FPnotebook Updates: April 2020

FPN: Resistant Hypertension (cv, htn)

fpnotebook.com — 4/2/2020 9:39:07 PM

Consider reasons for resistant hypertension, review Hypertension Risk Stratification and determine Hypertension Reduction Goal and consider secondary hypertension. Advance to next step if BP>15/10 mmHg above goal. Consolidate medications into combination agents and once daily regimens. Consider optimal strategies in specific populations when selecting medications.

FPN: Genital Ulcer (id, derm, std)

fpnotebook.com — 4/2/2020 9:39:07 PM

Mnemonic CHISEL: Chancroid, Herpes, Inguinale, Syphilis, drug eruption, Lymphogranuloma venereum (first 2 are painful).

FPN: De Winter T Wave (cv, ekg)

fpnotebook.com — 4/2/2020 9:39:07 PM

Hyperacute precordial T waves and J Point depression suggests acute LAD occlusion. Consider other causes of hyperacute T Waves including hyperkalemia.

FPN: Motor Exam (neuro, motor)

fpnotebook.com — 4/2/2020 9:39:07 PM

A couple of mnemonics to remember critical spinal nerve levels. C3-4-5 keeps the diaphragm alive. S2-3-4 keeps the stool off the floor.

FPN: Pulmonary Function Test (lung, lab)

fpnotebook.com — 4/2/2020 9:39:07 PM

Obtain spirometry in all patients with suspected persistent asthma or COPD, and point-of-care spirometry is reasonably accurate. Restrictive lung disease evaluation requires additional testing beyond lung function testing.

FPN: Corona Virus 19 (lung, id)

fpnotebook.com — 4/2/2020 9:39:07 PM

Expanding on management specific to Covid-19 as well as related topics in critical care. Of the up to 20% with significant respiratory illness in Italy, 97% could be supported with oxygen and CPAP.

FPN: Intensive Care (er, exam)

fpnotebook.com — 4/2/2020 9:39:07 PM

Expanding critical care related topics and approaches for fever, sedation and analgesia, FEN, respiratory, prevention (DVT, GI) and complications.

FPN: Fever in the Intensive Care Unit (id, fever)

fpnotebook.com — 4/2/2020 9:39:07 PM

Fever is due to non-infectious causes in 50% of ICU cases. Most common causes include SIRS (trauma, ARDS), postoperative fever, venous thromboembolism or transfusion.

FPN: Drug-Induced Fever (id, pharm, fever)

fpnotebook.com — 4/2/2020 9:39:07 PM

May be due to hypersensitivity reaction (rigors, rash, eosinophilia), idiosyncratic reaction or hypersensitivity syndrome (e.g. malignant hyperthermia).

FPN: Postoperative Fever (id, fever, surgery)

fpnotebook.com — 4/2/2020 9:39:07 PM

Major surgery results in fever in 15-40% on postoperative day 1 (most without infection), and it typically resolves in first 24-48 hours (if not infectious). Atelectasis is coincidental, but not causative of fever (atelectasis and fever are both caused by major surgery).

FPN: Thromboprophylaxis in Critical Illness and Major Trauma (hemeonc, prevent)

fpnotebook.com — 4/2/2020 9:39:07 PM

LMWH (enoxaparin) is indicated in most cases aside from active bleeding and severe thrombocytopenia. Adjust dosing for weight <50 kg, weight >120 kg or BMI >40-50, and in GFR <30.

FPN: Gastric Ulcer Prevention in Patients with Critically Illness (gi, pud)

fpnotebook.com — 4/2/2020 9:39:07 PM

GI Prophylaxis is indicated in mechanical ventilation or significant peptic ulcer risk (e.g. recent GI bleeding, high dose corticosteroids, coagulopathy). Prophylaxis with PPI (e.g. protonix) or H2 blocker (e.g. pepcid).

FPN: Anemia in the Intensive Care Unit (hemeonc, anemia)

fpnotebook.com — 4/2/2020 9:39:07 PM

Most patients in the ICU will drop Hgb by at least 1.5 g/dl, but supine position alone will result in a similar Hgb drop. Anemia of chronic disease, frequent blood draws and sepsis are the common causes of gradually decreasing hemoglobin. More rapid drops in hemoglobin require more urgent evaluation for acute blood loss or hemolysis. Conservative transfusion strategy for anemia in hemodynamically stable patients transfuse for Hgb <7 g/dl (or <8 g/dl if active myocardial ischemia). Glucose Control in the Intensive Care Unit.

FPN: Glucose Control in the Intensive Care Unit (endo, DM)

fpnotebook.com — 4/2/2020 9:39:07 PM

Hypoglycemia may result in acute catastrophic events (cardiac arrest, brain injury). Avoid tight glucose control in critical illness (esp. intubated and sedated patients). However, significant hyperglycemia in the hospitalized patient (esp. post-surgical) is associated with worse outcomes. Follow systematic approaches to keep glucose within relaxed target ranges (140-200 mg/dl).

FPN: Enteral Nutrition for Intubated Patients (gi, procedure)

fpnotebook.com — 4/2/2020 9:39:07 PM

Early enteral nutrition (first 24-48 hours of ICU admission) is preferred and has few contraindications.

FPN: Sedation and Analgesia in Intensive Care (lung, procedure)

fpnotebook.com — 4/2/2020 9:39:07 PM

Analgesics should specifically target pain and should not be used for sedation; typically start with fentanyl and wean to acetaminophen and longer acting opioids. Post-intubation sedation typically starts with propofol, then transitions to precedex for weaning, but consider ketamine with or without clonidine. Monitor with Richmond Agitation and Sedation Scale (RASS) and Critical Care Pain Observation Tool (CPOT).

FPN: Fluid Management in Critical Care (re, pharm, fen)

fpnotebook.com — 4/2/2020 9:39:07 PM

Fluid overload is much more common in the ICU, then volume depletion. Monitor input and output, IVC ultrasound closely and pursue diuresis for positive fluid balance >4-5 Liters above dry weight. Diuresis often involves furosemide with a thiazide diuretic.

FPN: Sepsis (id, fever)

fpnotebook.com — 4/2/2020 9:39:07 PM

Extensive updates made including fluids, antibiotic selection, stabilization.

FPN: Headache (neuro, headache)

fpnotebook.com — 4/2/2020 9:39:07 PM

Undertreatment of episodic headaches may predispose to transition to chronic headaches due to Headache Central Sensitization. Added extensive updates to headache diagnosis and management.

FPN: RSV Bronchiolitis (lung, peds, bronchi)

fpnotebook.com — 4/2/2020 9:39:07 PM

Warm Respiratory Scoring Tool >4 (or atopic/RAD history) may be an indication for bronchodilator trial in RSV.

FPN: Targeted Cancer Therapy

fpnotebook.com — 4/2/2020 9:39:07 PM

Reviewed CAR T-Cell Therapy and Immune Checkpoint Inhibitors, along with their adverse effects and management.

FPN: Thrombolytic (hemeonc, pharm)

fpnotebook.com — 4/2/2020 9:39:07 PM

There is no ideal rescue agent for thrombolytic-related life threatening bleeding (e.g. intracranial hemorrhage). Consider infusing fibrinogen concentrate or cryoprecipitate 10 pack. Consider fresh frozen plasma. Give Tranexamic Acid (TXA).

FPN: D-Dimer (hemeonc, lab)

fpnotebook.com — 4/2/2020 9:39:07 PM

Several studies have now shown cutoff <1000 ng/ml is safe compared with 500 ng/ml in patients at low risk of Pulmonary Embolism. This is well established for adults at age >75 years and for third trimester pregnancy. However, this is growing evidence for D-Dimer >1000 ng/ml for any age. Prior study used YEARS Score with all criteria absent.

FPN: Subarachnoid Hemorrhage (neuro, cv)

fpnotebook.com — 4/2/2020 9:39:07 PM

Since 2011, CT head was considered sufficient within 6 hours of acute onset severe headache in neurologically intact patient. However, there has been growing evidence that even under 6 hours, Lumbar puncture should still be performed after negative CT head in high suspicion cases.

FPN: Status Epilepticus (neuro, seizure)

fpnotebook.com — 4/2/2020 9:39:07 PM

No evidence for one antiepileptic over another (e.g. Keppra, phenytoin, Valproic acid), now with a study confirming this in children. Prior 2014 study demonstrated this in adults.

FPN: Cryosurgery (derm, procedure)

fpnotebook.com — 4/2/2020 9:39:07 PM

Not much has changed (besides the name Cryosurgery instead of Cryotherapy). Reviewed, updated and expanded the content.

FPN: Hallucinogen (psych, cd)

fpnotebook.com — 4/2/2020 9:39:07 PM

Types include Psychedelic Agents (Classic Hallucinogens) such as LSD and Psilocybin, Dissociative agents (e.g. ketamine, PCP) and delirium-inducing agents (e.g. anticholinergics). Toxicity includes risk of serotonin syndrome and water intoxication, but most patients will do well with calming and benzodiazepines.

FPN: Hyperosmolar Hyperglycemic Syndrome (endo, dm)

fpnotebook.com — 4/2/2020 9:39:07 PM

Severe hyperglycemia resulting in increased serum osmolality and secondary altered mental state. Presents with severe dehydration, glucose >600, serum osmolality >320, altered mental status and minimal to no ketosis. Management is reviewed including fluid resuscitation, glucose and electrolyte management and evaluation of underlying cause.

FPN: Pediatric Cervical Spine Injury (ortho, peds)

fpnotebook.com — 4/2/2020 9:39:07 PM

Added additional guidance on cervical spine clearance in children.

FPN: Hyperlipidemia Management (cv, lipids)

fpnotebook.com — 4/2/2020 9:39:07 PM

Nexletol (ATP-Citrate Lyase Inhibitor) is a new class of antihyperlipidemic that lowers LDL Cholesterol as a statin adjunct or alternative (but does not effect triglycerides, HDL). Unknown effect on longterm cardiovascular outcomes and costs $330/month. May consider in statin intolerant patients and those at very high cardiovascular risk, not at goal.

FPN: Diclofenac Gel (pharm, analgesic)

fpnotebook.com — 4/2/2020 9:39:07 PM

Will be OTC without a prescription in 2020. Limit to 1-2 small joints up to four times daily.

FPN: Migraine Prophylaxis in Children (neuro, headache, peds)

fpnotebook.com — 4/2/2020 9:39:07 PM

Migraine prophylaxis appears to be ineffective in children as compared with adults. Guidelines recommend lifestyle and behavioral changes (Headache Self-Help Measure).

FPN: Naltrexone

fpnotebook.com — 4/2/2020 9:39:07 PM

Low dose Naltrexone (0.5 mg to 4.5 mg/day) has also been proprosed for various conditions including chronic pain. No rigorous evidence of benefit at these low doses and for these varied conditions, but unlikely to cause harm. Postulated to up-regulate opioid receptors, increas endorphin production and act as analgesic and antiinflammatory. May cause opioid withdrawal if used soon after last use of opioids.

FPN: Atypical Antipsychotics (psych, pharm, psychosis)

fpnotebook.com — 4/2/2020 9:39:07 PM

Two more expensive atypical antipyschotics: Caplyta (lumateperone) and Secuado (asenapine patch).

FPN: Macrolides (id, pharm)

fpnotebook.com — 4/2/2020 9:39:07 PM

Macrolides in general (including azithromycin) may increase heart defects with first trimester exposure of 5-7 days. Previously only clarithromycin was considered a potential teratogen (cleft lip association)