Indications for weaning

1. Stable oxygenation
(PaO2/FiO2 >200); (PEEP
≤5cm H20)
2. Intact cough and airway
reflexes
3. No vasopressor agents
being administered
FAILURE: KILIPS CLASSIFICATION OF AMI with EXPECTED
1. RR ≥35 BPM for 5 HOSPITAL MORTALITY RATE
minutes Clas Clinical Presentation Expect
2. O2 sat <90% s ed
3. HR >140 BPM; 20% I No signs of pulmonary or 0-5%
increase/decrease from venous congestion
baseline II Moderate heart failure or 10-20%
4. Systolic BP <90/ >180 (+) of bibasal rales, S3
mm Hg gallop, tachypnea or sings
5. Increase anxiety of R heart failure inc.
diaphoresis venous and hepatic
SUCCESSFUL congestion
1. Breathing ratio of RR to III Severe heart failure, rales 35-45%
TV in L <105 >50% of the lung fields or
pulmonary edema
Criteria for Admission for CAP IV Shock with systolic pressure 85-95%
1. RR > 28 BPM of <90mm Hg and evidence
2. BP <90 mm Hg or 30 of peripheral
mm HG below baseline vasoconstriction, peripheral
3. New onset confusion or cyanosis, mental confusion
altered consciousness and oliguria
4. Hypoxemia: PO2 <60
while breathing Room Air
or o2 sat <90%
Leads Corresponding
5. Unstable comorbid
Areas
condtitons
6. Multilobular II, III, AVF Inferior wall
7. Pleural effusion I, AVF High Lateral
V1, V2 Septal
Glascow Coma Scale V3,V4 Anterior
Eyes V5, V6 Lateral
1. No response V1-V3 Anteroseptal
2. To pain V3-V6, I, Anterolateral
3. To command AVL
4. Spontaneously Mirror Posterior
Verbal Response image of V1
1. No response and V2
2. Incomprehensible All Diffuse/ global
words V3R, V4R RV wall
3. Inappropriate
words
4. Disoriented and Pericardial effusion
converses Small: 10mL
5. Oriented Moderate: 10-20mL
Motor Response Large: >20mL
1. No response
2. Decerebrate
3. Decorticate
4. Withdraws to pain
5. Localizes pain
6. Obeys to verbal
command Characteris Transuda Exudativ
tics te e
Spc gravity <1.016 >1.016
PF/S CHON <3g or 0.5 >3g or
>0.5
Fibrinogen Negative Positive
RBC <10,000 >10,000
WBC <1,000 >1,000
S. LDH <0.6 >0.6 SBP
PF/S LDH <200 IU >200 IU <150 -2
pH >7.3 <7.3 151-169 -1
Glucose Plasma 170-180 1
dec 181-199 2
Amylase >500 Scoring
u/mL ≥7 = 90% probable
bleed
Diff CT >50% >50% PMS
<7 = probable infarct
lymph

Thoracentesis
AORTIC ANEURYMS
Bottle 1 cell, ct different, total
De Bakey CHON, ldh
Type Ascending Aorta and Bottle 2 AFB, G/S, C/S
1 beyond Bottle 3 cytology and cell block
Type Ascending Aorta only
2
Type Aorta distal to the Indications for Mechanical
3 subclavian A. Ventilation
1. RR >35 BPM
Stanford 2. Inspiratory force <25
Type Ascending cmH20
A 3. Vital Capacity < 10-15
Type Descending cc/kg
B 4. PaO2 <60 mm Hg with
FiO2 >60%
5. PaCO2 >50mm Hg with pH
<7.35
6. Absent gag reflex
MURMUR GRADING
VR Set up
I So faint
TV-500
II Quiet but can be heard by BUR -16
stethoscope FiO2 100
III Loud PF -50
IV Moderately loud with thrill AC mode
V Very loud, audible with stet partly
off the chest
VI Very loud, audible with stet LIGHT’S CRITERIA
removed from the chest (exudative if any one of the ff)
1. Pleural CHON/ Serum CHON
>0.5
2. Pleural LDH/Serum LDH >0.6
3. Pleural LDH >2/3 upper limit
DIAZ STROKE SCALE
Character Grade
Vomiting 4 Motor Neuron Lesions
Level of Character UMN LMN
consciousness 4 Tone Hypertonic Hypotoni
Unarousable 2 clonus c
Drowsy 0 Fasciculati Neg Pos
Awake ons
Fever 3 Wasting Neg Pos
Respiratory pattern Reflexes Exagerated Neg
Ataxic/apneustic 3
Hyperventilation 2 Hepatic encephalopathy
Cheynes-strokes 1
Sta Mental Status Asterix EEG
Regular/Normal 0
ge ia
Upper GI bleed 3
I Euphoria or depression, Either N
Neuro deficit (max at 2 mild confusion, blurred
onset) speech, disorientation,
Headache 2 asleep
Nuchal rigidity 2 II Lethargy, moderate Pos AbN
DBP confusion
<90 -2 III Marked confusion, Pos AbN
91-99 0 incoherent speech,
>100 2 sleeping, arousable
IV Coma, initially Neg AbN 4. Inc WBC >12, 000
responsive to noxious 5. Dec WBC <4,000
stimuli; later 6. CBC >10%
unresponsive Bands

Indications for Thrombolytic

Therapy
1. Chest pain consistent with AMI
2. ECG changes Prerena Renal Post
a. ST segment elevation l renal
>/= 1 mm in atleast 2 Urine >500 <350 <350
contiguous leads Osmolality
b. ST segment elevation Spc >1.018 <1.015
>/= 2mm in atleast 2 Gravity
contiguous chest U/P >40 <20
leads or creatinine
c. New LBBB ratio
3. Time from chest pain to
Urine Na <20 >40 >40
thrombolytic treatment
a. <6h most beneficial BUN/ >20 <15 >15
b. 6-12h lesser but still Creatinine
important benefits FE Na (%) <1 >1 >4
c. 12-24h diminishing Renal <1 >1
benefits but may still failure
be useful in selected index
patients Sediment Acellular, Muddy Hyaline
Absolute Contraindication for transpar brown casts
Thrombolysis ent granular
1. Active internal bleeding hyaline cast
(except menses) cast
2. Recent (within 2 weeks) Causes Hypovole GN Calculi,
invasive or surgical procedure mia; dec vasculat CA,
3. Suspected aortic dissection CO, inc is, fibrosis
4. Previous hx of hemorrhagic resistanc ATN,
CVA or SAH e nephriti
5. Recent head trauma or known s
intracranial neoplasm
6. Persistent BP >200/120
Relative contraindication for
thrombolysis
1. Known bleeding diathesis
2. Prev streptokinase treatment
for the past 6-9 months
3. BP >/=180/100 on at least 2
readings
4. Active PUD
5. Hx of thrombotic CVA
6. Prolonged CPR >/= 10m or
traumatic CPR
7. Diabetic hemorrhagic
retinopathy or other
hemorrhagic ophthalmic
conditions
8. Pregnancy

5 Dressler’s Sign of Post-MI

Pericarditis
1. Pericarditis
2. Pneumonitis
3. Pleuritis
4. Pyrexia
5. Pain

SEPSIS (>2 or more)

1. Fever >38 or
<36
2. Tachypnea >24/min
3. Tachycardia >90/min
 DKA HSS
Stage Description GF Action
Glucose,a 13.9–33.3 (250– 33.3–66.6 (600– R
mmol/L 600) 1200) I Injury not >9 Diagnose and
(mg/dL) (asym acute with 0 treat
Sodium, 125–135 135–145 p) preserved progression,
meq/L GFR comorbid
Potassium Normal to Inc Normal conditions; dec
a
CV risk
II Mild kidney 60- Estimate rate of
Magnesiu Normal Normal (asym disease 89 progression
m p)
Chloride Normal Normal III Moderate 30- Treat
59 complications;
Phosphate Normal
ESRD, education
Creatinine Slightly inc. Moderately inc.
IV Severe 15- Prepare for ESRD
Osmolality 300-320 330-380 (symp 29 treatment
(mOsm/L) )
Plasma ++++ +/- V Kidney <1 Initiate ESRD
ketones (symp failure 5 treatment
Sodium <15 meq/L Normal to slightly )
bicarb dec
meq/L
Arterial 6.8-7.3 >7.3
pH
Arterial 20-30 Normal
Pco2 mm
Hg
Anion gap Inc Normal to slightly
[Na-cl + inc
HCO]

NYA Classification of CHF

IDyspnea occurs with greater
than ordinary physical activity
(climbs ≥2 flights of stairs with
ease
II Dyspnea occurs with ordinary
physical activity (climbs > 2
flights of stairs but with
difficulty)
III Dyspnea occurs with less than
ordinary physical activity
Neurologic Localizations
(climbs ≤2 flights of stairs)
IV Dyspnea may be present even Cerebell Limb/truncal ataxia
at rest um Intent tremors
Dysmetria and
dysdiadokinesia
Brainste Prominent cranial nerve
m deficit (CN III-XII)
Therapeutic Classification of
Ipsilateral CN deficits with
CHF
contralateral limb
A No restrictions motor/sensory deficits
B Severe effort restricted Ipsilateral CN deficits and
C Ordinary effort moderately cerebellar signs
restricted Cerebru Distured higher, intellectual
D Ordinary effort markedly m functions
restricted Emotional and behavioral
E Confined to bed/chair disturbances
Speech disturbances and
seizure
Basal Involuntary movement
ganglia Rigidity
Bradykinesia
Spinal Motor disturbances
Classification of CKD Cord (UMN/LMN)
 Sensory disturbances MVP Systolic murmur with
Autonomic disturbances mid systolic click seen
Peripher Motor disturbances (LMN, in young women
al distal and symmetrical) PDA` Continuous machinery
nerves Sensory disturbances like murmur
Autonomic disturbances
Myoneur Fatigability of muscles
al Proximal weakness of
Junction muscles Acute Respiratory Failure
(-) sensory or autonomic Type I Hypoxemia
disturbances (e.g. Pulmonary edema, pneumonia,
Muscles Motor disturbances etc)
(proximal and symmetrical) Type II Hypercarbia
(-) sensory or autonomic (e.g. Pneumothorax, Pleural effusion,
disturbances Atelectasis) with or with out
hypoxemia
Type Post-surgery patients
III
Dopamine Drips Type Shock
2-5 Vasodilator effect in the IV
µg/kg/min renal vasculature
5-16 Modest increase in
µg/kg/min myocardial contractility
and rate
>15 Vasoconstrictive agent
µg/kg/min

Approach to patient in COMA

1. Level of Consciousness
CSF u a. Cortical – Content
Normal Bac Viral TB b. ARAS and
Color Colorles Turbid; Clear Xanto- Brainstem –
s Greeni Cloudy chromm Arousal/wakefulne
sh ic ss
CHON 15- Inc Mild Inc Mild Inc c. Medullary – N
45mg/dl waking and
sleeping
Pressu 30- Inc Normal Normal
re 180mm 200- Mild Inc Mild Inc 2. Respiratory Pattern
H20 500 a. Chyne stroke –
diencephalon,
Glucos 45- Dec Normal Dec
diffuse cervical
e 70mg/d
b. Hyperventilation –
L
brainstem
Cells <6 Inc Lymph Lymph
c. Apneustic – PONS
lymph PMNs AFB
d. Ataxic cluster –
1000- stain
medulla
10000
3. Pupillary Size and
WBC
Reaction
a. Small reactive –
metabolic/
diencephalic
COMMON MURMURS b. Midpoint, fixed –
Aortic Crescendo-descrendo Midbrain
Stenosis systolic murmur c. Pinpoint – pons
Aortic High pitched blowing d. Larged fixed –
Regurgitatio murmur tectal
n 4. Diencephalic Reflexes –
Mitral Rumbling late diastolic brainstem
Stenosis murmur following a 5. Motor Responses
snap a. Decerebrate –
VSD/Mitral Holosystolic blowing Brainstem
Tricuspid murmur b. Decorticate –
Incompeten above internal
ce capsule
 WHO guidelines for PTB 3
Ca Initial Cont
t
1 New smear positive 2 HRZE 4HRE
TB with extensive
parenchymal
involvement; new
case of severe form
of extrapulmo TB
II Sputum smear 2 5 HRE
Anatomic Localizations in Stroke
positive relapse; txt HRZES
failure; txt +1 Cerebral Hemisphere, Lateral Aspect
interruption HRZE (MCA)
III New smear neg PTB; 2 HRZ 4HRE  Hemiparesis
new less severe  Hemisensory deficit
form of  Motor aphasia (Broca’s)
extrapulmonary TB  Central aphasia (Wernicke’s)
 Unilateral neglect, apraxias
H-Isoniazid; R-Rifmapicin; Z-
 Homonnymous hemianopia or
Pyrazinamide; E-ethambutol; S-
quadrantanopia
Streptomycin
 Gaze preference contralateral
to the lesion
Cerebral Hemispheres, Medial Aspect
(ACA)
First line Drugs in TB
 Paralysis of foot and leg with
Dru Action Dosage Metab S.E. or without paresis of arm
g  Cortical sensory loss over leg
H Cidal; 5mg/kg/d Liver Hepatitis;  Grasp or sucking reflexes
Both ay safest in  Urinary incontinence
pregnancy  Gait apraxia
R Cidal; 10-20 Liver Hepatitis; Cerebral Hemisphere, Posterior
Both mg/kg/da hemolysis; Aspect (PCA)
y thrombo-  Homonymous hemianopia
cytopenia  Cortical blindness
Z Cidal; 20-30 Liver Most  Memory deficit
intracel mg/kg/da hepato-  Dense sensory loss,
l- lular y toxic spontaneous pain,
ONLY dysesthesias, choreoathetosis
E Static; 15-20 Kidne Optic Brainstem, Midbrain (PCA)
Both mg/kg/da ys neuritis  Third nerve palsy and
y contralateral hemiplegia
S Static; 10-18 Kidne 8th nerve  Paralysis/paresis of vertical
Extrace mg/kg/da ys palsy eye movement
ll y  Convergence nystagmus,
disorientation
Brainstem, Pontomedullary Junction
(Basilar)
 Facial paralysis
PTB Classification (ATS)  Paresis of abduction of eye
 Paresis of conjugate gaze
Cla Exposur Infecti CXR Active
 Hemifacial sensory deficit
ss e on infiltrates Diseas
 Horner’s syndrome
e
 Diminished pain and thermal
0 (-) (-) (-) (-)
sense over half body (with or
1 (+) (-) (-) (-) without face)
2 (+) (+) (-) (-)  Ataxia
3 (+) (+) (+) (+) Brainstem, Lateral Medulla (Vertebral
4 (+) (+) (+) (-) A.)
5 (+) (+) (+) (+/-)  Vertigo, nystagmus
 Horner’s syndrome (miosis,
ptosis, dec sweating)
 Ataxia, falling toward side of
the lesion
 Impaired pain and thermal
sense over half body with or
without face

Ranson’s Criteria for Acute
Pancreatitis
At admission or diagnosis
 Age >55 yo
 Leukocytosis >16,000 per
cubic millimeter
 Hyperglycemia >11mmol/L
(>200 mg/dL)
 Serum LDH >400 IU/L
 Serum AST >250 IU/L
During initial 48 hours
 Fall in hematocrit by >10%
 Fluid deficit >4000mL
 Hypocalemia <1.9mmol/L
(<8.0 mg/dL)
 Hypoxemia (PO2 <60 mmHg)
 BUN rise >1.8 mmol/L
(>5mg/dL) after IV fluids
 Hypoalbuminemia <32g/L
(<3.2 g/dL)
Note: ≥3 factors at the time of
admission (1) during initial 48 hours
(2) indicates an increased mortality
rate. Patients need close monitoring
at the ICU
Blood Transfusion Order
 Transfuse _____ of _______ of
patient’s blood type after proper
crossmatching
 Baseline CP status and VS prior
to BT
 Mainline to PNSS at KVO
 Start initially at 5-10 µgtts/min
then increase to 20-25 µgtts
after an hour if without BT
reaction
 Monitor VS q15mins for the first
30 minutes while on BT, then
q30mins the following minutes
 Refer for dyspnea, fever,
itchiness
 Thank you
Criteria for Rheumatoid Arthritis
(1987 American College of
Rheumatology)
(Four out of the seven)
1. Morning stiffness – in and
around the joints lasting
one hour before maximal
improvement
2. Arthritis of three or more
joint areas – at least 3 joint
areas, observed by a
physician simultaneously,
have soft tissue swelling or
joint effusion, not just bony
overgrowth
3. Arthritis of hand joints –
arthritis of wrist,
metocarpophangeal joint,
proximal interphangeal
joint
4. Symmetric arthritis –
simultaneous involvement
of the same joint areas on
both sides of the body
5. Rheumatoid nodules –
subcutaneous nodules over
bony prominences,
extensor surfaces or
juxtaarticular regions
observed by MD
6. Serum rheumatoid factor –
demonstration of abnormal
amounts of serum
rheumatoid by any method
for which the result has
been positive in less than 5
percent of the normal
control subjects
7. Radiographic changes –
typical changes of RA on
posteroanterior hand and
wrist radiographs which
must include erosions or
unequivocal bony
decalcification localized in
or most marked adjacent
to the involved joints
Criteria 1-4 must be present for at
least 6 weeks
Criteria 2-5 must be observed by
MD
1982 Criteria for Classification of
Systemic Lupus Erythomatosus
(SLE)
1. Malar rash – fixed
erythema, flat or raised
over the malar eminences
2. Discoid rash –
erythematous raised
patches with adherent
keratotic scaling and
follicular plugging
3. Serositis – pleuritis or
pericarditis documented
on ECG, or rub or evidence
or pericardial effusion
4. Oral ulcers – oral and
nasopharyngeal ulcers
5. Arthritis – nonerosive
arthritis involving two or
more peripheral joints
 characterized by
tenderness, swelling or
effusion
6. Photosensitivity
7. Hematologic disorder –
hematolytic anemia or
leukopenia (<4000/uL) or
lymphopenia (<1500/uL)
or thmbocytopenia
(<100,000/uL)
8. Renal disorder –
proteinuria > 0.5 gm/day
or > than +3, or cellular
cast
9. Antinuclear antibody –
abnormal titer of ANAs by
immunofluorescense or an
equivalent assay at any
point in time in the
absence of drugs
10. Immunologic disorder –
Positive LE cell
preparation or anti-ds
DNA or anti-Sm antibodies
11. Neurologic disorder –
seizure without other
cause or psychosis
without other cause
 If FOUR of these criteria
are present any time
during the course of the
disease, a diagnosis of
SLE is made
 Some patients present
with only one or two
criteria but may have SLE
 Rule out drug induced
SLE: hydralazine, INH,
procainamide,
chlorpromazine and other
vasculitides