SGH notes

Stroke quality measures:

• DVT prophylaxis

• Anti-thrombotic at time of discharge

• AF with anticoagulation

• TPA < 2 hrs

• AT by D#2

• Statin at time of d/c

• Pt. edu

• Rehab assessment

• Stroke dysphagia screen

• Both Protein C and S reduced = lab error or Pt. on coumadin.

Shock lecture by Dr. P.

• Defnition:

  • SBP <90, MAP <60, hypoperfusion (MS changes, oliguria 0.5 ml/kg/hr; skin mottling), lactic acidosis.

• Types:

  • Hypovoelmic

    • Causes: Hypovolemic: trauma, GIB, ruptured Aorta, ruptured ectopic preg, burns, NH Pt. on diuretics.

    • Class I: 0 - 15% blood loss, tachy, capillary refill >3 sec

    • Class II: 15 - 30% blood loss, tachy, decreased pulse pressure, clammy skin, delayed capillary refill, orthostatic changes.

    • Class III: 30 - 40% blood loss; hypotensive

    • Class IV: >40%

  • Cardiogenic

    • AMI results in ~40% loss of viable myocardium. STEMI causes shock.

    • Papillary muscle rupture

    • VSD - free wall rupture

    • RV infarct: results in hypotension, JVD, no pulmonary edema. R. sided ECG.

    • VSD ( has thrill). Check TTE

    • Drug related: BB, CCB OD; Adriamycin, severe AS, MS; severe tachycardia (AF with RVR); bradyarrhythmia (3° HB)

  • Obstructive shock: AS, coarctation of aortia, PE, PTx, tamponade.

    • Tx cardiac tamponade medically with IVF bolus. Pericardiocentesis.

  • Distributive shock

    • septic

      • SIRS + end organ damage

        • • SIRS/Sepsis

            • Not a Dx but response to clinical condtions: pancreatitis, infection, burns, trauma. Characterized by two or more of the following:

            • Fever > 38 C, 100.4°F or <96.8°F or 36 C.

            • HR >90

            • RR >20

            • PaCO2 <32 mmHg

            • WBC: >12,000/uL or <4000/uL or 10% immature (band) form.

          • These findings should occur in the absence of other known causes of these abnormalities.

      • Sepsis: when there is evidence of inf + SIRS

      • Severe sepsis: organ dysfunction and hypoperfusion.

      • Septic shock: sepsis with hypotension despite adequate fluid resuscitation 40 - 60 mL/kg, or need of pressors; combined with altered mental status, oliguria, and/or lactic acidosis.

    • Neurogenic

      • loss of sympathetic tone resulting in hypotension

    • Anaphylactic

      • urticaria, angioedema, hypotension.

      • IV contrast - anaphylactoid shock, cause iodine is not an antigen.

      • Tx; with epi and steroids

• MRSA treated PO: Usually treated with Vancomycin, linezolid, daptomycin, or tigecycline. If you have to give PO equivalent, the following are suggested:

  • Bactrim, or doxycycline, linezolid (Zyvox), or clindamycin.

• MSSA: IV oxacallin/naficillin, dicloxacillin,

• If patient has history of pencillin allergy:

  • Rash: safe to use cephalosporin

  • Anaphylaxis: use vancomycin, macrolides (clarithromycin, azithromycin) or clindamycin

  • Severe infection: Vancomycin, linezolid, daptomycin

  • Minor infection: TMP/SMX, macrolides (azithromycin, clarithromycin), clindamycin

• Following medications are specific for Streptococcus: Penicillin, Ampicillin, Amoxicillin. All anti-staph medications are equally effective

• Medications that reduce seizure threshold and must not be given in patient's with h/o seizures:

  • Fluoroquinolones, metronidazole, monobactams, imipenems, cephalosporins, beta-lactamases, PCN.

  • Gram-negative bacilli (Rods):

    • Lactose fermenters: Mnemonic SEEK Carbs

      • Serratia

      • Enterobacter

      • Escherchia coli

      • Klebsiella sp.

      • Citrobacter

    • Nonlactose fermenters:

      • Morganella

      • Pseudomonas

• All of the following medications are effective for GNB: Cephalosporins, Cefepime, Ceftazidime

  • • Penicillins:

      • Piperacillin

      • Ticarcillin

    • Monobactam

      • Azteronam

    • Quinolones

      • Ciprofloxacin

      • Levofloxacin

        • Levofloxacin is a fluorquinolone that is effective in treatment of respiratory infections and UTI.

      • Gatifloxacin

      • Moxifloxacin

    • Aminoglycosides

      • Gentamicin

      • Tobramycin

      • Amikacin

    • Carbapenems

      • Imipenem

      • Meropenem

      • Ertapenem

    • Exceptions

      • Ertapenem is the only carbapenem that does not cover pseudomonas.

      • Piperacillin and ticarcillin also cover streptococci and anaerobes.

      • Levofloxacin, gatifloxacin, and moxifloxacin are excellent pneumococcal drugs.

      • Aminoglycosides work synergistically with other agents to treat staph and strep.

      • Carbapenems are excellent anti-anaerobic medications. They cover streptococci and all sensitive staphylococcus (MSSA).

      • Tigecycline covers MRSA and is broadly active against gram-negative bacilli.

  • Anaerobes

  • GI anaerobes (bacteroides): Metronidazole is the best medication for abdominal anaerobes. Carbapenems, piperacillin, and ticarcillin are equal in efficacy for abdominal anaerobes compared to metronidazole. Cefoxitin and cefotetan (in the cephamycin class) are the only cephalosporins that cover anerobes.

  • Respiratory anaerboes (anaerobic strep): Clindamycin is the best drug for anaerobic strep.

  • Medications with no anaerobic coverage:

    • Aminoglycosides

    • Aztreonam

    • Fluroquinolones

    • Oxacillin/naficillin

    • Cephalosporins, except cefoxitin and cefotetan.

• Criteria for cholecystitis - severity score to determine need for surgery. American Society of Anesthesiologists physical status scale