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- ref: New Strategies ... -
July 1998 - AFP
- meds I use are in asthma therapeutics. Other very
rarely used meds include:
- epinephrine (1:1000) .01 ml/kg/dose q 20 min. max 3/24h
- susphrine 0.005 ml/kg/dose s/q q6h
- isuprel: 0.25-0.5 ml (0.02 ml/kg/dosin 2.5-3.0 ml NSS q 1-2 h
- theophyllines: choledyl elixir (oxytriphylline): 5-7 mg/kg/dose q6h (MAX 800 mg) Theodur
typically 400 - 600 mg daily.
- poor response to therapy, esp. steroids: reevaluate diagnosis, consider reflux and
- use if failing inhaled steroids, along with long acting beta agonist inhaler
- may substitute for inhaled steroids in mild to moderate asthma
- age 12+ 20mg BID empty stomach
- pregnancy category B
|Less toxicity, but not impressive efficacy.
- adjunct in exercise-induced asthma
- improves FEV1
- 2-5 yrs: 4mg
- 6-14 yrs: 5mg chewabel in evening
- 15+ 10 mg in evening
- pregnancy category B
|No major interactions. Safety, age range, and dosing mean
this is likely a "keeper", even though efficacy is limited.
- exercise and aspirin induced asthma
- immediate FEV1 improvement
- age 12+ 600 mg QID
- pregnancy C
|Liver toxicity, drug interactions, lousy dosing schedule.
This drug won't last long.
- 0 - 18 mo: cough-variant asthma or aberrant innominate artery. Foreign body.
- 18 mo - 6 y: cough-variant asthma and sinusitis
- 6 y - 16 y: cough-variant asthma and psychogenic
- adult: post-infectious, asthma, GERD, postnasal drip, ACE-inhibitor, Pertussis
(esp. if < 6 weeks). Rare: Tb, Work, Infec, bronchiectasis, sarcoidosis, LVG,
interstitial lung disease, breast CA met, primary lung CA, hyperthyroid, carcinoid,
Hodgkin's, Zenker's divertic, foreign body.
- non-ACE, normal CXR: Consider PFT + methacholine, PPD, sinus CT, EGD
- try: antihistamine-decongestant, nasal steroids/Atrovent for 2 weeks
- try: add bronchodilator/inhaled steroids for 2 weeks
- try: GERD therapy (prilosec) for 2 weeks
Pleural Effusion And Thoracentesis
typical target is in post. mediolat. area; 7-8th interspace.
TRAY contents (if not preset):CONSENT, vacuum bottles, anaerobic and aerobic culture
media, #15 scalpel, gloves, valium or s/l ativan. Tubes: EDTA, blue, purple, and red tops,
blood gas. Send for pH, LDH, protein, glucose, culture, gram stain, AFB, cytology,
amylase, triglycerides, cell count and diff, gases (complement).
- anesth. rib and periosteum. Change to #19, advance to pleura and anesth pleura liberally
- attach #18 to 50 ml syringe and wd 30 ml. Take fluid for blood gas. May use 3-way
stopcock to take blood gas, 30 ml sample, and drain to vacuum bottle (vi).
- inject into purple top (cell count), red top (LDH, protein, amylase, glucose,
triglycerideand clear (C&S, gm stain, acid fastubes. Either inject into anaerobic
medium or save in sealed tube.
- remove remainder (up to 1 liteinto vacuum bottles for cell block/cytology. May switch to
large bore (#14 needle).
- similar to above but use #16 DESERET subclavian catheter and 3 way stopcock. Withdraw
needle partly and leave catheter in place.
- glucose: <40 mg/dl; empyema, RA and tb
- amylase: incr. in pancreatitis and esoph. rupture
- trigly: incr. in chylous effusion
- LDH and protein: diff transudate vs exudate
- ph: <7.3 in empyema, malignancy, CVD, esophageal rupture.
Always rule out PE and tb. Exudate: fluid/serum protein < 0.5, fluid LDH
>200, fluid/serum LDS >0.6, fluid protein > 3.
Transudate (protein < 3mg/dl)
- CHF - atelectasis - cirrhosis
- nephrotic syndrome
- (Meig's syndrome of Rt sided effusion with ovarian malignancy)
Exudate (protein > 3mg/dl)
- pnemonia (40% have effusion)
- pulmonary infarct (bloody, fever <101)
- tb (lymphocytic, +AFB)
- malignancy: breast, lung, prostate, lymphoma, ovary, gastric, melanoma (esp.
- pancreatitis (hi amylase)
- post-splenectomy (hard diff. from subphrenic abscess)
- RA (lo glu, pH; hi LDH, lo complement)
- SLE (glu = blood glu, may be transudate)
- MISC: lymphoproliferative disease, primary lymphedema, myxedema, peritoneal dialysis.
Chest Tube Sclerosis
Give demerol/phenergan 1/2h prior to proceedure.
Need 21 gauge needle, 7.5 gloves, betadine wipes, 2 chest tube clamps and blue pagd.
Clamp distal to the tube connector and inject the xylocaine, then the sclerosing solution
(slowlthen the saline. Wait 1/2 hour then UNCLAMP.
need sclerosing solutions plus:
- lidocaine 1% 20 ml in 50 ml NSS
- 30 to 50 ml NSS
sclerosing solutions (one or the other):
- tetracycline 2 gm in 50 ml NSS
- 150 mg atabrine and 15 ml 1% xylocaine and add NSS to total 50 ml
- home oximetry: >1% of time at O2 sat < 90% (screening)
- > 15 episodes of O2 sat < 4% below baseline (specific)
- indeterminant measures require further referral/sleep studies
- If normal test no further testing needed. If positive (as above) do PSG.
DATED MATERIAL. See also: Critical Care Values and Cardiology. This
stuff is so old I should probably delete it, but it's a useful starting point for me.
Oxygen transport and consumption
- CaO2= Hg x 1.38 x SaO2
- O2 transported = C.O. x CaO2 x 10. Ex: 900 ml/min = 5.0 x 18 ml/dl x 10
- O2 remaining = C.O. x CvO2 x 10 Ex: VO2 = C.O. x Hg x 13.8 x (SaO2 - SvO2)
- O2 consumed = transported-remaining
The response to decreased O2 delivery to tissues is to increase cardiac output (300%),
increase venous O2 extraction (dec. SvO2 to 30% from 70%). A healthy person can compensate
for a Hg as low as 1.6 without developing lactic acidosis (in theory).
- Intubation criteria: pH <= 7.25; more respiratory muscle fatigue &
- Extubation mechanics: Vc > 10-15 ml/kg; PIMAX < -25; shunt < 10-20%; [Vc *
30]/2 > Ve; PO2 >= 60 with FiO2 0.4-0.6.
(@2000 settings have changed to reduce ARDS incidence. See literature. These settings
are 10 years old.)
- tidal volume: normal 12 ml/kg. COPD 8-10 ml/kg.
- rate: norm 10-12; I:E 1:2 or 1:1.5
- peak insp. flow: norm 40 L/min; tachyp 70-90; RDS 85-100; COPD 40-60 L/min.
- Modes: Usually start with SIMV or assist/control to start. (SIMV of 8 is about same as
assist/control) PSV of 10 is equal to work of breathing through tube. Apply PSV gradually
until RR 20 and TV 7ml/kg.
- PEEP: In RDS use if PaO2 <60 with FiO2 >90.
- FiO2: Rule of 7: To incr PaO2 by 1% need incr FiO2 by 7mm Hg.
- valium 5 mg and MS 4mg then Pavulon 4mg; may repeat same with Pavulon 8 mg.
- IV Haldol (flush line with saline first)
Wait 20 minutes between doses, double the dose q20m until effective (max 40 mg qh)
- mild: 0.5-2.0 mg
- moderate: 5.0-10.0 mg
- severe: 10.0 mg plus.
- Pavulon: load with 0.05 to 0.1 mg/kg then give 0.02 to 0.05 q4h.
- high flow rates
- keep dry: use dopamine rather than fluids for BP support.
- If SWAN keep PCWP <=Must measure off PEEP during expiratory phase.
Author: John G. Faughnan.
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