old, see suspected sepsis, pages
108, 155.
-Ampicillin 100 mg/kg/day IV/IM q6h, max 12 gm/day
AND
-Gentamicin (Garamycin) or Tobramycin (Nebcin):
30 days-5 yr: 7.5 mg/kg/day IV/IM q8h.
5-10 yr: 6.0 mg/kg/day IV/IM q8h.
>10 yr: 5.0 mg/kg/day IV/IM q8h OR
-Cefotaxime (Claforan) 100 mg/kg/day IV/IM q8h, max
12 gm/day.
10. Symptomatic Medications:
-Acetaminophen (Tylenol) 10-15 mg/kg PO/PR q4-6h
prn temp >38°. ...
11. Extras and X-rays: Renal ultrasound.
12. Labs: CBC, SMA-7. UA with micro, urine culture and
sensitivity. Repeat urine culture and sensitivity 24-48
hours after initiation of therapy; blood culture and
sensitivity x 2; drug levels.
Osteomyelitis
1. Admit to:
2. Diagnosis: Osteomyelitis
3. Condition:
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: Keep involved extremity elevated. Consent
for osteotomy.
7. Diet:
8. IV Fluids:
9. Special Medications:
Children <3 yrs (H flu, strep, staph):
-Cefuroxime (Zinacef) 100-150 mg/kg/day IV/IM q8h,
max 9 gm/day.
Children >3 yrs (staph, strep, H flu):
-Nafcillin (Nafcil) or oxacillin (Bactophill) 100-150
mg/kg/day IV/IM q6h, max 12 gm/day OR
-Cefotaxime (Claforan) 100-150 mg/kg/day IV/IM q8h,
max 12 gm/day OR
-Cefazolin (Ancef) 100 mg/kg/day IV/IM q6-8h, max 6
gm/day OR
-Cefuroxime (Zinacef) 100-150 mg/kg/day IV/IM q8h,
max 9 gm/day.
Postoperative or Traumatic (staph, gram neg, Pseu-
domonas):
-Ticarcillin/clavulanate (Timentin) 200-300 mg/kg/day
of ticarcillin IV/IM q6-8h, max 24 gm/day OR
-Vancomycin (Vancocin) 40-60 mg/kg/day IV q6-8h,
max 4 gm/day AND
-Ceftazidime (Fortaz) 150 mg/kg/day IV/IM q8h, max
12 gm/day OR
-Nafcillin (Nafcil) or oxacillin (Bactocill) 150 mg/kg/day
IV/IM q6h, max 12 gm/day AND
-Tobramycin (Nebcin)
30 days-5 yr: 7.5 mg/kg/day IV/IM q8h.
5-10 yr: 6.0 mg/kg/day IV/IM q8h.
>10 yr: 5.0 mg/kg/day IV q8h.
Chronic Osteomyelitis (staphylococcal):
-Dicloxacillin (Dycill, Dynapen, Pathocil) 75-100
mg/kg/day PO q6h, max 2 gm/day [caps: 125, 250,
500 mg; susp: 62.5 mg/5 mL] OR
-Cephalexin (Keflex) 50-100 mg/kg/day PO q6-12h,
max 4 gm/day [caps: 250, 500 mg; drops 100
mg/mL; susp 125 mg/5 mL, 250 mg/5 mL; tabs: 500
mg, 1 gm].
10. Symptomatic Medications:
-Acetaminophen (Tylenol) 10-15 mg/kg PO/PR q4-6h
prn temp >38°.
11. Extras and X-rays: Bone scan, multiple X-ray views,
CT. Orthopedic and infectious disease consultations.
12. Labs: CBC, SMA 7, blood culture and sensitivity x 3,
ESR, sickle prep, UA, culture and sensitivity, antibiotic
levels, serum bacteriocidal titers.
Otitis Media
Acute Otitis Media (S pneumoniae, non-typable H flu,
M catarrhalis, Staph aureus, group A streptococcus):
-Amoxicillin (Amoxil) 25-50 mg/kg/day PO q8h, max 3
gm/day
[caps: 250, 500 mg; drops: 50 mg/mL; susp; 125
mg/5mL, 200 mg/5mL, 250 mg/5mL, 400 mg/5mL;
tabs: 500, 875 mg; tabs, chew: 125, 200, 250, 400
mg] OR
-Trimethoprim/Sulfamethoxazole (Bactrim, Septra) 6-8
mg/kg/day of TMP PO bid, max 320 mg TMP/day
[susp per 5 mL: TMP 40 mg/SMX 200 mg; tab DS:
TMP 160 mg/SMX 800 mg; tab SS: TMP
80mg/SMX 400 mg] OR
-Erythromycin/sulfisoxazole (Pediazole) 1 mL/kg/day
PO qid or 40 mg/kg/day of erythromycin PO qid,
max 50 mL/day
[susp per 5 mL: erythromycin 200 mg/sulfisoxazole
600 mg] OR
-Amoxicillin/clavulanate (Augmentin) 40 mg/kg/day of
amoxicillin PO q8h x 7-10d, max 500 mg/dose
[susp per 5 mL: 125, 250 mg; tabs: 250, 500 mg;
tab, chew: 125, 250 mg] OR
-Amoxicillin/clavulanate (Augmentin BID)
40 mg/kg/day PO q12h, max 875 mg of
amoxicillin/dose
[susp: 200 mg/5mL, 400 mg/5mL; tab: 875 mg; tab,
chew: 200, 400 mg]
-Azithromycin (Zithromax)
Children >2 yrs: 12 mg/kg/day PO qd x 5 days, max
500 mg/day
>16 yrs: 500 mg PO on day 1, 250 mg PO qd on
days 2-5
[cap: 250 mg; susp: 100 mg/5mL, 200 mg/5mL;
tabs: 250, 600 mg]
OR
-Clarithromycin (Biaxin) 15-30 mg/kg/day PO bid, max
1 gm/day
[susp: 125 mg/5 mL, 250 mg/5 mL; tabs: 250, 500
mg] OR
-Cefixime (Suprax) 8 mg/kg/day PO bid-qd, max 400
mg/day
[susp: 100 mg/5 mL; tabs: 200, 400 mg] OR
-Cefuroxime axetil (Ceftin) tab: child: 125-250 mg PO
bid; adult: 250-500 mg PO bid; susp: 30 mg/kg/day
PO q12h, max 500 mg/day
[susp: 125 mg/5 mL; tabs 125, 250, 500 mg] OR
-Loracarbef (Lorabid) 30 mg/kg/day PO bid, max 400
mg/day
[caps: 200, 400 mg; susp: 100 mg/5 mL, 200
mg/5mL] OR
-Cefpodoxime (Vantin) 10 mg/kg/day PO bid, max 800
mg/day
[susp: 50 mg/5 mL, 100 mg/5 mL; tabs: 100, 200
mg] OR
-Cefprozil (Cefzil) 30 mg/kg/day PO bid, max 1gm/day
[susp: 125 mg/5 mL, 250 mg/5 mL; tabs: 250 mg,
500 mg] OR
-Ceftriaxone (Rocephin) 50 mg/kg IM x one dose, max
2000 mg
Acute Otitis Media (resistant strains of Strep
pneumoniae):
-Amoxicillin (Amoxil) 80-90 mg/kg/day PO q12h, max
3 gm/day
[caps: 250, 500 mg; drops: 50 mg/mL; susp; 125
mg/5mL, 200 mg/5mL, 250 mg/5mL, 400 mg/5mL;
tabs: 500, 875 mg; tabs, chew: 125, 200, 250,
400mg]
-Amoxicillin/clavulanate (Augmentin BID) 80-90
mg/kg/day PO q12h.
[susp 200 mg/5 mL, 400 mg/5 mL; tab: 875 mg;
tab, chew: 200, 400 mg]
Prophylactic Therapy (>3 episodes in 6 months):
Therapy reserved for control of recurrent acute otitis
media, defined as three or more episodes per 6 months
or 4 or more episodes per 12 months.
-Sulfisoxazole (Gantrisin) 50 mg/kg/day PO qhs
[tab 500 mg; susp 500 mg/5 mL] OR
-Amoxicillin (Amoxil) 20 mg/kg/day PO qhs
[caps: 250,500 mg; drops: 50 mg/mL; susp; 125
mg/5mL, 200 mg/5mL, 250 mg/5mL, 400 mg/5mL;
tabs: 500, 875 mg; tabs, chew: 125, 200, 250,
400mg] OR
-Trimethoprim/Sulfamethoxazole (Bactrim, Septra) 4
mg/kg/day of TMP PO qhs
[susp per 5 mL: TMP 40 mg/SMX 200 mg; tab DS:
TMP 160 mg/SMX 800 mg; tab SS: TMP
80mg/SMX 400 mg]
Symptomatic Therapy:
-Ibuprofen (Advil) 5-10 mg/kg/dose PO q6-8 hrs prn
fever
[suspension: 100 mg/5 mL, tabs: 200, 300, 400,
600, 800 mg] AND/OR
-Acetaminophen (Tylenol) 10-15 mg/kg/dose PO/PR
q4-6h prn fever
[tabs: 325, 500 mg; chewable tabs: 80 mg; caplets:
160 mg, 500 mg; drops: 80 mg/0.8 mL; elixir: 120
mg/5 mL, 130 mg/5 mL, 160 mg/5 mL, 325 mg/5
mL; caplet, ER: 650 mg; suppositories: 120, 325,
650 mg].
-Benzocaine/antipyrine (Auralgan otic): fill ear canal
with 2-4 drops; moisten cotton pledget and place in
external ear; repeat every 1-2 hours prn pain [soln,
otic: Antipyrine 5.4%, benzocaine 1.4% in 10 mL
and 15 mL bottles]
Extras and X rays: Aspiration tympanocentesis,
tympanogram; audiometry.
Otitis Externa
Otitis Externa (Pseudomonas, gram negatives, pro-
teus):
-Polymyxin B/neomycin/hydrocortisone (Cortisporin
otic susp or solution) 2-4 drops in ear canal tid-qid
x 5-7 days.
[otic soln or susp per mL: neomycin sulfate 5 mg;
polymyxin B sulfate 10,000 units; hydrocortisone 10
mg in 10 mL bottles)].
The suspension is preferred. The solution should
not be used if the eardrum is perforated.
Malignant Otitis Externa in Diabetes (Pseudomonas):
-Ceftazidime (Fortaz) 100-150 mg/kg/day IV/IM q8h,
max 12gm/day OR
-Piperacillin (Pipracil) or ticarcillin (Ticar) 200-300
mg/kg/day IV/IM q4-6h, max 24gm/day OR
-Tobramycin (Nebcin)
30 days-5 yr: 7.5 mg/kg/day IV/IM q8h.
5-10 yr: 6.0 mg/kg/day IV/IM q8h.
>10 yr: 5.0 mg/kg/day IV q8h.
Tonsillopharyngitis
Streptococcal Pharyngitis:
-Penicillin V (Pen Vee K) 25-50 mg/kg/day PO qid x
10 days, max 3 gm/day [susp: 125 mg/5 mL, 250
mg/5 mL; tabs: 125, 250, 500 mg] OR
-Penicillin G benzathine (Bicillin LA) 25,000-50,000
U/kg (max 1.2 MU) IM x 1 dose OR
-Azithromycin (Zithromax) 12 mg/kg/day PO qd x 5
days, max 500 mg/day
[cap: 250 mg; susp: 100 mg/5mL, 200 mg/5mL;
tabs: 250, 600 mg] OR
-Clarithromycin (Biaxin)15 mg/kg/day PO bid, max 1
gm/day
[susp 125 mg/5 mL, 250 mg/5 mL; tabs: 250, 500
mg] OR
-Erythromycin (penicillin allergic patients) 40
mg/kg/day PO qid x 10 days, max 2 gm/day
Erythromycin ethylsuccinate (EryPed, EES)
[susp: 200 mg/5 mL, 400 mg/5 mL; tab: 400 mg;
tab, chew: 200 mg]
Erythromycin base (E-Mycin, Ery-Tab, Eryc)
[cap, DR: 250 mg; tabs: 250, 333, 500 mg]
Refractory Pharyngitis:
-Amoxicillin/clavulanate (Augmentin)
40 mg/kg/day of amoxicillin PO q8h x 7-10d, max
500 mg/dose
[susp: 125 mg/5 mL, 250 mg/5 mL; tabs: 250, 500
mg; tabs, chew: 125, 250 mg] OR
-Dicloxacillin (Dycill, Dynapen, Pathocil)
50 mg/kg/day PO qid, max 2 gm/day
[caps 125, 250, 500; elixir 62.5 mg/5 mL] OR
-Cephalexin (Keflex)
50 mg/kg/day PO qid-tid, max 4 gm/day
[caps: 250, 500 mg; drops 100 mg/mL; susp 125
mg/5 mL, 250 mg/5 mL; tabs: 500 mg, 1 gm].
Prophylaxis (5 strep infections in 6 months):
-Penicillin V Potassium (Pen Vee K)
40 mg/kg/day PO bid, max 3 gm/day
[susp 125 mg/5 mL, 250 mg/5 mL; tabs: 125, 250,
500 mg].
Retropharyngeal Abscess (strep, anaerobes, E
corrodens):
-Clindamycin (Cleocin) 25-40 mg/kg/day IV/IM q6-8h,
max 4.8 gm/day OR
-Nafcillin (Nafcil) or oxacillin (Bactocill, Prostaphlin)
100-150 mg/kg/day IV/IM q6h, max 12 gm/day AND
-Cefuroxime (Zinacef) 75-100 mg/kg/day IV/IM q8h,
max 9 gm/day
Labs: Throat culture, rapid antigen test; PA lateral and
neck films; CXR. Otolaryngology consult for incision and
drainage.
Epiglottitis
1. Admit to: Pediatric intensive care unit.
2. Diagnosis: Epiglottitis
3. Condition:
4. Vital Signs: Call MD if:
5. Activity:
6. Nursing: Pulse oximeter. Keep head of bed elevated,
allow patient to sit; curved blade laryngoscope,
tracheostomy tray and oropharyngeal tube at bedside.
Avoid excessive manipulation or agitation. Respiratory
isolation.
7. Diet: NPO
8. IV Fluids:
9. Special Medications:
-Oxygen, humidified, blow-by; keep sat >92%.
Antibiotics:
Most common causative organism is Haemophilus
influenzae.
-Ceftriaxone (Rocephin) 50 mg/kg/day IV/IM qd, max
2 gm/day OR
-Cefuroxime (Zinacef) 100-150 mg/kg/day IV/IM q8h,
max 9 gm/day OR
-Cefotaxime (Claforan) 100-150 mg/kg/day IV/IM q6-
8h, max 12 gm/day
10. Extras and X-rays: CXR PA and LAT, lateral neck.
Otolaryngology consult.
11. Labs: CBC, CBG/ABG. Blood culture and sensitivity,
latex agglutination; UA, urine antigen screen.
Sinusitis
Treatment of Sinusitis (S. pneumoniae, H flu, M cat-
arrhalis, group A strep, anaerobes):
-Treat for 14-21 days.
-Amoxicillin (Amoxil) 40 mg/kg/day PO tid, max 3
gm/day [caps: 250,500 mg; drops: 50 mg/mL; susp;
125 mg/5mL, 200 mg/5mL, 250 mg/5mL, 400
mg/5mL; tabs: 500, 875 mg; tabs, chew: 125, 200,
250 , 400mg] OR
-Azithromycin (Zithromax)
Children >2 yrs: 12 mg/kg/day PO qd x 5 days, max
500 mg/day
>16 yrs: 500 mg PO on day 1, 250 mg PO qd on
days 2-5
[cap: 250 mg; susp: 100 mg/5mL, 200 mg/5mL; tab:
250, 600 mg] OR
-Trimethoprim/sulfamethoxazole (Bactrim, Septra) 6-8
mg/kg/day of TMP PO bid, max 320 mg TMP/day
[susp per 5 mL: TMP 40 mg/SMX 200 mg; tab DS:
TMP 160 mg/SMX 800 mg; tab SS: TMP 80mg/SMX
400 mg] OR
-Erythromycin/sulfisoxazole (Pediazole) 1 mL/kg/day
PO qid or 40-50 mg/kg/day of erythromycin PO qid,
max 2 gm erythromycin/day
[susp per 5 mL: Erythromycin 200 mg, sulfisoxazole
600 mg] OR
-Amoxicillin/clavulanate (Augmentin) 40 mg/kg/day of
amoxicillin PO tid, max 500 mg/dose
[elixir 125 mg/5 mL, 250 mg/5 mL; tabs: 250, 500
mg; tabs, chew: 125, 250 mg] OR
-Amoxicillin/clavulanate (Augmentin BID)
40 mg/kg/day PO bid, max 875 mg
(amoxicillin)/dose
[susp: 200 mg/5 mL, 400 mg/5 mL; tab: 875 mg;
tabs, chew: 200, 400 mg] OR
-Cefuroxime axetil (Ceftin)
tab: child: 125-250 mg PO bid; adult: 250-500 mg
PO bid
susp: 30 mg/kg/day PO qid, max 500 mg/day
[susp: 125 mg/5 mL; tabs: 125, 250, 500 mg]
Labs: Sinus x-rays, MRI scan.
Anti-tuberculosis Agents
Cellulitis
1. Admit to:
2. Diagnosis: Cellulitis
3. Condition:
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: Keep affected extremity elevated; warm
compresses tid prn. Monitor area of infection.
7. Diet:
8. IV Fluids:
9. Special Medications:
Empiric Therapy for Extremity Cellulitis:
-Nafcillin (Nafcil) or oxacillin (Bactocill, Prostaphlin)
100-200 mg/kg/day/IV/IM q4-6h, max 12gm/day OR
-Cefazolin (Ancef) 75-100 mg/kg/day IV/IM q6-8h, max
6 gm/day OR
-Cefoxitin (Mefoxin) 100-160 mg/kg/day IV/IM q6h,
max 12 gm/day OR
-Ticarcillin/clavulanate (Timentin) 200-300 mg/kg/day
IV/IM q6-8h, max 24 gm/day OR
-Dicloxacillin (Dycill, Dynapen, Pathocil) 50-100
mg/kg/day PO qid, max 2 gm/day [caps: 125, 250,
500 mg; susp: 62.5 mg/5 mL].
Cheek/Buccal Cellulitis (H flu):
-Cefuroxime (Zinacef) 100-150 mg/kg/day IV/IM q8h,
max 9 gm/day OR
-Cefotaxime (Claforan) 100-150 mg/kg/day IV/IM q6-
8h, max 12 gm/day
Periorbital Cellulitis (H. flu, pneumococcus):
-Cefuroxime (Zinacef) 100-150 mg/kg/day IV/IM q8h,
max 9 gm/day OR
-Cefuroxime axetil (Ceftin)
tab: child: 125-250 mg PO bid; adult: 250-500 mg
PO bid
susp: 30 mg/kg/day PO qid, max 500 mg/day
[susp: 125 mg/5 mL; tabs: 125, 250, 500 mg]
10. Symptomatic Medications:
-Acetaminophen and codeine, 0.5-1 mg co-
deine/kg/dose PO q4-6h prn pain [elixir per 5 mL:
codeine 12 mg, acetaminophen 120 mg].
11. Extras and X-rays: X-ray views of site.
12. Labs: CBC, SMA 7, blood culture and sensitivity.
Leading edge aspirate, Gram stain, culture and
sensitivity; UA, urine culture.
Tetanus
History of One or Two Primary Immunizations or
Unknown:
Low risk wound - Tetanus toxoid 0.5 mL IM.
Tetanus prone - Tetanus toxoid 0.5 mL IM, plus
tetanus immunoglobulin (TIG) 250 U IM.
Three Primary Immunizations and 10 yrs or more
Since Last Booster:
Low risk wound - Tetanus toxoid, 0.5 mL IM.
Tetanus prone - Tetanus toxoid, 0.5 mL IM.
Three Primary Immunizations and 5-10 yrs Since Last
Booster:
Low risk wound - None
Tetanus prone - Tetanus toxoid 0.5 mL IM.
Three Primary Immunizations and <5 yrs Since Last
Booster:
Low risk wound - None
Tetanus prone - None
Treatment of Clostridium Tetani Infection:
-Tetanus immune globulin (TIG): single dose of 3,000
to 6,000 U IM (consider immune globulin intrave-
nous if TIG is not available). Part of the TIG dose
may be infiltrated locally around the wound. Keep
wound clean and débrided.
-Penicillin G 100,000 U/kg/day IV q4-6h, max 24
MU/day x 10-14 days OR
-Metronidazole (Flagyl) 30 mg/kg/day PO/IV q6h, max
4 gm/day x 10-14 days.
Pediculosis
Pediculosis Capitis (head lice):
-Permethrin (Nix) is the preferred treatment. Available
in a 1% cream rinse that is applied to the scalp and
hair for 10 minutes. A single treatment is adequate,
but a second treatment may be applied 7-10 days
after the first treatment [cream rinse: 1% 60 mL].
-Pyrethrin (Rid, A-2000, R&C). Available as a sham-
poo that is applied to the scalp and hair for 10
minutes. A repeat application 7-10 days later may
sometimes be necessary [shampoo (0.3% pyreth-
rins, 3% piperonyl butoxide): 60, 120, 240 mL].
-For infestation of eyelashes, apply petrolatum oint-
ment tid-qid for 8-10 days and mechanically remove
the lice.
Pediculosis Corporis (body lice):
-Treatment consists of improving hygiene and clean-
ing clothes. Infested clothing should be washed and
dried at hot temperatures to kill the lice.
Pediculicides are not necessary.
Pediculosis Pubis (pubic lice, “crabs”): Permethrin
(Nix) or pyrethrin-based products may be used as
described above for pediculosis capitis. Retreatment
is recommended 7-10 days later.
Scabies
Treatment:
Bathe with soap and water; scrub and remove scaling or
crusted detritus; towel dry. All clothing and bed linen
contaminated within past 2 days should be washed in
hot water for 20 min.
Permethrin (Elimite) - 5% cream: Adults and children:
Massage cream into skin from head to soles of feet.
Remove by washing after 8 to 14 hours. Treat infants
on scalp, temple and forehead. One application is
curative. [cream: 5% 60 gm]
Lindane (Kwell, Gamma benzene) - available as 1%
cream or lotion: Use 1% lindane for adults and older
children; not recommended in pregnancy, infants, or
on excoriated skin. 1-2 treatments are effective.
Massage a thin layer from neck to toes (including
soles). In adults, 20-30 gm of cream or lotion is
sufficient for 1 application. Bathe after 8 hours. May be
repeated in one week if mites remain or if new lesions
appear. Contraindicated in children <2 years of age.
[lotion: 1% 60, 473 mL; shampoo:1%: 60, 473 mL].
Dermatophytoses
Diagnostic procedures:
(1) KOH prep of scales and skin scrapings for hyphae.
(2) Fungal cultures are used for uncertain cases.
Treat for at least 4 weeks.
Tinea corporis (ringworm), cruris (jock itch), pedis
(athlete’s foot):
-Ketoconazole (Nizoral) cream qd [2%: 15, 30, 60 gm].
-Clotrimazole (Lotrimin) cream bid [1%: 15, 30, 45
gm].
-Miconazole (Micatin) cream bid [2%: 15, 30 gm].
-Econazole (Spectazole) cream bid [1%: 15, 30, 85
gm].
-Oxiconazole (Oxistat) cream or lotion qd-bid [1%
cream: 15, 30, 60 gm; 1% lotion: 30 mL].
-Sulconazole (Exelderm) cream or lotion qd-bid [1%
cream: 15, 30, 60 gm; 1% lotion: 30 mL].
-Naftifine (Naftin) cream or gel applied bid [1%: 15, 30
gm].
-Terbinafine (Lamisil) cream or applied bid [1% cream:
15, 30 gm; 1% gel: 5, 15, 30 gm].
Tinea capitis:
-Griseofulvin Microsize (Grisactin, Grifulvin V) 15-20
mg/kg/day PO qd, max 1000 mg/day [caps: 125, 250
mg; susp: 125 mg/5 mL; tabs: 250, 500 mg]
-Griseofulvin Ultramicrosize (Fulvicin P/G, Grisactin
Ultra, Gris-PEG) 5-10 mg/kg/day PO qd, max 750
mg/day [tabs: 125, 165, 250, 330 mg].
-Give griseofulvin with whole-milk or fatty foods to
increase absorption. May require 4-6 weeks of
therapy and should be continued for two weeks
beyond clinical resolution.
Tinea Unguium (Fungal Nail Infection):
-Griseofulvin (see dosage above) is effective, but may
require up to 4 months of therapy.
Tinea Versicolor:
-Cover body surface from face to knees with selenium
sulfide 2.5% lotion or selenium sulfide 1% shampoo
daily for 30 minutes for 1 week, then monthly x 3 to
help prevent recurrences.
Bite Wounds
1. Admit to:
2. Diagnosis: Bite Wound.
3. Condition: Guarded.
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: Cooling measures prn temp >38° C, age
appropriate pain scale.
7. Diet:
8. IV Fluids: D5 NS at maintenance rate.
9. Special Medications:
-Initiate antimicrobial therapy for: moderate/severe bite
wounds, especially if edema or crush injury is
present; puncture wounds, especially if bone, tendon
sheath, or joint penetration may have occurred;
facial bites; hand and foot bites; genital area bites;
wounds in immunocompromised or asplenic pa-
tients.
Dog Bites and Cat Bites:
Oral: amoxicillin/clavulanate
Oral, penicillin allergic: extended-spectrum
cephalosporins or trimethoprim-sulfamethoxazole
PLUS clindamycin
IV: ampicillin-sulbactam
IV, penicillin allergic: extended spectrum
cephalosporins or trimethoprim-sulfamethoxazole
PLUS clindamycin
Reptile Bites:
Oral: amoxicillin-clavulanate
Oral, penicillin allergic: extended-spectrum
cephalosporins or trimethoprim-sulfamethoxazole
PLUS clindamycin ..
IV: ampicillin-sulbactam PLUS gentamicin .
IV, penicillin allergic: clindamycin PLUS gentamicin
Human Bites:
Oral: amoxicillin-clavulanate
Oral, penicillin allergic: trimethoprim-sulfamethoxazole
PLUS clindamycin
IV: ampicillin-sulbactam
IV, penicillin allergic: extended-spectrum
cephalosporins or trimethoprim-sulfamethoxazole
PLUS clindamycin
Antibiotic Dosages:
-Amoxicillin/clavulanate (Augmentin)
40 mg/kg/day of amoxicillin PO tid, max 500
mg/dose
[elixir 125 mg/5 mL, 250 mg/5 mL; tabs: 250, 500
mg; tabs, chew: 125, 250 mg] OR
-Amoxicillin/clavulanate (Augmentin BID)
40 mg/kg/day PO bid, max 875 mg
(amoxicillin)/dose
[susp: 200 mg/5 mL, 400 mg/5 mL; tab: 875 mg;
tabs, chew: 200, 400 mg]
-Cefpodoxime (Vantin)
10 mg/kg/day PO bid, max 800 mg/day
[susp: 50 mg/5 mL, 100 mg/5 mL; tabs: 100 mg, 200
mg] OR
-Cefprozil (Cefzil)
30 mg/kg/day PO bid, max 1 gm/day
[susp 125 mg/5 mL, 250 mg/5 mL; tabs: 250, 500
mg] OR
-Cefixime (Suprax)
8 mg/kg/day PO bid-qd, max 400 mg/day
[susp: 100 mg/5 mL; tabs: 200, 400 mg]
-Trimethoprim/Sulfamethoxazole (Bactrim, Septra)
6-8 mg/kg/day of TMP PO/IV bid, max 320 mg
TMP/day
[inj per mL: TMP 16 mg/SMX 80 mg; susp per 5 mL:
TMP 40 mg/SMX 200 mg; tab DS: TMP 160
mg/SMX 800 mg; tab SS: TMP 80mg/SMX 400 mg]
-Clindamycin (Cleocin) 10-30 mg/kg/day PO q6-8h,
max 1800 mg/day or 25-40 mg/kg/day IV/IM q6-8h,
max 4.8 gm/day [cap: 75, 150, 300 mg; soln: 75
mg/5mL]
-Ampicillin-sulbactam (Unasyn) 100-200 mg/kg/day
ampicillin IV/IM a6h, max 12 gm ampicillin/day
[1.5 gm (ampicillin 1 gm and sulbactam 0.5 gm; 3
gm (ampicillin 2 gm and sulbactam 1 gm)]
-Cefotaxime (Claforan) 100-150 mg/kg/day IV/IM q6-
8h, max 12 gm/day
-Ceftriaxone (Rocephin) 50 mg/kg/day IV/IM qd, max
2 gm/day
-Gentamicin (Garamycin) (normal renal function):
<5 yr (except neonates): 7.5 mg/kg/day IV/IM q8h.
5-10 yr: 6.0 mg/kg/day IV/IM q8h.
>10 yr: 5.0 mg/kg/day IV/IM q8h.
Additional Considerations:
-Sponge away visible dirt. Irrigate with a copious
volume of sterile saline by high-pressure syringe
irrigation. Debride any devitalized tissue.
-Tetanus immunization if not up-to-date.
-Assess risk of rabies from animal bites and risk of
hepatitis and HIV from human bites.
10. Symptomatic Medications:
-Ibuprofen (Motrin) 5-10 mg/kg/dose PO q6-8h prn OR
-Acetaminophen (Tylenol) 15 mg/kg PO/PR q4h prn
temp >38°C or pain.
11. Extras and X-rays: X-ray views of site of injury.
12. Labs: CBC, SMA 7, wound culture.
Lyme Disease
1. Admit to:
2. Diagnosis: Lyme disease.
3. Condition:
4. Vital signs: Call MD if:
5. Activity:
6. Nursing:
7. Diet:
8. IV Fluids: Isotonic fluids at maintenance rate.
9. Special Medications:
Early Localized Disease:
Age >8 yrs: doxycycline 100 mg PO bid x 14-21 days
[caps: 50, 100 mg; susp: 25 mg/5mL; syrup: 50
mg/5mL; tabs 50, 100 mg]
All ages: amoxicillin 25-50 mg/kg/day PO bid (max 3
gm/day) x 14-21 days
[caps: 250,500 mg; drops: 50 mg/mL; susp; 125
mg/5mL, 200 mg/5mL, 250 mg/5mL, 400 mg/5mL;
tabs: 500, 875 mg; tabs, chew: 125, 200, 250 ,
400mg]
Early Disseminated and Late Disease:
Multiple Erythema Migrans: Take same oral regimen
as for early disease but for 21 days.
Isolated Facial Palsy: Take same oral regimen as for
early disease but for 21-28 days.
Arthritis: Take same oral regimen as for early dis-
ease but for 28 days.
Persistent or Recurrent Arthritis:
-Ceftriaxone (Rocephin) 75-100 mg/kg/day IM/IV 12-
24h (max 2 gm/dose) for 14-21 days OR
-Penicillin G 300,000 U/kg/day IV q4h (max 20
million units/day) x 14-21 days.
Carditis or Meningitis or Encephalitis:
-Ceftriaxone (Rocephin) 75-100 mg/kg/day IM/IV q12-
24h (max 2 gm/dose) for 14-21 days OR
-Penicillin G 300,000 U/kg/day IV q4h (max 20 million
units/day) x 14-21 days.
Lyme disease vaccine is available for children >15 years
of age.
10. Symptomatic Medications:
-Ibuprofen (Advil) 5-10 mg/kg/dose PO q6-8h prn
temp >38° C OR
-Acetaminophen (Tylenol) 15 mg/kg PO/PR q4h prn
temp >38° C.
11. Extras and X-rays: CXR, MRI.
12. Labs: IgM-specific antibody titer usually peaks
between weeks 3 and 6 after the onset of infection.
Enzyme immunoassay (EIA) is the most commonly
used test for detection of antibodies. The Western
immunoblot test is the most useful for corroborating a
positive or equivocal EIA test.
Gastrointestinal Disorders
Gastroenteritis
1. Admit to:
2. Diagnosis: Acute Gastroenteritis
3. Condition:
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: Inputs and outputs, daily weights, urine spe-
cific gravity.
7. Diet: Rehydralyte, Pedialyte or soy formula (Isomil
DF), bland diet.
8. IV Fluids: See Dehydration, page 147.
9. Special Medications:
Severe Gastroenteritis with Fever, Gross Blood and
Neutrophils in Stool (E coli, Shigella, Salmonella):
-Ceftriaxone (Rocephin) 50-75 mg/kg/day IV/IM q 12-
24h, max 4 gm/day OR
-Cefixime (Suprax) 8 mg/kg/day PO bid-qd, max 400
mg/day [susp: 100 mg/5 mL; tabs: 200, 400 mg]
OR
-Trimethoprim/Sulfamethoxazole (Bactrim, Septra) 10
mg of TMP component/kg/day PO bid x 5-7d, max
320 mg TMP/day [susp per 5 mL: TMP 40 mg/SMX
200 mg; tab DS: TMP 160 mg/SMX 800 mg; tab
SS: TMP 80mg/SMX 400 mg].
Salmonella (treat infants and patients with sep-
ticemia):
-Ceftriaxone (Rocephin) 50-75 mg/kg/day IV/IM q12-
24h, max 4 gm/day OR
-Cefixime (Suprax) 8 mg/kg/day PO bid-qd, max 400
mg/day [susp: 100 mg/5 mL; tabs: 200, 400 mg]
OR
-Ampicillin 100-200 mg/kg/day IV q6h, max 12 gm/day
or 50-100 mg/kg/day PO qid x 5-7d, max 4 gm/day
[caps: 250, 500 mg; drops: 100 mg/mL; susp: 125
mg/5 mL, 250 mg/5 mL, 500 mg/5 mL] OR
-Trimethoprim/Sulfamethoxazole (Bactrim, Septra) 10
mg TMP/kg/day PO bid x 5-7d, max 320 mg
TMP/day [susp per 5 mL: TMP 40 mg/SMX 200
mg; tab DS: TMP 160 mg/SMX 800 mg; tab SS:
TMP 80mg/SMX 400 mg] OR
-If >18 yrs: Ciprofloxacin (Cipro) 250-750 mg PO q12h
or 200-400 mg IV q12h [inj: 200, 400 mg; susp: 100
mg/mL; tabs: 100, 250, 500, 750 mg]
Antibiotic Associated Diarrhea and
Pseudomembranous Colitis (Clostridium difficile):
-Treat for 7-10 days. Do not give antidiarrheal drugs.
-Metronidazole (Flagyl) 30 mg/kg/day PO/IV (PO
preferred) q8h x 7 days, max 4 gm/day. [inj: 500
mg; tabs: 250, 500 mg; extemporaneous suspen-
sion] OR
-Vancomycin (Vancocin) 40 mg/kg/day PO qid x 7
days, max 2 gm/day [caps: 125, 250 mg; oral soln:
250 mg/5 mL, 500 mg/6 mL]. Vancomycin therapy
is reserved for patients who are allergic to
metronidazole or who have not responded to
metronidazole therapy.
Rotavirus supportive treatment, see Dehydration
page 147.
10. Extras and X-rays: Upright abdomen
11. Labs: SMA7, CBC; stool Wright stain for leukocytes,
Rotazyme. Stool culture and sensitivity for enteric
pathogens; C difficile toxin and culture, ova and para-
sites; occult blood. Urine specific gravity, UA, blood
culture and sensitivity.
Hepatitis A
1. Admit to:
2. Diagnosis: Hepatitis A
3. Condition:
4. Vital signs: Call MD if:
5. Activity: Up ad lib
6. Nursing: Contact precautions.
7. Diet:
8. IV Fluids: D5NS IV at maintenance rate.
9. Symptomatic Medications: -
Trimeth
obenza
m i d e
(Tigan)
15 mg/kg/day IM/PO/PR q6-8h, max 100 mg/dose
if <13.6 kg or 200 mg/dose if 13.6-41kg.
[caps: 100, 250 mg; inj: 100 mg/mL; supp: 100, 200
mg].
-Acetaminophen (Tylenol) 15 mg/kg PO/PR q4h prn
temp >38° C or pain.
-Meperidine (Demerol) 1 mg/kg IV/IM q2-3h prn pain.
10. Special Medications:
-Hepatitis A immune globulin, 0.02 mL/kg IM (usually
requires multiple injections at different sites), when
given within 2 weeks after exposure to HAV, is 85%
effective in preventing symptomatic infection.
-Hepatitis A vaccine (Havrix) if >2 yrs: 0.5 mL IM,
repeat in 6-12 months.
11. Extras and X-rays:Abdominal x-ray series.
12. Labs: IgM anti-HAV antibody, HAV IgG, liver function
tests, INR, PTT, stool culture for enteric pathogens.
Hepatitis B
1. Admit to:
2. Diagnosis: Hepatitis B.
3. Condition: Guarded.
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: Standard precautions.
7. Diet: Low fat diet.
8. IV Fluids: Isotonic fluids at maintenance rate.
9. Symptomatic Medications:
-Trimethobenzamide (Tigan)
15 mg/kg/day IM/PO/PR q6-8h, max 100 mg/dose
if <13.6 kg or 200 mg/dose if 13.6-41kg.
[caps: 100, 250 mg; inj: 100 mg/mL; supp: 100, 200
mg].
-Diphenhydramine (Benadryl) 1 mg/kg/dose
IV/IM/IO/PO q6h prn pruritus or nausea, max 50
mg/dose OR
-Acetaminophen (Tylenol)15 mg/kg PO/PR q4h prn
temp >38° C or pain.
-Meperidine (Demerol) 1 mg/kg IV/IM q2-3h prn pain.
Ulcerative Colitis
1.Admit to:
2.Diagnosis: Ulcerative colitis.
3.Condition:
4.Vital signs: Call MD if:
5.Activity:
6.Nursing: Daily weights, inputs and outputs.
7.Diet: NPO except for ice chips, no milk products.
8.IV Fluids:
9.Special Medications:
-Mesalamine (Asacol): 50 mg/kg/day PO q8-12h, max
800 mg PO TID [tab, EC: 400 mg] OR
-Mesalamine (Pentasa) 50 mg/kg/day PO q6-12h,
max 1000 mg PO qid [cap, CR: 250 mg] OR
-Mesalamine (Rowasa) >12 yrs: 60 mL (4 gm) reten-
tion enema at bedtime retained overnight for
approximately 8 hrs [4 gm/60 mL] OR > 12 yrs:
mesalamine (Rowasa) 1 suppository PR bid [supp:
500 mg] OR
-Olsalazine sodium (Dipentum) >12 yrs: 500 mg PO
with food bid [cap: 250 mg] OR
-Sulfasalazine (Azulfidine), children >2 yrs:
Mild exacerbation: 40-50 mg/kg/day PO q6h
Moderate to severe exacerbation: 50-75 mg/kg/day
PO q4-6h, max 6 gm/day.
Maintenance therapy: 30-50 mg/kg/day PO q4-8h,
max 2 gm/day.
[susp: 50 mg/mL; tab, EC: 500 mg] OR
-Hydrocortisone retention enema 100 mg PR qhs OR
-Hydrocortisone acetate 90 mg aerosol foam PR qd-
bid or 25 mg supp PR bid.
-Prednisone 1-2 mg/kg/day PO qAM or bid (max 40-
60 mg/day).
Other Medications:
-Vitamin B12 100 mcg IM qd x 5 days, then 100-200
mcg IM q month.
-Multivitamin PO qAM or 1 ampule IV qAM.
-Folic acid 1 mg PO qd.
10. Extras and X-rays: Upright abdomen, GI consult.
11. Labs: CBC, platelets, SMA 7, Mg, ionized calcium;
liver panel, blood culture and sensitivity x 2. Stool
culture and sensitivity for enteric pathogens, ova and
parasites, C. difficile toxin and culture, Wright's stain.
Gastroesophageal Reflux
A. Treatment:
-Thicken feedings; give small volume feedings; keep
head of bed elevated 30 degrees.
-Metoclopramide (Reglan) 0.1-0.2 mg/kg/dose PO qid
20-30 minutes prior to feedings, max 1 mg/kg/day
[concentrated soln: 10 mg/mL; syrup: 1 mg/mL;
tab: 10 mg]
-Cimetidine (Tagamet) 20-40 mg/kg/day IV/PO q6h
(20-30 min before feeding) [inj: 150 mg/mL; oral
soln: 60 mg/mL; tabs: 200, 300, 400, 800 mg]
-Ranitidine (Zantac) 2-4 mg/kg/day IV q8h or 4-6
mg/kg/day PO q12h [inj: 25 mg/mL; liquid: 15
mg/mL; tabs: 75, 150, 300 mg]
-Erythromycin (used as a prokinetic agent not as an
antibiotic) 2-3 mg/kg/dose PO q6-8h.
[ethylsuccinate susp: 200 mg/5mL, 400 mg/5mL]
Concomitant cisapride is contraindicated due to
potentially fatal drug interaction.
-Cisapride (Propulsid) 0.15-0.3 mg/kg/dose PO tid-
qid [susp: 1 mg/mL; tab, scored: 10 mg]. Available
via limited-access protocol only (Janssen, 1-800-
Janssen) due to risk of serious cardiac
arrhythmias.
B. Extras and X-rays: Upper GI series, pH probe, gastr-
oesophageal nuclear scintigraphy (milk scan), endos-
copy.
Constipation
I. Management of Constipation in Infants
A. Glycerin suppositories are effective up to 6 months
of age: 1 suppository rectally prn.Barley malt
extract, 1-2 teaspoons, can be added to a feeding
two to three times daily. Four to six ounces prune
juice are often effective. After 6 months of age,
lactulose 1 to 2 mL/kg/day is useful.
B. Infants that do not respond may be treated with
emulsified mineral oil (Haley’s MO) 2 mL/kg/dose
PO bid, increasing as needed to 6-8 oz per day.
II. Management of Constipation in Children >2 years
of Age
A. The distal impaction should be removed with
hypertonic phosphate enemas (Fleet enema).
Usually three enemas are administered during a
36 to 48 hour period.
B. Lactulose may also be used at 5 to 10 mL PO bid,
increasing as required up to 45 mL PO bid.
C. Emulsified mineral oil (Haley’s MO) may be begun
at 2 mL/kg/dose PO bid and increased as needed
up to 6 to 8 oz per day. Concerns about mineral oil
interfering with absorption of fat-soluble vitamins
have not been substantiated.
D. Milk of magnesia: Preschoolers are begun at 2 tsp
PO bid, with adjustments made to reach a goal of
one to three substantial stools a day over 1 to 2
weeks. Older children: 1-3 tablets (311mg magne-
sium hydroxide/chewable tablet) PO bid prn.
E. A bulk-type stool softener (e.g., Metamucil) should
be initiated. Increase intake of high-residue foods
(e.g. fruits, vegetables), bran, and whole grain
products. Water intake should be increased.
III. Stool Softeners and Laxatives:
A. Docusate sodium (Colace):
<3y 20-40 mg/day PO q6-24h
3-6y 20-60 mg/day PO q6-24h
6-12y 40-150 mg/day PO q6-24h
>12y 50-400 mg/day PO q6-24h
[caps: 50,100, 250 mg; oral soln: 10 mg/mL, 50
mg/mL]
B. Magnesium hydroxide (Milk of Magnesia) 0.5
mL/kg/dose or 2-5 yr: 5-15 mL; 6-12y: 15-30 mL;
>12y: 30-60 mL PO prn.
C. Hyperosmotic soln (CoLyte or GoLytely) 15-20
mL/kg/hr PO/NG.
D. Polyethylene glycol (MiraLax)
3-6 yr: 1 tsp powder dissolved in 3 ounces fluid PO
qd-tid
6-12 yr: ½ tablespoon powder dissolved in 4 ounces
fluid PO qd-tid
>12 yr: one tablespoon powder dissolved in 8 ounces
fluid PO qd-tid
E. Senna (Senokot, Senna-Gen) 10-20 mg/kg PO/PR
qhs prn (max 872 mg/day) [granules: 362
mg/teaspoon; supp: 652 mg; syrup: 218 mg/5mL;
tabs: 187, 217, 600 mg]
F. Sennosides (Agoral, Senokot, Senna-Gen), 2-6 yrs:
3-8.6 mg/dose PO qd-bid; 6-12 yrs: 7.15-15 mg/dose
PO qd-bid; > 12 yrs: 12-25 mg/dose PO qd-bid
[granules per 5 mL: 8.3, 15, 20 mg; liquid: 33 mg/mL;
syrup: 8.8 mg/5 mL; tabs: 6, 8.6, 15, 17, 25 mg]
IV. Diagnostic Evaluation: Anorectal manometry,
anteroposterior and lateral abdominal radiographs,
lower GI study of unprepared colon.
Toxicology
Poisonings
Gastric Decontamination:
Ipecac Syrup:
<6 mos: not recommended
6-12 mos: 5-10 mL PO followed by 10-20 mL/kg of
water
1-12 yrs: 15 mL PO followed by 10-20 mL/kg of water
>12 yrs: 30 mL PO followed by 240 mL of water
May repeat dose one time if vomiting does not occur
within 20-30 minutes. Syrup of ipecac is contraindi-
cated in corrosive or hydrocarbon ingestions or in
patients without or soon to lose gag reflex.
Activated Charcoal: 1 gm/kg/dose (max 50 gm) PO/NG;
the first dose should be given using product contain-
ing sorbitol as a cathartic. Repeat ½ of initial dose q4h
if indicated.
Gastric Lavage: Left side down, with head slightly lower
than body; place large-bore orogastric tube and check
position by injecting air and auscultating. Normal
saline lavage: 15 mL/kg boluses until clear (max 400
mL), then give activated charcoal or other antidote.
Save initial aspirate for toxicological exam. Gastric
lavage is contraindicated if corrosives, hydrocarbons,
or sharp objects were ingested.
Cathartics:
-Magnesium citrate 6% sln:
<6 yrs: 2-4 mL/kg/dose PO/NG
6-12 yrs: 100-150 mL PO/NG
>12 yrs: 150-300 mL PO/NG
Immediate 1-1.5
Warfarin Overdose
-Phytonadione (Vitamin K1)
-If no bleeding and rapid reversal needed and patient
will require further oral anticoagulation therapy, give
0.5-2 mg IV/SC
-If no bleeding and rapid reversal needed and patient
will not require further oral anticoagulation therapy,
give 2-5 mg IV/SC
-If significant bleeding but not life-threatening, give
0.5-2 mg IV/SC
-If significant bleeding and life-threatening, give 5 mg
IV
[inj: 2 mg/mL, 10 mg/mL]
Acetaminophen Overdose
1. Admit to:
2. Diagnosis: Acetaminophen overdose
3. Condition:
4. Vital signs: Call MD if
6. Nursing: ECG monitoring, inputs and outputs, pulse
oximeter, aspiration precautions.
7. Diet:
8. IV Fluids:
9. Special Medications:
-Gastric lavage with 10 mL/kg (if >5 yrs, use 150-200
mL) of normal saline by nasogastric tube if < 60
minutes after ingestion.
-Activated charcoal (if recent ingestion) 1 gm/kg PO/
NG q2-4h, remove via suction prior to acet-
ylcysteine.
-N-Acetylcysteine (Mucomyst, NAC) loading dose 140
mg/kg PO/ NG, then 70 mg/kg PO/NG q4h x 17
doses (20% sln diluted 1:4 in carbonated bever-
age); follow acetaminophen levels. Continue for full
treatment course even if serum levels fall below
nomogram.
-Phytonadione (Vitamin K) 1-5 mg PO/IV/IM/SQ (if
INR >1.5).
-Fresh frozen plasma should be administered if INR
>3.
10. Extras and X-rays: Portable CXR. Nephrology
consult for charcoal hemoperfusion.
11. Labs: CBC, SMA 7, liver panel, amylase, INR/PTT;
SGOT, SGPT, bilirubin, acetaminophen level now and
q4h until nondetectable. Plot serum acetaminophen
level on Rumack-Matthew nomogram to assess
severity of ingestion unless sustained release Tylenol
was ingested. Toxicity is likely with ingestion >150
mg/kg (or 7.5 gm in adolescents/adults).
Lead Toxicity
1. Admit to:
2. Diagnosis: Lead toxicity
3. Condition:
4. Vital signs: Call MD if
6. Nursing: ECG monitoring, inputs and outputs, pulse
oximeter
7. Diet:
8. IV Fluids:
9. Special Medications:
Symptoms of lead encephalopathy and/or blood level
>70 mcg/DL:
-Treat for five days with edetate calcium disodium and
dimercaprol:
-Edetate calcium disodium 250 mg/m2/dose IM q4h or
50 mg/kg/day continuous IV infusion or 1-1.5 gm/m2
IV as either an 8hr or 24 hr infusion.
-Dimercaprol (BAL): 4 mg/kg/dose IM q4h
Symptomatic lead poisoning without encephalopathy
or asymptomatic with blood level >70 mcg/dL:
-Treat for 3–5 days with edetate calcium disodium and
dimercaprol until blood lead level < 50 mcg/dL.
-Edetate calcium disodium 167 mg/m2 IM q4h or 1
gm/m2 as a 8-24 hr continuous IV infusion.
-Dimercaprol (BAL): 4 mg/kg IM x 1 then 3
mg/kg/dose IM q4h
Asymptomatic children with blood lead level 45-69
mcg/dL:
-Edetate calcium disodium 25 mg/kg/day as a 8-24 hr
IV infusion or IV q12h OR
-Succimer (Chemet): 10 mg/kg/dose (or 350
mg/m2/dose) PO q8h x 5 days followed by 10
mg/kg/dose (or 350 mg/m2/dose) PO q12h x 14
days [cap: 100 mg]
11. Labs: CBC, SMA 7, blood lead level, serum iron
level.
Theophylline Overdose
1. Admit to:
2. Diagnosis: Theophylline overdose
3. Condition:
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: ECG monitoring until serum level is less than
20 mcg/mL; inputs and outputs, aspiration and seizure
precautions.
7. Diet:
8. IV Fluids: Give IV fluids at rate to treat dehydration.
9. Special Medications:
-No specific antidote is available.
-Activated charcoal 1 gm/kg PO/NG (max 50 gm) q2-
4h, followed by cathartic, regardless of time of
ingestion. Multiple dose charcoal has been shown
to be effective in enhancing elimination.
-Gastric lavage if greater than 20 mg/kg was ingested
or if unknown amount ingested or if symptomatic.
-Charcoal hemoperfusion (if serum level >60 mcg/mL
or signs of neurotoxicity, seizure, coma).
10. Extras and X-rays: Portable CXR, ECG.
11. Labs: CBC, SMA 7, theophylline level; INR/PTT, liver
panel. Monitor K, Mg, phosphorus, calcium, acid/base
balance.
Iron Overdose
1. Admit to:
2. Diagnosis: Iron overdose
3. Condition:
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: Inputs and outputs
7. Diet:
8. IV Fluids: Maintenance IV fluids
9. Special Medications:
Toxicity likely if >60 mg/kg elemental iron ingested.
Possibly toxic if 20-60 mg/kg elemental iron ingested.
Induce emesis with ipecac if recent ingestion (<1 hour
ago). Charcoal is not effective. Gastric lavage if
greater than 20 mg/kg of elemental iron ingested or
if unknown amount ingested.
If hypotensive, give IV fluids (10-20 mL/kg normal
saline) and place the patient in Trendelenburg's po-
sition.
Maintain urine output of >2 mL/kg/h.
If peak serum iron is greater than 350 mcg/dL or if
patient is symptomatic, begin chelation therapy.
-Deferoxamine (Desferal) 15 mg/kg/hr continuous
IV infusion. Continue until serum iron is within
normal range.
Exchange transfusion is recommended in severely
symptomatic patients with serum iron >1,000 m-
cg/dL.
10. Extras and X-rays: KUB to determine if tablets are
present in intestine.
11. Labs: Type and cross, CBC, electrolytes, serum iron,
TIBC, INR/PTT, blood glucose, liver function tests,
calcium.
Neurologic and Endo-
crinologic Disorders
Seizure and Status Epilepticus
1. Admit to: Pediatric intensive care unit.
2. Diagnosis: Seizure
3. Condition:
4. Vital signs: Neurochecks q2-6h; call MD if:
5. Activity:
6. Nursing: Seizure and aspiration precautions, ECG
and EEG monitoring.
7. Diet: NPO
8. IV Fluids:
9. Special Medications:
Febrile Seizures: Control fever with antipyretics and
cooling measures. Anticonvulsive therapy is usually not
required.
Status Epilepticus:
1. Maintain airway, 100% O2 by mask; obtain brief
history, fingerstick glucose.
2. Start IV NS. If hypoglycemic, give 1-2 mL/kg D25W
IV/IO (0.25-0.5 gm/kg).
3. Lorazepam (Ativan) 0.1 mg/kg (max 4 mg) IV/IM.
Repeat q15-20 min x 3 prn.
4. Phenytoin (Dilantin) 15-18 mg/kg in normal saline
at <1 mg/kg/min (max 50 mg/min) IV/IO. Monitor BP
and ECG (QT interval).
5. If seizures continue, intubate and give phenobar-
bital loading dose of 15-20 mg/kg IV or 5 mg/kg IV
every 15 minutes until seizures are controlled or 30
mg/kg is reached.
6. If seizures are refractory, consider midazolam
(Versed) infusion (0.1 mg/kg/hr) or general anesthe-
sia with EEG monitoring.
7. Rectal Valium gel formulation
< 2 yrs: not recommended
2-5 yrs: 0.5 mg/kg
6-11 yrs: 0.3 mg/kg
>12 yrs: 0.2 mg/kg
Round dose to 2.5, 5, 10, 15, and 20 mg/dose.
Dose may be repeated in 4-12 hrs if needed. Do not
use more than five times per month or more than
once every five days.
[rectal gel (Diastat): pediatric rectal tip - 5 mg/mL
(2.5, 5, 10 mg size); adult rectal tip - 5 mg/mL (10,
15, 20 mg size)]
Generalized Seizures Maintenance Therapy:
-Carbamazepine (Tegretol):
<6 yr: initially 10-20 mg/kg/day PO bid, then may
increase in 5-7 day intervals by 5 mg/kg/day; usual
max dose 35 mg/kg/day PO q6-8h
6-12 yr: initially 100 mg PO bid (10 mg/kg/day PO
bid), then may increase by 100 mg/day at weekly
intervals; usual maintenance dose 400-800 mg/day
PO bid-qid.
>12 yr: initially 200 mg PO bid, then may increase by
200 mg/day at weekly intervals; usual maintenance
dose 800-1200 mg/day PO bid-tid
Dosing interval depends on product selected. Susp:
q6-8h; tab: q8- 12h; tab, chew:
q8-12h; tab, ER: q12h
[susp: 100 mg/5 mL; tab: 200 mg; tab, chewable:
100 mg; tab, ER: 100, 200, 400 mg] OR
-Divalproex sodium (Depakote, Valproic acid) PO:
Initially 10-15 mg/kg/day bid-tid, then increase by 5-
10 mg/kg/day weekly as needed; usual mainte-
nance dose 30-60 mg/kg/day bid-tid. Up to 100
mg/kg/day tid-qid may be required if other enzyme-
inducing anticonvulsants are used concomitantly.
IV: total daily dose is equivalent to total daily oral
dose but divide q6h and switch to oral therapy as
soon as possible. PR: dilute syrup 1:1 with water for
use as a retention enema, loading dose 17-20
mg/kg x 1 or maintenance 10-15 mg/kg/dose q8h
[cap: 250 mg; cap, sprinkle: 125 mg; inj: 100
mg/mL; syrup: 250 mg/5 mL; tab, DR: 125, 250,
500 mg] OR
-Phenobarbital (Luminal): Loading dose 10-20 mg/kg
IV/IM/PO, then maintenance dose 3-5 mg/kg/day
PO qd-bid
[cap: 16 mg; elixir: 15 mg/5mL, 4 mg/mL; inj: 30
mg/mL, 60 mg/mL, 65 mg/mL, 130 mg/mL; tabs:
8, 15, 16, 30, 32, 60, 65,100 mg] OR
-Phenytoin (Dilantin): Loading dose 15-18 mg/kg
IV/PO, then maintenance dose 5-7 mg/kg/day PO/IV
q8-24h (only sustained release capsules may be
dosed q24h)
[caps: 30, 100 mg; elixir: 125 mg/5 mL; inj: 50
mg/mL; tab, chewable: 50 mg]
-Fosphenytoin (Cerebyx): > 5 yrs: loading dose 10-20
mg PE IV/IM, maintenance dose 4-6 mg/kg/day PE
IV/IM q12-24h. Fosphenytoin 1.5 mg is equivalent to
phenytoin 1 mg which is equivalent to fosphenytoin
1 mg PE (phenytoin equivalent unit). Fosphenytoin
is a water-soluble pro-drug of phenytoin and must
be ordered as mg of phenytoin equivalent (PE).
[inj: 150 mg (equivalent to phenytoin sodium 100
mg) in 2 mL vial; 750 mg (equivalent to phenytoin
sodium 500 mg) in 10 mL vial]
Partial Seizures and Secondary Generalized Sei-
zures:
-Carbamazepine (Tegretol), see above OR
-Phenytoin (Dilantin), see above
-Phenobarbital (Luminal), see above OR
-Valproic acid (Depacon, Depakote, Depakene), see
above.
-Lamotrigine (Lamictal):
Adding to regimen containing valproic acid: 2-12
yrs: 0.15 mg/kg/day PO qd-bid weeks 1-2, then
increase to 0.3 mg/kg/day PO qd-bid weeks 3-4,
then increase q1-2 weeks by 0.3 mg/kg/day to
maintenance dose 1-5 mg/kg/day (max 200
mg/day)
>12 yrs: 25 mg PO qOD weeks 1-2, then increase
to 25 mg PO qd weeks 3-4, then increase q1-2
weeks by 25-50 mg/day to maintenance dose 100-
400 mg/day PO qd-bid
Adding to regimen without valproic acid: 2-12
yrs: 0.6 mg/kg/day PO bid weeks 1-2, then in-
crease to 1.2 mg/kg/day PO bid weeks 3-4, then
increase q1-2 weeks by 1.2 mg/kg/day to mainte-
nance dose 5-15 mg/kg/day PO bid (max 400
mg/day)
>12 yrs: 50 mg PO qd weeks 1-2, then increase to
50 mg PO bid weeks 3-4, then increase q1-2
weeks by 100 mg/day to maintenance dose 300-
500 mg/day PO bid.
[tabs: 25, 100, 150, 200 mg]
-Primidone (Mysoline) PO: 8 yrs: 50-125 mg/day qhs,
increase by 50-125 mg/day q3-7d; usual dose 10-25
mg/kg/day tid-qid
>8 yrs: 125-250 mg qhs; increase by 125-250
mg/day q3-7d, usual dose 750-1500 mg/day tid-qid
(max 2 gm/day).
[susp: 250 mg/5mL; tabs: 50, 250 mg]
10. Extras and X-rays: MRI with and without gadolinium,
EEG with hyperventilation, CXR, ECG. Neurology
consultation.
11. Labs: ABG/CBG, CBC, SMA 7, calcium, phosphate,
magnesium, liver panel, VDRL, anticonvulsant levels,
blood and urine culture. UA, drug and toxin screen.
Adjunctive Anticonvulsants
Felbamate (Felbatol)
2-14 yrs: 15 mg/kg/day PO tid-qid, increase weekly by
15 mg/kg/day if needed to maximum of 45 mg/kg/day
or 3600 mg/day (whichever is smaller)
>14 yrs: 1200 mg/day PO tid-qid, increase weekly by
1200 mg/day if needed to maximum of 3600 mg/day
[susp: 600 mg/5 mL; tabs: 400, 600 mg]
Warning: due to risk of aplastic anemia and hepatic
failure reported with this drug, written informed con-
sent must be obtained from patient/parent prior to
initiating therapy. Patients must have CBC, liver
enzymes, and bilirubin monitored before starting drug
therapy and q1-2 weeks during therapy. Discontinue
the drug immediately if bone marrow suppression or
elevated
liver function tests occur.
Gabapentin (Neurontin)
2-12 yrs: 5-35 mg/kg/day PO q8h
> 12 yrs: initially 300 mg PO tid, titrate dose upward if
needed; usual dose 900-1800 mg/day, maximum
3600 mg/day
[caps: 100, 300, 400 mg; soln: 250 mg/5 mL; tabs:
600, 800 mg]
Adjunctive treatment of partial and secondarily gener-
alized seizures.
Levetiracetam (Keppra)
> 16 yrs: 500 mg PO bid, may increase by 1000
mg/day q2 weeks to maximum of 3000 mg/day [tabs:
250, 500, 750 mg]
Tiagabine (Gabitril)
< 12 yrs: dosing guidelines not established
12-18 yrs: 4 mg PO qd x 1 week, then 4 mg bid x 1
week, then increase weekly by 4-8 mg/day and titrate
to response; maximum dose 32 mg/day bid-qid. [tabs:
2, 4, 12, 16, 20 mg]. Lower doses may be effective in
patients not receiving enzyme-inducing drugs.
Topiramate (Topamax)
2-16 yrs with partial onset seizures: 1-3 mg/kg/day PO
qhs x 1 week (max 25 mg/day), may increase q1-2
weeks by 1-3 mg/kg/day bid to usual maintenance
dose 5-9 mg/kg/day bid
2-16 yrs with primary generalized tonic clonic sei-
zures: use slower initial titration rate to max of 6
mg/kg/day PO by the end of eight weeks
> 16 yrs with partial onset seizures: 50 mg/day qhs x
1 week, then 100 mg/day bid x 1 week, then increase
by 50 mg/day q week; usual maintenance dose 200
mg bid, max 1600 mg/day
> 16 yrs with generalized tonic clonic seizures: use
slower initial titration rate to usual maintenance dose
200 mg bid, max 1600 mg/day
[caps, sprinkles: 15, 25, 50 mg; tabs: 25, 100, 200 mg]
Vigabatrin (Sabril) PO
3-9 yrs: 500 mg bid
> 9 yrs: 1000 mg bid, may increase if needed to max
4000 mg/day
[tab: 500 mg]. Most effective in complex partial sei-
zures, with or without generalization. Should be used
as add-on therapy in patients with drug-resistant
seizures, not as monotherapy. Do not abruptly discon-
tinue therapy; gradually taper off to avoid rebound
increase in seizure frequency and possible psychotic-
like episodes.
Diabetic Ketoacidosis
1. Admit to: Pediatric intensive care unit.
2. Diagnosis: Diabetic ketoacidosis
3. Condition: Critical
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: ECG monitoring; capillary glucose checks
q1-2h until glucose level is <200 mg/dL, daily weights,
inputs and outputs. O2 at 2-4 L/min by NC. Record
labs on flow sheet.
7. Diet: NPO
8. IV Fluids: 0.9% saline 10-20 mL/kg over 1h, then
repeat until hemodynamically stable. Then give 0.45%
saline, and replace ½ of calculated deficit plus insensi-
ble loss over 8h, replace remaining ½ of deficit plus
insensible losses over 16-24h. Keep urine output >1.0
mL/kg/hour.
Add KCL when potassium is <6.0 mEq/dL
Serum K+ Infusate KCL
<3 40-60 mEq/L
3-4 30
4-5 20
5-6 10
>6 0
Rate: 0.25-1 mEq KCL/kg/hr, maximum 1 mEq/kg/h or
20 mEq/h.
9. Special Medications:
-Insulin Regular (Humulin) 0.05-0.1 U/kg/hr (50 U in
500 mL NS) continuous IV infusion. Adjust to
decrease glucose by 50-100 mg/dL/hr.
-If glucose decreases at less than 50 mg/dL/hr,
increase insulin to 0.14-0.2 U/kg/hr. If glucose
decreases faster than 100 mg/dL/hr, continue
insulin at 0.05-0.1 U/kg/h and add D5W to IV fluids.
-When glucose approaches 250-300 mg/dL, add D5W
to IV. Change to subcutaneous insulin (lispro or
regular) when bicarbonate is >15, and patient is
tolerating PO food; do not discontinue insulin drip
until one hour after subcutaneous dose of insulin.
10. Extras and X-rays: Portable CXR, ECG. Endocrine
and dietary consultation.
11. Labs: Dextrostixs q1-2h until glucose <200, then q3-
6h. Glucose, potassium, phosphate, bicarbonate q3-
4h; serum acetone, CBC. UA, urine ketones, culture
and sensitivity.
Hematologic and Inflam-
matory Disorders
Sickle Cell Crisis
1.Admit to:
2.Diagnosis: Sickle Cell Anemia, Sickle Cell Crisis
3.Condition:
4.Vital signs: Call MD if
5.Activity:
6.Nursing: Age appropriate pain scale.
7.Diet:
8.IV Fluids: D5 ½ NS at 1.5-2.0 x maintenance.
9.Special Medications:
-Oxygen 2-4 L/min by NC.
-Morphine sulfate 0.1 mg/kg/dose (max 10-15 mg)
IV/IM/SC q2-4h prn or follow bolus with infusion of
0.05-0.1 mg/kg/hr prn or 0.3-0.5 mg/kg PO q4h prn
OR
-Acetaminophen/codeine 0.5-1 mg/kg/dose (max 60
mg/dose) of codeine PO q4-6h prn [elixir: 12 mg
codeine/5 mL; tabs: 15, 30, 60 mg codeine compo-
nent] OR
-Acetaminophen and hydrocodone [elixir per 5 mL:
hydrocodone 2.5 mg, acetaminophen] 167 mg; tabs:
Hydrocodone 2.5 mg, acetaminophen 500 mg;
Hydrocodone 5 mg, acetaminophen 500 mg;
Hydrocodone 7.5 mg, acetaminophen 500 mg,
Hydrocodone 7.5 mg, acetaminophen 650 mg,
Hydrocodone 10 mg, acetaminophen 500 mg,
Hydrocodone 10 mg, acetaminophen 650 mg
Children: 0.6 mg hydrocodone/kg/day PO q6-8h prn
<2 yr: do not exceed 1.25 mg/dose
2-12 yr: do not exceed 5 mg/dose
>12 yr: do not exceed 10 mg/dose
Patient Controlled Analgesia
-Morphine
Basal rate 0.01-0.02 mg/kg/hr
Intermittent bolus dose 0.01-0.03 mg/kg
Bolus frequency (“lockout interval”) every 6-15
minutes
-Hydromorphone (Dilaudid)
Basal rate 0.0015-0.003 mg/kg/hr
Intermittent bolus dose 0.0015-0.0045 mg/kg
Bolus frequency (“lockout interval”) every 6-15 min
Adjunctive Therapy:
-Hydroxyzine (Vistaril) 0.5-1 mg/kg/dose PO q6h (max
50 mg/dose)
-Ibuprofen (Motrin) 10 mg/kg/dose PO q6h (max 800
mg/dose) OR
-Ketorolac (Toradol) 0.4 mg/kg/dose IV/IM q6h (max
30 mg/dose); maximum 3 days, then switch to oral
ibuprofen
Maintenance Therapy:
-Hydroxyurea (Hydrea): 15 mg/kg/day PO qd, may
increase by 5 mg/kg/day q12 weeks to a maximum
dose of 35 mg/kg/day. Monitor for myelotoxicity.
[caps: 200, 300, 400, 500 mg]
-Folic acid 1 mg PO qd (if >1 yr).
-Transfusion PRBC 5 mL/kg over 2h, then 10 mL/kg
over 2h, then check hemoglobin. If hemoglobin is
less than 6-8 gm/dL, give additional 10 mL/kg.
-Deferoxamine (Desferal) 15 mg/kg/hr x 48 hours
(max 12 gm/day) concomitantly with transfusion or 1-
2 gm/day SQ over 8-24 hrs
-Vitamin C 100 mg PO qd while receiving
deferoxamine
-Vitamin E PO qd while receiving deferoxamine
<1 yr: 100 IU/day
1-6 yr: 200 IU/day
>6 yr: 400 IU/day
-Penicillin VK (Pen Vee K) (prophylaxis for
pneumococcal infections): <3 yrs: 125 mg PO bid;
>3 yrs: 250 mg PO bid [elixir: 125 mg/5 mL, 250
mg/5 mL; tabs: 125, 250, 500 mg]. If compliance
with oral antibiotics is poor, use penicillin G
benzathine 50,000 U/kg (max 1.2 million units) IM
every 3 weeks. Erythromycin is used if penicillin
allergic.
10. Extras and X-rays: CXR.
11. Labs: CBC, blood culture and sensitivity, reticulocyte
count, type and cross, SMA 7, parvovirus titers, UA,
urine culture and sensitivity.
Kawasaki Syndrome
1. Admit to:
2. Diagnosis:
3. Condition:
4. Vital signs: Call MD if:
5. Activity: Bedrest
6. Nursing: temperature at least q4h
7. Diet:
8. Special Medications:
-Immunoglobulin (IVIG) 2 gm/kg/dose IV x 1 dose.
Administer dose at 0.02 mL/kg/min over 30 min; if no
adverse reaction, increase to 0.04 mL/kg/min over
30 min; if no adverse reaction, increase to 0.08
mL/kg/min for remainder of infusion. Defer measles
vaccination for 11 months after receiving high dose
IVIG. [inj: 50 mg/mL, 100 mg/mL]
-Aspirin 100 mg/kg/day PO or PR q6h until fever
resolves, then 8-10 mg/kg/day PO/PR qd [supp: 60,
120, 125, 130, 195, 200, 300, 325, 600, 650 mg;
tabs: 325, 500, 650 mg; tab, chew: 81 mg].
-Ambubag, epinephrine (0.1 mL/kg of 1:10,000), and
diphenhydramine 1 mg/kg (max 50 mg) should be
available for IV use if an anaphylactic reaction to
immunoglobulin occurs.
9. Extras and X-rays: ECG, echocardiogram, chest X-
ray. Rheumatology consult.
10. Labs: CBC with differential and platelet count. ESR,
CBC, liver function tests, rheumatoid factor,
salicylate levels, blood culture and sensitivity x 2,
SMA 7.
Fluids and Electrolytes
Dehydration
1. Admit to:
2. Diagnosis: Dehydration
3. Condition:
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: Inputs and outputs, daily weights. Urine
specific gravity q void.
7. Diet:
8. IV Fluids:
Maintenance Fluids:
<10 kg 100 mL/kg/24h
10-20 kg 1000 mL plus 50 mL/kg/24h for each
kg >10 kg
>20 kg 1500 mL plus 20 mL/kg/24h for each
kg >20 kg.
Electrolyte Requirements:
Sodium: 3-5 mEq/kg/day
Potassium: 2-3 mEq/kg/day
Chloride: 3 mEq/kg/day
Glucose: 5-10 gm/100 mL water required (D5W - D10W)
Estimation of Dehydration
Degree of Dehy- Mild Moderate Severe
dration
Rehydralyte 75 20 65
Ricelyte 50 25 45
Pedialyte 45 20 35
Hyperkalemia
1. Admit to: Pediatric ICU
2. Diagnosis: Hyperkalemia
3. Condition:
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: Continuous ECG monitoring, inputs and
outputs, daily weights.
7. Diet:
8. IV Fluids:
Hyperkalemia (K+ >7 or EKG Changes)
-Calcium gluconate 50-100 mg/kg (max 1 gm) IV over
5-10 minutes or calcium chloride 10-20 mg/kg (max
1 gm) IV over 10 minutes.
-Regular insulin 0.1 U/kg plus glucose 0.5 gm/kg IV
bolus (as 10% dextrose).
-Sodium bicarbonate 1-2 mEq/kg IV over 3-5 min (give
after calcium in separate IV), repeat in 10-15 min if
necessary.
-Furosemide (Lasix) 1 mg/kg/dose (max 40 mg IV) IV
q6-12h prn, may increase to 2 mg/kg/dose IV [inj:
10 mg/mL]
-Kayexalate resin 0.5-1 gm/kg PO/PR. 1 gm resin
binds 1 mEq of potassium.
9. Extras and X-rays: ECG, dietetics, nephrology
consults.
10. Labs: SMA7, Mg, calcium, CBC, platelets. UA; urine
potassium.
Hypokalemia
1. Admit to: Pediatric ICU
2. Diagnosis: Hypokalemia
3. Condition:
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: ECG monitoring, inputs and outputs, daily
weights.
7. Diet:
8. IV Fluids:
If serum K >2.5 mEq/L and ECG changes are absent:
Add 20-40 mEq KCL/L to maintenance IV fluids. May
give 1-4 mEq/kg/day to maintain normal serum
potassium. May supplement with oral potassium.
K <2.5 mEq/L and ECG abnormalities:
Give KCL 1-2 mEq/kg IV at 0.5 mEq/kg/hr; max rate 1
mEq/kg/hr or 20 mEq/kg/hr in life-threatening
situations (whichever is smaller). Recheck serum
potassium, and repeat IV boluses prn; ECG moni-
toring required.
Oral Potassium Therapy:
-Potassium chloride (KCl) elixir 1-3 mEq/kg/day PO
q8-24h [10% soln = 1.33 mEq/mL].
9. Extras and X-rays: ECG, dietetics, nephrology
consults.
10. Labs: SMA7, Mg, calcium, CBC. UA, urine potas-
sium.
Hypernatremia
1. Admit to:
2. Diagnosis: Hypernatremia
3. Condition:
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: Inputs and outputs, daily weights.
7. Diet:
8. IV Fluids:
If volume depleted or hypotensive, give NS 20-40
mL/kg IV until adequate circulation, then give D5 ½
NS IV to replace half of body water deficit over first
24h. Correct serum sodium slowly at 0.5-1
mEq/L/hr. Correct remaining deficit over next 48-
72h.
Body water deficit (liter) = 0.6 x (weight kg) x (serum
Na -140)
Hypernatremia with ECF Volume Excess:
-Furosemide (Lasix) 1 mg/kg IV.
-D5 1/4 NS to correct body water deficit.
9. Extras and X-rays: ECG.
10. Labs: SMA 7, osmolality, triglycerides. UA, urine
specific gravity; 24h urine Na, K, creatinine.
Hyponatremia
1. Admit to:
2. Diagnosis: Hyponatremia
3. Condition:
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: Inputs and outputs, daily weights,
neurochecks.
7. Diet:
8. IV Fluids:
Hyponatremia with Edema (Hypervolemia)(low
osmolality <280, urine sodium <10 mM/L: nephrosis,
CHF, cirrhosis; urine sodium >20: acute/chronic renal
failure):
-Water restrict to half maintenance.
-Furosemide (Lasix) 1 mg/kg/dose IV over 1-2 min or
2-3 mg/kg/day PO q8-24h.
Hyponatremia with Normal Volume Status (low
osmolality <280, urine sodium <10 mM/L: water intoxica-
tion; urine sodium >20 mM/L: SIADH, hypothyroidism,
renal failure, Addison disease, stress, drugs):
-0.9% saline with 20-40 mEq KCL/L infused to correct
hyponatremia at rate of <0.5 mEq/L/hr) OR use 3%
NS in severe hyponatremia [3% NS = 513 mEq/liter].
Hyponatremia with Hypovolemia (low osmolality <280;
urine sodium <10 mM/L: vomiting, diarrhea, 3rd
space/respiratory/skin loss; urine sodium >20 mM/L:
diuretics, renal injury, renal tubular acidosis, adrenal
insufficiency, partial obstruction, salt wasting):
-If volume depleted, give NS 20-40 mL/kg IV until
adequate circulation.
-Gradually correct sodium deficit in increments of 10
mEq/L. Determine volume deficit clinically, and
determine sodium deficit as below.
-Calculate 24 hour fluid and sodium requirement and
give half over first 8 hours, then give remainder over
16 hours. 0.9% saline = 154 mEq/L
-Usually D5NS 60 mL/kg IV over 2h (this will increase
extracellular sodium by 10 mEq/L), then infuse at 6-8
mL/kg/hr x 12h.
Severe Symptomatic Hyponatremia:
-If volume depleted, give NS 20-40 mL/kg until ade-
quate circulation.
-Determine volume of 3% hypertonic saline (513
mEq/L) to be infused as follows:
Na(mEq) deficit = 0.6 x (wt kg) x (desired Na - actual
Na)
Volume of soln (L) = Sodium to be infused (mEq) ÷
mEq/L in solution
-Correct half of sodium deficit slowly over 24h.
-For acute correction, the serum sodium goal is 125
mEq/L; max rate for acute replacement is 1
mEq/kg/hr. Serum Na should be adjusted in incre-
ments of 5 mEq/L to reach 125 mEq/L. The first dose
is given over 4 hrs. For further correction for serum
sodium to above 125 mEq/L, calculate mEq dose of
sodium and administer over 24-48h.
9. Extras and X-rays: CXR, ECG.
10. Labs: SMA 7, osmolality, triglyceride. UA, urine
specific gravity. Urine osmolality, Na, K; 24h urine Na,
K, creatinine.
Hypophosphatemia
Indications for Intermittent IV Administration:
1. Serum phosphate <1.0 mg/dL or
2. Serum phosphate <2.0 mg/dL and patient symp-
tomatic or
3. Serum phosphate <2.5 mg/dL and patient on ventilator
Treatment of Hypophosphatemia
IV Phosphate Cations:
Sodium phosphate: Contains sodium 4 mEq/mL,
phosphate 3 mM/mL
Potassium phosphate: Contains potassium 4.4
mEq/mL, phosphate 3 mM/mL
Max rate 0.06 mM/kg/hr
Oral Phosphate Replacement
1-3 mM/kg/day PO bid-qid
Potassium Phosphate:
Powder (Neutra-Phos-K): phosphorus 250 mg [8 mM]
and potassium 556 mg [14.25 mEq] per packet; Tab
(K-Phos Original): phosphorus 114 mg [3.7 mM],
potassium 144 mg [3.7 mEq]
Sodium Phosphate: Phosphosoda Soln per 100 mL:
sodium phosphate 18 gm and sodium biphosphate 48
gm [contains phosphate 4 mM/mL]
Sodium and Potassium Phosphate: Powd Packet:
phosphorus 250 mg [8 mM], potassium 278 mg [7.125
mEq], sodium 164 mg [7.125 mEq];
Tabs:
K-Phos MF: phosphorus 125.6 mg [4 mM], potassium
44.5 mg [1.1 mEq], sodium 67 mg [2.9 mEq]
K-Phos Neutral: phosphorus 250 mg [8 mM], potas-
sium 45 mg [1.1 mEq], sodium 298 mg [13 mEq]
K-Phos No 2: phosphorus 250 mg [8 mM], potassium
88 mg [2.3 mEq], sodium 134 mg [5.8 mEq]
Uro-KP-Neutral: phosphorus 250 mg [8 mM], potas-
sium 49.4 mg [1.27 mEq], sodium 250.5 mg [10.9
mEq]
Hypomagnesemia
Indications for Intermittent IV Administration:
1. Serum magnesium <1.2 mg/dL
2. Serum magnesium <1.6 mg/dL and patient symptom-
atic
3. Calcium resistant tetany
Magnesium Sulfate, Acute Treatment:
APGAR Score
Sign 0 1 2
General Measures:
1. Review history, check equipment, oxygen, masks,
laryngoscope, ET tubes, medications.
Vigorous, Crying Infant: Provide routine delivery room
care for infants with heart rate >100 beats per minute,
spontaneous respirations, and good color and tone:
warmth, clearing the airway, and drying.
Meconium in Amniotic Fluid:
1. Deliver the head and suction meconium from the
hypopharynx on delivery of the head. If the newly born
infant has absent or depressed respirations, heart rate
<100 bpm, or poor muscle tone, perform direct tra-
cheal suctioning to remove meconium from the airway.
2. If no improvement occurs or if the clinical condition
deteriorates, bag and mask ventilate with intermittent
positive pressure using 100% Fi02; stimulate vigor-
ously by drying. Initial breath pressure: 30-40 cm H2O
for term infants, 20-30 cm H2O for preterm infants.
Ventilate at 15-20 cm H20 at 30-40 breaths per minute.
Monitor bilateral breath sounds and expansion.
3. If spontaneous respirations develop and heart rate is
normal, gradually reduce ventilation rate until using
onlycontinuous positive airway pressure (CPAP).
Wean to blow-by oxygen, but continue blow-by oxygen
if the baby remains dusky.
4. Consider intubation if the heart rate remains <100
beats per minute and is not rising, or if respirations are
poor and weak.
Resuscitation:
1. Provide assisted ventilation with attention to oxygen
delivery, inspiratory time, and effectiveness as judged
by chest rise if stimulation does not achieve prompt
onset of spontaneous respirations or the heart rate is
<100 bpm.
2. Provide chest compressions if the heart rate is absent
or remains <60 bpm despite adequate assisted ventila-
tion for 30 seconds. Coordinate chest compressions
with ventilations at a ratio of 3:1 and a rate of 120
events per minute to achieve approximately 90 com-
pressions and 30 breaths per minute.
3. Chest compressions should be done by two thumb-
encircling hands in newly born infants and older
infants. The depth of chest compression should be one
third of the anterior-posterior diameter of the chest.
Chest compressions should be sufficiently deep to
generate a palpable pulse.
4. If condition worsens or if there is no change after 30
seconds, or if mask ventilation is difficult: use laryngo-
scope to suction oropharynx and trachea and intubate.
Apply positive pressure ventilation. Check bilateral
breath sounds and chest expansion. Check and adjust
ET tube position if necessary. Continue cardiac
compressions if heart rate remains depressed. Check
CXR for tube placement.
Hypotension or Bradycardia or Asystole: Epinephrine
0.1-0.3 mL/kg [0.01-0.03 mg/kg (0.1 mg/mL =
1:10,000)] IV or ET q3-5min. Dilute ET dose to 2-3 mL
in NS. If infant fails to respond, consider increasing
dose to 0.1 mg/kg (0.1 mL/kg of 1 mg/mL = 1:1000).
Hypovolemia: Insert umbilical vein catheter and give O
negative blood, plasma, 5% albumin, Ringer’s lactate,
or normal saline 10 mL/kg IV over 5-10 minutes.
Repeat as necessary to correct hypovolemia.
Severe Birth Asphyxia, Mixed Respiratory/Metabolic
Acidosis (not responding to ventilatory support;
pH <7.2): Give sodium Bicarbonate 1 mEq/kg, dilute
1:1 in sterile water IV q5-10min as indicated.
Narcotic-Related Depression:
1. Naloxone (Narcan) 0.1 mg/kg = 0.25 mL/kg (0.4
mg/mL concentration) or 0.1 mL/kg (1 mg/mL concen-
tration) ET/IV/IM/SC, may repeat q2-3 min. May cause
drug withdrawal and seizures in the infant if the mother
is a drug abuser.
2. Repeat administration may be necessary since the
duration of action of naloxone may be shorter than the
duration of action of the narcotic.
Apnea
1. Admit to:
2. Diagnosis: Apnea
3. Condition:
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: Heart rate monitor, impedance apnea moni-
tor, pulse oximeter. Keep bag and mask resuscitation
equipment at bed side. Rocker bed or oscillating water
bed.
7. Diet: Infant formula ad lib
8. IV Fluids:
9. Special Medications:
Apnea of Prematurity/Central Apnea:
-Aminophylline: loading dose 5 mg/kg IV, then mainte-
nance 5 mg/kg/day IV q12h [inj: 25 mg/mL] OR
-Theophylline: loading dose 5 mg/kg PO, then 5
mg/kg/day PO q12h. [elixir: 80 mg/15mL].
-Caffeine citrate: Loading dose 10-20 mg/kg IV/PO,
then 5 mg/kg/day PO/IV q12-24h [inj: 20 mg/mL, oral
soln: 20 mg/mL, extemporaneously prepared oral
suspension: 10 mg/mL].
10. Extras and X-rays: Pneumogram, cranial ultra-
sound. Upper GI (rule out reflux), EEG.
11. Labs: CBC, SMA 7, glucose, calcium, theophylline
level (therapeutic range 6-14 mcg/mL) , caffeine level
(therapeutic range 10-20 mcg/mL).
Hyperbilirubinemia
1. Admit to:
2. Diagnosis: Hyperbilirubinemia.
3. Condition: Guarded.
4. Vital signs: Call MD if:
5. Activity:
6. Nursing: Inputs and outputs, daily weights, monitor
skin color, monitor for lethargy and hypotonia
7. Diet:
8. IV Fluids: Isotonic fluids at maintenance rate (100-
150 mL/kg/day). Encourage enteral feedings if possi-
ble.
9. Special Medications:
-Phenobarbital 5 mg/kg/day PO/IV q12-24h [elixir: 15
mg/5mL, 20 mg/5mL; inj: 30 mg/mL, 60 mg/mL, 65
mg/mL, 130 mg/mL]
-Phototherapy
-Exchange transfusion for severely elevated bilirubin
10. Symptomatic Medications:
11. Extras and X-rays:
12. Labs: Total bilirubin, indirect bilirubin, albumin, SMA
7. Blood group typing of mother and infant, a direct
Coombs' test. Complete blood cell count, reticulocyte
count, blood smear. In infants of Asian or Greek
descent, glucose-6-phosphate dehydrogenase
(G6PD) should be measured.
Hepatitis Prophylaxis
Infant born to HBs-Ag Positive Mother or Unknown
Status Mother:
-Hepatitis B immune globulin (HBIG) 0.5 mL IM x 1
within 12 hours of birth
-Hepatitis B vaccine 0.5 mL IM (at separate site)
within 12 hours of birth, second dose at age 1-2
months, third dose at age 6 months.
Surgical Documentation
for Gynecology
Gynecologic Surgical History
Identifying Data. Age, gravida (number of pregnancies),
para (number of deliveries).
Chief Compliant. Reason given by patient for seeking
surgical care.
History of Present Illness (HPI). Describe the course of
the patient's illness, including when it began, character of
the symptoms; pain onset (gradual or rapid), character of
pain (constant, intermittent, cramping, radiating); other
factors associated with pain (urination, eating, strenuous
activities); aggravating or relieving factors. Other related
diseases; past diagnostic testing.
Obstetrical History. Past pregnancies, durations and
outcomes, preterm deliveries, operative deliveries.
Gynecologic History: Last menstrual period, length of
regular cycle.
Past Medical History (PMH). Past medical problems,
previous surgeries, hospitalizations, diabetes, hyperten-
sion, asthma, heart disease.
Medications. Cardiac medications, oral contraceptives,
estrogen.
Allergies. Penicillin, codeine.
Family History. Medical problems in relatives.
Social History. Alcohol, smoking, drug usage, occupa-
tion.
Review of Systems (ROS):
General: Fever, fatigue, night sweats.
HEENT: Headaches, masses, dizziness.
Respiratory: Cough, sputum, dyspnea.
Cardiovascular: Chest pain, extremity edema.
Gastrointestinal: Vomiting, abdominal pain, melena
(black tarry stools), hematochezia (bright red blood
per rectum).
Genitourinary: Dysuria, hematuria, discharge.
Skin: Easy bruising, bleeding tendencies.
Discharge Summary
Patient's Name:
Chart Number:
Date of Admission:
Date of Discharge:
Admitting Diagnosis:
Discharge Diagnosis:
Name of Attending or Ward Service:
Surgical Procedures:
History and Physical Examination and Laboratory
Data: Describe the course of the disease up to the time
the patient came to the hospital, and describe the physi-
cal exam and laboratory data on admission.
Hospital Course: Describe the course of the patient's
illness while in the hospital, including evaluation, treat-
ment, outcome of treatment, and medications given.
Discharged Condition: Describe improvement or
deterioration in condition.
Disposition: Describe the situation to which the patient
will be discharged (home, nursing home).
Discharged Medications: List medications and instruc-
tions.
Discharged Instructions and Follow-up Care: Date of
return for follow-up care at clinic; diet, exercise instruc-
tions.
Problem List: List all active and past problems.
Copies: Send copies to attending physician, clinic, con-
sultants and referring physician.
Surgical Progress Note
Surgical progress notes are written in “SOAP” format.
Date/Time:
Post-operative Day Number:
Problem List: Antibiotic day number and
hyperalimentation day number if applicable. List
each surgical problem separately (eg, status-post
appendectomy, hypokalemia).
Subjective: Describe how the patient feels in the
patient's own words, and give observations about
the patient. Indicate any new patient complaints,
note the adequacy of pain relief, and passing of
flatus or bowel movements. Type of food the patient
is tolerating (eg, nothing, clear liquids, regular diet).
Objective:
Vital Signs: Maximum temperature (Tmax) over
the past 24 hours. Current temperature, vital
signs.
Intake and Output: Volume of oral and intrave-
nous fluids, volume of urine, stools, drains, and
nasogastric output.
Physical Exam:
General appearance: Alert, ambulating.
Heart: Regular rate and rhythm, no murmurs.
Chest: Clear to auscultation.
Abdomen: Bowel sounds present, soft,
nontender.
Wound Condition: Comment on the wound
condition (eg, clean and dry, good granula-
tion, serosanguinous drainage). Condition of
dressings, purulent drainage, granulation
tissue, erythema; condition of sutures,
dehiscence. Amount and color of drainage
Lab results: White count, hematocrit, and
electrolytes, chest x-ray
Assessment and Plan: Evaluate each numbered
problem separately. Note the patient's general con-
dition (eg, improving), pertinent developments, and
plans (eg, advance diet to regular, chest x-ray). For
each numbered problem, discuss any additional
orders and plans for discharge or transfer.
Procedure Note
A procedure note should be written in the chart when a
procedure is performed. Procedure notes are brief
operative notes.
Procedure Note
Discharge Note
Date/time:
Diagnoses:
Treatment: Briefly describe treatment provided
during hospitalization, including surgical procedures
and antibiotic therapy.
Studies Performed: Electrocardiograms, CT
scans.
Discharge Medications:
Follow-up Arrangements:
Postoperative Check
A postoperative check should be completed on the
evening after surgery. This check is similar to a daily
progress note.
Date/time:
Postoperative Check
Subjective: Note any patient complaints, and note
the adequacy of pain relief.
Objective:
General appearance:
Vitals: Maximum temperature in the last 24
hours (Tmax), current temperature, pulse, respi-
ratory rate, blood pressure.
Urine Output: If urine output is less than 30 cc
per hour, more fluids should be infused if the
patient is hypovolemic.
Physical Exam:
Chest and lungs:
Abdomen:
Wound Examination: The wound should be
examined for excessive drainage or bleeding,
skin necrosis, condition of drains.
Drainage Volume: Note the volume and char-
acteristics of drainage from Jackson-Pratt drain
or other drains.
Labs: Post-operative hematocrit value and
other labs.
Assessment and Plan: Assess the patient’s over-
all condition and status of wound. Comment on
abnormal labs, and discuss treatment and dis-
charge plans.
Interpretation Result
Negative for intraepithelial lesion or malignancy (when
there is no cellular evidence of neoplasia, state this in the
General Categorization above and/or in the Interpreta-
tion/Result section of the report, whether there are organ-
isms or other non-neoplastic findings)
Infection (Trichomonas vaginalis, Candida spp., shift in
flora suggestive of bacterial vaginosis, Actinomyces
spp., cellular changes consistent with Herpes simplex
virus)
Other Non-neoplastic Findings (Optional to report; list
not inclusive):
Reactive cellular changes associated with inflammation
(includes typical repair) radiation, intrauterine contra-
ceptive device (IUD)
Glandular cells status post-hysterectomy
Atrophy
Other
Endometrial cells (in a woman >40 years of age) (spec-
ify if "negative for squamous intraepithelial lesion")
Epithelial Cell Abnormalities
Squamous Cell
Atypical squamous cells
-of undetermined significance (ASC-US)
-cannot exclude HSIL (ASC-H)
Low-grade squamous intraepithelial lesion (LSIL)
encompassing: HPV/mild dysplasia/CIN 1
High-grade squamous intraepithelial lesion (HSIL)
encompassing: moderate and severe dysplasia,
CIS/CIN 2 and CIN 3 with features suspicious for
invasion (if invasion is suspected)
Squamous cell carcinoma
Glandular Cell
Atypical
-Endocervical cells (not otherwise specified or
specify in comments)
-Glandular Cell (not otherwise specified or spec-
ify in comments)
-Endometrial cells (not otherwise specified or
specify in comments)
-Glandular cells (not otherwise specified or spec-
ify in comments)
Atypical
-Endocervical cells, favor neoplastic
-Glandular cells, favor neoplastic
Endocervical adenocarcinoma in situ
Adenocarcinoma (endocervical, endometrial,
extrauterine, not otherwise specified (not otherwise
specified)
Other Malignant Neoplasms (specify)
Contraception
Approximately 31 percent of births are unintended; about
22 percent were "mistimed," while 9 percent were "un-
wanted."
I. Sterilization
A. Sterilization is the most common and effective form
of contraception. While tubal ligation and vasectomy
may be reversible, these procedures should be
considered permanent.
B. Essure microinsert sterilization device is a
permanent, hysteroscopic, tubal sterilization device
which is 99.9 percent effective. The coil-like device
is inserted in the office under local anesthesia into
the fallopian tubes where it is incorporated by tissue.
After placement, women use alternative contracep-
tion for three months, after which hysterosalping-
ography is performed to assure correct placement.
Postoperative discomfort is minimal.
C. Tubal ligation is usually performed as a laparo-
scopic procedure in outpatients or in postpartum
women in the hospital. The techniques used are
unipolar or bipolar coagulation, silicone rubber band
or spring clip application, and partial salpingectomy.
D. Vasectomy (ligation of the vas deferens) can be
performed in the office under local anesthesia. A
semen analysis should be done three to six months
after the procedure to confirm azoospermia.
II.Oral contraceptives
A. Combined (estrogen-progestin) oral contraceptives
are reliable, and they have noncontraceptive bene-
fits, which include reduction in dysmenorrhea, iron
deficiency, ovarian cancer, endometrial cancer.
Monophasic combinations
(0.5) (35)
Multiphasic Combinations
Drug Progestin, mg Estrogen
B. Pharmacology
1. Ethinyl estradiol is the estrogen in virtually all
OCs.
2. C o m m o n l y u s e d p r o g e s t i n s i n c l u d e
norethindrone, norethindrone acetate, and
levonorgestrel. Ethynodiol diacetate is a
progestin, which also has significant estrogenic
activity. New progestins have been developed
with less androgenic activity; however, these
agents may be associated with deep vein throm-
bosis.
C. Mechanisms of action
1. The most important mechanism of action is
estrogen-induced inhibition of the midcycle
surge of gonadotropin secretion, so that ovula-
tion does not occur.
2. Another potential mechanism of contraceptive
action is suppression of gonadotropin secretion
during the follicular phase of the cycle, thereby
preventing follicular maturation.
3. Progestin-related mechanisms also may contrib-
ute to the contraceptive effect. These include
rendering the endometrium is less suitable for
implantation and making the cervical mucus less
permeable to penetration by sperm.
D. Contraindications
1. Absolute contraindications to OCs:
a. Previous thromboembolic event or stroke
b. History of an estrogen-dependent tumor
c. Active liver disease
d. Pregnancy
e. Undiagnosed abnormal uterine bleeding
f. Hypertriglyceridemia
g. Women over age 35 years who smoke heavily
(greater than 15 cigarettes per day)
2. Screening requirements. Hormonal contracep-
tion can be safely provided after a careful medi-
cal history and blood pressure measurement.
Pap smears are not required before a prescrip-
tion for OCs.
E. Efficacy. When taken properly, OCs are a very
effective form of contraception. The actual failure
rate is 2 to 3 percent due primarily to missed pills or
failure to resume therapy after the seven-day pill-
free interval.
Products that
Objective Action achieve the ob-
jective
Missed pill
If it has been less than 24 hours since the last pill was
taken, the patient takes a pill right away and then returns to
normal pill-taking routine.
If it has been 24 hours since the last pill was taken, the
patient takes both the missed pill and the next scheduled pill
at the same time.
If it has been more than 24 hours since the last pill was
taken (ie, two or more missed pills), the patient takes the
last pill that was missed, throws out the other missed pills
and takes the next pill on time. Additional contraception is
used for the remainder of the cycle.
Emergency Contraception
Endometriosis
Endometriosis is characterized by the presence of
endometrial tissue on the ovaries, fallopian tubes or other
abnormal sites, causing pain or infertility. Women are
usually 25 to 29 years old at the time of diagnosis.
Approximately 24 percent of women who complain of
p e l vi c p a i n a r e s u b s equently found to have
endometriosis. The overall prevalence of endometriosis
is estimated to be 5 to 10 percent.
I. Clinical evaluation
A. Endometriosis should be considered in any woman
of reproductive age who has pelvic pain. The most
c o m m o n s y m p t o m s a r e d ys m e n o r r h e a ,
dyspareunia, and low back pain that worsens during
menses. Rectal pain and painful defecation may
also occur. Other causes of secondary
dysmenorrhea and chronic pelvic pain (eg, upper
genital tract infections, adenomyosis, adhesions)
may produce similar symptoms.
Adverse
Drug Dosage effects
Primary Amenorrhea
Amenorrhea (absence of menses) results from dysfunc-
tion of the hypothalamus, pituitary, ovaries, uterus, or
vagina. It is often classified as either primary (absence of
menarche by age 16) or secondary (absence of menses
for more than three cycle intervals or six months in
women who were previously menstruating).
I. Etiology
A. Primary amenorrhea is usually the result of a
genetic or anatomic abnormality. Common etiolo-
gies of primary amenorrhea:
1. Chromosomal abnormalities causing gonadal
dysgenesis: 45 percent
2. Physiologic delay of puberty: 20 percent
3. Müllerian agenesis: 15 percent
4. Transverse vaginal septum or imperforate hy-
men: 5 percent
5. Absent production of gonadotropin-releasing
hormone (GnRH) by the hypothalamus: 5 percent
6. Anorexia nervosa: 2 percent
7. Hypopituitarism: 2 percent
Abnormality Causes
Pregnancy
Anatomic abnormalities
Disorders of
hypothalamic-pituitary
ovarian axis
Hypothalamic dysfunc-
tion
Pituitary dysfunction
Ovarian dysfunction
Abnormality Causes
Other Hyperthyroidism
Hypothyroidism
Diabetes mellitus
Exogenous androgen use
Secondary Amenorrhea
Amenorrhea (absence of menses) can be a transient,
intermittent, or permanent condition resulting from
dysfunction of the hypothalamus, pituitary, ovaries,
uterus, or vagina. Amenorrhea is classified as either
primary (absence of menarche by age 16 years) or
secondary (absence of menses for more than three
cycles or six months in women who previously had
menses). Pregnancy is the most common cause of
secondary amenorrhea.
I. Diagnosis
A. Step 1: Rule out pregnancy. A pregnancy test is
the first step in evaluating secondary amenorrhea.
Measurement of serum beta subunit of hCG is the
most sensitive test.
B. Step 2: Assess the history
1. Recent stress; change in weight, diet or exercise
habits; or illnesses that might result in hypotha-
lamic amenorrhea should be sought.
2. Drugs associated with amenorrhea, systemic
illnesses that can cause hypothalamic
amenorrhea, recent initiation or discontinuation
of an oral contraceptive, androgenic drugs
(danazol) or high-dose progestin, and
antipsychotic drugs should be evaluated.
3. Headaches, visual field defects, fatigue, or
p o l yu r i a a n d p o l yd i p s i a m a y s u g g e s t
hypothalamic-pituitary disease.
4. Symptoms of estrogen deficiency include hot
flashes, vaginal dryness, poor sleep, or de-
creased libido.
5. G a l a c t o r r h e a i s s u g g e s t i v e o f
hyperprolactinemia. Hirsutism, acne, and a
history of irregular menses are suggestive of
hyperandrogenism.
6. A history of obstetrical catastrophe, severe
bl eeding, dilatatio n a n d c u ret t a g e , o r
endometritis or other infection that might have
caused scarring of the endometrial lining sug-
gests Asherman's syndrome.
Abnormality Causes
Pregnancy
Anatomic abnormalities
Disorders of
hypothalamic-pituitary
ovarian axis
Hypothalamic dysfunc-
tion
Pituitary dysfunction
Ovarian dysfunction
Causes of Amenorrhea due to Abnormalities in
the Hypothalamic-Pituitary-Ovarian Axis
Abnormality Causes
Other Hyperthyroidism
Hypothyroidism
Diabetes mellitus
Exogenous androgen use
Menopause
Menopause is defined as the cessation of menstrual
periods in women. The average age of menopause is 51
years, with a range of 41-55. The diagnosis of meno-
pause is made by the presence of amenorrhea for six to
twelve months, together with the occurrence of hot
flashes. If the diagnosis is in doubt, menopause is
indicated by an elevated follicle-stimulating hormone
(FSH) level greater than 40 mlU/mL.
I. Perimenopausal transition is defined as the two to
eight years preceding menopause and the one year
after the last menstrual period. It is characterized by
normal ovulatory cycles interspersed with anovulatory
(estrogen-only) cycles. As a result, menses become
irregular, and heavy breakthrough bleeding, termed
dysfunctional uterine bleeding, can occur during longer
periods of anovulation.
II. Effects of estrogen deficiency after menopause
A. Hot flashes. The most common acute change
during menopause is the hot flash, which occurs in
75 percent of women. About 50 to 75 percent of
women have cessation of hot flashes within five
years. Hot flashes typically begin as a sudden
sensation of heat centered on the face and upper
chest that rapidly becomes generalized. The
sensation lasts from two to four minutes and is
often associated with profuse perspiration. Hot
flashes occur several times per day.
B. Sexual function. Estrogen deficiency leads to a
decrease in blood flow to the vagina and vulva.
This decrease is a major cause of decreased
vaginal lubrication, dyspareunia, and decreased
sexual function in menopausal women.
C. Urinary incontinence. Menopause results in
atrophy of the urethral epithelium with subsequent
atrophic urethritis and irritation; these changes
predispose to both stress and urge urinary inconti-
nence.
D. Osteoporosis. A long-term consequence of estro-
gen deficiency is the development of osteoporosis
and fractures. Bone loss exceeds bone reforma-
tion. Between 1 and 5 percent of the skeletal mass
can be lost per year in the first several years after
the menopause. Osteoporosis may occur in as little
as ten years.
E. Cardiovascular disease. The incidence of myo-
cardial infarction in women, although lower than in
men, increases dramatically after the menopause.
III. Estrogen replacement therapy
A. Data from the WHI and the HERS trials has deter-
mined that continuous estrogen-progestin therapy
does not appear to protect against cardiovascular
disease and increases the risk of breast cancer,
coronary heart disease, stroke, and venous
thromboembolism over an average follow-up of 5.2
years. As a result, the primary indication for estro-
gen therapy is for control of menopausal symp-
toms, such as hot flashes.
IV. Prevention and treatment of osteoporosis
A. Screening for osteoporosis. Measurement of
BMD is recommended for all women 65 years and
older regardless of risk factors. BMD should also
be measured in all women under the age of 65
years who have one or more risk factors for osteo-
porosis (in addition to menopause). The hip is the
recommended site of measurement.
B. Bisphosphonates
1. Alendronate (Fosamax) has effects compara-
ble to those of estrogen for both the treatment
of osteoporosis (10 mg/day or 70 mg once a
week) and for its prevention (5 mg/day).
Alendronate (in a dose of 5 mg/day or 35
mg/week) can also prevent osteoporosis in
postmenopausal women.
2. Risedronate (Actonel), a bisphosphonate, has
been approved for prevention and treatment of
osteoporosis at doses of 5 mg/day or 35 mg
once per week. Its efficacy and side effect
profile are similar to those of alendronate.
C. Raloxifene (Evista) is a selective estrogen recep-
tor modulator. It is available for prevention and
treatment of osteoporosis. At a dose of 60 mg/day,
bone density increases by 2.4 percent in the
lumbar spine and hip over a two year period. This
effect is slightly less than with bisphosphonates.
D. Calcium. Maintaining a positive calcium balance in
postmenopausal women requires a daily intake of
1500 mg of elemental calcium; to meet this most
women require a supplement of 1000 mg daily.
E. Vitamin D. All postmenopausal women should take
a multivitamin containing at least 400 IU vitamin D
daily.
F. Exercise for at least 20 minutes daily reduces the
rate of bone loss. Weight bearing exercises are
preferable.
V. Treatment of hot flashes and vasomotor instability
A. The manifestations of vasomotor instability are hot
flashes, sleep disturbances, headache, and irrita-
bility. Most women with severe vasomotor instabil-
ity accept short-term estrogen therapy for these
symptoms.
B. Short-term estrogen therapy for relief of vaso-
motor instability and hot flashes
1. Short-term estrogen therapy remains the best
treatment for relief of menopausal symptoms,
and therefore is recommended for most
postmenopausal women, with the exception of
those with a history of breast cancer, CHD, a
previous venous thromboembolic event or
stroke, or those at high risk for these complica-
tions. Short-term therapy is continued for six
months to four or five years. Administration of
estrogen short-term is not associated with an
increased risk of breast cancer.
2. Low dose estrogen is recommended (eg, 0.3
mg conjugated estrogens [Premarin] daily or 0.5
mg estradiol [Estrace] daily). These doses are
adequate for symptom management and pre-
vention of bone loss.
3. Endometrial hyperplasia and cancer can occur
after as little as six months of unopposed estro-
gen therapy; as a result, a progestin must be
added in those women who have not had a
hysterectomy. Medroxyprogesterone (Provera),
2.5 mg, is usually given every day of the month.
4. After the planned treatment interval, the estro-
gen should be discontinued gradually to mini-
mize recurrence of the menopausal symptoms,
for example, by omitting one pill per week (6
pills per week, 5 pills per week, 4 pills per
week).
C. Treatment of vasomotor instability in women
not taking estrogen
1. Selective serotonin reuptake inhibitors
(SSRIs) also relieve the symptoms of vasomotor
instability.
a. Venlafaxine (Effexor), at doses of 75 mg
daily, reduces hot flashes by 61 percent.
Mouth dryness, anorexia, nausea, and con-
stipation are common.
b. Paroxetine (Zoloft), 50 mg per day, relieves
vasomotor instability.
c. Fluoxetine (Prozac) 20 mg per day also has
beneficial effects of a lesser magnitude.
2. Clonidine (Catapres) relieves hot flashes in
80%. In a woman with hypertension, clonidine
might be considered as initial therapy. It is
usually given as a patch containing 2.5 mg per
week. Clonidine also may be given orally in
doses of 0.1 to 0.4 mg daily. Side effects often
limit the use and include dry mouth, dizziness,
constipation, and sedation.
3. Megestrol acetate (Megace) is a synthetic
progestin which decreases the frequency of hot
flashes by 85 percent at a dose of 40 to 80 mg
PO daily. Weight gain is the major side effect.
VI. Treatment of urogenital atrophy
A. Loss of estrogen causes atrophy of the vaginal
epithelium and results in vaginal irritation and
dryness, dyspareunia, and an increase in vaginal
infections. Systemic estrogen therapy results in
relief of symptoms.
B. Treatment of urogenital atrophy in women not
taking systemic estrogen
1. Moisturizers and lubricants. Regular use of a
vaginal moisturizing agent (Replens) and lubri-
cants during intercourse are helpful. Water
soluble lubricants such as Astroglide are more
effective than lubricants that become more
viscous after application such as K-Y jelly. A
more effective treatment is vaginal estrogen
therapy.
2. Low-dose vaginal estrogen
a. Vaginal ring estradiol (Estring), a silastic
ring impregnated with estradiol, is the pre-
ferred means of delivering estrogen to the
vagina. The silastic ring delivers 6 to 9 µg of
estradiol to the vagina daily for a period of
three months. The rings are changed once
every three months by the patient. Concomi-
tant progestin therapy is not necessary.
b. Conjugated estrogens (Premarin), 0.5 gm
of cream, or one-eighth of an applicatorful
daily into the vagina for three weeks, followed
by twice weekly thereafter. Concomitant
progestin therapy is not necessary.
c. Estrace cream (estradiol) can also by given
by vaginal applicator at a dose of one-eighth
of an applicator or 0.5 g (which contains 50
µg of estradiol) daily into the vagina for three
weeks, followed by twice weekly thereafter.
Concomitant progestin therapy is not neces-
sary.
d. Estradiol (Vagifem). A tablet containing 25
micrograms of estradiol is available and is
inserted into the vagina twice per week.
Concomitant progestin therapy is not neces-
sary.
References: See page 282.
I. Symptoms
A. The most common physical manifestation of PMS is
abdominal bloating, which occurs in 90 percent of
women with this disorder; breast tenderness and
headaches are also common, occurring in more
than 50 percent of cases.
B. The most common behavioral symptom of PMS is
an extreme sense of fatigue which is seen in more
than 90 percent. Other frequent behavioral com-
plaints include irritability, tension, depressed mood,
labile mood (80 percent), increased appetite (70
percent), and forgetfulness and difficulty concentrat-
ing (50 percent).
C. Other common findings include acne, oversensitivity
to environmental stimuli, anger, easy crying, and
gastrointestinal upset. Hot flashes, heart palpita-
tions, and dizziness occur in 15 to 20 percent of
patients. Symptoms should occur in the luteal phase
only.
Affective Somatic
Depression Breast tenderness
Angry outbursts Abdominal bloating
Irritability Headache
Confusion Swollen extremities
Social withdrawal
Fatigue
E. Differential diagnosis
1. PMDD should be differentiated from
premenstrual exacerbation of an underlying
major psychiatric disorder, as well as medical
conditions such as hyper- or hypothyroidism.
2. About 13 percent of women with PMS are found
to have a psychiatric disorder alone with no
evidence of PMS, while 38 percent had
premenstrual exacerbation of underlying depres-
sive and anxiety disorders.
3. Women who present with PMS have a much
higher incidence of major depression in the past
and are at greater risk for major depression in
the future.
4. 39 percent of women with PMDD meet criteria
for mood or anxiety disorders.
5. The assessment of patients with possible PMS
or PMDD should begin with the history, physical
examination, chemistry profile, complete blood
count, and serum TSH. The history should focus
in particular on the regularity of menstrual cy-
cles. Appropriate gynecologic endocrine evalua-
tion should be performed if the cycles are irregu-
lar (lengths less than 25 or greater than 36
days).
6. The patient should be asked to record symp-
toms prospectively for two months. If the patient
fails to demonstrate a symptom free interval in
the follicular phase, she should be evaluated for
a mood or anxiety disorder.
II. Treatment of premenstrual dysphoric disorder
A. Serotonin reuptake inhibitors
1. Fluoxetine (Sarafem) is an effective treatment
for PMDD when given in a daily dose of 20
mg/day. The response rate is 60 to 75 percent.
The most common reasons for failure to con-
tinue the treatment are headache, anxiety, and
nausea.
2. Other drugs that inhibit serotonin reuptake, such
as clomipramine (Anafranil [given either
throughout the menstrual cycle or restricted to
the luteal phase]), sertraline (Zoloft) 50 to 150
mg/day throughout the menstrual cycle, and
nefazodone (Serzone) 100-300 mg bid also may
be effective in PMS.
3. Venlafaxine (Effexor) selectively inhibits the
reuptake of both serotonin and norepinephrine
and is also effective (50 to 200 mg/day).
4. Intermittent therapy given during the luteal
phase only (starting on cycle day 14) has been
shown to be effective.
B. Alprazolam (Xanax), 0.25 mg TID OR qid, has
been shown in double-blind, placebo-controlled
crossover studies to be beneficial in PMS.
C. GnRH agonists (leuprolide [Lupron] or
buserelin) have shown some benefit. However,
women with severe premenstrual depression are
unresponsive to GnRH agonists. The physical
symptoms may be more responsive than mood
symptoms in women with PMS, and side effects
(hypoestrogenism) may limit the use of these drugs
for long-term therapy.
1. GnRH agonists and "add-back" therapy. Add-
back therapy with estrogen (and a progestin if
indicated) mitigates concerns about bone loss
from prolonged administration of GnRH
agonists. Leuprolide alone led to a 75 percent
improvement in luteal phase symptom scores.
This benefit was maintained (60 percent im-
provement) during a crossover period in which
estrogen/progestin replacement was added.
Alendronate can be considered in women who
do not tolerate hormonal add-back therapy but
need osteoporosis prophylaxis.
D. Danazol inhibits pituitary gonadotropin secretion,
and is an effective therapy for PMS. However, the
androgenic side effects of danazol limit its use to
patients who fail to respond adequately to the
above therapies.
Other
Spirolactone (Aldactone) 25-200 mg qd
Cabergoline (Dostinex) 0.25 mg - 1 mg twice a week during
the luteal phase for breast pain
Breast Disorders
Breast pain, nipple discharge and a palpable mass are
the most common breast problems for which women
consult a physician.
I. Nipple Discharge
A. Clinical evaluation
1. Nipple discharge may be a sign of cancer; there-
fore, it must be thoroughly evaluated. About 8%
of biopsies performed for nipple discharge dem-
onstrate cancer. The duration, bilaterality or
unilaterality of the discharge, and the presence of
blood should be determined. A history of oral
contraceptives, hormone preparations,
phenothiazines, nipple or breast stimulation or
lactation should be sought. Discharges that flow
spontaneously are more likely to be pathologic
than discharges that must be manually ex-
pressed.
2. Unilateral, pink colored, bloody or non-milky
discharge, or discharges associated with a mass
are the discharges of most concern. Milky dis-
charge can be caused by oral contraceptive
agents, estrogen replacement therapy,
phenothiazines, prolactinoma, or hypothyroidism.
Nipple discharge secondary to malignancy is
more likely to occur in older patients.
3. Risk factors. The assessment should identify
risk factors, including age over 50 years, past
personal history of breast cancer, history of
hyperplasia on previous breast biopsies, and
family history of breast cancer in a first-degree
relative (mother, sister, daughter).
B. Physical examination should include inspection of
the breast for ulceration or contour changes and
inspection of the nipple. Palpation should be per-
formed with the patient in both the upright and the
supine positions to determine the presence of a
mass.
C. Diagnostic evaluation
1. Bloody discharge. A mammogram of the in-
volved breast should be obtained if the patient is
over 35 years old and has not had a
mammogram within the preceding 6 months.
Biopsy of any suspicious lesions should be
completed.
2. Watery, unilateral discharge should be referred
to a surgeon for evaluation and possible biopsy.
3. Non-bloody discharge should be tested for the
presence of blood with a Hemoccult card. Nipple
discharge secondary to carcinoma usually con-
tains hemoglobin.
4. Milky, bilateral discharge should be evaluated
with assays of prolactin and thyroid stimulating
hormone to exclude an endocrinologic cause.
a. A mammogram should be performed if the pa-
tient is due for routine mammographic screen-
ing.
b. If results of the mammogram and the
endocrinologic screening studies are normal,
the patient should return for a follow-up visit in
6 months to ensure that there has been no
specific change in the character of the dis-
charge, such as development of bleeding.
II. Breast Pain
A. Breast pain is the most common breast symptom
causing women to consult primary care physicians.
Mastalgia is more common in premenopausal
women than in postmenopausal women, and it is
rarely a presenting symptom of breast cancer.
B. The evaluation of breast pain should determine the
type of pain, its location and its relationship to the
menstrual cycle. Most commonly, breast pain is
associated with the menstrual cycle (cyclic
mastalgia).
C. Cyclic pain is usually bilateral and poorly localized.
The pain is often relieved after the menses. Cyclic
breast pain occurs more often in younger women
and resolves spontaneously.
D. Noncyclic mastalgia is most common in women 40
to 50 years of age. It is often a unilateral pain.
Noncyclic mastalgia is occasionally secondary to
the presence of a fibroadenoma or cyst, and the
pain may be relieved by treatment of the underlying
breast lesion.
E. Evaluation. A thorough breast examination should
be performed to exclude the presence of a breast
mass. Women 35 years of age and older should
undergo mammography unless a mammogram was
obtained in the past 12 months. If a suspicious
lesion is detected, biopsy is required. When the
physical examination is normal, imaging studies are
not indicated in women younger than 35 years of
age. A follow-up clinical breast examination should
be performed in 1-2 months.
F. Mastodynia
1. Mastodynia is defined as breast pain in the
absence of a mass or other pathologic abnormal-
ity.
2. Causes of mastodynia include menstrually
related pain, costochondritis, trauma, and
sclerosing adenosis.
III.Fibrocystic Complex
A. Breast changes are usually multifocal, bilateral, and
diffuse. One or more isolated fibrocystic lumps or
areas of asymmetry may be present. The areas are
usually tender.
B. This disorder predominantly occurs in women with
premenstrual abnormalities, nulliparous women,
and nonusers of oral contraceptives.
C. The disorder usually begins in mid-20's or early
30's. Tenderness is associated with menses and
lasts about a week. The upper outer quadrant of the
breast is most frequently involved bilaterally. There
is no increased risk of cancer for the majority of
patients.
D. Suspicious areas may be evaluated by fine needle
aspiration (FNA) cytology. If mammography and
FNA are negative for cancer, and the clinical
examination is benign, open biopsy is generally not
needed.
E. Medical management of fibrocystic complex
1. Oral contraceptives are effective for severe
breast pain in most young women. Start with a
pill that contains low amounts of estrogen and
relatively high amounts of progesterone
(Loestrin, LoOvral, Ortho-Cept).
2. If oral contraceptives do not provide relief,
medroxyprogesterone, 5-10 mg/day from days
15-25 of each cycle, is added.
3. A professionally fitted support bra often provides
significant relief.
4. Danazol (Danocrine), an antigonadotropin, has
a response rate of 50 to 75 percent in women
with cyclic pain who received danazol in a dos-
age of 100 to 400 mg per day. Danazol therapy
is recommended only for patients with severe,
activity-limiting pain. Side effects include men-
strual irregularity, acne, weight gain and
hirsutism.
5. Evening primrose oil (g-linolenic acid) is effec-
tive in about 38 to 58 percent of patients with
mastalgia; 2 - 4 g per day.
IV. Breast Masses
A. The normal glandular tissue of the breast is nodu-
lar. Nodularity is a physiologic process and is not
an indication of breast pathology. Dominant
masses may be discrete or poorly defined, but they
differ in character from the surrounding breast
tissue. The differential diagnosis of a dominant
breast mass includes macrocyst (clinically evident
cyst), fibroadenoma, prominent areas of fibrocystic
change, fat necrosis and cancer.
B. Cystic Breast Masses
1. Cysts are a common cause of dominant breast
masses in premenopausal women more than 40
years of age, but they are an infrequent cause of
such masses in younger women. Cysts are
usually well demarcated, firm and mobile.
2. Ultrasonography or aspiration must establish a
definitive diagnosis for a cyst. Cysts require
surgical biopsy if the aspirated fluid is bloody, the
palpable abnormality does not resolve com-
pletely after the aspiration of fluid or the same
cyst recurs multiple times in a short period of
time. Routine cytologic examination of cyst fluid
is not indicated.
3. Nonpalpable cysts identified by mammography
and confirmed to be simple cysts by ultrasound
examination require no treatment.
C. Solid Breast Masses
1. Noncystic masses in premenopausal women that
are clearly different from the surrounding breast
tissue require histologic sampling by fine-needle
aspiration, core cutting, needle biopsy or
excisional biopsy.
2. Solid Masses in Women Less Than 40 Years
of Age
a. If the physical examination reveals no evi-
dence of a dominant breast mass, the patient
should be reassured and instructed in breast
self-examination. If the clinical significance of
a physical finding is uncertain, a directed
ultrasound examination is performed. If this
examination does not demonstrate a mass,
the physical examination is repeated in two to
four months. In women 35 to 40 years of age
who have a normal ultrasound examination, a
mammogram may also be obtained.
b. A suspicious mass is solitary, discrete, hard
and adherent to adjacent tissue. Mammogra-
phy should be performed before obtaining a
pathologic diagnosis.
c. If a clinically benign mass is present, an
ultrasound examination and fine-needle aspi-
ration are performed to confirm that the mass
is benign. This approach is the “triple test”
(clinical examination, ultrasonography [or
mammography] and fine-needle aspiration).
3. Solid Masses in Women More Than 40 Years
of Age. Abnormalities detected on physical
examination in older women should be regarded
as possible cancers until they are proven to be
benign. In women more than 40 years of age,
diagnostic mammography is a standard part of
the evaluation of a solid breast mass.
References: See page 282.
Sexual Assault
Sexual assault is defined as any sexual act performed by
one person on another without the person's consent.
Sexual assault includes genital, anal, or oral penetration
by a part of the accused's body or by an object. It may
result from force, the threat of force, or the victim's
inability to give consent. The annual incidence of sexual
assault is 200 per 100,000 persons.
I. Psychological effects
A. A woman who is sexually assaulted loses control
over her life during the period of the assault. Her
integrity and her life are threatened. She may
experience intense anxiety, anger, or fear. After the
assault, a "rape-trauma" syndrome often occurs.
The immediate response may last for hours or days
and is characterized by generalized pain, head-
ache, chronic pelvic pain, eating and sleep distur-
bances, vaginal symptoms, depression, anxiety,
and mood swings.
B. The delayed phase is characterized by flashbacks,
nightmares, and phobias.
II. Medical evaluation
A. Informed consent must be obtained before the
examination. Acute injuries should be stabilized.
About 1% of injuries require hospitalization and
major operative repair, and 0.1% of injuries are
fatal.
B. A history and physical examination should be
performed. A chaperon should be present during
the history and physical examination to reassure
the victim and provide support. The patient should
be asked to state in her own words what happened,
identify her attacker if possible, and provide details
of the act(s) performed if possible.
Clinical Care of the Sexual Assault Victim
Medical
Obtain informed consent from the patient
Obtain a gynecologic history
Assess and treat physical injuries
Obtain appropriate cultures and treat any existing
infections
Provide prophylactic antibiotic therapy and offer
immunizations
Provide therapy to prevent unwanted conception
Offer baseline serologic tests for hepatitis B vi-
rus, human immunodeficiency virus (HIV), and
syphilis
Provide counseling
Arrange for follow-up medical care and counsel-
ing
Legal
Provide accurate recording of events
Document injuries
Collect samples (pubic hair, fingernail scrapings,
vaginal secretions, saliva, blood-stained clothing)
Report to authorities as required
Assure chain of evidence
Emergency Contraception
Initial Examination
Infection
• Testing for and gonorrhea and chlamydia from speci-
mens from any sites of penetration or attempted pene-
tration
• Wet mount and culture or a vaginal swab specimen for
Trichomonas
• Serum sample for syphilis, herpes simplex virus, hepati-
tis B virus, and HIV
Pregnancy Prevention
Prophylaxis
• Hepatitis B virus vaccination and hepatitis B immune
globulin.
• Empiric recommended antimicrobial therapy for
chlamydial, gonococcal, and trichomonal infections and
for bacterial vaginosis:
Ceftriaxone, 125 mg intramuscularly in a single dose,
plus
Metronidazole, 2 g orally in a single dose, plus
Doxycycline 100 mg orally two times a day for 7 days
Azithromycin (Zithromax) is used if the patient is unlikely
to comply with the 7 day course of doxycycline; single
dose of four 250 mg caps.
If the patient is penicillin-allergic, ciprofloxacin 500 mg
PO or ofloxacin 400 mg PO is substituted for
ceftriaxone. If the patient is pregnant, erythromycin
500 mg PO qid for 7 days is substituted for
doxycycline.
HIV prophylaxis consists of zidovudine (AZT) 200 mg
PO tid, plus lamivudine (3TC) 150 mg PO bid for 4
weeks.
Osteoporosis
Over 1.3 million osteoporotic fractures occur each year in
the United States. The risk of all fractures increases with
age; among persons who survive until age 90, 33 percent
of women will have a hip fracture. The lifetime risk of hip
fracture for white women at age 50 is 16 percent. Osteo-
porosis i s c h aracterized by low bone mass,
microarchitectural disruption, and increased skeletal
fragility.
Urinary Incontinence
Women between the ages of 20 to 80 year have an
overall prevalence for urinary incontinence of 53.2
percent.
I. Types of Urinary Incontinence
A. Stress Incontinence
1. Stress incontinence is the involuntary loss of
urine produced by coughing, laughing or exercis-
ing. The underlying abnormality is typically
urethral hypermobility caused by a failure of the
anatomic supports of the bladder neck. Loss of
bladder neck support is often attributed to injury
occurring during vaginal delivery.
2. The lack of normal intrinsic pressure within the
urethra--known as intrinsic urethral sphincter
deficiency--is another factor leading to stress
incontinence. Advanced age, inadequate estro-
gen levels, previous vaginal surgery and certain
neurologic lesions are associated with poor
urethral sphincter function.
B. Overactive Bladder. Involuntary loss of urine
preceded by a strong urge to void, whether or not
the bladder is full, is a symptom of the condition
commonly referred to as “urge incontinence.” Other
commonly used terms such as detrusor instability
and detrusor hyperreflexia refer to involuntary
detrusor contractions observed during urodynamic
studies.
II.History and Physical Examination
A. A preliminary diagnosis of urinary incontinence can
be made on the basis of a history, physical exami-
nation and a few simple office and laboratory tests.
B. The medical history should assess diabetes,
stroke, lumbar disc disease, chronic lung disease,
fecal impaction and cognitive impairment. The
obstetric and gynecologic history should include
gravity; parity; the number of vaginal, instru-
ment-assisted and cesarean deliveries; the time
interval between deliveries; previous hysterectomy
and/or vaginal or bladder surgery; pelvic radiother-
apy; trauma; and estrogen status.
Drug Dosage
Stress Incontinence
Overactive bladder
Amoxicillin-clavulanate(Au
gmentin), 500 mg twice
daily
Up to 3
days Trimethoprim-sulfamethox
azole (Bactrim) 160/800 IV
twice daily
Ceftriaxone (Rocephin), 1 g
IV per day
Ciprofloxacin (Cipro), 400
mg twice daily
Ofloxacin (Floxin), 400 mg
twice daily
Levofloxacin (Penetrex), 250
mg per day
Aztreonam (Azactam), 1 g
three times daily
Gentamicin (Garamycin), 3
mg per kg per day in 3 di-
vided doses every 8 hours
Pubic Infections
I. Molluscum contagiosum
A. This disease is produced by a virus of the pox virus
family and is spread by sexual or close personal
contact. Lesions are usually asymptomatic and
multiple, with a central umbilication. Lesions can be
spread by autoinoculation and last from 6 months to
many years.
B. Diagnosis. The characteristic appearance is
adequate for diagnosis, but biopsy may be used to
confirm the diagnosis.
C. Treatment. Lesions are removed by sharp dermal
c u r e t t e , l i q u i d n i t r o g e n c r yo s u r g e r y, o r
electrodesiccation.
II. Pediculosis pubis (crabs)
A. Phthirus pubis is a blood sucking louse that is
unable to survive more than 24 hours off the body.
It is often transmitted sexually and is principally
found on the pubic hairs. Diagnosis is confirmed by
locating nits or adult lice on the hair shafts.
B. Treatment
1. Permethrin cream (Elimite), 5% is the most
effective treatment; it is applied for 10 minutes
and washed off.
2. Kwell shampoo, lathered for at least 4 minutes,
can also be used, but it is contraindicated in
pregnancy or lactation.
3. All contaminated clothing and linen should be
laundered.
III. Pubic scabies
A. This highly contagious infestation is caused by the
Sarcoptes scabiei (0.2-0.4 mm in length). The
infestation is transmitted by intimate contact or by
contact with infested clothing. The female mite
burrows into the skin, and after 1 month, severe
pruritus develops. A multiform eruption may de-
velop, characterized by papules, vesicles, pustules,
urticarial wheals, and secondary infections on the
hands, wrists, elbows, belt line, buttocks, genitalia,
and outer feet.
B. Diagnosis is confirmed by visualization of burrows
and observation of parasites, eggs, larvae, or red
fecal compactions under microscopy.
C. Treatment. Permethrin 5% cream (Elimite) is
massaged in from the neck down and remove by
washing after 8 hours.
References: See page 282.
I. Chlamydia Trachomatis
A. Chlamydia trachomatis is the most prevalent STI in
the United States. Chlamydial infections are most
common in women age 15-19 years.
B. Routine screening of asymptomatic, sexually active
adolescent females undergoing pelvic examination
is recommended. Annual screening should be done
for women age 20-24 years who are either inconsis-
tent users of barrier contraceptives or who acquired
a new sex partner or had more than one sexual
partner in the past 3 months.
II. Gonorrhea. Gonorrhea has an incidence of 800,000
cases annually. Routine screening for gonorrhea is
recommended among women at high risk of infection,
including prostitutes, women with a history of repeated
episodes of gonorrhea, women under age 25 years
with two or more sex partners in the past year, and
women with mucopurulent cervicitis.
III. Syphilis
A. Syphilis has an incidence of 100,000 cases annu-
ally. The rates are highest in the South, among
African Americans, and among those in the 20- to
24-year-old age group.
B. Prostitutes, persons with other STIs, and sexual
contacts of persons with active syphilis should be
screened.
IV.Herpes simplex virus and human papillomavirus
A. An estimated 200,000-500,000 new cases of
herpes simplex occur annually in the United States.
New infections are most common in adolescents
and young adults.
B. Human papillomavirus affects about 30% of young,
sexually active individuals.
References: See page 282.
• Pregnancy test
• Microscopic exam of vaginal discharge in saline
• Complete blood counts
• Tests for chlamydia and gonococcus
• Urinalysis
• Fecal occult blood test
• C-reactive protein(optional)
Vaginitis
Vaginitis is the most common gynecologic problem
encountered by primary care physicians. It may result
from bacterial infections, fungal infection, protozoan
infection, contact dermatitis, atrophic vaginitis, or allergic
reaction.
I. Clinical evaluation of vaginal symptoms
A. The type and extent of symptoms, such as itching,
discharge, odor, or pelvic pain should be deter-
mined. A change in sexual partners or sexual
activity, changes in contraception method, medica-
tions (antibiotics), and history of prior genital infec-
tions should be sought.
B. Physical examination
1. Evaluation of the vagina should include close
inspection of the external genitalia for excoria-
tions, ulcerations, blisters, papillary structures,
erythema, edema, mucosal thinning, or mucosal
pallor.
2. The color, texture, and odor of vaginal or cervical
discharge should be noted.
C. Vaginal fluid pH can be determined by immersing
pH paper in the vaginal discharge. A pH level
greater than 4.5 indicates the presence of bacterial
vaginosis or Trichomonas vaginalis.
D. Saline wet mount
1. One swab should be used to obtain a sample
from the posterior vaginal fornix, obtaining a
"clump" of discharge. Place the sample on a
slide, add one drop of normal saline, and apply a
coverslip.
2. Coccoid bacteria and clue cells (bacteria-coated,
stippled, epithelial cells) are characteristic of
bacterial vaginosis.
3. Trichomoniasis is confirmed by identification of
trichomonads – mobile, oval flagellates. White
blood cells are prevalent.
E. Potassium hydroxide (KOH) preparation
1. Place a second sample on a slide, apply one
drop of 10% potassium hydroxide (KOH) and a
coverslip. A pungent, fishy odor upon addition of
KOH – a positive whiff test – strongly indicates
bacterial vaginosis.
2. The KOH prep may reveal Candida in the form of
thread-like hyphae and budding yeast.
F. Screening for STDs. Testing for gonorrhea and
chlamydial infection should be completed for
women with a new sexual partner, purulent cervical
discharge, or cervical motion tenderness.
II. Differential diagnosis
A. The most common cause of vaginitis is bacterial
vaginosis, followed by Candida albicans. The
prevalence of trichomoniasis has declined in recent
years.
B. Common nonvaginal etiologies include contact
dermatitis from spermicidal creams, latex in con-
doms, or douching. Any STD can produce vaginal
discharge.
1-day regimens
Clotrimazole vaginal tablets (Mycelex G), 500 mg hs**
Fluconazole tablets (Diflucan), 150 mg PO
Itraconazole capsules (Sporanox), 200 mg PO bid
Tioconazole 6.5% vaginal ointment (Vagistat-1), 4.6 g hs**
[5 g]
3-day regimens
Butoconazole nitrate 2% vaginal cream (Femstat 3), 5 g hs
[28 g]
Clotrimazole vaginal inserts (Gyne-Lotrimin 3), 200 mg hs**
Miconazole vaginal suppositories (Monistat 3), 200 mg hs**
Terconazole 0.8% vaginal cream (Terazol 3), 5 g hs
Terconazole vaginal suppositories (Terazol 3), 80 mg hs
Itraconazole capsules (Sporanox), 200 mg PO qd (4)
5-day regimen
Ketoconazole tablets (Nizoral), 400 mg PO bid (4)
7-day regimens
Clotrimazole 1% cream (Gyne-Lotrimin, Mycelex-7,
Sweet'n Fresh Clotrimazole-7), 5 g hs**
Clotrimazole vaginal tablets (Gyne-Lotrimin, Mycelex-7,
Sweet'n Fresh Clotrimazole-7), 100 mg hs**
Miconazole 2% vaginal cream (Femizol-M, Monistat 7), 5 g
hs**
Miconazole vaginal suppositories (Monistat 7), 100 mg hs**
Terconazole 0.4% vaginal cream (Terazol 7), 5 g hs
14-day regimens
Nystatin vaginal tablets (Mycostatin), 100,000 U hs
Boric acid No. 0 gelatin vaginal suppositories, 600 mg bid
(2)
Initial measures
Metronidazole (Flagyl, Protostat), 2 g PO in a single dose,
or metronidazole, 500 mg PO bid X 7 days, or
metronidazole, 375 mg PO bid X 7 days
Treat male sexual partners
Normal Labor
Labor consists of the process by which uterine contrac-
tions expel the fetus. A term pregnancy is 37 to 42 weeks
from the last menstrual period (LMP).
I. Obstetrical history and physical examination
A. History of the present labor
1. Contractions. The frequency, duration, onset,
and intensity of uterine contractions should be
determined. Contractions may be accompanied
by a '’bloody show" (passage of blood-tinged
mucus from the dilating cervical os). Braxton
Hicks contractions are often felt by patients
during the last weeks of pregnancy. They are
usually irregular, mild, and do not cause cervical
change.
2. Rupture of membranes. Leakage of fluid may
occur alone or in conjunction with uterine con-
tractions. The patient may report a large gush of
fluid or increased moisture. The color of the
liquid should be determine, including the pres-
ence of blood or meconium.
3. Vaginal bleeding should be assessed. Spotting
or blood-tinged mucus is common in normal
labor. Heavy vaginal bleeding may be a sign of
placental abruption.
4. Fetal movement. A progressive decrease in
fetal movement from baseline, should prompt an
assessment of fetal well-being with a nonstress
test or biophysical profile.
B. History of present pregnancy
1. Estimated date of confinement (EDC) is
calculated as 40 weeks from the first day of the
LMP.
2. Fetal heart tones are first heard with a Doppler
instrument 10-12 weeks from the LMP.
3. Quickening (maternal perception of fetal move-
ment) occurs at about 17 weeks.
4. Uterine size before 16 weeks is an accurate
measure of dates.
5. Ultrasound measurement of fetal size before 24
weeks of gestation is an accurate measure of
dates.
6. Prenatal history. Medical problems during this
pregnancy should be reviewed, including urinary
tract infections, diabetes, or hypertension.
7. Antepartum testing. Nonstress tests, contrac-
tion stress tests, biophysical profiles.
8. Review of systems. Severe headaches,
scotomas, hand and facial edema, or epigastric
pain (preeclampsia) should be sought. Dysuria,
urinary frequency or flank pain may indicate
cystitis or pyelonephritis.
C. Obstetrical history. Past pregnancies, durations
and outcomes, preterm deliveries, operative deliv-
eries, prolonged labors, pregnancy-induced hyper-
tension should be assessed.
D. Past medical history of asthma, hypertension, or
renal disease should be sought.
II. Physical examination
A. Vital signs are assessed.
B. Head. Funduscopy should seek hemorrhages or
exudates, which may suggest diabetes or hyperten-
sion. Facial, hand and ankle edema suggest
preeclampsia.
C. Chest. Auscultation of the lungs for wheezes and
crackles may indicate asthma or heart failure.
D. Uterine Size. Until the middle of the third trimester,
the distance in centimeters from the pubic
symphysis to the uterine fundus should correlate
with the gestational age in weeks. Toward term, the
measurement becomes progressively less reliable
because of engagement of the presenting part.
E. Estimation of fetal weight is completed by palpa-
tion of the gravid uterus.
F. Leopold's maneuvers are used to determine the
position of the fetus.
1. The first maneuver determines which fetal pole
occupies the uterine fundus. The breech moves
with the fetal body. The vertex is rounder and
harder, feels more globular than the breech, and
can be moved separately from the fetal body.
2. Second maneuver. The lateral aspects of the
uterus are palpated to determine on which side
the fetal back or fetal extremities (the small
parts) are located.
3. Third maneuver. The presenting part is moved
from side to side. If movement is difficult, en-
gagement of the presenting part has occurred.
4. Fourth maneuver. With the fetus presenting by
vertex, the cephalic prominence may be palpa-
ble on the side of the fetal small parts.
G. Pelvic examination. The adequacy of the bony
pelvis, the integrity of the fetal membranes, the
degree of cervical dilatation and effacement, and
the station of the presenting part should be deter-
mined.
H. Extremities. Severe lower extremity or hand
edema suggests preeclampsia. Deep-tendon
hyperreflexia and clonus may signal impending
seizures.
I. Laboratory tests
1. Prenatal labs should be documented, including
CBC, blood type, Rh, antibody screen, serologic
test for syphilis, rubella antibody titer, urinalysis,
culture, Pap smear, cervical cultures for gonor-
rhea and Chlamydia, and hepatitis B surface
antigen (HbsAg).
2. During labor, the CBC, urinalysis and RPR are
repeated. The HBSAG is repeated for high-risk
patients. A clot of blood is placed on hold.
J. Fetal heart rate. The baseline heart rate, variabil-
ity, accelerations, and decelerations are recorded.
Delivery Note
1. Note the age, gravida, para, and gestational age.
2. Time of birth, type of birth (spontaneous vaginal delivery), position (left occiput
anterior).
3. Bulb suctioned, sex, weight, APGAR scores, nuchal cord, and number of cord
vessels.
4. Placenta expressed spontaneously intact. Describe episiotomy degree and repair
technique.
5. Note lacerations of cervix, vagina, rectum, perineum.
6. Estimated blood loss:
7. Disposition: Mother to recovery room in stable condition. Infant to nursery in stable
condition.
E. Ancillary tests
1. Vibroacoustic stimulation is performed by
placing an artificial larynx on the maternal abdo-
men and delivering a short burst of sound to the
fetus. The procedure can shorten the duration of
time needed to produce reactivity and the fre-
quency of nonreactive NSTs, without compro-
mising the predictive value of a reactive NST.
2. Oxytocin challenge test
a. The oxytocin challenge test (OCT) is done by
intravenously infusing dilute oxytocin until
three contractions occur within ten minutes.
The test is interpreted as follows:
b. A positive test is defined by the presence of
late decelerations following 50 percent or
more of the contractions
c. A negative test has no late or significant
variable decelerations
d. An equivocal-suspicious pattern consists of
intermittent late or significant variable decel-
erations, while an equivocal-hyperstimulatory
pattern refers to fetal heart rate decelerations
occurring with contractions more frequent
than every two minutes or lasting longer than
90 seconds
e. An unsatisfactory test is one in which the
tracing is uninterpretable or contractions are
fewer than three in 10 minutes
f. A positive test indicates decreased fetal
reserve and correlates with a 20 to 40 per-
cent incidence of abnormal FHR patterns
during labor. An equivocal-suspicious test
with repetitive variable decelerations is also
associated with abnormal FHR patterns in
labor, which are often related to cord com-
pression due to oligohydramnios.
3. Fetal biophysical profile
a. The fetal biophysical profile score refers to
the sonographic assessment of four biophysi-
cal variables: fetal movement, fetal tone, fetal
breathing, amniotic fluid volume and
nonstress testing. Each of these five parame-
ters is given a score of 0 or 2 points, depend-
ing upon whether specific criteria are met.
Fetal BPS is a noninvasive, highly accurate
means for predicting the presence of fetal
asphyxia.
b. Criteria
(1) A normal variable is assigned a score of
two and an abnormal variable a score of
zero. The maximal score is 10/10 and the
minimal score is 0/10.
(2) Amniotic fluid volume is based upon an
ultrasound-based objective measurement
of the largest visible pocket. The selected
largest pocket must have a transverse
diameter of at least one centimeter.
c. Clinical utility
(1) The fetal BPS is noninvasive and highly
accurate for predicting the presence of
fetal asphyxia. The probability of fetal
acidemia is virtually zero when the score
is normal (8 to 10). The false negative
rate (ie, fetal death within one week of a
last test with a normal score) is exceed-
ingly low. The likelihood of fetal compro-
mise and death rises as the score falls.
(2) The risk of fetal demise within one week
of a normal test result is 0.8 per 1000
women tested. The positive predictive
value of the BPS for evidence of true fetal
compromise is only 50 percent, with a
negative predictive value greater than
99.9 percent.
d. Indications and frequency of testing
(1) ACOG recommends antepartum test-
ing in the following situations:
(a) Women with high-risk factors for fetal
asphyxia should undergo antepartum
fetal surveillance with tests (eg, BPS,
nonstress test)
(b) Testing may be initiated as early as
26 weeks of gestation when clinical
conditions suggest early fetal compro-
mise is likely. Initiating testing at 32 to
34 weeks of gestation is appropriate
for most pregnancies at increased
risk of stillbirth.
(c) A reassuring test (eg, BPS of 8 to 10)
should be repeated periodically
(weekly or twice weekly) until delivery
when the high-risk condition persists.
(d) Any significant deterioration in the
clinic al s tatus (eg, worsening
preeclampsia, decreased fetal activ-
ity) requires fetal reevaluation.
(e) Severe oligohydramnios (no vertical
pocket >2 cm or amniotic fluid index
<5) requires either delivery or close
maternal and fetal surveillance.
(f) Induction of labor may be attempted
with abnormal antepartum testing as
long as the fetal heart rate and con-
tractions are monitored continuously
and are reassuring. Cesarean deliv-
ery is indicated if there are repetitive
late decelerations.
(2) The minimum gestational age for testing
should reflect the lower limit that interven-
tion with delivery would be considered.
This age is now 24 to 25 weeks.
(3) Modified biophysical profile. Assess-
ment of amniotic fluid volume and
nonstress testing appear to be as reliable
a predictor of long-term fetal well-being
as the full BPS. The rate of stillbirth within
one week of a normal modified BPS is
the same as with the full BPS, 0.8 per
1000 women tested.
Prevention of D Isoimmunization
The morbidity and mortality of Rh hemolytic disease can
be significantly reduced by identification of women at risk
for isoimmunization and by administration of D immuno-
globulin. Administration of D immunoglobulin [RhoGAM,
Rho(D) immunoglobulin, RhIg] is very effective in the
preventing isoimmunization to the D antigen.
I. Prenatal testing
A. Routine prenatal laboratory evaluation includes
ABO and D blood type determination and antibody
screen.
B. At 28-29 weeks of gestation woman who are D
negative but not D isoimmunized should be re-
tested for D antibody. If the test reveals that no D
antibody is present, prophylactic D immunoglobulin
[RhoGAM, Rho(D) immunoglobulin, RhIg] is indi-
cated.
C. If D antibody is present, D immunoglobulin will not
be beneficial, and specialized management of the
D isoimmunized pregnancy is undertaken to man-
age hemolytic disease of the fetus and hydrops
fetalis.
II. Routine administration of D immunoglobulin
A. Abortion. D sensitization may be caused by abor-
tion. D sensitization occurs more frequently after
induced abortion than after spontaneous abortion,
and it occurs more frequently after late abortion
than after early abortion. D sensitization occurs
following induced abortion in 4-5% of susceptible
women. All unsensitized, D-negative women who
have an induced or spontaneous abortion should
be treated with D immunoglobulin unless the father
is known to be D negative.
B. Dosage of D immunoglobulin is determined by the
stage of gestation. If the abortion occurs before 13
weeks of gestation, 50 mcg of D immunoglobulin
prevents sensitization. For abortions occurring at
13 weeks of gestation and later, 300-mcg is given.
C. Ectopic pregnancy can cause D sensitization. All
unsensitized, D-negative women who have an
ectopic pregnancy should be given D immunoglob-
ulin. The dosage is determined by the gestational
age, as described above for abortion.
D. Amniocentesis
1. D isoimmunization can occur after amniocente-
sis. D immunoglobulin, 300 mcg, should be
administered to unsensitized, D-negative,
susceptible patients following first- and second-
trimester amniocentesis.
2. Following third-trimester amniocentesis, 300
mcg of D immunoglobulin should be adminis-
tered. If amniocentesis is performed and delivery
is planned within 48 hours, D immunoglobulin
can be withheld until after delivery, when the
newborn can be tested for D positivity. If the
amniocentesis is expected to precede delivery
by more than 48 hours, the patient should re-
ceive 300 mcg of D immunoglobulin at the time
of amniocentesis.
E. Antepartum prophylaxis
1. Isoimmunized occurs in 1-2% of D-negative
women during the antepartum period. D immu-
noglobulin, administered both during pregnancy
and postpartum, can reduce the incidence of D
isoimmunization to 0.3%.
2. Antepartum prophylaxis is given at 28-29 weeks
of gestation. Antibody-negative, Rh-negative
gravidas should have a repeat assessment at 28
weeks. D immunoglobulin (RhoGAM, RhIg), 300
mcg, is given to D-negative women. However, if
the father of the fetus is known with certainty to
be D negative, antepartum prophylaxis is not
necessary.
F. Postpartum D immunoglobulin
1. D immunoglobulin is given to the D negative
mother as soon after delivery as cord blood
findings indicate that the baby is Rh positive.
2. A woman at risk who is inadvertently not given D
immunoglobulin within 72 hours after delivery
should still receive prophylaxis at any time up
until two weeks after delivery. If prophylaxis is
delayed, it may not be effective.
3. A quantitative Kleihauer-Betke analysis should
be performed in situations in which significant
maternal bleeding may have occurred (eg, after
maternal abdominal trauma, abruptio placentae,
external cephalic version). If the quantitative
determination is thought to be more than 30 mL,
D immune globulin should be given to the
mother in multiples of one vial (300 mcg) for
each 30 mL of estimated fetal whole blood in her
circulation, unless the father of the baby is
known to be D negative.
G. Abruptio placentae, placenta previa, cesarean
delivery, intrauterine manipulation, or manual
removal of the placenta may cause more than 30
mL of fetal-to-maternal bleeding. In these condi-
tions, testing for excessive bleeding (Kleihauer-
Betke test) or inadequate D immunoglobulin dos-
age (indirect Coombs test) is necessary.
References: See page 282.
Complications of Preg-
nancy
Nausea and Vomiting of Preg-
nancy and Hyperemesis
Gravidarum
Nausea and vomiting to affects about 70% to 85% of
pregnant women. Symptoms of nausea and vomiting of
pregnancy (NVP) are most common during the first
trimester; however, some women have persistent nausea
for their entire pregnancy. Hyperemesis often occurs in
association with high levels of human chorionic gonado-
tropin (hCG), such as with multiple pregnancies,
trophoblastic disease, and fetal anomalies such as
triploidy.
Viral gastroenteritis
Gestational trophoblastic disease
Hepatitis
Urinary tract infection
Multifetal gestation
Gallbladder disease
Migraine
Antihistamines
Phenothiazines
Prokinetic agents
Metoclopramide (Reglan) 10 to 20 mg po/iv every 6
hr
Corticosteroids
F. Pharmacologic Therapy
1. Prescribed medication is the next step if dietary
modifications and vitamin B6 therapy with
doxylamine are ineffective. The phenothiazines
are safe and effective, and promethazine
(Phenergan) often is tried first. One of the dis-
advantages of the phenothiazines is their
potential for dystonic effects.
2. Metoclopramide (Reglan) is the antiemetic
drug of choice in pregnancy in several Euro-
pean countries. There was no increased risk of
birth defects.
3. Ondansetron (Zofran) has been compared
with promethazine (Phenergan), and the two
drugs are equally effective, but ondansetron is
much more expensive. No data have been
published on first trimester teratogenic risk with
ondansetron.
II. Hyperemesis gravidarum
A. Hyperemesis gravidarum occurs in the extreme
0.5% to 1% of patients who have intractable vomit-
ing. Patients with hyperemesis have abnormal
electrolytes, dehydration with high urine-specific
gravity, ketosis and acetonuria, and untreated
have weight loss >5% of body weight. Intravenous
hydration is the first line of therapy for patients with
severe nausea and vomiting. Administration of
vitamin B1 supplements may be necessary to
prevent Wernicke's encephalopathy.
B. Antiemetics are given parenterally to patients with
hyperemesis. Corticosteroids may have a benefit
in hyper-emesis if other antiemetic therapy has
failed. One proposed regimen is
methylprednisolone 15 to 20 mg given intrave-
nously every 8 hours. A methylprednisolone oral
taper regimen is more effective than oral
promethazine.
References: See page 282.
Spontaneous Abortion
Abortion is defined as termination of pregnancy resulting
in expulsion of an immature, nonviable fetus. A fetus of
<20 weeks gestation or a fetus weighing <500 gm is
considered an abortus. Spontaneous abortion occurs in
15% of all pregnancies.
I. Threatened abortion is defined as vaginal bleeding
occurring in the first 20 weeks of pregnancy, without
the passage of tissue or rupture of membranes.
A. Symptoms of pregnancy (nausea, vomiting, fatigue,
breast tenderness, urinary frequency) are usually
present.
B. Speculum exam reveals blood coming from the
cervical os without amniotic fluid or tissue in the
endocervical canal.
C. The internal cervical os is closed, and the uterus is
soft and enlarged appropriate for gestational age.
D. Differential diagnosis
1. Benign and malignant lesions. The cervix often
bleeds from an ectropion of friable tissue.
Hemostasis can be accomplished by applying
pressure for several minutes with a large swab or
by cautery with a silver nitrate stick. Atypical
cervical lesions are evaluated with colposcopy
and biopsy.
2. Disorders of pregnancy
a. Hydatidiform mole may present with early
pregnancy bleeding, passage of grape-like
vesicles, and a uterus that is enlarged in
excess of that expected from dates. An ab-
sence of heart tones by Doppler after 12
weeks is characteristic. Hyperemesis,
preeclampsia, or hyperthyroidism may be
present. Ultrasonography confirms the diag-
nosis.
b. Ectopic pregnancy should be excluded when
first trimester bleeding is associated with
pelvic pain. Orthostatic light-headedness,
syncope or shoulder pain (from diaphragmatic
irritation) may occur.
(1) Abdominal tenderness is noted, and pelvic
examination reveals cervical motion ten-
derness.
(2) Serum beta-HCG is positive.
E. Laboratory tests
1. Complete blood count. The CBC will not reflect
acute blood loss.
2. Quantitative serum beta-HCG level may be
positive in nonviable gestations since beta-HCG
may persist in the serum for several weeks after
fetal death.
3. Ultrasonography should detect fetal heart
motion by 7 weeks gestation or older. Failure to
detect fetal heart motion after 9 weeks gestation
should prompt consideration of curettage.
F. Treatment of threatened abortion
1. Bed rest with sedation and abstinence from
intercourse.
2. The patient should report increased bleeding
(>normal menses), cramping, passage of tissue,
or fever. Passed tissue should be saved for
examination.
II. Inevitable abortion is defined as a threatened abor-
tion with a dilated cervical os. Menstrual-like cramps
usually occur.
A. Differential diagnosis
1. Incomplete abortion is diagnosed when tissue
has passed. Tissue may be visible in the vagina
or endocervical canal.
2. Threatened abortion is diagnosed when the
internal os is closed and will not admit a finger-
tip.
3. Incompetent cervix is characterized by dilata-
tion of the cervix without cramps.
B. Treatment of inevitable abortion
1. Surgical evacuation of the uterus is necessary.
2. D immunoglobulin (RhoGAM) is administered to
Rh-negative, unsensitized patients to prevent
isoimmunization. Before 13 weeks gestation, the
dosage is 50 mcg IM; at 13 weeks gestation, the
dosage is 300 mcg IM.
III. Incomplete abortion is characterized by cramping,
bleeding, passage of tissue, and a dilated internal os
with tissue present in the vagina or endocervical canal.
Profuse bleeding, orthostatic dizziness, syncope, and
postural pulse and blood pressure changes may occur.
A. Laboratory evaluation
1. Complete blood count. CBC will not reflect
acute blood loss.
2. Rh typing
3. Blood typing and cress-matching.
4. Karyotyping of products of conception is com-
pleted if loss is recurrent.
B. Treatment
1. Stabilization. If the patient has signs and symp-
toms of heavy bleeding, at least 2 large-bore IV
catheters (<16 gauge) are placed. Lactate
Ringer’s or normal saline with 40 U oxytocin/L is
given IV at 200 mL/hour or greater.
2. Products of conception are removed from the
endocervical canal and uterus with a ring for-
ceps. Immediate removal decreases bleeding.
Curettage is performed after vital signs have
stabilized.
3. Suction dilation and curettage
a. Analgesia consists of meperidine (Demerol),
35-50 mg IV over 3-5 minutes until the patient
is drowsy.
b. The patient is placed in the dorsal lithotomy
position in stirrups, prepared, draped, and
sedated.
c. A weighted speculum is placed intravaginally,
the vagina and cervix are cleansed, and a
paracervical block is placed.
d. Bimanual examination confirms uterine posi-
tion and size, and uterine sounding confirms
the direction of the endocervical canal.
e. Mechanical dilatation is completed with
dilators if necessary. Curettage is performed
with an 8 mm suction curette, with a single-
tooth tenaculum on the anterior lip of the
cervix.
4. Post-curettage. After curettage, a blood count
is ordered. If the vital signs are stable for several
hours, the patient is discharged with instructions
to avoid coitus, douching, or the use of tampons
for 2 weeks. Ferrous sulfate and ibuprofen are
prescribed for pain.
5. Rh-negative, unsensitized patients are given IM
RhoGAM.
6. Methylergonovine (Methergine), 0.2 mg PO
q4h for 6 doses, is given if there is continued
moderate bleeding.
IV.Complete abortion
A. A complete abortion is diagnosed when complete
passage of products of conception has occurred.
The uterus is well contracted, and the cervical os
may be closed.
B. Differential diagnosis
1. Incomplete abortion
2. Ectopic pregnancy. Products of conception
should be examined grossly and submitted for
pathologic examination. If no fetal tissue or villi
are observed grossly, ectopic pregnancy must
be excluded by ultrasound.
C. Management of complete abortion
1. Between 8 and 14 weeks, curettage is neces-
sary because of the high probability that the
abortion was incomplete.
2. D immunoglobulin (RhoGAM) is administered to
Rh-negative, unsensitized patients.
3. Beta-HCG levels are obtained weekly until zero.
Incomplete abortion is suspected if beta-HCG
levels plateau or fail to reach zero within 4
weeks.
V. Missed abortion is diagnosed when products of
conception are retained after the fetus has expired. If
products are retained, a severe coagulopathy with
bleeding often occurs.
A. Missed abortion should be suspected when the
pregnant uterus fails to grow as expected or when
fetal heart tones disappear.
B. Amenorrhea may persist, or intermittent vaginal
bleeding, spotting, or brown discharge may be
noted.
C. Ultrasonography confirms the diagnosis.
D. Management of missed abortion
1. CBC with platelet count, fibrinogen level, partial
thromboplastin time, and ABO blood typing and
antibody screen are obtained.
2. Evacuation of the uterus is completed after fetal
death has been confirmed. Dilation and evacua-
tion by suction curettage is appropriate when the
uterus is less than 12-14 weeks gestational size.
3. D immunoglobulin (RhoGAM) is administered
to Rh-negative, unsensitized patients.
References: See page 282.
<100 0 5%dextrose/Lactated
Ringer's solution
Diabetes Mellitus
Approximately 4 percent of pregnant women have diabe-
tes: 88 percent have gestational diabetes mellitus, while
the remaining 12 percent have pregestational diabetes.
Of those with pregestational diabetes, 35 percent have
type 1 and 65 percent type 2 diabetes.
I. Glycemic control and fetal and maternal complica-
tions
A. Pregnancy in diabetes is associated with an in-
crease in risk of congenital anomalies and sponta-
neous abortions in women who are in poor glycemic
control during the period of fetal organogenesis,
which is nearly complete at seven weeks
postconception.
B. Macrosomia. Another consequence of poor
glycemic control in pregnant women with diabetes
is fetal macrosomia, which leads to dystocia, an
increased need for cesarean delivery, and an
increase in fetal morbidity.
C. Glucose monitoring. Frequent measurements of
blood glucose are mandatory in women with type 1
diabetes during pregnancy. If the first morning
blood glucose value is high, testing should also be
performed at bedtime and in middle of the night.
Test Frequency
Preterm Labor
Preterm labor is the leading cause of perinatal morbidity
and mortality in the United States. It usually results in
preterm birth, a complication that affects 8 to 10 percent
of births.
Medi- Mechanism of
cation action Dosage
• Hypokalemia
• Hyperglycemia
• Hypotension
• Pulmonary edema
• Arrhythmias
• Cardiac insufficiency
• Myocardial ischemia
• Maternal death
B. Corticosteroid therapy
1. Dexamethasone and betamethasone are the
preferred corticosteroids for antenatal therapy.
Corticosteroid therapy for fetal maturation re-
duces mortality, respiratory distress syndrome
and intraventricular hemorrhage in infants be-
tween 24 and 34 weeks of gestation.
2. In women with preterm premature rapture of
membranes (PPROM), antenatal corticosteroid
therapy reduces the risk of respiratory distress
syndrome. In women with PPROM at less than
30 to 32 weeks of gestation, in the absence of
clinical chorioamnionitis, antenatal corticosteroid
use is recommended because of the high risk of
intraventricular hemorrhage at this early gesta-
tional age.
Medication Dosage
Betamethasone 12 mg IM every 24 hours for two
(Celestone) doses
Diagnosis of Preeclampsia
Drug Dose
6 6 15 40
7. M a n a g e m e n t o f o x y t o c i n - i n d u c e d
hyperstimulation
a. The most common adverse effect of
hyperstimulation is fetal heart rate decelera-
tion associated with uterine
hyperstimulation. Stopping or decreasing
the dose of oxytocin may correct the abnor-
mal pattern.
b. Additional measures may include changing
the patient to the lateral decubitus position
and administering oxygen or more intrave-
nous fluid.
c. If oxytocin-induced uterine hyperstimulation
does not respond to conservative measures,
intravenous terbutaline (0.125-0.25 mg) or
magnesium sulfate (2-6 g in 10-20% dilu-
tion) may be used to stop uterine contrac-
tions.
References: See page 282.
Shoulder Dystocia
Shoulder dystocia, defined as failure of the shoulders to
deliver following the head, is an obstetric emergency. The
incidence varies from 0.6% to 1.4% of all vaginal deliver-
ies. Up to 30% of shoulder dystocias can result in brachial
plexus injury; many fewer sustain serious asphyxia or
death. Most commonly, size discrepancy secondary to
fetal macrosomia is associated with difficult shoulder
delivery. Causal factors of macrosomia include maternal
diabetes, postdates gestation, and obesity. The fetus of
the diabetic gravida may also have disproportionately
large shoulders and body size compared with the head.
I. Prediction
A. The diagnosis of shoulder dystocia is made after
delivery of the head. The “turtle” sign is the retrac-
tion of the chin against the perineum or retraction of
the head into the birth canal. This sign demon-
strates that the shoulder girdle is resisting entry into
the pelvic inlet, and possibly impaction of the
anterior shoulder.
B. Macrosomia has the strongest association. ACOG
defines macrosomia as an estimated fetal weight
(EFW) greater than 4500 g.
C. Risk factors for macrosomia include maternal birth
weight, prior macrosomia, preexisting diabetes,
obesity, multiparity, advanced maternal age, and a
prior shoulder dystocia. The recurrence rate has
been reported to be 13.8%, nearly seven times the
primary rate. Shoulder dystocia occurs in 5.1% of
obese women. In the antepartum period, risk
factors include gestational diabetes, excessive
weight gain, short stature, macrosomia, and
postterm pregnancy. Intrapartum factors include
prolonged second stage of labor, abnormal first
stage, arrest disorders, and instrumental (especially
midforceps) delivery. Many shoulder dystocias will
occur in the absence of any risk factors.
II. Management
A. Shoulder dystocia is a medical and possibly surgi-
cal emergency. Two assistants should be called for
if not already present, as well as an anesthesiolo-
gist and pediatrician. A generous episiotomy should
be cut. The following sequence is suggested:
1. McRoberts maneuver: The legs are removed
from the lithotomy position and flexed at the
hips, with flexion of the knees against the abdo-
men. Two assistants are required. This maneu-
ver may be performed prophylactically in antici-
pation of a difficult delivery.
2. Suprapubic pressure: An assistant is re-
quested to apply pressure downward, above the
symphysis pubis. This can be done in a lateral
direction to help dislodge the anterior shoulder
from behind the pubic symphysis. It can also be
performed in anticipation of a difficult delivery.
Fundal pressure may increase the likelihood of
uterine rupture and is contraindicated.
3. Rotational maneuvers: The Woods' corkscrew
maneuver consists of placing two fingers against
the anterior aspect of the posterior shoulder.
Gentle upward rotational pressure is applied so
that the posterior shoulder girdle rotates anteri-
orly, allowing it to be delivered first. The Rubin
maneuver is the reverse of Woods's maneuver.
Two fingers are placed against the posterior
aspect of the posterior (or anterior) shoulder and
forward pressure applied. This results in
adduction of the shoulders and displacement of
the anterior shoulder from behind the symphysis
pubis.
4. Posterior arm release: The operator places a
hand into the posterior vagina along the infant's
back. The posterior arm is identified and fol-
lowed to the elbow. The elbow is then swept
across the chest, keeping the elbow flexed. The
fetal forearm or hand is then grasped and the
posterior arm delivered, followed by the anterior
shoulder. If the fetus still remains undelivered,
vaginal delivery should be abandoned and the
Zavanelli maneuver performed followed by
cesarean delivery.
5. Zavanelli maneuver: The fetal head is replaced
into the womb. Tocolysis is recommended to
produce uterine relaxation. The maneuver
consists of rotation of the head to occiput ante-
rior. The head is then flexed and pushed back
into the vagina, followed abdominal delivery.
Immediate preparations should be made for
cesarean delivery.
6. If cephalic replacement fails, an emergency
symphysiotomy should be performed. The ure-
thra should be laterally displaced to minimize the
risk of lower urinary tract injury.
B. The McRoberts maneuver alone will successfully
alleviate the shoulder dystocia in 42% to 79% of
cases. For those requiring additional maneuvers,
vaginal delivery can be expected in more than 90%.
Finally, favorable results have been reported for the
Zavanelli maneuver in up to 90%.
References: See page 282.
Induction of Labor
Induction of labor refers to stimulation of uterine contrac-
tions prior to the onset of spontaneous labor. Between
1990 and 1998, the rate of labor induction doubled from
10 to 20 percent.
I. Indications for labor induction:
A. Preeclampsia/eclampsia, and other hypertensive
diseases
B. Maternal diabetes mellitus
C. Prelabor rupture of membranes
D. Chorioamnionitis
E. Intrauterine fetal growth restriction (IUGR)
F. Isoimmunization
G. In-utero fetal demise
H. Postterm pregnancy
II. Absolute contraindications to labor induction:
A. Prior classical uterine incision
B. Active genital herpes infection
C. Placenta or vasa previa
D. Umbilical cord prolapse
E. Fetal malpresentation, such as transverse lie
II. Requirements for induction
A. Prior to undertaking labor induction, assessments of
gestational age, fetal size and presentation, clinical
pelvimetry, and cervical examination should be
performed. Fetal maturity should be evaluated, and
amniocentesis for fetal lung maturity may be needed
prior to induction.
B. Clinical criteria that confirm term gestation:
1. Fetal heart tones documented for 30 weeks by
Doppler.
2. Thirty-six weeks have elapsed since a serum or
urine human chorionic gonadotropin (hCG)
pregnancy test was positive.
3. Ultrasound measurement of the crown-rump
length at 6 to 11 weeks of gestation or biparietal
diameter/femur length at 12 to 20 weeks of
gestation support a clinically determined gesta-
tional age equal to or greater than 39 weeks.
C. Assessment of cervical ripeness
1. A cervical examination should be performed
before initiating attempts at labor induction.
2. The modified Bishop scoring system is most
commonly used to assess the cervix. A score is
calculated based upon the station of the present-
ing part and cervical dilatation, effacement,
consistency, and position.
0 1 2 3
Drug Protocol
Methylergonovine 0.2 mg IM
(Methergine)
F. Volume replacement
1. Patients with postpartum hemorrhage that is refrac-
tory to medical therapy require a second large-bore
IV catheter. If the patient has had a major blood
group determination and has a negative indirect
Coombs test, type-specific blood may be given
without waiting for a complete cross-match. Lac-
tated Ringer's solution or normal saline is gener-
ously infused until blood can be replaced. Replace-
ment consists of 3 mL of crystalloid solution per 1
mL of blood lost.
2. A Foley catheter is placed, and urine output is
maintained at greater than 30 mL/h.
G. Surgical management of postpartum hemorrhage.
If medical therapy fails, ligation of the uterine or
uteroovarian artery, infundibulopelvic vessels, or
hypogastric arteries, or hysterectomy may be indi-
cated.
H. Management of uterine inversion
1. The inverted uterus should be immediately reposi-
tioned vaginally. Blood and/or fluids should be
administered. If the placenta is still attached, it
should not be removed until the uterus has been
repositioned.
2. Uterine relaxation can be achieved with a
halogenated anesthetic agent. Terbutaline is also
useful for relaxing the uterus.
3. Following successful uterine repositioning and
placental separation, oxytocin (Pitocin) is given to
contract the uterus.
References: See page 282.
Acute Endometritis
Acute endometritis is characterized by the presence of
microabscesses or neutrophils within the endometrial glands.
I. Classification of endometritis
A. Acute endometritis in the nonobstetric population is
usually related to pelvic inflammatory disease (PID)
secondary to sexually transmitted infections or
gynecologic procedures. Acute endometritis in the
obstetric population occurs as a postpartum infection,
usually after a labor concluded by cesarean delivery.
B. Chronic endometritis in the nonobstetric population is
due to infections (eg, chlamydia, tuberculosis, and
other organisms related to cervicitis and PID),
intrauterine foreign bodies (eg, intrauterine device,
submucous leiomyoma), or radiation therapy. In the
obstetric population, chronic endometritis is associated
with retained products of conception after a recent
pregnancy.
C. Symptoms in both acute and chronic endometritis
consist of abnormal vaginal bleeding and pelvic pain.
However, patients with acute endometritis frequently
have fevers in contrast to chronic endometritis.
II. Postpartum endometritis
A. Endometritis in the postpartum period refers to infection
of the decidua (ie, pregnancy endometrium), frequently
with extension into the myometrium (endomyometritis)
and parametrial tissues (parametritis).
B. The single most important risk factor for postpartum
endometritis is route of delivery. The incidence of
endometritis after a vaginal birth is less than three
percent, but is 5 to 10 times higher after cesarean
delivery.
C. Other proposed risk factors include prolonged labor,
prolonged rupture of membranes, multiple vaginal
examinations, internal fetal monitoring, maternal
diabetes, presence of meconium, and low socioeco-
nomic status.
D. Microbiology. Postpartum endometritis is usually a
polymicrobial infection, produced by a mixture of
aerobes and anaerobes from the genital tract.
Gram positive
Group B streptococci 8
Enterococci 7
S. epidermidis 9
Lactobacilli 4
Diphtheroids 2
S. Aureus 1
Gram negative
G. vaginalis 15
E. Coli 6
Enterobacterium spp. 2
P. mirabilis 2
Others 3
Anaerobic
S. bivius 11
Other Bacteroides spp. 9
Peptococci-peptostreptocc 22
i
Mycoplasma
U. urealyticum 39
M. hominis 11
C. trachomatis 2
References
References may be obtained at www.ccspublishing.com/ccs.
Commonly Used Formulas
A-a gradient = [(PB-PH2O) FiO2 - PCO2/R] - PO2 arterial
= (713 x FiO2 - pCO2/0.8 ) -pO2 arterial