Pocket Medicine (Pocket Notebook Series)

Drug

Class

Dose

per kg

average

Pressors, Inotropes, and Chronotropes

Phenylephrine

α₁

10–300 μg/min

Norepinephrine

α₁ >β₁

1–40 μg/min

Vasopressin

V₁

0.01–0.1 U/min (usually <0.04)

Epinephrine

α₁, α₂, β₁, β₂

2–20 μg/min

Isoproterenol

β₁, β₂

0.1–10 μg/min

Dopamine

D

β, D

α, β, D

0.5–2 μg/kg/min

2–10 μg/kg/min

>10 μg/kg/min

50–200 μg/min

200–500 μg/min

500–1000 μg/min

Dobutamine

β₁ >β₂

2–20 μg/kg/min

50–1000 μg/min

Milrinone

PDE

± 50 μg/kg over 10 min then 0.25–0.75 μg/kg/min

3–4 mg over 10 min then 20–50 μg/min

Vasodilators

Nitroglycerin

NO

5–500 μg/min

Nitroprusside

NO

0.25–10 μg/kg/min

10–800 μg/min

Labetalol

α₁, β₁, and β₂ blocker

20–80 mg q10min or 10–120 mg/h

Fenoldopam

D

0.1–1.6 μg/kg/min

10–120 μg/min

Clevidipine

CCB

1–32 mg/h

Epoprostenol

vasodilator

2–20 ng/kg/min

Antiarrhythmics

Amiodarone

K et al. (Class III)

150 mg over 10 min, then 1 mg/min × 6 h, then 0.5 mg/min × 18 h

Lidocaine

Na channel (Class IB)

1–1.5 mg/kg then

1–4 mg/min

100 mg then

1–4 mg/min

Procainamide

Na channel (Class IA)

17 mg/kg over 60 min

then 1–4 mg/min

1 g over 60 min then 1–4 mg/min

Ibutilide

K channel (Class III)

1 mg over 10 min,

may repeat × 1

Propranolol

β blocker

0.5–1 mg q5min then 1–10 mg/h

Esmolol

β₁ >β₂ blocker

500–1000 μg/kg

then 50–200 μg/kg/min

20–40 mg over 1 min then 2–20 mg/min

Verapamil

CCB

2.5–5 mg over 1–2′, repeat 5–10 mg in 15–30′ prn 5–20 mg/h

Diltiazem

CCB

0.25 mg/kg over 2 min reload 0.35 mg/kg × 1 prn then 5–15 mg/h

20 mg over 2 min reload 25 mg × 1 prn then 5–15 mg/h

Adenosine

purinergic

6 mg rapid push; if no response: 12 mg → 12–18 mg

Sedation

Morphine

opioid

1–30 (in theory, unlimited) mg/h

Fentanyl

opioid

50–100 μg then 50–800 (? unlimited) μg/h

Propofol

anesthetic

1–3 mg/kg then

0.3–5 mg/kg/h

50–200 mg then 20–400 mg/h

Dexmedetomidine

α₂ agonist

1 μg/kg over 10 min → 0.2–0.7 μg/kg/h

Diazepam

BDZ

1–5 mg q1–2h then q6h prn

Midazolam

BDZ

0.5–2 mg q5min prn; 0.02–0.1 mg/kg/h or 1–10 mg/h

Lorazepam

BDZ

0.01–0.1 mg/kg/h

Naloxone

opioid antag.

0.4–2 mg q2–3min to total of 10 mg

Flumazenil

BDZ antag.

0.2 mg over 30 sec then 0.3 mg over 30 sec prn may repeat 0.5 mg over 30 sec to total of 3 mg

Miscellaneous

Aminophylline

PDE

5.5 mg/kg over 20 min then 0.5–1 mg/kg/h

250–500 mg

then 10–80 mg/h

Octreotide

somatostatin analog

50 μg then 50 μg/h

Glucagon

hormone

3–10 mg IV slowly over 3–5 min then 3–5 mg/h

Mannitol

osmole

1.5–2 g/kg over 30–60 min repeat q6–12h to keep osm 310–320

Generation

Properties

Spectrum

Natural (penicillin)

Active vs. many GPC, GPR, anaerobes (not Bacteroides), some Gram ⊖ coccobacilli & Gram ⊖ diplococci

Most streptococci, many enterococci, Listeria, C. acnes, Pasteurella, Actinomyces, syphilis

Anti-staph (eg, nafcillin)

Active vs. PCNase-producing Staph Little activity vs. Gram ⊖

Staphylococci (except MRSA) Streptococci

Amino (eg, ampicillin)

Penetrate porin channel of Gram ⊖

Not stable against PCNases

PCN plus E. coli, Proteus, H. influenzae, Salmonella, Shigella

Extended (eg, piperacillin)

Penetrate porin channel of Gram ⊖ More resistant to PCNases

Most GNR incl. Enterobacter, Pseudomonas, Serratia

β-lact. inhib. (eg, sulbactam, clavulanate) with PCN derivative

Inhibits some plasma-mediated β-lactamases

Adds staph (not MRSA), most PCN-R anaerobes, & some GNR (H. flu, M. cat, some enterics); intrinsic activity against Acinetobacter

Resistant to most penicillin b-lactamases. No activity vs. enterococci.

Generation

Spectrum

Indications

1^st (eg, cefazolin)

Most GPC (incl. staph & strep, not MRSA); some GNR (incl. E. coli, Proteus, Klebsiella)

Used for surgical Ppx & skin infxns

2^nd (eg, cefuroxime, cefotetan)

↓ activity vs. GPC, ↑ vs. GNR. 2 subgroups:

Resp: H. influenzae & M. catarrhalis

GI/GU: ↑ activity vs. B. fragilis

PNA/COPD flare

Abdominal infxns

3^rd (eg, ceftriaxone, ceftazidime)

Broad activity vs. GNR (not ESBL), streptococci, & some anaerobes. Ceftazidime active vs. Pseudomonas, less vs. strep

PNA, sepsis, meningitis

4^th (eg, cefepime)

↑ resistance to β-lactamases (incl. Enterobacter)

Similar to 3^rd gen. MonoRx for nonlocalizing febrile neutropenia

5^th (eg, ceftaroline)

Only class of cephalosporin with MRSA activity. GN activity similar to ceftriaxone. NOT active vs. Pseudomonas.

MRSA. Not 1^st line for MRSA bacteremia.

Combination (eg, ceftolozane-tazobactam, ceftazidime- avibactam)

MDR GNRs, incl. Pseudomonas. Ceftaz-avi has activity vs. some carbapenemases.

Complicated UTIs, complicated intra-abdominal infections.

Class

Properties

Spectrum

Carbapenems (eg, imipenem)

Resistant to most β-lactamases

Most Gram ⊕ & ⊖, incl. anaerobes; not MRSA or VRE

Monobactams (aztreonam)

Active vs. Gram ⊖ but not Gram ⊕

Gram ⊖ bacterial infxn in Pt w/ PCN or Ceph allergy

Antibiotic

Spectrum

Vancomycin

Gram ⊕ bacteria incl. MRSA, PCNase-producing pneumococci and enterococci (except VRE)

Linezolid

GPC incl. MRSA & VRE (check susceptibility for VRE)

Daptomycin

Quinolones

GNR & atypicals. Levo and esp moxi ↑ activity vs. Gram ⊕.

Aminoglycosides

GNR. Synergy w/ cell-wall active abx (β-lactam, vanco) vs. GPC. ↓ activity in low pH (eg, abscess). No activity vs. anaerobes.

Macrolides

GPC, some respiratory Gram ⊖, atypicals

TMP/SMX

Most enteric GNR, Staph incl CA-MRSA, Stenotrophomonas, Nocardia, Toxo, Pneumocystis

Clindamycin

Most Gram ⊕ (except enterococci) & anaerobes (increasing resistance, especially GI)

Metronidazole

Almost all anaerobic Gram ⊖, most anaerobic Gram ⊕, some protozoa (Entamoeba, Trichomonas, et al.)

Doxycycline

Rickettsia, Ehrlichia, Anaplasma, Chlamydia, Mycoplasma, Nocardia, Lyme; many Staph and GNR

Tigecycline

Many GPC incl. MRSA & VRE; most GNR incl. ESBL but not Pseudomonas or Proteus; most anaerobes

Hemodynamic Parameters

Normal Value

Mean arterial pressure

70–100 mmHg

Heart rate (HR)

60–100 bpm

Right atrial pressure (RA)

≤6 mmHg

Right ventricular (RV)

systolic 15–30 mmHg

diastolic 1–8 mmHg

Pulmonary artery (PA)

systolic 15–30 mmHg

mean 9–18 mmHg

diastolic 6–12 mmHg

Pulmonary capillary wedge pressure (PCWP)

≤12 mmHg

Cardiac output (CO)

4–8 L/min

Cardiac index

2.6–4.2 L/min/m²

Stroke volume

60–120 mL/contraction

Stroke volume index

40–50 mL/contraction/m²

Systemic vascular resistance (SVR)

800–1200 dynes × sec/cm⁵

Pulmonary vascular resistance (PVR)

120–250 dynes × sec/cm⁵

Pattern

Pathophysiology

Ddx

Consolidation

Radiopaque material in air space & interstitium patent airway → “air bronchograms”

Acute: water (pulm. edema), pus (PNA), blood

Chronic: neoplasm (BAC, lymphoma), aspiration, inflammatory (COP, eosinophilic PNA), PAP, granuloma (TB/fungal, alveolar sarcoid)

Ground glass (CT easier than CXR)

Interstitial thickening or partial filling of alveoli (but vessels visible)

Acute: pulm. edema, infxn (PCP, viral, resolving bact. PNA)

Chronic: ILD

w/o fibrosis: acute hypersens., DIP/RB, PAP

w/ fibrosis: IPF

Septal lines Kerley A & B

Radiopaque material in septae

Cardiogenic pulm. edema, interstitial PNA viral, mycoplasma, lymphangitic tumor

Reticular

Lace-like net (ILD)

ILD (esp. IPF, CVD, bleomycin, asbestos)

Nodules

Tumor

Granulomas

Abscess

Cavitary: Primary or metastatic cancer, TB (react. or miliary), fungus, Wegener’s, RA septic emboli, PNA

Noncavitary: any of above + sarcoid, hypersens. pneum., HIV, Kaposi’s sarcoma

Wedge opac.

Peripheral infarct

PE, cocaine, angioinv. aspergillus, Wegener’s

Tree-in-bud (best on CT)

Inflammation of small airways

Bronchopneumonia, endobronchial TB/MAI, viral PNA, aspiration, ABPA, CF, asthma, COP

Hilar fullness

↑ LN or pulm. arteries

Neoplasm (lung, mets, lymphoma)

Infxn (AIDS); Granuloma (sarcoid/TB/fungal)

Pulmonary hypertension

Upper lobe

n/a

TB, fungal, sarcoid, hypersens. pneum., CF, XRT

Lower lobe

n/a

Aspiration, bronchiect., IPF, RA, SLE, asbestos

Peripheral

n/a

COP, IPF & DIP, eos PNA, asbestosis

Points Scored

1

2

3

Ascites

None

Easily controlled

Poorly controlled

Encephalopathy

None

Grade 1 or 2

Grade 3 or 4

Bilirubin (mg/dL)

<2

2–3

>3

Albumin (g/dL)

>3.5

2.8–3.5

<2.8

PT (sec >control)

or INR

<4

<1.7

4–6

1.8–2.3

>6

>2.3

Classification

A

B

C

Total points

5–6

7–9

10–15

1-y survival

100%

80%

45%

Feature

Abnormalities and Diagnoses

Size

normocytic vs. microcytic vs. macrocytic → see below

Shape

Anisocytosis → unequal RBC size; poikilocytosis → irregular RBC shape acanthocytes = spur cells (irregular sharp projections) → liver disease

Bite cells (removal of Heinz bodies by phagocytes) → G6PD deficiency echinocytes = burr cells (even, regular projections) → uremia, artifact

Pencil cell → long, thin, hypochromic–very common in adv. iron deficiency

Rouleaux → hyperglobulinemia (eg, multiple myeloma)

Schistocytes, helmet cells → MAHA (eg, DIC, TTP/HUS), mechanical valve

Spherocytes → HS, AIHA; sickle cells → sickle cell anemia

Stomatocyte → central pallor appears as curved slit → liver disease, EtOH

Target cells → liver disease, hemoglobinopathies, splenectomy

Tear drop cells = dacryocytes → myelofibrosis, myelophthisic anemia, megaloblastic anemia, thalassemia

Intra- RBC findings

Basophilic stippling (ribosomes) → abnl Hb, sideroblastic, megaloblastic

Heinz bodies (denatured Hb) → G6PD deficiency, thalassemia

Howell-Jolly bodies (nuclear fragments) → splenectomy or functional asplenia (eg, advanced sickle cell)

Nucleated RBCs → hemolysis, extramedullary hematopoiesis

WBC findings

Blasts → leukemia, lymphoma; Auer rods → acute myelogenous leukemia

Hypersegmented (>5 lobes) PMNs: megaloblastic anemia (B₁₂/folate def.)

Pseudo-Pelger-Huët anomaly (bilobed nucleus, “pince-nez”) → MDS

Toxic granules (coarse, dark blue) and Döhle bodies (blue patches of dilated endoplasmic reticulum) → (sepsis, severe inflammation)

Platelet

Clumping → artifact, repeat plt count

# → periph blood plt count ~10,000 plt for every 1 plt seen at hpf (100×)

Size → MPV (mean platelet volume) enlarged in ITP

80 U/kg bolus

18 U/kg/h

PTT

Adjustment

<40

bolus 5000 U, ↑ rate 300 U/h

40–49

bolus 3000 U, ↑ rate 200 U/h

50–59

↑ rate 150 U/h

60–85

no Δ

86–95

↓ rate 100 U/h

96–120

hold 30 min, ↓ rate 100 U/h

>120

hold 60 min, ↓ rate 150 U/h

60 U/kg bolus (max 4000 U)

12 U/kg/h (max 1000 U/h)

PTT

Adjustment

<40

bolus 3000 U, ↑ rate 100 U/h

40–49

↑ rate 100 U/h

50–75

no Δ

76–85

↓ rate 100 U/h

86–100

hold 30 min, ↓ rate 100 U/h

>100

hold 60 min, ↓ rate 200 U/h

Drugs that ↑ PT

Drugs that ↓ PT

Amiodarone

Antimicrobials: erythromycin, ? clarithro, ciprofloxacin, MNZ, sulfonamides

Antifungals: azoles

Acetaminophen, cimetidine, levothyroxine

Antimicrobials: rifampin

CNS: barbiturates, carbamazepine, phenytoin (initial transient ↑ PT)

Cholestyramine

0′

30′

60′

Interpretation

5.3

15.5

23.2

Normal stimulation test

1.5

13.3

21.1

Acute central AI (eg, apoplexy or CNS bleed). Can look normal.

1.2

1.5

2.0

1° AI (eg, Addisons or adrenal bleed). Flat or minimal stim.

0.8

10.0

19.7

Acute effect of glucocorticoids: low initial value but stims >threshold

5.3

7.2

8.9

Chronic 2° AI: some cortisol production and stim, but evidence of adrenal atrophy

6.7

19.5

17.2

“Early peak” (fast metab): ~5% of Pts peak at 30’ rather than 60’

6.3

11.5

16.2

Equivocal test. Can occur due to mild AI, acute illness, liver disease, low cortisol binding protein, renal disease, etc.