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ADULT PROTOCOLS
Preface:
The purpose of the following protocols aims to enhance the disposition of our patients and improve the management
of adult cases early in the ER setting. In order to facilitate fast discharge of our patients, I suggest the following evidence-based
or guideline-based management for selected common diseases we commonly encounter at the ER and ward referrals. I believe
that aside from the convenience especially those who are working in a time constrained ER setting, this will help ER RODs
avoid missing-out on some important work-ups or management which can greatly alter the progress of our patients once
admitted. From our experience in a government tertiary hospital handling bulk of patients at one time with limited resources,
we find it more efficient, economical and faster to discharge patient when we order all necessary bundle of care at ER settings
one big time trying to work-up all differentials in a single order rather than working up one labs and bit-by-bit treatment at a
time. However, these are not strict recommendations and each patient case should be treated special or individualized. In the
end, the physician’s clinical eye, referral to a specialist and evidence-based management in a case to case basis are far more
supreme than any mentioned facts in this protocol. So please do not treat this protocol to be absolutely followed
-MNJr.

Contents
I. COMMUNITY ACQUIRED PNEUMONIA................................................................................................................................... 2
II. CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN ACUTE EXACERBATION .......................................................................... 4
III. BRONCHIAL ASTHMA IN ACUTE EXACERBATION .................................................................................................................. 8
IV. URINARY TRACT INFECTIONS.............................................................................................................................................. 10
V. SEPSIS AND SEPTIC SHOCK .................................................................................................................................................. 15
VI. DENGUE FEVER ................................................................................................................................................................... 19
VII. ACUTE GASTROENTERITIS ................................................................................................................................................. 22
VIII. ELECTROLYTE IMBALANCE ................................................................................................................................................ 24
IX. UPPER GASTROINTESTINAL BLEEDING ............................................................................................................................... 29
X. STROKE ................................................................................................................................................................................ 32
XI. SEIZURE ............................................................................................................................................................................... 40
XII. DIABETES MELLITUS........................................................................................................................................................... 42
XIII. HEART FAILURE ................................................................................................................................................................. 46
XIV. ACUTE CORONARY SYNDROME ........................................................................................................................................ 49
XV. ARRHYTHMIA..................................................................................................................................................................... 52
XVI. SHOCK............................................................................................................................................................................... 57
XVII ANEMIA ............................................................................................................................................................................ 59
XVIII COMMON LIVER DISEASES .............................................................................................................................................. 63
I. LIVER CIRRHOSIS ......................................................................................................................................................... 63
II. SCHISTOSOMIASIS ...................................................................................................................................................... 65
III. NONALCOHOLIC FATTY LIVER DISEASE ....................................................................................................................... 65
IV. HEPATITIS B ................................................................................................................................................................ 66
V. HEPATITIS C ................................................................................................................................................................ 67
VI. NONSPECIFIC TRANSAMINITIS.................................................................................................................................... 67
VII. DRUG or HERBAL INDUCED LIVER INJURY (DILI OR HILI; PTB MEDICATIONS) ............................................................ 67
XIX ANTIBIOTICS ...................................................................................................................................................................... 69
I. BASIC PRINCIPLES......................................................................................................................................................... 69
II. PNEUMONIA ................................................................................................................................................................ 70
III. SKIN AND SOFT TISSUE INFECTIONS (SSTIs)................................................................................................................. 72
IV. INTRAABDOMINAL INFECTIONS .................................................................................................................................. 73
V. URINARY TRACT INFECTIONS....................................................................................................................................... 74
VI. CENTRAL NERVOUS SYSTEM INFECTIONS ................................................................................................................... 76
VII. JOINTS AND OSTEOMYELITIS ....................................................................................................................................... 77
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I. COMMUNITY ACQUIRED PNEUMONIA

I. DIAGNOSIS:
Clinical: Productive cough, dyspnea, pleuritic chest pain, crackles

II. RISK STRATIFICATION AND MANAGEMENT:

CAP- MODERATE RISK

➢ Definition: Any of the following
o RR ≥ 30/min
o PR ≥ 125/min
o Temp ≤ 36C or ≥ 40C
o SBP <90mmhg or DBP ≤ 60mmhg
o Altered mental state
o Suspected aspiration
o Unstable comorbids: (uncontrolled DM; active cancer, neurologic disease in evolution, congestive heart
failure, unstable coronary artery disease, renal failure, uncompensated COPD, decompensated liver
disease)
o Presence of any of following:
▪ (+) multilobar infiltrates, (+) pleural effusion, (+) empyema, (+) abscess, (+) consolidation , (+)
cavitation or (+) pneumatocoeles
➢ Management:
o Diet: DAT
o IVF: PNSS 1L (rate as maintenance)
o VS q4
o I and O qshift
o Dx:
▪ CXR PAL view,
▪ Sputum GS/CS KOH x 2, sputum DSSM x 2 (if cough >2 weeks)
▪ CBC, Na, K, Crea, BUN
▪ ABG (if dyspneic or hypotensive)
o Medications:
▪ Ceftriaxone 2gm IV OD
▪ Alternative to ceftriaxone:
• (+) pseudomonas risk (immunocompromised or severe COPD):
o Cefepime 1gm in 100cc PNSS x 2 hrs q8hrly or Piperacillin-Tazobactam
4.5gm IV q8
▪ Azithromycin 500mg 1 tab OD x 5 days
▪ ADD Clindamycin 600mg IV Q8 if suspected aspiration (Stroke, alcohol, vomiting, MRSA risk)
▪ N-Acetylcysteine 600mg sachet 1 sachet in glass H20 (if with tight sputum)
o Moderate high back rest
o O2 support at 2-4LPM as needed for desat

CAP – HIGH RISK

➢ Definition: Any of the following:
o Any of the features of moderate risk CAP PLUS Severe Sepsis and Septic shock (or hypotension
whatever the cause) OR need for mechanical ventilation (CPAP or invasive);
o Hypoxemia <90% (from previous CAP guidelines).
➢ Advised tertiary hospital transfer.
➢ Orders:
o Diet:
▪ DAT if able to feed
▪ If cannot tolerate feeding or intubated, Insert NGT and start OTF at 1400kcal initial feeding then
may increase to 30-40kcal/kg in the coming days as tolerated.
o IVF:
▪ PNSS or PLR at maintenance rate
 Page |3

▪ If with hypotension or sepsis, fast drip PNSS 30ml/kg (usually 1800ml) for 3 hrs then correct as
needed then maintenance rate
o VS q4
o I/O qshift
o Dx:
▪ CXR PAL view
▪ Sputum GS/CS KOH, AFB x 2
▪ Blood GS/CS
▪ CBC, Na, K, BUN Crea, SGPT
▪ 12L ECG (for >40 yo, heart disease or CKD)
▪ ABG
o Medications:
▪ Cefepime 2gm in 100cc PNSS q8 (to run for 3hrs) OR
• Alternative: Meropenem 1gm in 100cc PNSS (run for 3hrs)
▪ Azithromycin 500mg IV OD (or as tab if not available)
▪ Gentamicin 3mg/kg OD
▪ If with MRSA risk or prior flu symptoms*:
o ADD Vancomycin 15mg/kg q12h OR
o Clindamycin 600mg q8 IV
▪ Salbutamol + Ipratropium neb 1 neb q8 PRN for dyspnea with rhonchi or wheezes (but shouldn’t
be routine)
o If intubated – transfer to ICU-set up
o Moderate high back rest
o O2 support as needed via f.m. at 4-6 LPM maintain O2sat >94%.

*[*MRSA risk: Hospitalized > 2 days in previous 90 days, use of antibiotics for the past 90 days, immunosuppression,
Nonambulatory status, Tube feedings, Gastric acid suppression, Severe COPD or bronchiectasis. Nosocomial MRSA:
Hospitalization ≥ 2 days in previous 90 days, Use of antibiotics in previous 90 days, Chronic hemodialysis in previous 30 days,
Documented prior MRSA colonization, Congestive heart failure, Gastric acid suppression (use of PPI). Community acquired
MRSA: Cavitary infiltrate or necrosis, Gross hemoptysis, Neutropenia, Erythematous rash, Concurrent influenza; Young,
previously healthy status; Summer-month onset.
*Pseudomonas aeruginosa risk: Severe structural lung disease such as severe COPD and bronchiectasis;
immunocompromised host (HIV, solid organ transplant and those receiving immunosuppressant); recent antibiotic use within
90 days; History of chronic or prolonged (>7 days within the past month) use of broad-spectrum antibiotic therapy; Malnutrition
; Chronic use of steroid therapy >7.5mg/day]

V. When to discharge:
Ideally on the day 3-5th of antibiotics for philhealth coverage.
During the 24hrs before discharge, the patient should have the following characteristics:
1. temperature 36-37C
2. HR <100/min
3. RR 16-24/min
4. SBP >90mmhg
5. O2sat >90%
6. Functional gastrointestinal tract
VI. Step down meds: Ideally culture based but can give:
1. Amoxiclav 1gm BID x 7 days
2. Cefixime 200mg BID x 7 days
3. PLUS Azithromycin 500mg OD as continuation up to 5 days.
4. Advise vaccination with flu and pneumococcal vaccine as outpatient.
 Page |4

II. CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN ACUTE EXACERBATION

I. DIAGNOSIS:
Clinical features: smoking or biomass use history, dyspnea, chronic cough, sputum production, history of lower
respiratory tract infection; wheezes, rhonchi and crackles or poor chest expansion, sometimes decreased breath sounds on all
lung fields.
Acute respiratory failure (Please reflect on diagnosis as it will change philhealth claims): RR > 30 breaths per minute,
using accessory respiratory muscles, increase in PaCO2, hypoxemia requiring venturi mask at least >35% FiO2 (if face mask
> 6LPM O2 support). Has 2 categories:
➢ Non-life Threatening: No change in mental status, hypoxemia improved with Venturi mask >35% FiO2 (face mask
> 6LPM). PaCO2 50-60 mmHg.
➢ Life Threatening: (+) Mental status changes, hypoxemia not improved with venturi mask or requiring >40% FiO2.
Hypercarbia >60mmHg or acidosis pH ≤ 7.25. → Triage to ICU

II. MANAGEMENT:

➢ Triage:
o Admit to ward after initial resuscitation at ER if responsive to bronchodilators
▪ ICU admission or transfer to higher level hospital:
1. Severe dyspnea that responds inadequately to initial emergency therapy
2. confusion, lethargy, coma
3. persistent hypoxemia PaO2 <5.3 kPa or 40mmHg) and severe/worsening respiratory acidosis
(pH <7.25) despite supplemental oxygen and noninvasive ventilation.
4. Need for invasive mechanical ventilation
5. Need for vasopressors.
➢ DAT
➢ IVF: PNSS or PLR at maintenance rate or
o KVO if with evidence of cor pulmonale (edema, distended neck veins, p-pulmonale on ECG)
➢ VS q4
➢ I/O qshift
➢ DX:
o CXR PAL view
o 12L ECG
o ABG
o CBC, Na, K, Mg, BUN, Crea, SGPT
o Sputum GS/CS KOH and AFB or DSSM x 2 sites
o Spirometry test if able to comply and pulmonary function test

➢ Medications:
o Salbutamol + Ipratropium nebulization q4-8hrs.
▪ More frequent until wheezing improves
▪ If tachycardic or cardiac patient may use: Ipratropium bromide neb (Atrovent) 1 neb q4-8hrs or
Tiotropium (Spiriva respimat) inhaled caps 18g/cap 1 puff OD. (Caution with BPH, glaucoma,
bladder neck obstruction)
o Tiotropium + Olodaterol 2.5mcg/2.5mcg (Spiolto Respimat) inhaler 2 puffs once a day may be started once
patient is stable
▪ If patient cannot afford or not available may use:
▪ Indacaterol/glycopyrronium (Ultibro breezehaler) DPI 110mcg/50mcg 1 cap via inhaler OD
▪ Salmeterol + Fluticasone PMDI or Diskus 250mcg/50mcg or 125mcg/25mcg 2 puffs BID OR
Formoterol + Budesonide turbohaler 320mcg/4.5mcg or 160mcg/4.5mcg 2 puffs BID
▪ LABA + ICS combo above is also preferred for: those with sputum eosinophil count >100 cells/uL,
history of moderate exacerbations ≥2/y or 1 hospitalization, blood eosinophil >300cells/uL, Hx of
asthma
o Prednisone 20mg 1 tab BID (with breakfast and lunch) x 5-7 days. No need for titration down.
▪ If cannot take PO meds, may use: Hydrocortisone 100mg IV Q8
o Piperacillin-Tazobactam 4.5gm IV q6 OR Cefepime 1gm IV q8 OR Ceftazidime 1gm IV q8 if with severe
structural lung disease or suspicion of bronchiectasis for pseudomonas coverage
 Page |5

o Azithromycin 500mg 1 tab OD x 5 days

o Additional meds if still uncontrolled COPD:

▪ Roflumilast (Daxas) 500mcg/day 1 tab OD (for those with persistent bronchitis and desaturation).
Use associated with GI effects like abdominal pain and diarrhea.
▪ If stable, N-acetylcysteine 600mg 1 tab in ½ glass H2O OD at HS OR Erdosteine 300mg tab 1 tab
BID
▪ Methylxanthines like Aminophylline or Doxophylline are not recommended during exacerbations
due to increased adverse effects.

➢ NIPPV (Non-invasive positive pressure ventilation) with CPAP or BiPAP with the following indications:
▪ In case of respiratory failure defined as PaCo2 of > 45mmHg, or pH ≤ 7.35
▪ Severe dyspnea with signs of muscle fatigue, increased work of breathing or both such as use of
respiratory accessory muscles, paradoxical motion of the abdomen, or retraction of the intercostal
spaces.
▪ Persistent hypoxemia despite supplemental oxygen therapy

➢ Intubate patient if:

▪ Unable to tolerate NIV or NIV failure or NIPPV not available
▪ Status post respiratory or cardiac arrest
▪ Diminished consciousness or psychomotor agitation
▪ Massive aspiration or persistent vomiting
▪ Persistent inability to remove secretions
▪ Severe hemodynamic instability w/o response to fluids or vasoactive drugs.
▪ Severe ventricular or supraventricular arrhythmias
▪ Life threatening hypoxemia in patients unable to tolerate NIV.

OTHER CARE
➢ Chest physiotherapy (ask watcher to tap the back of the patient every waking hrs)
➢ Oxygen support as needed maintain O2 at 88-92%. Maintain >90% if with RV failure or polycythemia. Ideally with
venturi masks.
➢ DVT prophylaxis (SQ heparin or enoxaparin)
➢ Treat comorbidities

III. DISCHARGE:
➢ Once patient is stable, feeding comfortably, ideally no wheezes, on 3-7th day of antibiotics, reassess inhaler technique,
understanding of maintenance therapy
➢ ABG: acidosis and CO2 retention normalized if baseline ABG is respiratory acidosis.

III. TAKE HOME MEDICATIONS FOR STABLE COPD:

➢ Risk stratify patients first as follows to guide you what meds to give:
 Page |6

mMRC DYSPNEA SCALE:

CAT ASSESSMENT
 Page |7

III. MANAGEMENT FOR STABLE COPD:

[Included below are those readily available in Philippines only]

TAKE HOME MEDICATIONS:
1. Salbutamol + Ipratropium nebulization q4-8hrs as needed for acute dyspnea;
2. Tiotropium + Olodaterol 2.5mcg/2.5mcg (Spiolto Respimat) inhaler 2 puffs once a day
OR Indacaterol/glycopyrronium (Ultibro breezehaler) DPI 110mcg/50mcg 1 cap via inhaler OD
OR Salmeterol + Fluticasone PMDI or Diskus 250mcg/50mcg or 125mcg/25mcg 2 puffs BID
OR Formoterol + Budesonide turbohaler 320mcg/4.5mcg or 160mcg/4.5mcg 2 puffs BID
*Inhalational steroids: (use strongly supported with eosinophil count >100 cells/uL, history of
moderate exacerbations ≥2/y or 1 hospitalization, blood eosinophil >300cells/uL, Hx of asthma)
3. Antibiotics: Step-down as per CAP protocol + Azithromycin (may take longer than 5 days for bronchiectasis and
chronic smokers)

ADDITIONAL MEDS IF NECESSARY:

3. Roflumilast (Daxas) 500mcg/day 1 tab OD (Group D). Disadvantage of use associated with GI effects like headache,
abdominal pain and diarrhea.
4. N-acetylcysteine 600mg 1 tab in ½ glass H2O OD at HS for those with evidence of bronchiectasis
OR Erdosteine 300mg tab 1 tab BID
5. Give O2 support 15hrs a day to keep O2 sat >90% at home.
For hypoxemia (paO2 < 55mmHg or O2sat <88% or paO2 55-60mmhg + Right heart failure and
erythrocytosis)
6. Vaccinations for influenza, pneumococcus, DPT, COVID-19 and Zoster (shingles)
7. Advise complete smoking cessation
 Page |8

III. BRONCHIAL ASTHMA IN ACUTE EXACERBATION

I. DIAGNOSIS:
Patient known asthmatic, or use of nebulization for relief of dyspnea, nocturnal cough, history of atopy (allergic
dermatitis or rhinitis) or in the family. Symptoms of URTI as trigger. Rule out anaphylaxis or other causes of wheezing.

II. SEVERITY EVALUATION:

SEVERE exacerbation:
o If upon starting SABA, systemic steroid and oxygen patient still
▪ dyspneic or speak only in words, hunched sits forward, agitated
▪ drowsy, confused, silent chest
▪ RR > 30 rpm
▪ HR > 120
▪ O2 sat <90%
▪ PEF ≤ 50% predicted or best
o Plan transfer to tertiary hospital if not resolved by nebulization.

MILD – MODERATE:
o Talks in phrases, prefers sitting to lying, not agitated, no accessory muscle use, parameters below threshold
for severe asthma.
o If stabilized, may admit to regular ward (make sure to reverse above findings first)

III. MANAGEMENT:
➢ Diet: DAT once stable, NPO temporarily if dyspneic.
➢ IVF: PNSS or PLR as maintenance rate. KVO if with congestion or Cor pulmonale
➢ VS q4; q15mins while at ER
➢ I/O qshift
➢ Dx:
o Chest Xray PAL view
o CBC, Na, K, Mg, Crea, BUN, SGPT
o ABG
o 12L ECG if > 40 yo.
o Sputum GS/CS KOH AFB x 2 (as indicated)
o Spirometry
➢ Medications:
o Salbutamol + Ipratropium nebulization 1 neb every 20mins for 1 hr then q4-8 hrs as needed
▪ OR use of Salbutamol pMDI + spacer 4-10 puffs every 20 mins for 1 hr
o Prednisolone 20mg tab BID with breakfast and lunch x 5-7 days.
▪ Alternative hydrocortisone 100mg IV now then q8 if cannot take PO
o Salmeterol + Fluticasone PMDI or Diskus 250mcg/50mcg or 125mcg/25mcg 2 puffs BID
▪ OR Formoterol + Budesonide turbohaler 320mcg/4.5mcg or 160mcg/4.5mcg 2 puffs BID
o Montelukast 10mg 1 tab OD (but should not be routine)
o Ceftriaxone 2gm IV OD (if with suspected CAP ie. Fever, purulent sputum or pneumonia on Xray)
o Azithromycin 500mg 1 tab OD (as indicated)
o Others:
▪ Magnesium sulfate 2gm in 100cc D5W infusion over 20 mins. (can be helpful if still not relieved on
initial therapy but not routinely recommended)

[Note: Aminophylline or theophyllines are no longer recommended and associated with more adverse effects]

➢ Oxygen support: as needed to maintain O2 sat 93-95%. O2sat should be no higher than 96%.
➢ Moderate high back rest
➢ Avoid NSAIDs including aspirin

IV. DISCHARGE:
➢ Once patient is stable, feeding comfortably, no wheezes, on 3-4th day of antibiotics.
 Page |9

V. TAKE HOME MEDS:

1. Salbutamol Ipratropium neb as needed for dyspnea every 8 hrs.
2. Salmeterol + Fluticasone PMDI or Diskus 250mcg/50mcg or 125mcg/25mcg 2 puffs BID OR Formoterol + Budesonide
Turbohaler 160/4.5 2 puffs BID
3. Prednisone 40mg 1 tab OD with breakfast to complete for 5-7 days. (No need to titrate down)
4. Montelukast 10mg 1 tab OD.
5. Antibiotics as step-down based on CAP protocol + Azithromycin x 5 days (if started)
6. Advise pneumococcal and flu vaccinations
7. Advise avoidance of trigger.
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IV. URINARY TRACT INFECTIONS

Disease Definition/Diagnosis Management Meds/Follow-up

Screening and Treat:
(asymptomatic women): ➢ All pregnant women Meds for pregnant
➢ 2 UA samples with similar bacterial ➢ Those who will undergo patient:
strain with count >100,000 cfu/ml genitourinary manipulation
(eg. catheter, gyne/uro 1. Cephalexin 500mg
(asymptomatic men): procedure, papsmear etc) BID x 7D
➢ 1 UA sample with similar bacterial 2. Cefuroxime axetil
sp >100,000 cfu/ml Don’t treat if w/o Sx: 500mg BID x 7D
➢ Diabetics (strong 3. Fosfomycin
(catheterized M/F): recommendation) trometanol 3g single
➢ 1 UA sample with bacterial count ➢ Elderly dose
Asymptomatic
>100 cfu/ml ➢ HIV (weak recommendation) 4. Co-amox 625mg
bacteriuria
➢ Spinal cord injuries (weak) BID x 7D
Screening test for pregnant (9-17th ➢ Urologic abnormalities (weak) 5. Nitrofurantoin
wk AOG) OR planned genitourinary ➢ Solid organ transplant px 100mg QID x 7D
procedures: (weak) 100mg BID x 7D for
- Ideally urine culture ➢ Indwelling catheters (weak monohydrate
- If culture not available: recommendation): except in macrocystal prep (can
➢ May do 2 consecutive UA those with neutropenia, be given only on 2nd
samples positive if: with WBC urologic procedures, trim til 32 wks AOG)
>10/hpf, >2 bacteria/oif. pregnant, high incidence of
(>1 bac/oif in pregnant px). bacteremia)

➢ premenopausal non-pregnant First line: Not recommended as

women presenting with acute onset 1. Nitrofurantoin macrocrystal first line:
of dysuria, frequency, urgency, and formulation 100 mg QID x 5D. Fluoroquinolones
gross hematuria; and without Cotrimoxazole (unless
Acute
vaginal discharge. Other recommended: culture guided)
Uncomplicated
2. Fosfomycin 3gm single dose
Cystitis
➢ UA is NOT necessary if w/ >1 If symptoms worsen or
above symptoms w/o vaginal Alternatives (in order of choice): do not improve after
(usually in women
discharge and complicating 3. Cefixime 400mg OD x 7D Abx completion:
only since men
conditions 4. Cefpodoxime proxetil 100mg ➢ Change antibiotic
are usually
BID x 7D. ➢ UA + Urine culture
labeled as
5. Coamoxiclav 625mg BID x ➢ Manage as
complicated UTI)
7D complicated UTI
6. Cefuroxime 500mg BID x 7D
7. Cefaclor 500mg TID x 7D

➢ healthy women with no clinical or Admit if: Oral (primary meds):

historical evidence of anatomic or • Inability to maintain oral 1. Ciprofloxacin
functional urologic abnormalities, hydration or take medications 500mg BID x7-10D
who present with the classic • Concern about compliance 2. Ciprofloxacin ext
syndrome of fever (T ≥38°C), chills, • Presence of possible release 1gm OD x 7D
Acute flank pain, costovertebral angle complicating conditions 3. Levofloxacin 750mg
Uncomplicated tenderness, nausea and vomiting, • Severe illness with high fever, OD x 5D
Pyelonephritis with or without signs and symptoms severe pain, marked debility,
of lower UTI. and signs of sepsis. Alternative:
(usually in women 1. Cefixime 400mg OD
only since men WORK-UPS: Primary IV meds: x 14D
are usually 1. CBC, UA and Urine culture. 1. Ceftriaxone 2gm IV OD or 2. Cefuroxime 500mg
labeled as 2. Blood culture if with signs of sepsis. 2. Ciprofloxacin 400mg Q12 or BID x 14D
complicated UTI) - pyuria (≥5 WBC/HPF of 3. Levofloxacin 500mg IV OD 3. Co-amox (if GS is
centrifuged urine) on urinalysis and gram positive
bacteriuria with counts of ≥10,000 MDRO: otherwise it is
CFU/mL on urine culture. 1. Ertapenem (if ESBL discouraged) 625mg
3. Creatinine prevalence >10%) 1gm IV TID x 14D
4. KUB USD (not routine) only in: q24hrs
 P a g e | 11

- Hx of urolithiasis; pH >7.0; AKI/CKD 2. Piptaz 4.5gm IV q8hrs Ff-up:

(or high creatinine) - Rpt urine culture
- Px remain febrile w/in 72hrs → refer to NOT necessary if
URO if (+) imaging findings. clinically responding
w/in 72hrs unless
otherwise

Recurrence of Sx:
- Rpt culture and Abx
based on culture
sensitivity result for
14D
- KUB USD
- if similar organism,
extend Abx to 4-6wks
regimen.
➢ healthy non-pregnant woman with Treatment in acute episodes: Prophylaxis method:
no known urinary tract abnormalities Similar to Acute uncomplicated
has 3 or more episodes of acute cystitis Continuous (C): Daily
uncomplicated cystitis documented antibiotics x 6-12mos
by urine culture during a 12-month Prophylactic antibiotics
period OR 2 or more episodes in a indication: Post-coital (P): single
6- month period. 1. Px had unacceptable level of dose after sex
discomfort, plans for pregnancy,
WORK UPS: commitment, preference. Intermittent (I): self-
➢ Urine culture, creatinine, UA, CBC 2. Behavioral changes didn’t treatment with single
➢ KUB USD with post-void residual work dose based on
urine and/or CT stonogram esp: perceived need.
No response to appropriate Behavioral changes:
antibiotic or rapid relapse after such 1. post-defecation and anal C.P.I. meds dose
therapy cleansing antero-posteriorly 1. Nitrofurantoin 50-
Gross hematuria during a UTI always in women to avoid 100mg ODHS or
episode or persistent microscopic contaminating the periurethral single dose
hematuria area with fecal flora 2. Ciprofloxacin
Obstructive symptoms 2. post-coital douche or post 125mg ODHS or
Clinical impression of persistent coital urination single dose
infection 3. liberal fluid intake especially
Infection with urea-splitting bacteria after intercourse C.P. only
Recurrent UTI (Proteus, Morganella, Providencia) 4. avoidance of tight-fitting 1. Cefalexin 125-250
History of pyelonephritis underwear mg ODHS or single
History of or symptoms suggestive 5. use of alternative form of dose
of urolithiasis contraception for women using
History of childhood UTI spermicide-containing C.I. only
Elevated serum creatinine contraceptives Cefaclor 250mg
ODHS or single dose
Biologics:
1. Cranberry juice 300ml or C. only:
500mg capsule containing Fosfomycin 3g
36mg PACs BID. (Not really for q10days
prevention but to avoid
emergence of resistant E.coli to I. only:
Cipro, Amox and Cotri) 1.. Amoxicillin 500mg
x 1 dose
Hormonal for post 2. Cefuroxime 250mg
menopausal: x 1 dose
1. intravaginal estriol cream OD
HS x 2 weeks followed by twice-
weekly applications for at least
8 mos. OR estradiol releasing
silicone vaginal ring for 3
months
 P a g e | 12

Defined as significant bacteriuria WORK UPS: Outpatient parenteral

(>100,000 CFU/ml or <100k in 1. UA + Culture before initiating antibiotic therapy
catheterized px) plus clinical symptoms, Abx. (OPAT):
in the setting of (1) functional or 2. CT scan preferred over KUB - when oral regimen
anatomic abnormalities of the urinary USD (but financially not available or
tract or kidneys, or (2) the presence of challenging) - if IV continuation is
an underlying disease that interferes Creatinine, BUN, CBC necessary and
with host defense mechanisms, or (3) - no other indication
any condition that increases the risk of Admit px if: for hospitalization and
acquiring [persistent] infection and/or 1. Marked debility and signs of - pt can comply
treatment failure such as follows: sepsis,
2. uncertainty in diagnosis, Ff-up:
o (+) indwelling urinary catheter or 3. concern about adherence to > Repeat urine culture
intermittent catheterization treatment, or, 1-2 wks of Abx
o Incomplete bladder emptying with 4. unable to maintain oral completion.
>100ml retained urine post-voiding hydration or take oral > If significant
o Neurogenic bladder, cystocoele medications bacteriuria persists
o Obstructive uropathy (stone, post-treatment,
strictures, BPH, tumor) Empiric Treatment: consider referral to
Complicated UTI
o Vesicoureteral reflux and urologic specialists (infectious
abn Mild to moderate: oral or OPD diseases, nephrology,
o Chemical or radiation injuries of 1. Ciprofloxacin 500 -750 mg urology
uroepithelium BID or 1000 mg extended
o Peri- or postoperative UTI release tablet OD x 7-14d* or
o Azotemia due to intrinsic renal 2. Levofloxacin 500-750 mg OD
disease x 7-14d*
o Renal transplant 3. 1. Nitrofurantoin macrocrystal
o Diabetes mellitus formulation 100 mg QID x 5D
o Immunocompromised host (AIDS, or
febrile neutropenia) 4. Fosfomycin 3gm single dose
o UTI caused by unusual pathogens
(MTB, candida) Severe:
o UTI caused by MDR organisms Ertapenem 1 gm. q24h
o UTI in males except in young males Meropenem 1g q8h
with exclusively lower UTI symptoms Gentamicin 3-5 mg/kg/day q24h
o Urosepsis Amikacin 15mg/kg q24h
(monitor kidney function for
genta and amikacin)
SPECIFIC COMPLICATED UTIs
WORK-UPS Treatment same with general complicated UTI.
1. Pre and posttreatment (after 1-2wks of
abx completion) urine GS/CS.
Diabetic
2. Blood GS/CS for severely ill
3. KUB USD or CT scan- if no response
to empiric therapy w/in 48-72hrs.
Definition: Treatment:
1. Fever and/or other signs or symptoms 7 days – for those with prompt resolution of symptoms
compatible with UTI w/o other identified 10-15 days – those whose response is delayed
source of infection;
2. At least 103 colony forming units Remove catheter first
(cfu)/mL of at least 1 bacterial species
are present in a single catheter urine Mild to moderate (5-10 days treatment):
Catheter specimen or in a midstream voided urine 1. Ciprofloxacin 500mg PO BID or
associated UTI specimen; 2. Levofloxacin 750mg OD or
3. with an indwelling urethral, suprapubic 3. Cefpodoxime 200mg PO q12 or Cefixime 400mg PO
or condom catheter, or which has been OD or
removed within the previous 48 hours 4. Co-amoxiclav 875mg/tab BID

Pyuria, cloudy or odorous urine alone is Severe or unable to tolerate oral therapy (5-14days)
not diagnostic and not an indication for 1. Ciprofloxacin 400mg IV q12 or
Abx. 2. Levofloxacin 750 mg IV OD
 P a g e | 13

3. Ceftriaxone 2gm IV OD
Obtain specimen for culture from a 4. Cefepime 1gm IV q12
freshly inserted catheter. 5. Piperacillin-Tazobactam 3.375gm IV q6
6. Meropenem 1gm IV q8 (ESBL known or suspect)

Antipseudomonal: (risk: male transfer to ICU; Abx

already started on admission; ICU stay or >10 days
hospital stay; neurogenic bladder, Hx of prostate
surgery or urologic procedures, foreign body in urinary
tract, chronic steroid use)
1. Meropenem 1gm q8
2. Cefepime 1gm IV q8
3. Ceftazidime 1gm IV q8

(+) Staph risk: (+invasive medical device, surgical

procedures like joint replacement, and contact with
devices found in a hospital setting, immunocompromised
state (HIV, cancer, or chemotherapy), enteral feeding,
prolonged or recent hospitalization, prior levofloxacin or
macrolide use)
1. Add Vancomycin 1gm IV q12

MDRE klebsiella, pseudomonas, acetinobacter:

Colistin and Tigecycline (need IDS referral)

➢ strongly considered in diabetic Management: Antibiotic

patients with hypotension and renal 1. lesions <5 cm in diameter preference:
impairment. - antibiotics for 4-10 weeks until - Similar to Catheter
➢ considered for patients suspected to the abscess has completely related UTI.
have upper UTI who remain febrile regressed as evidenced by CT - Add Vancomycin if
and hypotensive 72 hours after initial scan. Drainage need not be with Staph risk.
intravenous (IV) antibiotic done.
Renal Abscess administration. - repeat CT scan after 4-6wks

Work-ups: 2. >5 cm lesion

1. CT scan over KUB USD – percutaneous drainage. Keep
2. Blood and Urine GS/CS or abscess open if loculated or percutaneous
aspirate GS/CS if drainage was done. not successful. Abx for 4 weeks
3. CBC, Creatinine, etc. after drainage.

➢ presence of Candida species First line:

regardless of colony count in Fluconazole 400 mg loading
properly collected urine specimens dose, then 200 mg/day for 7–14
taken on two separate occasions at days
least two days apart
Urinary
➢ yeast + pyuria Prior azole use; C. glabrata:
Candidiasis
IV amphotericin B deoxycholate
(AmBd) 0.3–1.0 mg/kg/day

Refractory cystitis due to

candida:
Amphotericin B bladder irrigation
50mg/L sterile water x 5D.
Post-transplant UTI, Urologic procedures, (skipped for this protocol since rarely applicable in our institution)
UTI IN PREGNANCY
➢ urinary frequency, urgency, Medication: Ff-up:
dysuria, and bacteriuria without 1. Cephalexin 500mg BID x 5D 1. Repeat urine culture
Acute Cystitis in fever and costovertebral angle 2. Cefuroxime 500mg BID x 7D 1-2 weeks after
Pregnancy tenderness. Gross hematuria 3. Cefixime 200mg BID x 7D completion of Abx
may also be present 4. Fosfomycin 3gm single dose 2. Monthly monitoring for
pregnant women with
 P a g e | 14

WORK UPS: (Other antibiotics not mentioned pyelonephritis, recurrent

1. Pretreatment urine GS/CS due to availability, price or UTIs, concurrent
2. If no culture available, UA: safety issues) gestational DM,
- pyuria: > 8 pus cells/mm3 of concurrent
uncentrifuged urine, OR > 5 pus nephrolithiasis or
cells/HPF of centrifuged urine AND urolithiasis, and pre-
(+) leukocyte esterase and nitrite test eclampsia until delivery.
in dipstick.
➢ fever (T> 38°C), chills, flank pain, Admit if: Recurrent UTI
costovertebral angle tenderness, • Inability to maintain oral prevention:
nausea and vomiting, with or hydration or take medications Close surveillance with
without signs and symptoms of • Concern about compliance urine culture every 2
lower urinary tract infection. • Presence of possible weeks until 36 weeks.
complicating (co-morbid)
WORK UPS: conditions Meds:
1. UA: Pyuria • Severe illness with high fever, 1. Ceftriaxone 2gm IV
➢ (≥ 5 WBC/HPF of centrifuged severe pain, marked debility OD
urine) on urinalysis and • Signs of preterm labor 2. Ceftazidime 2gm IV
bacteriuria with counts of • Signs of sepsis q8
>10,000 CFU/mL on urine culture
2. Urine GS/CS Treatment: 14D duration Alternative:
3. Blood GS/CS if with signs of sepsis Ampi-Sulbactam 1.5gm
Acute 4. KUB USD if no improvement to If symptoms recur and culture IV q6 (if GS shows gram
uncomplicated initial treatment shows similar organisms – 4- (+))
Pyelonephritis 6wks regimen recommended Piptazo 4.5gm IV q8

Oral: (started when

48hrs afebrile and based
on IV Abx or culture
result)
1. Cephalexin 500mg
QID x 14D
2. Cefuroxime 500mg
BID x 14D
3. Cefixime 200mg BID x
14D
4. Co-amoxiclav 625mg
BID x 14D
 P a g e | 15

V. SEPSIS AND SEPTIC SHOCK

I. DIAGNOSIS:
Definition: life-threatening organ dysfunction caused by a dysregulated host response to infection.
Diagnostic screening: quick SOFA score: (+) if 2 of the following are met in a patient with proven or suspected
infection:
• SBP ≤ 100mmHg
• Respiratory rate >21
• Altered mental status

SIRS criteria: at least 2 of the following plus suspected or proven infection but qSOFA not met → observe for
progression to sepsis: (no longer recommended as screening tool for sepsis but only as clue). See algorithm below.
• Temp >38 or <36oC
• Respiratory rate >20 breaths per min or PaCO2 <32mmHg
• Heart rate >90 beats per minute
• Leukocyte count >12,000/ml or <4,000/ml or >10% immature band forms

Lifted from PSMID Sepsis Criteria 2020. See SOFA scoring criteria below.
 P a g e | 16

II. SEVERITY
Severe Sepsis – hypotension responding to initial IV bolus.
Septic shock - Sepsis-3 clinical criteria of:
(1) hypotension requiring vasopressor to maintain MAP ≥65mmHg, and
(2) a serum lactate level >2mmol/L (18mg/dl) after adequate fluid resuscitation be used to identify patients
with septic shock
> Patient who are poorly responsive or requiring higher dose of inotropes and elderly may need transfer to
tertiary hospital as per internist assessment.

III. MANAGEMENT:
Goal: Stabilize patient → Identify source of infection
➢ Admit to ward if severe sepsis and can be stabilized at the ER level. Otherwise transfer to tertiary hospital if septic
shock.
➢ Diet: > If hemodynamically stable:
o Insert NGT and start OTF at 1200kcal/day within 24hrs then may slowly increase to 30kcal/day
If hemodynamically unstable:

> If unstable:
o Start parenteral feeding (nutriflex, kabiven, combiflex etc) 1400kcal IV to run for 24hrs.
➢ IVF: If hypotensive, give 30ml/kg IV PNSS bolus then recheck MAP if ≥65mmHg (MAP goal 75-85mmHg for known
hypertensives). Max fluid of 5L per 24hrs.
➢ VS q4; q15mins to q1hr if on inotropes
➢ I/O qshift; if on foley cath, q1hrly
➢ CBG TID premeals
➢ Dx:
o Blood culture prior to initiation of antibiotics
o Sputum or urine or wound culture depending on site of infection
o CBC with BTRh, Na, K, Mg, HbA1c
o Crea, BUN, SGPT, SGOT, alkPhos, Amylase/lipase (if liver or pancreatitis suspected as source)
o Procalcitonin (if available)
o CRP
o Urinalysis and/or stool exam if indicated
o 12L ECG, ABG (for base excess, CO computation by Fick’s Law), 2D echo if indicated (rule out cardiac
cause)
o Serum Lactate (if available)
 P a g e | 17

o Chest Xray; KUB or W/A USD (if suspected UTI or abdominal source); CT scan (if indicated esp abdominal
source)
➢ Tx:
o Meds stabilizing the BP:
▪ If MAP still <65 despite IVF PNSS bolus and appears hypovolemic, may use plasma expanders
(start Albumin drip 20% to run for 4hrs) with IVF bolus until MAP goal achieved.
▪ If MAP still <65 despite expander, start norepinephrine drip 4mg in 46cc PNSS to run at 0.05 to
3mcg/kg/min (you can use Medscape to estimate drip rate) to achieve MAP ≥ 65 (75-85mmHg for
hypertensives), or lactate <2mmol/L , or base excess improvement on ABG if less than -3. Next
vasopressor of choice is Vasopressin 0.03 units/minute (0.01 to 0.04 units/min).
▪ If MAP still <65 at 6hrs of inotropes, start Hydrocortisone 50mg IV q6hr or 200mg IV drip in 24hrs

o Start antibiotics within 1hr of presentation (ideally after extracting blood culture if it does not delay
antibiotics) [will be considering only those readily available]
▪ CAP-HR:
➢ (without MRSA or P.aeruginosa risk):
o Ceftriaxone 2gm IV OD + Azithromycin 500mg IV OD OR Levofloxacin 750mg IV OD

➢ (with risk of P. aeruginosa risk): (History of chronic or prolonged (>7 days within the past
month) use of broad-spectrum antibiotic therapy; With severe underlying bronchopulmonary
diseases; Malnutrition ; Chronic use of steroid therapy >7.5mg/day; immunocompromised host)
o Cefepime 2gm in 100cc PNSS to run 2hrs IV q8 OR Meropenem 1gm IV in 100cc to run
3hrs IV q8 PLUS
o Azithromycin 500mg IV OD or Levofloxacin 750mg IV OD

➢ (with MRSA risk): (have invasive vascular catheters, previous intravenous antibiotics in the
past 90 days, and previous MRSA infection or colonization)
o Add Vancomycin 15mg/kg IV q12 or Linezolid 600mg IV q12

▪ HOSPITAL ACQUIRED PNEUMONIA:

➢ Not at high risk for mortality but with factors increasing the likelihood of MRSA:
o Ceftazidime or Cefepime 2g IV q8 OR Meropenem 1g IV q8 PLUS
o Vancomycin 15mg/kg IV q12

➢ High risk of mortality or receipt of IV antibiotics during the prior 90 days:

(high risk for mortality include: need for ventilator support and septic shock)
2 of the following but avoid 2 beta lactams:
o Ceftazidime OR Cefepime 2g IV q8 OR Meropenem 1g IV q8

PLUS EITHER:
o Ciprofloxacin 400mg IV q8 OR Levofloxacin 750mg IV OD OR
o Amikacin 15-20mg/kg IV q24 OR Gentamicin 5-7mg/kg IV q24

PLUS:
o Vancomycin 15mg/kg IV q12

o INTRAABDOMINAL INFECTIONS
▪ Severe community-acquired complicated intraabdominal infection:
▪ Ceftriaxone 2gm IV OD PLUS Metronidazole 500mg IV q8

▪ Severe healthcare associated complicated intraabdominal infection:

▪ Meropenem 1gm IV q8 with or without Vancomycin 15mg/kg IV q12

o SEVERE SKIN AND SOFT TISSUE INFECTION

▪ Severe purulent SSTI (patients who have failed incision and drainage plus oral antibiotics with signs of
SIRS or those who are immunocompromised.)
▪ Vancomycin 15mg/kg IV q12
 P a g e | 18

▪ Severe nonpurulent SSTI (necrotizing infection/cellulitis/erysipeplas). (patients who have failed

oral antibiotic treatment or those with signs of SIRS, or those who are immunocompromised, or those with
clinical signs of deeper infection such as bullae, skin sloughing, hypotension, or evidence of organ
dysfunction. Clindamycin should be administered as soon as possible to patients with necrotizing fasciitis)
▪ Vancomycin 15mg/kg IV q12 PLUS
▪ Ceftriaxone 2gm IV OD PLUS Metronidazole 500mg IV q8 OR
▪ Meropenem 1gm IV q8

o SOURCE UNCLEAR
▪ Meropenem 1gm in 100cc PNSS x 3 hrs IV q8hr PLUS
▪ Vancomycin 25-30mg/kg IV loading dose then 1g IV q8

o Source control
▪ specific anatomical diagnosis of infection requiring consideration for emergent source control
(e.g., necrotizing soft tissue infection, complicated intra-abdominal infection) within first 6-12hrs
▪ Remove intravascular devices if they are the source of severe sepsis.

o Glycemic control
▪ CBG goal 110-180mg/dl, use insulin for CBG control if >2 consecutive CBG >180mg/dl. Avoid
Metformin and sulfonylureas (Gliclazide, Glimeperide etc).
o DVT prophylaxis with Enoxaparin 0.2cc SQ BID or compression stockings (if with contraindication to
anticoagulant).
o Omeprazole 40mg tab 1 tab OD prebreakfast (stress ulcer prophylaxis)

➢ Step-down antibiotics based on culture results and patient is stable

➢ Apply compression stockings
➢ O2 support as needed, transfer if mechanical ventilator needed.
➢ Blood transfusion with pRBC threshold is Hg <7.0 among anemic patients
 P a g e | 19

VI. DENGUE FEVER

I. DIAGNOSIS:
Fever, arthlagia, flushing or hermann’s rash, periorbital and/or bone pain, or bleeding episodes, tourniquet test (+).
Careful with common mimickers such as Chikungunya, Typhoid fever and Schistosomiasis.

II. SEVERITY EVALUATION:

A. Dengue without warning signs: absence of below symptoms. → May discharge if can commit good care at home.
B. Dengue with warning signs: Abdominal pain or tenderness, persistent vomiting, clinical fluid accumulation,
mucosal bleed, lethargy; restlessness, liver enlargement >2cm, laboratory: increase in HCT concurrent with rapid decrease in
platelet count.
C. Severe Dengue: above symptoms with shock (DSS), fluid accumulation with respiratory distress, severe bleeding,
severe organ impairment: (AST or ALT >1000, seizures, impaired consciousness, myocarditis, renal failure) → Stabilize and
refer for ICU admission.
> Compensated shock: Stable SBP but with signs of plasma leakage like hemoconcentration or reduced
perfusion (dizziness, renal failure, dyspnea, cold extremities).
> Hypotensive shock: Hypotensive, undetectable pulse or BP

III. MANAGEMENT DENGUE FEVER WITH OR WITHOUT WARNING SIGNS:

➢ Diet: DAT except dark colored foods
➢ IVF: D5LR or D5NSS x 5-7ml/kg x 2hrs then 3-5ml/kg x 4hrs then 2-3ml/kg/hr or less based on clinical response (Hct
– decreasing in a stable patient)
o Increase rate back to 5-10ml/kg/hr for 1-2hrs if Hct rapidly rises or worsening vital signs.
➢ VS q4
➢ I/O qshift – accurate measurement is a must to determine clinical response
➢ Dx:
o CBC with BT Rh, CBC q 6-12 as needed
o Dengue duo test
o Crea, SGPT, SGOT – if indicated such as severe dengue
o 12L ECG – if suspected myocarditis (with chest pain)
o Chest xray: if with dyspnea or respiratory distress
o Typhidot test if PLT low despite high fever
o Schistosoma test (rectal biopsy or Kato Katz smear) if suggestive based on exposure and PE
o WA USD – if indicated such as rising liver function test.

➢ Treatment:
o Paracetamol 500mg 1 tab or 600mg IV q4 PRN for fever
o Omeprazole 40mg 1 cap OD for those with epigastric pain or low PLT.
o No NSAID, aspirin, or intramuscular injections.

IV. MANAGEMENT FOR SEVERE DENGUE:

➢ Diet: DAT if able to tolerate feeding otherwise NGT feeding
➢ IVF:
COMPENSATED SHOCK (stable SBP but with signs of plasma leakage) → give PNSS 5-10ml/kg x 1 hr.
(Obtain baseline Hct prior to IV bolus)
o If patient improves (based on Hct):
▪ 5-7 ml/kg/hr for 1-2 hr, then to 3-5 ml/kg/hr for 2-4 hr, then to 2-3 ml/kg/hr for 2-4 hr and then reduced
further depending on haemodynamic status

o If patient still unstable request for Hct after 1 hr IVF bolus:

▪ If Hct increases/ still high (>50%), repeat a second bolus of crystalloid solution at 10-20 ml/kg/hr
for 1 hr.
• If with improvement after second bolus, reduce rate to 7-10 ml/kg/hr for 1-2 hr, continue to
reduce as above.
▪ If Hct decreases, this indicates bleeding and need to cross-match and transfuse blood as soon as
possible
 P a g e | 20

HYPOTENSIVE SHOCK
▪ Give PNSS at 20ml/kg as bolus for 15-30 mins. May use colloids to raise BP urgently i.e. pulse
pressure (SBP – DBP) of <10 mmHg.(E.g. use of Voluven IV or Dextran 10% in 40cc NSS or
albumin but too costly)
o If condition improves,
▪ Give a crystalloid/colloid infusion of 10 ml/kg/hour for 1 hour.
▪ then crystalloid infusion reduce to 5−7 ml/kg/hour for 1−2 hrs
▪ then to 3−5 ml/kg/hour for 2−4 hours, and
▪ finally to 2−3 ml/kg/hour (or less) x 24−48 hours
o If still unstable or shock persists, request for Hct
▪ If Hct normal or low (<35-40% (F) or <40-45% (M)), this may indicate bleeding. Identify source.
• If there’s severe overt bleeding: prepare and crossmatch fresh whole blood or fresh packed
RBC and transfuse.
• If no severe bleeding: give 2nd bolus 10-20 ml/kg of colloid over 30 mins to 1hr. Rpt clinical
assessment and Hct level.
▪ If Hct high compared to baseline value,
• change IVF to colloid solutions (eg Voluven) at 10−20 ml/kg as a second bolus over 30
minutes to 1 hour.
• If the condition improves, reduce the rate to 7−10 ml/kg/hour for 1−2 hours, then change
back to crystalloid solution and reduce the rate of infusion as mentioned above.
▪ If still unstable, Repeat Hct after second bolus
• Hct low (<40% (F) or <45% (M)) → indicate bleeding and need to cross-match and
transfuse blood ASAP
• Hct increases or high >50% →
o continue colloid solutions at 10−20 ml/kg as a third bolus over 1 hour.
o after this dose, reduce the rate to 7−10 ml/kg/hour for 1−2 hours, then change
back to crystalloid solution and reduce the rate of infusion as mentioned above
when the patient’s condition improves.
o If the condition is still unstable, repeat the haematocrit after the third bolus. Then
assess need for blood transfusion or repeat IVF boluses as above.
➢ VS q15mins to q1hrly
➢ I/O q6-8hrly
➢ Dx:
o CBC with PLT, baseline Hct then as frequent as needed
o CXR PAL (look for pleural effusion, signs of ARDS or edema)
o Creatinine, BUN, SGPT, SGOT, BTRh, Bleeding time, Clotting time
o WA USD (look for possible source of bleeding)
o Urinalysis
o CBG
o Electrolytes, ABG (metabolic acidosis in severe bleeding), O2sat
o FOBT (or do DRE to check for GI bleed), D-dimers if indicated
o PT APTT
o 12L ECG (identify possible cardiac comorbidities to avoid congestion during IV bolus)
➢ Tx:
o Paracetamol 500mg 1 tab or 600mg IV q4 PRN for fever
o No NSAID, aspirin, or intramuscular injections.

V. MANAGEMENT OF HEMORRHAGIC DENGUE

Diagnosis:
➢ persistent and/or severe overt bleeding in the presence of unstable haemodynamic status, regardless of the
hematocrit level;
➢ a decrease in hematocrit after boluses of fluid resuscitation together with unstable hemodynamic status;
➢ refractory shock that fails to respond to consecutive fluid resuscitation of 40–60 ml/kg;
➢ hypotensive shock with inappropriately low/normal haematocrit;
➢ persistent or worsening metabolic acidosis in patients with a well-maintained systolic BP, especially in those with
severe abdominal tenderness and distension.
 P a g e | 21

Treatment:
➢ Give 5-10 ml/kg of fresh packed red cells or 10-20 ml/kg fresh whole blood
➢ Omeprazole and ranitidine can be used for upper GI bleeding (efficacy studies limited).
➢ IV vitamin K 10mg – in special cases of prolonged PT secondary to liver failure
➢ No evidence of giving PLT concentrate for low PLT count or FFP to control bleeding except in scenarios such as
surgeries or deliveries. Limited data on use of PLT concentrate in PLT <10,000 with active bleeding (physician
discretion advised).

VI. DISCHARGE CRITERIA: (all must be present)

1. No fever for 48hrs
2. Improvement in clinical picture
3. Increasing trend of PLT count
4. No respiratory distress
5. Stable hematocrit without IVF
 P a g e | 22

VII. ACUTE GASTROENTERITIS

I. DIAGNOSIS: nausea, vomiting, abdominal pain, diarrhea (3 loose stools in 24hrs), fever
II. SEVERITY CLASSIFICATION:

Parameter Mild Moderate Severe

General Awake Less active Lethargic or comatose
Eyes Normal Sunken Sunken
Mucosa Normal Dry Dry
Thirst Normal Thirsty Unable to drink
BP Normal Orthostatic hypotension Hypotensive, syncope
HR Normal Tachycardic, thready pulse Tachycardic
RR Normal Tachypneic Tachypneic or Kussmauls
Skin Moist Reduced turgor Skin tenting, dry axilla
Urine output >0.5ml/kg/hr Normal <0.5ml/kg/hr
Capillary refill time <2secs <2secs >2secs
Body weight <3% reduction in weight for 7 days 3-5% reduction for 7 days >5% reduction

1. Mild dehydration – send home

2. Moderate dehydration – may admit
3. Severe dehydration – admit, possible ICU

Indication for aggressive fluid resuscitation (IAFR): (any 1 of the following):

1. Systolic BP < 100mmHg
2. HR > 100 bpm
3. Capillary refill >2s or peripheries cold to touch
4. RR > 20 cpm

III. MANAGEMENT:
➢ Diet: Low fat, no dairy foods, no milk
➢ IVF:
o Moderate: 500-1000ml PLR fast drip then reassess IAFR
o Severe: 1000-2000ml PLR fast drip then reassess IAFR
▪ Assess patient every 500ml of fast drip to avoid congestion.
▪ If patient still hypotensive <90mmhg SBP after 2L:
• rule out other causes of hypotension such as sepsis
• start inotropes to achieve MAP > 65mmhg.
o Maintenance rate after successful resuscitation:
▪ BW <50kg → 2-3ml/kg//hr
▪ BW >50kg → 1.5-2ml/kg/hr
▪ Replace vol-per-vol for bouts of diarrhea or vomiting
➢ VS q4
➢ I/O qshift. Q1hrly if oliguric or anuric
➢ Dx:
o CBC
o UA
o Fecalysis
o BUN and Crea
o ABG (optional)
o Stool culture – in immunocompromised, high fever, severe dehydration, dysenteric stool, severe abdominal
pain
o Na, K, Mg

➢ Medications:
o Empiric Antibiotics: any of the ff: fever; fever and bloody stools; symptoms persisting for > 3 days
▪ Azithromycin 1gm single dose OR Ciprofloxacin 500mg BID x 3-5 days.
 P a g e | 23

o Usual regimens:
▪ Cholera: Azithromycin 1gm single dose OR ciprofloxacin 1-2gm single dose or 500mg BID x 3days
OR Doxycycline 100mg BID x 3 days
▪ Shigella: Ceftriaxone 1gm OD x 5 days OR Ciprofloxacin 500mg BID x 5 days OR Azithromycin
1gm single dose
▪ Non-typhoidal salmonella: Ciprofloxacin 500mg BID x 5days or Ceftriaxone 1gm IV OD x 5 days
▪ Amoebiasis: Metronidazole 500-750mg TID x 10 days. Diloxanide furoate 500mg TID +
Metronidazole for intestinal cyst.
o Racecadotril 100mg TID. (reduce frequency and duration, avoid use in amoebiasis)
o Erceflora 1 vial BID x 5 days. (limited data). Avoid in suspected amoebiasis.

➢ Correct severe hypernatremia/hyponatremia and hypokalemia accordingly

➢ Correct metabolic acidosis if serum HCO3 less than 10 and pH <7.10
➢ Renal replacement therapy in AKI indicated for the following:
o Refractory fluid overload
o Severe hyperkalemia (plasma potassium concentration > 6.5 meq/L)
o Signs of uremia, such as pericarditis, encephalopathy or an otherwise unexplained decline in mental status
o Severe metabolic acidosis (pH 7.1)

IV. DISCHARGE:

May discharge patients after 3 days for moderate-severe AGE for PHIC purposes.
 P a g e | 24

VIII. ELECTROLYTE IMBALANCE

I. HYPONATREMIA
Class Na Serum level Symptoms
Mild 130-135 meq/L Usually nonspecific
Moderate 120-129 meq/L Headache, nausea, vomiting, fatigue, gait disturbance,
confusion, restlessness, irritability
Severe <120 meq/L Seizure, obtundation, coma, respiratory arrest

CLASSIFICATION: (important to classify otherwise you will be clueless on which management to follow)
1. Hypovolemic – Active GI losses, signs of fluid loss (low BP or tachycardia), renal losses, diuretics, poor Na intake
2. Euvolemic – No edema, normal JVP, Presence of infection or malignancy (SIADH usually the most common),
Drugs (SSRI)
3. Hypervolemic – Heart failure, ascites in cirrhosis, renal failure, polydipsia

MANAGEMENT:
➢ Admit to ICU or tertiary hospital if with neurologic symptoms such as seizure or sensorial changes.
➢ May admit to ward with caution if suspected chronic and GCS 15.
➢ Diet: Water restriction for hypervolemic hyponatremia
➢ VS q4.
➢ I/O qshift but accurate measurement. Q1 if reduced urine output.
➢ IVF:
o Hypovolemic hyponatremia – PNSS1L x rate computed as follows:
▪ Step 1: A (Na deficit) = (Desired – Actual) x 0.5 x BW (kg)
▪ Step 2: B (number of liters PNSS needed) = A/154mEqs
▪ Step 3: C (infusion limit in hrs) = (Desired – Actual)/0.5
▪ Step 4: D (hydration rate in ml/hr) = B/C
o Euvolemic – SIADH usually don’t response to PNSS hydration but may be attempted with similar
computations above
o Hypervolemic – restrict IVF or set at KVO unless severely symptomatic
➢ Dx:
o CBC
o Chest Xray (esp TB suspect which can cause SIADH)
o Creatinine, BUN
o Urinalysis
o Liver function test if with ascites or suspected cirrhosis
o 12L ECG
o Ser. Na (q8hrly), Ser K, Mg
o Urine Na, K if available
o Urine osm if available
o Ser uric acid (low in SIADH)
o TSH, FT4
➢ Tx:
o NaCl 1gm/tab (17meqs) tab TID for hypovolemic and euvolemic hyponatremia
o Furosemide 20mg 1 tab BID-TID (for euvolemic hyponatremia). Higher dose in CKD patient (hypervolemic
hyponatremia).
o Tolvaptan 15mg ½ tab OD as needed (for euvolemic hyponatremia and cardiac and liver cirrhosis)
o Enalapril 10mg 1 tab OD (for cardiac patients)
o Correct other electrolytes abnormalities

➢ WOF: deterioration in sensorium, seizure during correction – might indicate osmotic demyelination syndrome.

II. HYPERNATREMIA
Class Na Serum level Symptoms
Mild 145-150 meq/L Usually asymptomatic
Moderate 151-158 meq/L Lethargy, weakness, irritability
 P a g e | 25

Severe >158 meq/L Twitching, hyperreflexia, seizure coma

Acute hypernatremia < 48 hrs (goal: replace water deficit in 24hrs). Usually in diabetes insipidus.
Chronic hypernatremia > 48 hrs (majority of the patients)

DIFFERENTIALS: (history alone usually suffice)

1. Increased Extracellular fluid volume – usually iatrogenic secondary to hypertonic NaCl or NaHCO3, ingestion of
saline water.
2. Decreased Extracellular fluid volume:
A. Minimum volume of concentrated urine: Insensible water loss, limited fluid intake or GI water loss, renal
water loss
B. High urine volume (>3L/day):
> Urine osmole >750 mOsm/d – cause: use of diuretics
> Low urine Osm: cause: central diabetes insipidus VS nephrogenic diabetes insipidus (Serum
vasopressin to differentiate)

MANAGEMENT:
➢ Admit patient with sensorial changes, seizure and twitching to tertiary or ICU set up
➢ Diet: If patient conscious encourage drinking water or via nasogastric tube with free water flushing 200cc q6 pre and
post feeding.
➢ IVF:
o Acute hypernatremia: Start D5W x 3-6ml/kg/hr then regulate to 1ml/kg/hr once serum Na 140 is achieved.
Replace ongoing water losses
▪ Monitor serum Na every every 1-2 hrs until ser Na <145 then q2-4hrly until ser Na 140 is restored

o Chronic hypernatremia: Start D5W x 1.35ml/kg/hr as initial then add ongoing hourly water losses, if known.
▪ Then monitor Na every 4-6hrs until target 10meq/L in 24hr reduction in serum Na is achieved.
Otherwise modify infusion rate then monitor Na after 4-6hrs. If target reduction achieved reduce
monitoring to q12-24hr until normonatremia is achieved.
➢ VS q4
➢ I/O qshift but accurate 24hrs measurement
➢ Dx:
o Na (monitoring as stated above), K, Mg
o Creatinine, BUN
o CBC
o Chest Xray
o Ideally urine osmolarity or serum vasopressin
➢ Treatment:
o Treat specific etiology. Hold diuretics (mannitol, furosemide etc).
o Correct hyperglycemia for diabetics
o (For diabetes insipidus) Desmopressin 2-4mcg SQ or IV daily in 2 divided doses. Observe fluid restriction.

III. HYPOKALEMIA
Class K Serum Symptoms ECG Changes
level
Mild 2.9-3.5 meq/L Usually asymptomatic Broad T wave flattening (decreased amplitude)
Moderate 2.6-2.9 meq/L Muscle weakness, muscle cramps, Appearance of U waves, increased P wave
fatigue amplitude and width; prolonged PR, slight ST
depression, risk of SVTs (Paroxysmal atrial
tachycardia, aFib, atrial flutter
Severe <2.6 meq/L Rhabdomyolysis, bradycardia, Pronounce ST depression, u-wave height
arrhythmia, respiratory failure increased followed by TU fusion. PVCs, torsades
de pointes, Vtach, Vfib

DIFFERENTIALS: (mostly history alone will suffice to know etiology)

A. K loss
1. GI losses – usually diarrhea, vomiting leading to alkalosis
2. Renal losses – use of loop diuretics, thiazides, renal tubular acidosis, hypogmagnesemia, hyperaldosteronism
 P a g e | 26

3. Vascular – dialysis, plasmapheresis

B. K shift to the cells

1. Alkalosis, insulin use, Inc beta-adrenergic activity (use of salbutamol + steroids), hypokalemic periodic paralysis,
Hypothermia, RBC production

C. Recurrent Hypokalemia (usual causes)

1. Thyrotoxic hypokalemic paralysis
2. Renal tubular acidosis (most common)
a) RTA type 1 (distal) → Urine pH always >5.3, plasma HCO3 variable (maybe below 10 meq/L, Increased
urine Calcium/Creatinine ratio, (+) nephrolithiasis/nephrocalcinosis
b) RTA type 2 (proximal) → Urine pH variable (maybe >5.3 in bicarbonaturia periods), plasma HCO3 12-
20meq/L, Normal Calcium/Creatinine ratio, No nephrolithiasis/nephrocalcinosis
3. Hypokalemic periodic paralysis (diagnosis of exclusion)

COMPUTE DEFICIT: (several methods)

➢ K def = (4 – actual K) x 150
➢ K def = (target K – actual K) x wt (kg) x 0.4
➢ Gross estimation:
o 200 meqs → ser K of 3-4.0
o 400 meqs → ser K of 2-3.0
o 600 meqs → ser K of <2.0

MANAGEMENT:
➢ Admit to ward if asymptomatic or ECG suggestive of mild hypokalemia.
➢ Admit to ICU set-up if with evidence of paralysis and presence of tachyarrhythmias unless you can correct the deficit
at ER level.
➢ Diet: DAT + 2 Bananas TID (better K content are avocados, nuts, seaweed, bran cereals)
➢ IVF: Goal is to correct half of the deficit using IV line.
o Peripheral line: Start PNSS1L + 60meqs KCl to run at 100-160cc/hr. Start another line with PNSS 1L +
60meqs KCL to run at 100cc/hr.
o Central line: (although difficult to apply in our setting) – may give 40meqs/hr especially in life threatening
instances
➢ VS q4 for mild. Q1 for moderate to severe
➢ I/O qshift
➢ Dx:
o ABG (for diagnosing RTA)
o Monitor ser K q6-8hrly ideally
o Urinalysis (important is presence of cast, urine pH for RTA)
o TSH FT4 (hyperthyroidism cause hypokalemia)
o CBC
o Ser. Na, K, Mg, Ca, Phosphate
o Plasma K (suspected pseudohypokalemia esp in leukemia pt)
o KUB USD (look for nephrocalcinosis or stone, adrenal enlargement)
o Ideally urine Na, K, Ca
➢ Tx:
o Start KCl (10-20meqs/tab) give 2 tabs QID (based on computed deficit)
o For thyrotoxic periodic paralysis:
▪ Propranolol 3mg/kg PO or 1mg IV
▪ 30meqs of KCl tab every 2hrs until improvement begins. Max dose of 90 meqs in 24hrs.
o Correct hypomagnesemia: (1 - actual) x 10 = grams of MgSO4 needed to be given
▪ i.e. Give 2gm MgSO4 + 100cc D5W soluset to be given for 2hrs then give the rest of deficit in 250cc
D5W to run for 12hrs.
o Renal tubular acidosis Type 1:
▪ Potassium-HCO3 650mg (7.7meqs) (avoid use in the presence of urolithiasis). Goal HCO3 of 22-
24 meqs/L.
• If HCO3 <16 meq/L, give 4 tabs (30meqs) QID as starting
 P a g e | 27

• If HCO3 >16 meq/L, give 6 tabs (40meqs) BID as starting

o Repeat ABG after 1 week to check HCO3 goal if achieved.
o Then maintenance at 4 tabs BID once goal HCO3 level is achieved
▪ (alternative) K-citrate 1 tab 10meqs/tab, give 3 tabs QID if HCO3 <16; 4 tabs BID if HCO3 >16.
Maintenance with 3 tabs BID once goal HCO3 is achieved.
o Renal tubular acidosis Type 2: (usually higher doses). Similar goal HCO3 of 22-24 meqs/L.
▪ K-citrate 15meqs/tab 10 tabs every 4 hrs!
▪ Avoid NaHCO3 as it may worsen Hypokalemia
▪ K-citrate requirement may be lowered with adding Hydrochlorothiazide 12mg 1 tab OD
▪ Add spironolactone 25mg 1 tab BID

DISCHARGE CRITERIA:
1. Etiology identified
2. Level of K at 3-3.5 without symptoms and normal ECG

IV. HYPERKALEMIA
Class K Serum Symptoms ECG Changes
level
Mild 5.5 - 6 meq/L Usually asymptomatic Peaked T waves (usually the earliest sign)
Moderate 6 - 7 meq/L Muscle cramps, irritability or P wave widens and flattens
paresthesias. Nonspecific symptoms. PR segment lengthens
P waves eventually disappear
Severe >7- 9 Muscle weakness or paralysis, cardiac Prolonged QRS interval with bizarre QRS
conduction abnormalities, cardiac morphology
arrhythmias High-grade AV block with slow junctional and
ventricular escape rhythms
Any kind of conduction block (bundle branch
blocks, fascicular blocks)
Sinus bradycardia or slow AF
Development of a sine wave appearance (a pre-
terminal rhythm)
Lethal >9.0 Death Asystole
Ventricular fibrillation
PEA with bizarre, wide complex rhythm

SEVERITY ASSESMENT:
- Identify possible causes. (e.g. CKD or AKI, hemolysis, tumor lysis syndrome, GI bleed, trauma leading to rhabdomyolysis
etc., adrenal crisis)
- Transfer to Tertiary hospital if:
o If ECG changes noted suggestive of moderate hyperkalemia → give first doses of hyperkalemic regimen
prior to transfer,
o Presence of muscle weakness or paralysis
o No ECG changes but ser. K >6,5 meqs

- If can be corrected at ER level with improvement of T wave upon giving initial meds, may admit at our ward assuming not
due to CKD V which may warrant immediate dialysis.
- May not treat if ser K < 5.3 in the absence of ECG changes.

MANAGEMENT
➢ Diet: Low potassium diet
➢ IVF:D5W x KVO
➢ VS q15 mins while at ER
➢ I/O qshift with strict monitoring
➢ Dx:
o Ser. Na, K, Mg, Ca. Ser K every 6-8hrs until less than 5 or ECG changes normalizes
o Creatinine, BUN
o 12L ECG as frequent as needed in severe cases.
o CBC
 P a g e | 28

o ABG
o KUB USD if CKD or adrenal problem suspected

➢ Tx: Start the following hyperkalemic regimen then give initial dose. May hold once ser K <5.0
o Calcium gluconate 10% in 1:1 dilution (10ml) to run for 2-3 mins. Give every 2 mins until ECG changes
improves.
o Salbutamol 4 nebs in 4cc NSS 1 neb now then q4-q6 hrly
o Kalimate sachet 2 sachet in 1 glass H2O TID or QID (patient must have bowel movement to be effective)
o RI 10 units + D50 1 vial (may not add D50 if CBG >200-250mg/dl) IV q6
o Furosemide 60mg IV q6-8hrly. Higher dose in CKD
 P a g e | 29

IX. UPPER GASTROINTESTINAL BLEEDING

SEVERITY EVALUATION:
A. Hemodynamic assessment:
Factors I II III IV
Blood loss <15% 15-30% 30-40% >40%
(<750ml) (750-1500ml) (1500-2000ml) (>2000ml)
Pulse >100 >100 >120 >140
BP Normal Normal/possible orthostatic Hypotension Marked hypotension
hypotension
Capillary refill <2s 2-3s 3-4s >5s
Respiratory rate 14-20 20-30 30-40 >40
Urine output >30ml 20-30ml 5-10ml Negligible
Mental status Slightly anxious Mildly anxious Anxious and confused Confused, lethargic
Disposition May possibly admit Prompt gastroenterology ICU, prompt surgical ICU, prompt surgical
at our ward referral referral referral

B. Glasgow-Blatchford score can better stratify patient whether they can be admitted to ward or not.

Blood urea nitrogen  Female ≥12 g/dL [≥120 g/L] (0 points)

 <18.2 mg/dL [<6.5 mmol/L] (0 points)  Female ≥10 and <12 g/dL [≥100 and <120 g/L] (1 point)
 ≥18.2 and <22.4 mg/dL [≥6.5 and <8  Male or female <10 g/dL [<100 g/L] (6 points)
mmol/L] (2 points)
 ≥22.4 and <28 mg/dL [≥8 and <10 Systolic blood pressure
mmol/L] (3 points)  ≥110 mmHg (0 points)
 ≥28 and <70 mg/dL [≥10 and <25  100 to 109 mmHg (1 point)
mmol/L] (4 points)  90 to 99 mmHg (2 points)
 ≥70 mg/dL [≥25 mmol/L] (6 points)  <90 mmHg (3 points)

Hemoglobin Other markers

 Male ≥13 g/dL [≥130 g/L] (0 points)  Heart rate ≥100 per minute (1 point)
 Male ≥12 and <13 g/dL [≥120 and  Melena at presentation (1 point)
<130 g/L] (1 point)  Syncope at presentation (2 points)
 Male ≥10 and <12 g/dL [≥100 and  Hepatic disease present (2 points)
<120 g/L] (3 points)  Cardiac failure
 present (2 points)

Score of ≤1 means low risk. Score of > 1 means high risk and a need of transfusion, endoscopy or
surgery

C. Admit patient to ICU if:

→ with hemodynamic instability or active bleeding (manifested by hematemesis, bright red blood
per NGT, or hematochezia). The rest with stable findings may admit to ward.

D. DISCHARGE CRITERIA:
1. Stable vital signs
2. Hg> 10 g/dl or >7g/dl if no cardiopulmonary comorbidities
3. No evidence of bleeding (melena resolved, no hematochezia or hematemesis)
4. Tolerates oral feeding.

I. BLEEDING PEPTIC ULCER DISEASE

A. DIAGNOSIS:
History of NSAID use, elderly, epigastric pain, hematemesis, hematochezia, melena and dizziness.
Ask about past medical history and medication use.

B. MANAGEMENT:
➢ Admit patient to ICU or transfer to tertiary hospital with hemodynamic instability or hematemesis or
hematochezia
➢ Diet: NPO until melena improves. May insert siliconized NGT for lavage if endoscopy anticipated
upon transfer.
 P a g e | 30

➢ IVF: Insert gauge16-18 needle x 2 IV sites.

o If unstable: Fast drip PNSS or PLR as per estimated blood loss. Remember 1:4 ratio (for
every 1L blood loss, we need to give alternative replacement of 4L of PNSS or PLR). For
hemorrhagic shock often 3-5L fluids is needed to stabilize BP.
o Once blood products available: Give pRBC based on estimated blood loss (by history and
by the table shown above) and other blood products in 1:1:1 ratio (for every 1 unit PRBC,
give 1u PLT concentrate and 1u FFP) to further stabilize BP.
o Once stable: Hydrate with PNSS1L x 140cc/hr or maintenance rate.
➢ Dx:
o CBC with BT Rh – we usually set transfusion threshold at 7.0g/dL level of Hg for those
without comorbidities. Hg level of 10 g/dL for those with cardiopulmonary diseases.
o Na, K, Creatinine, BUN
o 12L ECG
o Chest Xray AP view
o Albumin, PT, APTT
o SGPT, SGOT
o Stool H.pylori antigen testing
➢ Tx:
o Give Omeprazole or Pantoprazole 80mg IVTT now then start Omeprazole drip 80mg in
80cc PNSS to run at 10cc/hr in cycles until melena resolves or improves, then shift to
esomeprazole 40mg IVTT q12 premeals
o Rebamipide 100mg 1 tab TID (if with NSAID abuse)
o Once on oral feeding, may give Maalox plus chewable tablet TID PRN for epigastric pain
o Once melena totally resolves and already >72hrs from the last GI bleeding, may shift to
omeprazole 40mg tab q12 premeals
C. DISCHARGE
➢ Once for discharge, refer to endoscopy unit as outpatient scheduling if not urgent.
➢ Discharge medications:
o H. pylori complicated ulcer:
▪ Omeprazole 40mg 1 tab BID x 4 weeks then OD x 2-4 weeks (for duodenal ulcer)
OR
▪ Omeprazole 40mg 1 tab BID x 6 weeks then OD x 4-6 weeks (for gastric ulcer)
▪ Clarithromycin 500mg 1 tab BID x 14 days
▪ Amoxicillin 1gm 1 tab BID x 14 days
o For NSAID ulcer:
▪ Omeprazole 40mg OD x 4-8 weeks
▪ After high dose PPI maintain omeprazole 20mg OD as maintenance if Aspirin
cannot be removed for cardiac indications
▪ Rebamipide 100mg 1 tab TID
o Non H.pylori non-NSAID ulcer:
▪ Omeprazole 40mg 1 tab OD preBF for uncomplicated ulcer (no bleeding, no
obstruction etc) x 4 weeks
▪ Omeprazole 40mg 1 tab OD preBF x 8 weeks for gastric ulcer or any
complicated ulcer

➢ We continue maintenance antisecretory therapy with a PPI (eg, omeprazole 20 mg daily) in the
following patients with peptic ulcer disease:
o Giant (>2 cm) peptic ulcer and age >50 years or multiple co-morbidities
o H. pylori-negative, NSAID-negative ulcer disease
o Failure to eradicate H. pylori (including salvage therapy)
o Frequently recurrent peptic ulcers (>2 documented recurrences a year)
o Continued NSAID use such as aspirin for cardiac indications.

II. BLEEDING ESOPHAGEAL VARICES

Diagnosis: Usually hematemesis which is painless with known liver disease (cirrhosis or liver fibrosis from
schistosomiasis), other signs of portal hypertension evident such as ascites and signs of liver failure like jaundice.
 P a g e | 31

Severity Assessment
- Significant bleeding – transfusion requirement of 2 units of blood or more within 24hrs with SBP <100mmHg,
postural hypotension or pulse rate >100bpm at time of admission.

Triage:
- Anticipatory transfer to endoscopy capable hospital is a must because of high risk rebleeding esp in significant
bleeding.

B. MANAGEMENT:
➢ Admit patient to ICU or transfer to tertiary hospital with hemodynamic instability or hematemesis or
hematochezia
➢ Diet: NPO until melena improves. May insert siliconized NGT for lavage if endoscopy anticipated upon
transfer.
➢ IVF: Insert gauge16-18 needle x 2 IV sites.
▪ If unstable: Fast drip PNSS or PLR as per estimated blood loss. Remember 1:4 ratio (for every
1L blood loss, we need to give alternative replacement of 4L of PNSS or PLR). For
hemorrhagic shock often 3-5L fluids is needed to stabilize BP.
▪ Once blood products available: Give pRBC based on estimated blood loss (by history and by
the table shown above) and other blood products in 1:1:1 ratio (for every 1 unit PRBC, give 1u
PLT concentrate and 1u FFP) to further stabilize BP.
▪ Once stable: Hydrate with PNSS1L x 140cc/hr or maintenance rate.
❖ Dx:
▪ CBC with BT Rh – we usually set transfusion threshold at 7.0g/dL level of Hg for those without
comorbidities. Hg level of 9 g/dL for those with coronary artery disease and elderly. Give
maximum of pRBC 1-2units.
▪ Na, K, Creatinine, BUN
▪ 12L ECG
▪ Chest Xray AP view
▪ PT, APTT
▪ Alkaline phosphatase, SGPT, SGOT, albumin, total bilirubin (IB and DB)
▪ WA USD or katokatz smear/rectal biopsy.
❖ Tx:
▪ Give Omeprazole or Pantoprazole 80mg IVTT now then start Omeprazole drip 80mg in 80cc
PNSS to run at 10cc/hr in cycles until melena resolves or improves, then shift to esomeprazole
40mg IVTT q12 premeals
▪ Give Octreotide 50mcg IV bolus then start as drip 600mcg in 250cc PNSS to run for 24hrs in
cycle until bleeding resolves OR Somatostatin 250mcg bolus over 3-5mins then 3.5mcg/kg/hr
infusion until bleeding ceased.
▪ Start Ceftriaxone 2gm IVTT OD
▪ Start therapy for portal hypertension and liver support:
• Propranolol 20mg BID or Nadolol 20mg OD 5 days after initial bleeding episode
• Vitamin K 10mg slow IV push (for 15 mins) q8 PRN for high PT (INR)
• Aminoleban 500mg IV q12 for nutritional support
• Lactulose enema if encephalopathy also suspected and cannot feed. If can be
resumed on PO diet, may start 30cc lactulose q2hrs until able to have loose stools
2x/day.
• If resumed on feeding after at least 48hrs of bleeding, may start Rifaximin 200mg 2
tabs TID
• Hepamerz drip 6 vial in 100 PNSS x 6 hrs then 4 vials in 100cc PNSS to run for 4hrs
OD thereafter (but very costly, only if patient can afford).
• Cryoprecipitate if with active or poorly controlled bleeding 1 bag per 10kg or 6 bags
for a 60kg patient.
❖ Transfer → transfer to Endoscopy capable unit or ICU hospital.
 P a g e | 32

X. STROKE

I. TRANSIENT ISCHEMIC ATTACK

- Refers to stroke symptoms with resolution within 24hrs
❖ EVALUATION
▪ Risk assessment with ABCD2 score (see below diagram). Always consider stroke mimickers

❖ MANAGEMENT: (similar management to CVD ischemic infarct below)

For ABCD2 ≥ 4, start Short term DAPT (Dual antiplatelet therapy)
▪ Aspirin 80mg 2 to 4 tabs loading dose then 1 tab daily x 21 days
▪ Clopidogrel 4 tabs loading dose then 1 tab once daily x 21 days
▪ Atorvastatin 80mg 1 tab ODHS

II. ACUTE CVA INFARCT

A. ISCHEMIC STROKE

I. EVALUATION
Diagnosis: Lateralizing signs and symptoms. Acute in onset with risk factors of ASCVD. BP usually
high. Embolic causes such as atrial fibrillation and possible carotid embolic sources have been rule out. Always
consider stroke mimickers.
Severity Assessment: NIHSS based scoring.
 P a g e | 33

Mild CVD Infarct: NIHSS 0-5, GCS 13-15

Moderate CVD Infarct: NIHSS 6-21, GCS 10-12
Severe CVD Infarct: NIHSS >22, GCS 3-9
Triage: Transfer to tertiary hospital if severe deficit on NIHSS and/or deteriorating sensorium, drowsy
and not following commands (possible malignant infarct or brainstem infarct). Candidates for thrombolytic
therapy will also warrant transfer to capable institutions if therapy can be administered within 4.5hrs from the
time of ictus.

II. MANAGEMENT:
❖ Evaluate if candidate for thrombolytic therapy
▪ Inclusion criteria:
• Clinical diagnosis of ischemic stroke causing measurable deficit (CT scan warranted)
• Onset of symptoms < 4.5hrs. If exact time of stroke is not known, it is defined as the time the
patient was last seen normal
 P a g e | 34

• Age ≥18 years old

▪ Exclusion criteria:
• Patient History/Clinical:
o Ischemic stroke or severe head trauma in the previous three months
o Previous intracranial hemorrhage
o Intra-axial intracranial neoplasm
o Gastrointestinal malignancy
o Gastrointestinal hemorrhage in the previous 21 days
o Intracranial or intraspinal surgery within the prior three months
o Symptoms suggestive of subarachnoid hemorrhage
o Persistent blood pressure elevation (systolic ≥185 mmHg or diastolic ≥110 mmHg)
o Active internal bleeding
o Presentation consistent with infective endocarditis
o Stroke known or suspected to be associated with aortic arch dissection
o Acute bleeding diathesis, including but not limited to conditions defined under
'Hematologic'
• Hematologic
o Platelet count <100,000/mm3*
o Current anticoagulant use with an INR >1.7 or PT >15 seconds or aPTT >40 seconds*
o Therapeutic doses of low molecular weight heparin received within 24 hours (eg, to treat
VTE and ACS); this exclusion does not apply to prophylactic doses (eg, to prevent VTE)
o Current use (ie, last dose within 48 hours in a patient with normal renal function) of a
direct thrombin inhibitor or direct factor Xa inhibitor with evidence of anticoagulant effect
by laboratory tests such as aPTT, INR, ECT, TT, or appropriate factor Xa activity assays
• CT scan:
o Evidence of hemorrhage
o Extensive regions of obvious hypodensity consistent with irreversible injury
• CONSIDERATIONS (patient may receive alteplase considering the risk-to-benefits:
o Only minor and isolated neurologic signs or rapidly improving symptoms – may be given
if disabling deficits such as vision, severe aphasia, motor deficits, and depends on
clinical judgement
o Serum glucose <50 mg/dL (<2.8 mmol/L) – may be given once CBG normalized
o Serious trauma in the previous 14 days – bleeding risk due to trauma vs stroke related
deficits
o Major surgery in the previous 14 days – bleeding risk vs stroke related deficits
o History of gastrointestinal bleeding (remote) or genitourinary bleeding – consider risks
o Seizure at the onset of stroke with postictal neurologic impairments – rTPA may be
given if deficit is due to acute stroke.
o Pregnancy – may be given if benefits of treating severe stroke outweighs uterine
bleeding risk
o Arterial puncture at a noncompressible site in the previous seven days (uncertain risks)
o Large (≥10 mm), untreated, unruptured intracranial aneurysm (uncertain risks)
o Untreated intracranial vascular malformation (uncertain risks)
• WARNINGS for more than 3 to 4.5 hrs from symptoms onset:
o Age > 80 yrs old
o Oral anticoagulant regardless of INR
o Severe stroke (NIHSS > 25)
o Combination of both previous ischemic stroke and DM

❖ Admit to ICU or higher facility for those who will be receiving rTPA, severe stroke with markedly reduced
sensorium, and intubated cases.
❖ Admit to ward if mild to moderate with fully awake state.
❖ Diet: Low salt low fat diet. If dysarthric or with bulbar symptoms do dysphagia screening first prior to
initiation of diet. Otherwise, start NGT feeding at 1400kcal/day in 6 divided feedings.
❖ IVF: PNSS 1L x 80cc/hr
❖ VS q4
❖ NVS q4
❖ I/O qshift
❖ CBG QID or q6 premeals
❖ Dx:
 P a g e | 35

▪ Cranial CT scan plain

▪ CBC,
▪ Na, K,
▪ PT APTT
▪ Creatinine, BUN, SGPT
▪ Chest Xray PA view
▪ 12L ECG
▪ FBS, Lipid profile, Urinalysis
❖ Tx:
▪ For rTPA candidate patients, give alteplase 0.9mg/kg (max dose of 90mg) → please refer to
neurologist
• Pt weight < 100kg, give 0.09 mg/kg (10% of 0.9mg/kg dose) as IV bolus over 1 minute,
then 0.81 mg/kg (90% of 0.9mg/kg dose) as continuous infusion over 60mins.
• Pt weight > 100kg, 9mg (10% of 90mg) as an IV bolus over 1 min, followed by 81mg
(90% of 90mg) as continuous infusion over 60 mins.
▪ Start Aspirin after about 24hrs of giving rTPA dose.
▪ For NIHSS ≤ 5
• Start DAPT, Aspirin 80mg 2 to 4 tabs loading dose then 1 tab daily plus Clopidogrel 4
tabs loading dose then 1 tab once daily for 21 days. Then aspirin 80mg 1 tab once daily
thereafter. May extend DAPT to 90 days if due to large intracranial artery stenosis of
70-99%. Then, continue aspirin indefinitely.
▪ For NIHSS > 5
• Start Aspirin 80mg 2-4 tabs OD (Start only if CT scan reveals infarcts, no hemorrhagic
conversion and no malignant infarct i.e. no >2/3 infarction of the brain hemisphere
involved, no dense MCA sign → otherwise refer to neurologist).
• Atorvastatin 80mg 1 tab ODHS
• Citicoline 2gm IV then 1gm 1 tab BID (pt own stock)
• Omeprazole 40mg 1 tab OD prebreakfast if at risk of stress ulcer
• May start antihypertensives if SBP >220/110mmHg or MAP >130mmHg.
o May use amlodipine 10mg 1 tab OD or
o Carvedilol 25mg BID if also suspected IHD.
• Please no captopril or clonidine! Use nicardipine if you want to lower down BP under
controlled set-up to avoid sudden >25% SBP drop if with severe hypertension.
❖ Refer to rehab medicine for early rehab
❖ Order the following Goals for neuroprotection:
▪ MAP 110-130 mmHg
▪ CBG 140-180mg/dl. May give regular insulin if CBG > 180mg/dl
▪ Avoid fever. Ideally temp 37oC or below
▪ O2sat > 94%
▪ Avoid sudden drop in BP > 25% from baseline
▪ Head Bed elevation >15-300

DISCHARGE:
❖ Discharge after 3-5 days if stable neurostatus
❖ Plan for post-stroke rehabilitation. Give referral for rehabilitation medicine consult.
❖ Continue aspirin and atorvastatin and other maintenance medications.

B. EMBOLIC STROKE

I. EVALUATION
Diagnosis: Lateralizing signs and symptoms usually sudden onset. (+) carotid bruit or irregular
heartbeat or history of AF.
Severity: Based on NIHSS Score above.
Triage: Transfer to tertiary hospital if severe deficit on NIHSS and/or deteriorating sensorium, drowsy
and not following commands (possible malignant infarct or brainstem infarct).
 P a g e | 36

II. MANAGEMENT:
❖ Admit to ward if mild to moderate with fully awake state.
❖ Diet: Low salt low fat diet. If dysarthric or with bulbar symptoms do dysphagia screening first prior to
initiation of diet. Otherwise, start NGT feeding at 1400kcal/day in 6 divided feedings.
❖ IVF: PNSS 1L x 80cc/hr. D5W x KVO if with cardiac conditions and at risk for congestion.
❖ VS q4
❖ NVS q4
❖ I/O qshift
❖ CBG TID premeals
❖ Dx:
▪ Cranial CT scan plain
▪ CBC,
▪ Na, K,
▪ Creatinine, BUN
▪ Chest Xray PA view
▪ 12L ECG
▪ FBS, Lipid profile, Urinalysis
▪ 2D echo for those with AF, heart murmurs or known cardiac problem.
▪ Carotid duplex scan if with carotid bruit.
❖ Tx:
▪ Oral anticoagulant or NoACs (for atrial fibrillation): (please check creatinine if elevated.
Refer to IM for dose titration. Start NoACs ONLY IF CT scan reveals infarcts, no hemorrhagic
conversion and no malignant infarct i.e. no >2/3 infarction of the brain hemisphere involved).
• Apixaban 5mg 1 tab BID OR
• Dabigatran 110mg 1 tab BID OR
• Rivaroxaban 20mg OD at evening
▪ When to start oral anticoagulant?
• Mild stroke NIHSS <8 → 3 days after onset
• Moderate stroke NIHSS 8-15 → 6 days after onset
• Severe stroke NIHSS ≥16→ 12 days after onset
▪ Instead of NoACs, use warfarin 2.5mg 1 tab ODHS for patient with mechanical heart valves or
mitral valve stenosis.
▪ If with contraindication to NoACs may use Aspirin 80mg 2-4 tabs OD x 14 days
▪ Atorvastatin 40-80mg 1 tab ODHS – if indicated based on cardiac or lipid profile
▪ Omeprazole 40mg 1 tab OD prebreakfast
▪ May start antihypertensives if SBP >220/110mmHg or MAP >130mmHg.
• Carvedilol 25mg BID
• Please no captopril or clonidine! Use nicardipine if you want to lower down BP under
controlled set-up to avoid sudden >25% SBP drop if with severe hypertension.
❖ Order the following Goals for neuroprotection:
▪ MAP 110-130 mmHg
▪ CBG 110-180mg/dl. May give regular insulin if CBG > 180mg/dl
▪ Avoid fever. Ideally temp 37oC or below
▪ O2sat > 94%
▪ Head Bed elevation >15-300
▪ HR <80bpm for those with AF
❖ Refer to rehabMed for early rehab

DISCHARGE:
❖ Discharge after 3-5 days if stable neurostatus and oral anticoagulant given for >24hrs without
complications noted.
❖ Plan for post-stroke rehabilitation. Give referral for rehabilitation medicine consult.
❖ Continue anticoagulant and atorvastatin and other maintenance medications

III. ACUTE CVA BLEED

I. EVALUATION
 P a g e | 37

Diagnosis: Sudden onset lateralizing neurologic deficit with progressive decrease in sensorium.
Usually with prior headache, elderly, and uncontrolled BP. BP usually very high on presentation. Ask about
medications especially anticoagulants or antiplatelets.

Severity assessment:
Factors Score Mortality rate
Age
<80 0 ICH Score → Mortality rate
≥80 1 0 → 0%
Hematoma volume 1 → 13%
<30 0 2 → 26%
≥30 1 3 → 72%
Intraventricular Hemorrhage 4 → 94%
No 0 5 → 100%
Yes 1 6 → 100%
Infratentorial Origin of Hemorrhage
No 0
Yes 1
Glasgow Coma Scale Score
13-15 0
5-12 1
3-4 2
Total score 6

Mild CVD Bleed: NIHSS 0-5, GCS 13-15

Moderate CVD Bleed: NIHSS 6-21, GCS 10-12
Severe CVD Bleed: NIHSS >22, GCS 3-9

Triage: Transfer to ICU capable hospital with neurosurgical capability for supratentorial bleed > 30cc or bleed
>3cm for cerebellar bleed. If mild stroke on NIHSS and not decreased sensorium, may admit to ward with precaution.
Transfer all acute CVA bleed patients to level 2 or tertiary hospital.

II. MANAGEMENT:
❖ May admit to ward if mild NIHSS score and no deterioration in sensorium (GCS >12)
❖ Diet: LSLF if fully awake. Dysphagia screening if with bulbar symptoms and NGT feeding if necessary.
❖ VS q1 for the first 4 hrs
❖ NVS q1 for the first 4 hrs
❖ I/O qshift
❖ CBG TID premeals
❖ Dx:
▪ Stat Cranial CT scan plain
▪ CBC (PLT < 50,000 may warrant PLT transfusion)
▪ Na, K, SGPT
▪ Creatinine, BUN, RBS
▪ Chest Xray PA view, 12L ECG
▪ FBS, Lipid profile, Urinalysis
▪ PT, APTT (reverse warfarin induced coagulopathy with Vit. K and or FFP)
▪ ABG
❖ Compute for Ser Osmolality = 2 x [Na+K] + RBS (mg/dl)/18 + BUN/2.8
▪
❖ Tx:
▪ Start nicardipine drip 10mg in 90cc PNSS to run at 15cc/hr (maximum rate 90cc/hr) titrate by
2.5cc/hr every 15-30 mins to achieve SBP <140 for those with baseline SBP 150-220mmhg
(conflicting evidence with INTERACT trial (beneficial) VS AHA guideline (can be harmful)). For
safety, aim for SBP 130 to 150mmHg if patient’s sensorium is not worse than lethargic.
 P a g e | 38

• If baseline SBP >220 mmHg, target SBP between 140-180 mmHg within 6 hrs then
may target <140 mmHg if patient is fully awake.
▪ Amlodipine 10mg 1 tab OD AND/OR Carvedilol 25mg 1 tab BID AND/OR Telmisartan 80mg 1
tab OD OR Irbesartan 300g 1 tab OD
▪ Omeprazole 40mg IV OD prebreakfast.
▪ For increased ICP may start, Mannitol 20% solution 1.5gm/kg IV bolus or 300cc IV to run for
15mins then 0.5gm/kg or 150cc-200cc every 4-6hrs for those with decreased sensorium up to
5-7 days.
▪ For increased ICP may also start, Hypertonic Lactate (Totilac) 125cc IV q8 as additional support
if persistently decreased sensorium or as continuation to mannitol [Goal serum Osm 300 to 320
= 2(Na) + glucose/18 +BUN/2.8]
▪ Diazepam 5mg IV PRN for frank seizure.
❖ Head elevation >30o to 45o.
❖ Intubate patient with respiratory failure with O2sat <90% by pulse oximeter and PaO2 <60mmHg and
PaCO2 >55 mmHg. Hyperventilate to achieve PCO2 30-35 limited within 6hrs only.
❖ Sedation protocols care of ICU set-up if still persistently low sensorium.
❖ Maintain neuroprotection goals
▪ MAP 90-130 mmHg
▪ CBG 140-180mg/dl. May give regular insulin if CBG > 180mg/dl
▪ Avoid fever. Ideally temp 37oC or below
▪ O2sat > 94%
▪ HR <80bpm for those with AF

DISCHARGE:
▪ May discharge after 5-7 days if stable neuro status
▪ Repeat electrolytes if normal
▪ Mannitol and totilac consumed and no longer necessary
▪ BP controlled with oral antihypertensives with no more drips.

IV. SUBARACHNOID HEMORRHAGE

I. EVALUATION
Diagnosis: Severe sudden onset headache ever experienced by the patient. Progressive
deterioration of sensorium with meningismus, loss of consciousness, onset after exertion.

Severity assessment:
Hunt and Hess Manifestation Intervention Mortality Rate
Classification
1 Minimal headache, alert slight nuchal rigidity Surgical 30%
2 Moderate to severe headache, nuchal rigidity, no Surgical 40%
neurologic deficit other than cranial nerve palsy
3 Drowsiness, confusion or mild focal neurologic Medical then if 50%
deficit improved → Surgical
4 Stupor, moderate to severe hemiparesis, possible Medical/Palliative 80%
early decerebrate rigidity and vegetative
disturbances
5 Deep coma, decerebrate ridigity, moribund Medical/Palliative 90%
appearance

II. MANAGEMENT: Initial ER management then transfer to neurosurgery capable institution

❖ IVF: D5NSS 1L x 80cc/hr
❖ Diet: NPO, once sedated and stabilized, may insert NGT (siliconized) and start OTF at 1400kcal/day
divided in 6 equal feedings.
❖ VS q15mins
❖ NVS q15mins
❖ I/O q1hrly
❖ CBG q4-6hrly
❖ Dx: Will probably take a lot of time requesting for other work-ups so focus on stabilizing the patient.
▪ CBG,
 P a g e | 39

▪ CBC with BT Rh.

▪ 12L ECG
▪ ABG if available
▪ Other labs necessary as mentioned for other types of stroke
❖ Tx:
▪ Nicardipine drip 10mg + 90cc PNSS to run at 5cc/hr then uptitrate by 2.5cc/hr q15mins to achieve
SBP < 160mmHg if patient is fully conscious. If decreased sensorium, target cerebral perfusion
pressure at 60-70mmHg but you can’t compute this without ICP monitor so we often hold
antihypertensives if no ICP monitoring unless severe SBP >220mmHg (Probably target SBP
<220mmHg in this case)
▪ Nimodipine 30mg/tab 2 tabs every 4hrs for 21 days
▪ Omeprazole 40mg IV OD prebreakfast.
▪ For increased ICP:
• Mannitol 20% solution 1gm/kg IV bolus or 300cc IV to run for 15mins then 0.5gm/kg or
150cc every 4-6hrs for those with decreased sensorium up to 7 days.
• Totilac 125cc IV q8 as additional support if persistently decreased sensorium [Goal
serum Osm 300 to 320 = 2(Na) + glucose/18 +BUN/2.8]
▪ Diazepam 5mg IV PRN for frank seizure. Avoid phenytoin as antiseizure drugs.
▪ Paracetamol 300mg IV q3-4hrs RTC for pain
❖ Intubate patient who are below GCS <8 and signs of respiratory failure O2sat <90% by pulse oximeter
and PaO2 <60mmHg and PaCO2 >55 mmHg. Unlike in CVD bleed, hyperventilation is avoided in SAH
to avoid vasospasm.
❖ Head elevation at 30oC.
❖ Sedation with midazolam drip 10mg in 100cc PNSS, load 0.2mg/kg (10mg loading dose for a 60kg patient)
then maintenance rate of 0.05mg/kg/hr (3mg/hr or 30cc/hr) then titrate by 25-50% (± 5-10cc/hr) as needed
for sedation.
❖ Transfer all suspected SAH to tertiary hospital
 P a g e | 40

XI. SEIZURE

I. EVALUATION
❖ Diagnosis:
▪ Main category
• Focal: unimpaired consciousness. Can progress to generalized seizure.
• Generalized: (+) loss of consciousness
▪ Cause:
• Childhood onset: Epilepsy syndromes, CNS infection history
• Adolescent onset: Trauma, brain tumor, infection
• Young adult 18-35 yo: Trauma, alcohol withdrawal, infection, illicit drugs, brain tumor
• Older adult >35 yo: Stroke, brain tumor, alcohol, metabolic (uremia, liver failure,
hypoglycemia or hyperglycemia, electrolyte abnormalities)
❖ Severity:
▪ Usually depends on the cause or etiology
▪ Status epilepticus – seizure lasting >5mins; can be life threatening especially in generalized
convulsive status epilepticus.
▪ Transfer diagnosed status epilepticus upon resuscitation to tertiary hospital with neurology
consult due to high recurrence.

II. MANAGEMENT
❖ Diet: Ensure airway is intact and consciousness prior to feeding with aspiration precaution. NPO if full
consciousness cannot be ascertained.
❖ IVF: D5NSS x 120cc/hr
❖ VS q4
❖ I/O qshift
❖ CBG now then q6hrly
❖ Dx:
▪ CT scan cranial (plain → with contrast if stroke unlikely)
▪ CBC
▪ 12L ECG
▪ Na, K, Mg, Ca
▪ CXR PAL
▪ Total bilirubin, SGPT, SGOT,
▪ Urinalysis, Creatinine, BUN
▪ Drug testing, alcohol levels etc. if indicated
▪ RBS
❖ Tx;
• For Status Epilepticus (SE)
o Midazolam 0.2mg/kg or 10mg IVTT now.
o If still persistent, give Phenytoin 20mg/kg or 1,200mg IV in non-D5 containing
or PNSS solution to run for 40mins, Alternative is Levetiracetam 1gm – 1.5gm
IV bolus.
o If > 30mins-48h (refractory SE) → give loading dose midazolam 10mg IV (2
mg per minute!). May give additional boluses every 5 mins until seizure stops
(maximum of 2mg/kg or 120mg) then start as drip 0.1-2mg/kg/hr. Eg. For a
60kg patient, give loading dose 10mg IV now (for a period of 5 mins) then start
drip 50mg in 100cc PNSS solution, to run initially at 10cc/hr titrate by ± 5cc/hr
every 4hrs with max dose of 100cc/hr for seizure control. If still not controlled,
▪ May add propofol 1-2mg/kg loading dose over 5 mins and repeat
0.5mg/kg to 2mg/kg until seizure stops up to maximum total dose of
10mg/kg (600mg) then start as maintenance dose at 1.2mg/kg/hr
with titration every hr to maintain seizure free state.
• Diazepam 5mg IV for frank seizure.
• For Focal seizure
o Start Phenytoin 100mg/tab 1 tab TID AND/OR
 P a g e | 41

o Carbamazepine 200mg 1 tab BID AND/OR

o Valproic acid 500mg 1 tab BID or TID AND/OR
o Levetiracetam 500mg 1 tab BID or 1gm BID
• For Generalized tonic clonic seizure
o Valproic acid 500mg 1 tab BID or TID OR
o Lamotrigine 100mg/tab 1 tab BID
• Manage etiology accordingly.
❖ Maintain a quiet environment
❖ Avoid caffeine and sleep deprivation
❖ Aspiration precaution

- DISCHARGE:
❖ Seizure free for 24hrs with only PO meds
❖ Etiology identified and addressed
❖ Follow up scheduled and family commitment.
 P a g e | 42

XII. DIABETES MELLITUS

I. DIAGNOSIS: Work up for diabetes aged >45 years every 3 years and screening individuals at an earlier age if they
are overweight (BMI >23 kg/m2) + being a Filipino (pacific islander).
• Use FBS or HBa1c for screening. If positive, must be repeated.
• Criteria for diagnosis (Any 1 of the ff):
o FPG ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.* OR
o 75g 2-h OGTT ≥200 mg/dL (11.1 mmol/L)
o A1C ≥6.5% (48 mmol/mol). The test should be performed in a laboratory using a method that
is NGSP certified and standardized to the DCCT assay.* OR
o In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma
glucose ≥200 mg/dL (11.1 mmol/L).

II. MANAGEMENT:

A. Goals: For long term:

• HbA1c <7%; 6.5% if no significant hypoglycemia or adverse effect; <8% for history of severe
hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications,
extensive comorbid conditions, or long-standing diabetes
• Premeal CBG 80-130mg/dl

B. TRIAGE:
OPD: Those without admissible comorbidities and CBG <300 after initial insulin dose or hydration
Admit:
➢ Those with admissible comorbidities
➢ Hyperglycemic Crisis: DKA and HHS (to tertiary hospital)
➢ Severe hypoglycemia related to diabetes medication

C. MANAGEMENT (Hyperglycemic Crisis)

➢ Diet: NPO temporarily, may start feeding once CBG <200 and patient fully awake.
➢ IVF: First hydration:
o Hypovolemia: PNSS 1L fast drip for 1 hr (15-20ml/kg/hr)
o Mild dehydration with high or normal Corrected serum Na+: 0.45%NaCl 250-500ml/hr.
o Mild dehydration with Low corrected serum Na+, use PNSS to run 250-500ml/hr. Add 20-
30meqs KCl in each liter of IVF except of ser. K <5.2meq/L
Once CBG 200mg/dl (DKA) or 300mg/dl (HHS),
o IVF: D5-0.45% NaCl at 150-250ml/hr or D5LR 150-250ml/hr
➢ VS and I/O q1
➢ CBG q1
➢ Dx:
o CXR PAL (if pneumonia suspected)
 P a g e | 43

o CBC, Na, K, Cl, BUN, Crea, amylase

o RBS, HBA1c
o ABG
o UA with urine ketones
o ECG
o Trop-I (if MI suspected)
➢ Computations:
o Ser Osmolality = 2 x [Na+K] + RBS (mg/dl)/18 + BUN/2.8
o Corrected Na = Na + 0.024 x [RBS(mg/dl) – 100]
o Anion gap = Na – (Cl + HCO3)
➢ Tx:
o Give Regular insulin 0.1 U/kg IV bolus then start as RI drip: 100u in 100cc PNSS to run at
0.1U/kg/hr IV (i.e. 7ml/hr for a 70kg patient).
▪ If CBG does not fall by at least 10% after 1st hr, give 0.14U/kg as IV bolus then
continue drip. May also increase RI drip rate by 2u/hr
▪ (in DKA),Once CBG reaches 200mg/dl, regulate RI drip to 0.02 – 0.05 U/kg/hr IV (eg.
RI 2-3ml/hr for a 70kg px). OR Give RI 0.1 U/kg SC every 2hrs (eg. 7u RI SC q2hr
for a 70kg px)
• Keep CBG 150-200mg/dl until resolution of DKA
• If controlled, may reduce CBG monitoring to q2hrly
▪ (in HHS), Once CBG reaches 300mg/dl, regulate RI drip to 0.02 – 0.05 U/kg/hr IV
(eg. RI 2-3ml/hr for a 70kg px).
• Keep CBG 200-300mg/dl mg/dl until patient is mentally alert

o Hold insulin drip if ser K <3.3 mmol/L or CBG <80mg/dl

o Correct K <3.3 meq/L by KCl drip ideally 20-30meq/hr
▪ Monitor serum K every 2hrs
o Correct bicarbonate if pH <6.9: 100meqs NaHCO3 in 400ml water + 20meqs x 2hrs
▪ Repeat ABG after 2hrs until pH ≥ 7.
o Correct Hypoglycemia:
▪ CBG 70-79 give D50W 15ml IV push
▪ CBG 60-69 give D50W 20ml IV push
▪ CBG 50-59 give D50W 25ml IV push
▪ CBG <50 give D50W 30ml IV push
o Once patient recovers and able to eat, start subcutaneous long acting and short acting insulin
then discontinue drip 2hrs after given SQ insulin regimen.
▪ 0.5U/kg to 0.8U/kg per day (eg. 35-40 total insulin U per day)
▪ Eg. Give 15U Glargine SQ OD at 9PM then RI 6u TID premeals.

o Treat the triggers: i.e. Infection, MI, Stroke, Pancreatitis, Dehydration/Starvation

D. MANAGEMENT (Other Indication for Admission)

➢ Diet: DM diet or as indicated
➢ IVF: As indicated
➢ Dx:
o Lipid profile
o Creatinine
o HbA1c, RBS
o Urinalysis
➢ CBG TID or QID premeals (5am 11am 5pm 11pm) for eating patients. CBG q4-q6 if NPO
➢ Tx:
o Continue maintenance medications if HbA1c normal

NONCRITICAL
o Insulin initiation threshold: CBG > 180mg/dl. CBG 180-250mg/dl – tolerated in severe
comorbidities and close monitoring is not feasible
 P a g e | 44

▪ Patients on NPO or poor intake with CBG >180mg/dl: (Basal + correction)

• Start Glargine U300 /Detemir/Degludec 0.2u/kg/d SQ at bedtime.
(eg. 60kg px = 12u SQ OD at 9PM; U300 has advantage of lower risk
of hypoglycemia)
• Start correction scale using RI/Glulisine/Lispro 0.05u x excess beyond
180mg/dl.
(eg Px with 240mg/dl CBG: 240-180 = 60mg/dl*0.05U = 3U RI SC to
be given as correction).
▪ Patients who are Feeding with CBG > 180mg/dl : (Basal + prandial +
correction)
• Start Glargine U300 /Detemir/Degludec 0.2u/kg/d SQ at bedtime
• Start preprandial administration (Regular insulin/Glulisine/Lispro) with 1
unit per 10-15gm carbohydrates per meal.
(eg. 1 cup rice in a meal = 50gm carbs. 50gm/10gm = 5U of insulin to
be given premeals. Rule of thumb is 5-10u RI premeals depending on
intake and may be adjusted based on 24hrs monitoring)
• Start correction scale using RI/Glulisine/Lispro as usual.
CRITICAL
o Start Regular insulin drip 100U/100cc PNSS to run at 6cc/hr then titrate accordingly by
±2cc/hr to keep CBG 80-180mg/dl
E. MANAGEMENT (Perioperative Care)
➢ Diet: DM diet, NPO as indicated
➢ IVF: As indicated, Use D5 containing IVF once on NPO
➢ CBG QID or TID if feeding. Q2-4hrly if on NPO
o Monitor CBG q1-2hrly intraOP
o Monitor CBG q4-6hrly postop until cleared to feed.
➢ Perioperative goal: CBG 80-180mg/dl
➢ Dx:
o HbA1c, Lipid profile, Creatinine, SGPT, Urinalysis, RBS/FBS
➢ Tx:
o Hold the following:
▪ Metformin (on the day of surgery)
▪ SGLT-2i like Empagliflozin, dapagliflozin etc (3-4 days of surgery)
▪ Other OHAs on the morning of surgery
o If on insulin, give 75-80% of dose of long acting insulin evening before surgery (eg. Px on
Glargine U300 10 units as maintenance, give only 8u at bedtime SQ).
o While on NPO, Give rescue RI 4u SQ for CBG > 240mg/dl
o DM1
▪ Give long acting insulin even while on NPO
▪ Hold short acting or rapid acting insulin when on NPO
o DM2 (controlled)
▪ Short surgeries: diet alone
▪ Long surgeries (>2hrs): may give supplemental insulin
▪ Complicated surgeries: use RI drip

F. MANAGEMENT (Obstetric Cases)

➢ Diet: As indicated
➢ IVF: D5 containing fluids
➢ CBG q1-q4hrly
➢ Tx:
During Labor
o Give last dose of maintenance insulin or long acting insulin the night or morning before labor
o Start Regular insulin drip 100 in 200cc PNSS to run at 1-2cc/hr if CBG >120mg/dl
o Goal CBG: 80-120mg/dl
o Discontinue IV insulin immediately prior to delivery
➢ For Cesarean delivery:
o Give last dose of insulin the night before CS day
 P a g e | 45

o CBG prior to CS then q1hrly

o Start Regular insulin drip 100 in 200cc PNSS to run at 1-2cc/hr to if CBG >120mg/dl
o If General anesthesia is used, monitor CBG q30mins
o Discontinue RI drip immediately prior to delivery
o Rpt CBG 2 hrs post CS then q4hrly until 24hrs
➢ Post-delivery
o Monitor CBG q4-6hrly x 24hrs
o Regular insulin rescue scale as indicated but at a reduced dose
o May resume Metformin and glibenclamide but avoid other OHAs during breastfeeding

III. DISCHARGE:
➢ All indications for admission resolved and is on oral hypoglycemics or insulin therapy with CBG
controlled 80-180mg/dl at least 24hrs. May tolerate up to 250mg/dl for those with severe
comorbidities or limited lifespan
➢ First line: Metformin 500mg/tab 1 tab TID (in the absence of contraindication). Add Vitamin B
complex or Vit. B12.
➢ Contraindications: eGFR <30ml/min/1.73m2 (<45 eGFR in Harrison), Radio-contrast
studies, Acidosis, Hospitalized patients, NPO patients, Unstable CHF, Liver disease,
Severe hypoxemia
➢ A1c > 1.5% above target 7.0% → Consider early combination therapy
➢ Established ASCVD, heart failure or CKD → ideally must start below recommendations
➢ (+) ASCVD Risk: Dapagliflozin 5-10mg/tab 1 tab OD. Ideally in combo with Metformin
2000mg/10mg OD.
➢ Heart failure EF < 45%: Empagliflozin(Jardiance) 10mg-25mg/tab 1 tab OD or Dapagliflozin
(Forxiga)
➢ CKD:
➢ Dapagliflozin 10mg tab OD or Canagliflozin 100-300mg 1 tab OD
➢ Exenatide (black box warning for extended release: risk of thyroid C-cell tumor – discuss
with patient). Immediate release : 5mcg SQ 2x a day 1 hr prebreakfast and 1 hr predinner.
Increase dose to 10mcg after 30 days in order to achieve glycemic goals
➢ Semaglutide (PO) 3mg tab PO OD x 30 days then 7mg OD x 30 days then 14mg OD
thereafter OR Semaglutide (SQ) 0.25mg to 2mg dose SQ once weekly (but very costly)
➢ Cost is a major issue:
➢ Sulfonylureas: Gliclazide 40-80mg 1 tab OD, Glimepiride 1-3mg 1 tab OD
➢ Thiazolidinediones: Pioglitazone 15-45 mg 1 tab OD (black box: can exacerbate CHF),
Rosiglitazone
➢ Other add-on (DPP4i) especially ESRD cases or risk of hypoglycemia (critical cases)
➢ Linagliptin: 5mg 1 tab OD (can be added to insulin if safety is a big concern)
➢ Insulin therapy in addition to metformin (fastest way to achieve glycemic goals:
➢ Indications:
▪ DM1, Weight loss, ketosis, hypertriglyceridemia, symptoms of hyperglycemia
(polyuria,polydipsia), A1c > 10%, CBG > 300
➢ Basal insulin (NPH Insulin, U-100 glargine or detemir, U-300 glargine or degludec)
▪ Initial: 0.1-0.2 u/kg/day (DM2) (eg. 7U-14U at bedtime in a 70kg px)
▪ 0.4-1.0 u/kg/d (DM1) usually 0.5u/kg/d
▪ Titrate on level of hyperglycemia
• (ie. Each unit lowers 25mg/dl [in obese] and 50mg/dl [in thin patients]
➢ Prandial insulin (rapid-acting or RI)
▪ 4-6u or 10% of basal insulin given at the largest meal.
➢ Disadvantage: Anabolic effect so expect patient to gain more weight and have more appetite.
 P a g e | 46

XIII. HEART FAILURE

I. DIAGNOSIS: Modified Framingham criteria: 2 major or 1 major and 2 minor
MAJOR MINOR

• Paroxysmal nocturnal dyspnea • Bilateral leg edema

• Orthopnea • Night cough
• Elevated JVP • Dyspnea on exertion
• Pulmonary rales • Hepatomegaly
• S3 heart sounds • Pleural effusion
• Cardiomegaly (X-ray) • Tachycardia (>120bpm)
• Pulmonary edema (X-ray) • Weight loss > 4.5kg in 5 days in
• Weight loss > 4.5kg in 5 days in response to tx response to diuretics
of presumed heart failure

II. CLASSIFICATIONS OF LV FAILURE:

a. Heart Failure with Preserved Ejection Fraction : EF ≥ 50%
b. Heart Failure with Reduced Ejection Fraction: EF < 40 (Severe)
c. Heart Failure with Mildly Reduced Ejection Fraction: 40-49%

III. NYHA FUNCTIONAL CLASSIFICATION:

Class I: No symptoms of heart failure.
Class II: Symptoms of heart failure with moderate exertion, such as ambulating two blocks or two flights of
stairs.
Class III: Symptoms of heart failure with minimal exertion, such as ambulating one block or one flight of
stairs, but no symptoms at rest.
Class IV: Symptoms of heart failure at rest.

III. TRIAGE:
A. OPD: Patient with normal VS, not in distress, chronic symptoms, no desaturation, no arrhythmias, can comply
with oral meds, dyspnea relieved by bolus diuretics
B. Admit:
Acutely decompensated heart failure (ADHF) – progressive dyspnea, evidence of congestion (pulmonary,
hepatic peripheral and/or neurologic)
a. Ward: (Normal BP) Still persistent crackles and dyspnea barely relieved with first dose IV
furosemide, no arrhythmia or myocardial infarction.
b. ICU: Hypoperfusion and hypotension SBP <90mmHg, HR <40 or >130 bpm, and/or desaturation
<90% despite O2 support, arrhythmia not resolved with initial resuscitation, requiring inotropic
support or vasopressors. Evidence of ACS.

IV. MANAGEMENT: (goal is to stabilize patient, relieve congestion and manage cause)
➢ Diet: LSLF (limit oral fluid intake <1L/day)
➢ IVF: Heplock
➢ Labs:
➢ 12L ECG
➢ CXR – PAL view
➢ CBC, Na, K, Mg, UA, serial monitoring of electrolytes daily with diuretics
➢ FBS, Lipid profile, Creatinine BUN, SGPT
➢ ProNT-BNP
➢ Trop-I, TSH if indicated
➢ 2D echo with doppler
➢ Get initial weight of patient prior to starting all medications
➢ Medications (will depend on status of decompensation of patient as follows):
A. Typical ADHF – typical manifestations without hypoxia
a. Hypertensive
➢ Furosemide 40-80mg IV bolus (max of 200mg), then may start as drip 80mg in 80cc D5W
to run at 5-10cc/hr. May titrate up to 40cc/hr as needed.
 P a g e | 47

▪ For eGFR <30ml/min/1.73m2, start initial at 20cc/hr. May increase up to 40cc/hr

➢ Spironolactone 25mg/tab 1 tab BID.
▪ (Ensure the following before starting spironolactone: serum creatinine ≤2.5
mg/dL in men and ≤2 mg/dL in women or eGFR >30 mL/minute/1.73 m2 and
serum potassium <5 mEq/L)
➢ Nitroglycerin (5-10ug/min up to 200ug/min) 50mg in 250cc D5W to run at 6ml/hr (max of
60ml/hr)
b. Normotensive
i. Furosemide 40-80mg IV bolus (max of 200mg), then may start as drip 80mg in 80cc D5W
to run at 5-10cc/hr. May titrate up to 40cc/hr as needed.
ii. Spironolactone 25mg/tab 1 tab BID

B. ADHF with Pulmonary edema – presence of hypoxia or distress (RR > 25 with use of accessory
muscles)
i. Hook to O2 support via nasal cannula or facemask 4-6LPM to keep O2 sat >90%
ii. Start diuretics as mentioned above
C. ADHF with Low output – no hypotension but narrow or low pulse pressure (i.e. Systolic BP – Diastolic
BP < 25% of Systolic BP) cool extremities, hepatic congestion, elevated creatinine
i. Start dobutamine 250mg in 200cc D5W to run at 10ml/hr (max of 50ml/hr but usually do
not exceed > 30ml/hr)
ii. If available, Milrinone 40mg in 200ml to run 60ml/hr (max 120ml/hr)
iii. PLUS Furosemide and/or Spironolactone as mentioned above with BP precaution
iv. May add nitroglycerin if no hypotension
D. Cardiogenic shock – Extreme distress, requiring inotropic support for hypotension
i. Start dobutamine 250mg in 200cc D5W to run at 10ml/hr (max of 50ml/hr but usually do
not exceed > 30ml/hr). Titrate by 5cc/hr every 15 mins to achieve MAP > 65mmHg.
ii. If still hypotensive, may start Norepinephrine 8mg in 92cc PNSS to run at 15cc/hr titrate by
+/- 5cc/hr every 15mins to keep MAP > 65mmHg.
iii. Start diuretics as drip altogether with inotropes
E. Resistant to diuretics
i. Proceed with Hemodialysis if still with persistent congestion not corrected by diuretics.

IV. MAINTENANCE
A. Additional Medications to add: depending on class of heart failure
REDUCED EJECTION FRACTION PRESERVED EJECTION FRACTION
(Combination of ARNI/ACEi/ARB + BB+ Diuretic)

ACE-I/ARNI Mineralocorticoid antagonist

▪ Sacubitril-Valsartan 100mg BID ▪ Spironolactone 25mg OD
▪ Enalapril 2.5mg BID ACE-I/ARNI
▪ Captopril 6.25mg TID ▪ Sacubitril-Valsartan 100mg BID
▪ Losartan 50mg TID ▪ Enalapril 2.5mg BID
▪ Valsartan 40mg BID ▪ Captopril 6.25mg TID
▪ Candesartan 4-8mg OD ▪ Losartan 50mg TID
Beta Blocker (Avoid in congestion >10cm above ▪ Valsartan 40mg BID
hemidiaphragm, PR > 240ms, hyperreactive airways, ▪ Candesartan 4-8mg OD
2nd degree to high grade AV blocks) Beta Blocker (HR control) (Avoid in congestion >10cm
▪ Metoprolol 12.5mg BID above hemidiaphragm, PR > 240ms, hyperreactive
▪ Carvedilol 6.25mg BID airways, 2nd degree to high grade AV blocks)
▪ Bisoprolol 1.25 OD ▪ Metoprolol 12.5mg BID
Mineralocorticoid antagonist ▪ Carvedilol 6.25mg BID
▪ Spironolactone 25mg OD ▪ Bisoprolol 1.25 OD
Rate controllers Rate controllers
▪ Ivabradine 5mg BID ▪ Ivabradine 5mg BID
▪ Digoxin 0.25mg OD (lower dose in elderly and ▪ Digoxin 0.25mg OD (lower dose in elderly and
CKD) CKD)
SGLT2i (Diabetic) SGLT2i (Diabetic)
 P a g e | 48

V. DISCHARGE
1. Cause of heart failure identified and addressed
2. Patient can start oral medications
3. Not requiring O2 support and/or inotropes
4. No need to totally decongest patients, may discharge at ER level if responsive to diuretics immediately.
 P a g e | 49

XIV. ACUTE CORONARY SYNDROME

I. CATEGORIES AND TRIAGE:

1. STEMI – typical 1mv ST elevation on limb leads and/or 2mV ST elevation precordial leads → to ICU
2. NSTEMI – Trop-I increased without ST elevation → to ICU
3. Unstable Angina –angina >20mins, increasing angina more frequent and more prolonged (Cresendo
pattern), BUT Trop-I negative → to WARD
4. Chronic Stable Angina/”CAD” → to OPD

II. TRIAGING SCORE FOR ER SUSPECTED PATIENTS:

SCORE:

0-3 : Discharge patient

4-6: further work-up and admission
7-10: Critical unit and early invasive strategy

III. SEVERITY SCORING: (Killips Class)

TRANSFER TO ICU ESPECIALLY THOSE WITH:

• Killips III and IV

• Significant arrhythmias,
• inferior/posterior MI,
• AV blocks
• Requiring inotropic support

V. MANAGEMENT
 P a g e | 50

A. STEMI
ii. Diet: Low salt low fat diet
iii. IVF: D5W x KVO
iv. Hook to cardiac monitor
v. VS q1hrly, q15mins if unstable
vi. I/O: qshift or q1hrly if reduced urine output
vii. Laboratories:
1. CBC
2. 12L ECG and Trop-I – most important
3. CXR PAL view
4. 2D echo
5. proNT-BNP – especially if with heart failure
6. Electrolytes (Na, K, Ca, Mg, Cl)
7. Lipid profile (HDL,LDL,TGL)
8. HbA1c/FBS, do OGTT if inconclusive
9. Creatinine, BUN
10. SGPT, PT APTT
11. Urinalysis
12. TSH, FT4 (if suspected thyroid problem)
viii. Hook to O2 support. May give at least 6hrs for those with cyanosis and respiratory
distress to keep O2 sat > 90%
ix. Ideally patient should undergo Percutaneous Coronary Intervention (PCI) but in our set-up
fibrinolysis is a better option within 3-6hrs. Earlier thrombolytics < 3hrs has comparable
outcome with performing PCI in some studies.
x. Medications:
1. Alterplase (rTPA): 15mg bolus then 0.5mg/kg for the next 60 mins (1:1
dilution) OR
Streptrokinase: Give 1.5million units IV over 60mins.
Fibrinolytics given if symptoms < 12hrs and no contraindications.
Absolute contraindications: any prior intracranial hemorrhage; known
structural cerebral vascular lesion; known malignant intracranial neoplasm;
ischemic stroke within 3 months except acute ischemic stroke within 3 hours;
suspected aortic dissection;
active bleeding; or significant closed head or facial trauma.
Relative contraindications: history of chronic severe, poorly controlled
hypertension; history of prior ischemic stroke, dementia, or intracranial
pathology; traumatic or prolonged cardiopulmonary rescucitation or major
surgery;recent internal bleeding (within 2 to 4 weeks); pregnancy; active
peptic ulcer disease; current use of anticoagulants
2. Aspirin 80mg 4 tabs chew and swallow then 1-2 tab OD
3. Clopidogrel 75mg 4 tabs then 1 tab OD
4. Atorvastatin 80mg 1 tab now then ODHS
5. Metoprolol 50mg 1 tab BID or Carvedilol 6.25mg BID
Contraindications for Betablockers:
i. hypotension,
ii. active bronchospasm;
iii. severe bradycardia <40 bpm or heart block greater than
1st degree unless with pacemaker; PR > 240ms
iv. cocaine use;
v. overt heart failure including pulmonary edema
6. ISDN 5mg SL q5mins until 3 doses for pain followed by ISDN 10mg/amp +
90cc PNSS to run at 10cc/hr then titrate by 5cc/hr as needed until chest pain
free (for persistent) OR ISMN 60mg slow release 1 tab OD. 20mg BID if
immediate release.
Contraindication of nitrates:
i. BP <90 mm Hg or ≥30 mm Hg below baseline;
 P a g e | 51

ii. HR <50bpm; HR >100bpm in the absence of Sx heart

failure
iii. RV infarction
iv. PDE5 intake within 24-48 hrs
7. Enoxaparin 30mg IV bolus (for <75yrs old only) followed by 0.4cc (prefilled
syringe) SC q12 for <60kg patients OR 0.6cc SC q12 for >60kg patients.
For patients at high risk of bleeding use Fondaparinux instead: 2.5 mg
intravenously, followed by 2.5 mg subcutaneously every 24 hours.
8. Captopril 6.125mg TID or Telmisartan (if intolerant to ACE-i) 40-80mg 1 tab
OD or other ARBs. (Avoid ACEi or ARB if SBP less than 30mmHg from
baseline BP)
9. Ivabradine (optional) 5mg 1 tab q12 if heart rate goal not achieved. Useful
for those with contraindications to beta blockers such as reactive airways,
severe congestion or hypotension.
10. Morphine 2-4mg IV every 5-15mins for severe chest pain not relieved by
beta blockers and nitrates. (Last option). Not recommended for those with
hypotension.
11. Other anginal supportive therapy (optional only if with contraindications to
nitrates, beta blockers and/or morphine): Trimetazidine 35mg MR tab BID
OR Ranolazine 375mg 1 tab BID.

xi. Goals: HR <55-60 bpm, pain VAS 0/10, Stable vitals, O2Sat > 90%
xii. Complete bed rest without bathroom privilege.

B. NSTEMI / UNSTABLE ANGINA

➢ Similar management with STEMI without the fibrinolytic therapy.
➢ May add calcium channel blocker for unstable angina only if no congestion or severe LV
dysfunction. (eg. Verapamil, Diltiazem)
C. Hypotension in Right Ventricular Wall MI or Inferior Wall MI

ECG like this with inferior wall leads (II, III, aVF) STEMI may warrant right sided leads to rule in RV wall
MI (anticipated ST elevation on lead V4R as shown)
➢ Fast drip PNSS 1-2L (congestion precaution) with evaluation every 300cc to check blood
volume status.
➢ Start Norepinephrine drip as initial vasopressors. 8mg in 92cc PNSS to run at 15cc/hr then
titrate by ± 5cc/hr to keep MAP ≥ 65.
➢ Nitrates contraindicated
➢ Avoid beta blockers for now

D. Arrhythmias (Follow ACLS Algorithm on following topic)

 P a g e | 52

XV. ARRHYTHMIA
I. INITIAL ASSESSMENT:
➢ Diagnosis: existing cardiac condition, with palpitations, chest pain/discomfort, syncope, dizziness,
sensorial changes and/or with signs of shock in severe cases.
➢ ECG: bradyarrhythmia (<50bpm) or tachyarrythmia (>150bpm)

II. INITIAL TRIAGE:

➢ Some arrhythmias maybe corrected immediately at the ER level such as SVTs if patient remained
stable and cause can be immediately identified and be discharged safely with your IM or Cardio
consultants call.
➢ Admission decision depends on:
• Presence of structural heart disease (admit all LV heart failure, MI, cardiomyopathy,
valvular problems etc to higher level facility, ward if with cardiac monitoring or better to
ICU)
• Etiology of arrhythmia and associated symptoms (ie. chest pain, dyspnea, dizziness,
syncope and unstable presentation as mentioned below warrants admission to ICU or
higher facility)
• Drugs needed can be given in-hospital only (antiarrhythmia and inotropic drips requires
ICU set-up or high facility)
• Specialists referral recommendations
➢ Severity (considered unstable if with):
• Hypotension
• Acutely altered mental status
• Signs of shock
• Ischemic chest discomfort
• Acute heart failure

III. INITIAL MANAGEMENT:

➢ Hook to cardiac monitor, take 12LECG and take vital signs ASAP, taking note of sensorium level
➢ Hook to O2 support
➢ Insert IV access on large veins on antecubital fossa as much as possible
➢ VS q15mins after resuscitation then q1hrly upon stabilization
➢ I/O q1hrly
➢ Labs (obtain following as STAT!):
• 12L ECG (daily or more frequently as needed)
• 2D echo with doppler studies
• ABG
• CBC, Na, K, Mg, Ca
• Crea, BUN
• Trop-I, proNT BNP
• CBG now or RBS, HBA1c
• Chest X-ray PAL view
• D-dimer
• TSH, FT4 if suspected thyroid problem (non-stat)
• Lipid profile (non-stat)
• PT,APTT, SGPT
• Drug testing
➢ Refer to onboard cardiologist/specialist

IV. BRADYARRHYTHMIA - defined as heart rate < 50bpm

Treatment summary:
ASYMPTOMATIC BRADYCARDIA BRADYCARDIA (<50bpm) (UNSTABLE PATIENT)

Observe and correct causes Atropine 1mg IV bolus q3mins (Max of 3 doses)
 P a g e | 53

Dopamine or Epinephrine drip or Pacing

Possible Causes:

5Hs

• Hypovolemia
• Hypoxia
• Hydrogen ion excess
(acidosis)
• Hypoglycemia
• Hypokalemia
• Hyperkalemia
• Hypothermia
5Ts

• Tension
pneumothorax
• Tamponade –
Cardiac
• Toxins
• Thrombosis
(pulmonary embolus)
• Thrombosis
(myocardial
infarction)

Sample order:
1. (60kg patient): Dopamine 200mg in
250cc D5W to run at 20cc/hr titrate by
±5cc/hr (max of 90cc/hr)

2. (60kg patient): Epinephrine (use near

antecubital fossa access only for large vein
or IJ access only). 1mg in 1L D5W to run at
2cc/hr (max of 10cc/hr)

How to do transcutaneous pacing since transvenous pacing is not readily available:

1. Prepare pacer machine or defibrillator with pacer function.
2. Discuss with patient/watcher and secure consent
3. Sedate patient (options as follows):

o Etomidate and ketamine – hemodynamically neutral sedative hence more preferred in cardiac
cases. Etomidate (no analgesia effect) is usually given 0.3 mg/kg (18mg in 60kg Px) slow IV over
30-60 secs.
 P a g e | 54

o Ketamine (has analgesia effect) – give 1-2mg/kg (60-120mg in 60kg Pt) over 1-2mins. May give
subsequent 0.5-1mg/kg doses every 5-10mins as needed.
o Propofol (no analgesia effect) – hypotension usually mild and transient. Give initial dose of 0.5 to
1mg/kg (30mg-60mg in 60kg patient) slow IV push. Then 0.25 to 0.5mg/kg every 1-3 mins as
needed for appropriate sedation.
o Midazolam (no analgesia effect) – give 0.02 to 0.03mg/kg (1 to 1.5mg in 60kg Pt) over 1-2 mins.
Should not excess 2.5mg single dose.

3. Attach cardiac monitor electrodes

4. Attach anterior pacing pad to sternum while opposing posterior pacing pad at the left of thoracic spine
5. Attach electrodes wirings to pads and to the pacer machine. Turn it on and set to pacing mode (as “demand"
mode).
6. Start pacing with settings as follows:
• pacing rate: 70-80 beats per minute (or add 30 bpm on current intrinsic heart rate),
• initial current to 60mA (milliamperes) to 70mA; increase or decrease by 5 to 10mA until threshold
(minimum mA to achieve capture or generate wide QRS complexes).
• If pacing rate not captured even increasing to 120-130mA, try setting up to “fixed mode” and or resite
the electrodes pads and repeat above process.
• Add 5-10mA to threshold current and this will be your final current set-up.
7. Facilitate transfer to higher facility if with indication for permanent pacemaker or irreversible cause.

V. TACHYARRHYTHMIA - defined as heart rate > 150bpm

Treatment Summary:

TACHYCARDIA (>150 BPM) WITHOUT HEMODYNAMIC COMPROMISE

QRS REGULAR IRREGULAR

Adenosine 6mg → 12mg

AF: Amiodarone 150mg x 10mins then
OR
1mg/min x 6hrs. OR
NARROW Verapamil 5-10mg over >2mins. May rpt after 15-
Digoxin (for congested patients) 0.25mg IV x 2-
30mins if no response OR
5mins
Digoxin 0.25mg IV x 2-5mins

Monomorphic: Amiodarone 150mg to run 15mins Preexcited AF: Procainamide 20-50mg/min.

WIDE (procainamide/lidocaine; may consider Adenosine) Avoid all other antiarrhythmia drugs
Polymorphic: 20-50mg/min Torsades: MgSO4 drip 2gm for 15mins

TACHYCARDIA (>150 BPM) WITH HEMODYNAMIC COMPROMISE

QRS REGULAR IRREGULAR

NARROW Cardiovert 50-100J Cardiovert 120-200J biphasic

pVtach/Torsades: Defibrillate + MgSO4 2gm

WIDE Cardiovert 100J
Preexcited AF: Cardiovert 100J

How to give above mentioned drugs or intervention:

1. Adenosine – Create IV access close to antecubital fossa veins as possible, rapid IV push 6mg with 10cc NSS
flushing. If no response within 1-2 mins may give another 12mg.
2. Amiodarone – 150mg in 100ml D5W or NSS to run for 10 mins. Then, 900mg in 500ml D5W or NSS to run at
30cc/hr for 6 hrs then 16cc/hr for 18 hrs.
3. Procainamide – 1gm in 50ml D5W to run at 1cc/min (60ml/hr) slow IV for 25-30mins loading dose until arrhythmia
resolves, hypotension ensues, QRS duration increases > 50%. Once arrhythmia resolves,
maintain as 1gm in 250cc D5W to run at 1cc/min (60ml/hr) watching out for hypotension or QRS
 P a g e | 55

widening. Avoid in CHF or prolonged QT. Then may start procainamide capsule after 4 hrs of IV
maintenance infusion.
4. MgSO4 drip (prolonged QT with intermittent Torsades or Torsades with Pulse): 2gm MgSo4 in 100cc D5W
slow IV for 15mins → May repeat for a max dose of 4gm in 1hr. May follow with MgSo4 drip 2gm
in 100cc D5w x 6hrs.
4. MgSO4 bolus (Torsades Pointes without a pulse or associated with Vfib/Vtach) – 2gm in 10ml D5W IV
bolus to run for 2 mins. May give another dose 2gm x 2 mins for 2 more doses as needed with
maximum of 6gm total.
4. Electrical Cardioversion
➢ Discuss with patient/watcher and secure consent
➢ Sedate patient (options as follows):
o Etomidate and ketamine – hemodynamically neutral sedative hence more preferred in cardiac
cases. Etomidate (no analgesia effect) is usually given 0.3 mg/kg (18mg in 60kg Px) slow IV over
30-60 secs.
o Ketamine (has analgesia effect) – give 1-2mg/kg (60-120mg in 60kg Pt) over 1-2mins. May give
subsequent 0.5-1mg/kg doses every 5-10mins as needed.
o Propofol (no analgesia effect) – hypotension usually mild and transient. Give initial dose of 0.5 to
1mg/kg (30mg-60mg in 60kg patient) slow IV push. Then 0.25 to 0.5mg/kg every 1-3 mins as
needed for appropriate sedation.
o Midazolam (no analgesia effect) – give 0.02 to 0.03mg/kg (1 to 1.5mg in 60kg Pt) over 1-2 mins.
Should not excess 2.5mg single dose.
➢ Turn on defibrillator
➢ Select appropriate energy level (for a biphasic defibrillator):
o AFib – 120-200J
o Atrial flutter – 50-100J
o Atrial tachycardia – 50J as starting
o Vtach with pulse – 100J
o May increase defibrillating dose to 360J or more if still sinus rhythm not achieved.
➢ Activate synchronize mode by pressing synchronize button or “Sync”. If not pressed the machine will
deliver shock in defibrillation mode.
➢ Check if machine senses R wave
➢ Charge machine to energy level
➢ Press deliver shock once everyone is cleared. Remember it takes few split seconds to deliver the shock
because the machine tries to synchronize with the instrinsic R waves of the patient.

Things to be cautioned with before doing cardioversion:

➢ Patient with chronic Atrial fibrillation must have documented INR > 2.0 if on warfarin or no doses missed
during the last 4 weeks. This must be confirmed within 12hrs of procedure. Otherwise TEE must be done
prior to cardioversion if no such anticoagulant therapy has been complied for at last 4 weeks to reduce
cardioembolic risk after cardioversion.
P a g e | 56
 P a g e | 57

XVI. SHOCK
I. Definition: organ dysfunction resulting from imbalance from cellular oxygen supply and demand
II. General types:

Clue in diagnosis: First approach in shock is determine JVP 6-8cm (normal <4cm from sternal angle). If low JVP
(venous pressure barely appreciated) and therefore low CVP then you are dealing with either distributive vs
hypovolemic shock. Next is to palpate the proximal extremities, if warm then you are dealing distributive shock rather
than hypovolemic type (capillary refill time delayed). If elevated JVP (>4cm from sternal angle), then it is either
cardiogenic vs obstructive shock. History and further PE might lead you to your specific diagnosis. Such as reduced
breath sounds in tension pneumothorax, muffled heart tones in pericardial tamponade etc.

➢ Cardiogenic – MI, myocarditis, arrhythmia, valvular (aortic or mitral insufficiency)

➢ Hypovolemic – Hemorrhage, GI losses, burns, polyuria
➢ Obstructive shock –Tension pneumothorax, cardiac tamponade, constrictive pericarditis, aortic
dissection
➢ Distributive shock – Septic shock, pancreatitis, severe burns, anaphylactic shock, neurogenic
shock, adrenal crisis

III. General management:

➢ IVF: Insert 2 peripheral access. (see following common cases for hydration guide)
➢ NPO temporarily
➢ Work-ups:
▪ CBC
▪ Crea BUN, Urinalysis
▪ Electrolytes
▪ SGPT, SGOT
▪ Trop-I, 12L ECG
▪ ABG
▪ Chest Xray AP view
▪ Lactate
▪ PT, APTT
▪ Blood culture and other site culture if sepsis considered
▪ Pregnancy testing
▪ 2D echo if indicated
A. Hypovolemic shock
➢ In general may give initial fast drip of 30ml/kg then next option is to give volume expanders like
voluven 1L fast drip and/or albumin with congestion precaution
➢ GI losses: (see Acute Gastroenteritis part of this protocol)
➢ Hemorrhage: (see UGIB part of this protocol), in other causes like traumatic or burn injury, stat
referral for evaluation and possible transfer with surgery as well as fluid challenge 1-2L.
B. Cardiogenic shock
➢ Arrhythmia and MI: (see ACS and Arrhythmia part of this protocol)
➢ LV heart failure: (see CHF part of this protocol)
 P a g e | 58

➢ Myocarditis, Valvular and other causes:

i. fluid challenge if no signs of congestion like fast drip PNSS 1-2L with frequent check of
volume status every 200cc-500cc of drip →
ii. Next in line is Dobutamine 250mg in 200cc D5W to run at 10ml/hr (max of 50ml/hr but
usually do not exceed > 30ml/hr). Be wary of vasodilating effect of dobutamine especially
in the background of sepsis. Titrate by ±5cc/hr every 15 mins to achieve MAP ≥ 65mmHg
→
iii. If still hypotensive, may start Norepinephrine 8mg in 92cc PNSS to run at 15cc/hr titrate by
+/- 5cc/hr every 15mins to keep MAP > 65mmHg.
iv. Dopamine usually very last option because of hemodynamic and proarrhythmogenic
effects. Valvular causes might need immediate surgical intervention.
C. Distributive shock
➢ Septic shock (see Sepsis part of this protocol)
➢ Anaphylactic shock –
i. Hook to O2 support at 8-10LPM.
ii. Give epinephrine 0.3 to 0.5 mg intramuscularly, preferably in the mid-outer thigh. Can repeat
every 5 to 15 minutes (or more frequently), as needed.
iii. Treat hypotension with rapid infusion of 1 to 2 liters IV.
iv. If no respond to Epinephrine IM, may start Epinephrine drip 1mg in 1L to run at 6-7cc/hr (0.1
mcg/kg/minute) by infusion pump.
v. Give Salbutamol 2.5 to 5 mg in 3 mL saline via nebulizer for bronchospasm resistant to IM
epinephrine.
vi. Consider giving cetirizine 10 mg IV (given over 2 minutes) or diphenhydramine 25 to 50 mg
IV (given over 5 minutes) – for relief of urticaria and itching only.
vii. Consider giving methylprednisolone 125 mg IV.
➢ Neurogenic shock – common spinal cord injury or post-spinal anesthesia manifesting as
hypotension, bradyarrhythmia, temperature dysregulation.
i. First give fast drip PNSS 1-2L then reevaluate for need of vasopressor (norepinephrine
preferred) and inotropic support to keep MAP 85-90mmHg for 7 days to improve spinal cord
perfusion.
ii. May also give atropine 1mg IV for bradycardia.

D. Obstructive Shock (treatment dependent on the cause. Usually need urgent surgical intervention).
➢ Pericardial effusion with tamponade (Beck’s triad) – Stat pericardiocentesis or pericardiostomy or
pericardial window in restrictive pericarditis.
➢ Tension pneumothorax (COPD, PTB or tall thin patients with sudden dyspnea, chest pain and
unilateral decreased breath sounds) – emergency thoracotomy and CTT.
➢ Aortic dissection (lancinating chest pain, weak pulse, with variable BP on arms and legs) – TCVS
referral or transfer to capable institutions.
➢ SVC syndrome (facial edema, suspected or known cancer or thoracic mass, hand edema) –
transfer to radio-onco capable institutions. May start dexamethasone 6mg IV q6.
 P a g e | 59

XVII ANEMIA
I. DIAGNOSIS:

➢ Clinical: Pallor, fatigue, low stamina, breathlessness, tachycardia, predisposing acute or chronic
disease
➢ WHO criteria:
Population Hemoglobin
Male <13g/dl
Female <12g/dl
Pregnant <11g/dl
➢ Definition:
o Acute blood loss – hypovolemia dominates clinical picture with loss of 10-15% of total
blood volume causing vascular instability
o Anemia - State of reduced hemoglobin concentration. Late manifestation of acute blood
loss.

II. SEVERITY ASSESSMENT:

Clinical:
➢ Pale skin or mucus membrane (80-100mg/L) [Severe]
➢ Palmar creases are lighter than surrounding skin (<8 g/dL) [Severe-Critical]

Severity Hemoglobin Level

Mild 10-12 (women), 10-13 (men)
Moderate 8-10
Severe 6.5-7.9
Life threatening <6.5

III. MANAGEMENT

➢ Diagnostics (please extract blood prior to BT):

o CBC with (MCV, MCH, MCHC, RDW)

▪ Normochromic defined as ≥ 30. Hypochromic < 30

▪ RDW >15% or Higher number means high likeliness of abnormality or red cell
variations in sizes (anisocytosis)
o Reticulocyte count
o Serum Iron
o TIBC (Total iron binding capacity)
o % Transferrin (serum iron level/TIBC x 100%)
o Ferritin
➢ Compute for Reticulocyte production index (RPI) once with reticulocyte count result:
▪ Equals to Absolute reticulocyte count (ARC) / Correction factor
• Absolute reticulocyte count =
o Reticulocyte count % x (Patient’s Hct % ÷ 42%).
 P a g e | 60

• Correction or maturation factor is usually 2. Or may use the guide below

depending on Px Hct level.

Hct % Correction factor

≤ 45 1.0
≤ 35 1.5
≤ 25 2.0
≤ 15 2.5
Eg. 60 yo male with chronic melena. CBC Hg 7g/dl, Reticulocyte of 0.5%. Hct = Hg x 3. So, Hct = 7 x 3 = 21%. ARC
= 0.5% x 21%/42% = 0.25. Correction factor for the given Hct is 2.0. Hence, RPI = 0.25/2 = 0.125 (Hypoproliferative).

▪ RPI < 2.0 → (hypoproliferative) eg. Hypoproliferative anemias and maturation

disorders
▪ RPI 2.0-2.5 → (adequate response) eg. Hemorrhage,
▪ RPI >2.5 → (increased response) eg. Hemolytic anemia
o Peripheral Blood Smear – helps rule out possible leukemias, determine RBC morphology
features to guide differential diagnosis
o Other pertinent labs:
▪ Creatinine BUN (CKD work ups)
▪ FOBT, Colonoscopy or endoscopy
▪ CRP, Rheumatic factor, Cancer markers
▪ Coomb’s test, ANA, LDH – for suspected hemolytic causes
o Chest Xray – rule out chronic pulmonary diseases like PTB
o BMA aspiration and biopsy if indicated

➢ Identify possible causes from History, CBC and reticulocyte counting, and peripheral blood smear
alone. See algorithm below
 P a g e | 61

COMMON SYSTEMIC DISEASES PRESENTATION

Chronic Inflammation like rheumatoid arthritis Microcytic hypochromic
Tuberculosis Microcytic hypochromic
Cancer Normocytic normochromic
Chronic Kidney Disease Normocytic normochromic

Remember: Most anemias are multifactorial but there is one disease entity that predominates hence treatment is
focused on this primary etiology.

IV. TREATMENT:
Principles:
• Begin treatment of mild to moderate anemia ONLY when a specific diagnosis is made
• Whether the anemia is gradual or acute, treat the cause
• Cause is usually multifactorial
• Assess iron status before and after treatment
• If you can avoid transfusion, avoid it unless really necessary!

A. IRON DEFICIENCY ANEMIA

➢ Asymptomatic with intact GI tract:
o Establish iron deficiency (Anemia + s. iron <30 u/dl + ferritin <15 u/dl)
o Diet: Iron-rich – oyster, kidney bean, beef liver, tofu, beef, turkey leg, whole-wheat bread, tuna,
eggs, shrimp, peanut butter, brown rice, raisin bran, lentils and beans
o Goal: oral intake 200mg elemental Iron daily
 ORAL: FeSO4 325mg (65mg elemental Fe) 1 tab TID before meals until anemia is corrected
(recheck CBC after 2 weeks). Then continue for another 6-12 mo’s to provide adequate Iron
store of 0.5-1gm.
 OR FeSO4 525mg (105mg elemental Fe) extended release BID
 Vitamin C 500mg/tab OD (theoretical increased absorption effect)
o Iron Requirements
 Body weight (kg) x 2.3 x (15 – Pt’s Hg in g/dL) + 500 or 1000mg (for stores)
▪ Eg. 60kg pt with Hg of 10 g/dl and ferritin of 25 u/dl will need:
60 kg x 2.3 x (15-10)+ 1000mg Fe = 1690 mg of elemental Fe (in blood)
▪ How long the treatment will be for above example?
▪ If given FeSO4 325mg (65mg elemental Fe) x 3 doses daily (equivalent to
absorption rate of ~50mg/day)
▪ You will need, 1690mg/50mg = 34 days of TID dosing treatment
o You can also modify treatment by giving high dose treatment for 2 weeks as tolerated then repeat
CBC. Continue correction then 1 tab OD to restore iron store for 6-12mos.

➢ Parenteral Therapy:
o When to use IV option:
 Cannot tolerate oral iron
 Acute/urgent correction
 Ongoing persistent bleed
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o Iron needed by individual:

 Body weight (kg) x 2.3 x (15 – Pt’s Hg in g/dL) + 500 or 1000mg (for iron store)
▪ (Eg. 60kg pt with Hg of 7.5g/dl and ferritin of 20 u/dl will need… ➔ 60 kg x 2.3 x
(15-7.5)+ 1000mg Fe = 2,035 mg of elemental Fe
o Tx: Give Iron Sucrose 10-15ml (200-300mg elemental Fe) in 100cc PNSS to run for 2hrs every
other day for 10 sessions total (2035mg/200mg iron sucrose = 10 sessions). Dialysis patients
may have it 2-3x a week.

➢ pRBC BT
o Primary indication:
 Cardiovascular instability
 Continued excessive blood loss
 Signs of anemia (Severe or critical)
 Hg level <7-8 without serious cardiovascular or pulmonary disease
 Hg level <8-9 if WITH serious cardiovascular or pulmonary disease

➢ Erythropoietin
o Primary indication:
 CKD Stage 3 and beyond
▪ Hg < 10 g/dL → treat until Hg >10 g/dL or usually 4 weeks treatment
▪ Treatment:
✓ On dialysis → 50-100 u/kg 3x a week
- (eg. 60kg pt: 50 to 100U*60kg = 3000 to 6000U, give EPO 4000U SQ 3x
a week)
✓ Not on dialysis → 50-100 u/kg once a week
▪ Rpt CBC after 2 weeks,
▪ If Hg does not increase >1g/dL after 4 weeks, increase dose by 25%.
▪ If Hg increases >1g/dL after 2 weeks, reduce dose by 25%.
▪ If still no increase after 12weeks, discontinue treatment, investigate other causes

 Anemia of acute and chronic infection/inflammation

 Chemo induced anemia
▪ Treat if Hg <10g/dL
▪ 150-300 U/kg 3x a week (May increase to 300 U/kg if no response after 4 weeks)
 Elective surgeries
▪ Pre-op: 250 to 500 units/kg every 48 hours with target Hg 12 g/dL
▪ Post-op: 250 to 500 units/kg every 48 hours with target Hg >10 g/dL
▪ Also give folic acid, Vit B12, Iron supplementation
▪ Suggest DVT prophylaxis with anticoagulation

FINALLY! NOT all anemias will require iron supplementation, blood transfusions or erythropoietin. ALWAYS ASSESS
THE CAUSE in non-severe/life threatening anemias because some anemia etiologies will have more adverse reactions
to the above mentioned treatment such as iron toxicity in hemolytic forms of anemia, exacerbation of SLE in lupus
patients and transfusion reactions.
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XVIII COMMON LIVER DISEASES

I. LIVER CIRRHOSIS
❖ Common etiologies: Hepatitis B or C, alcoholic liver disease and NAFLD
❖ Clinical:
➢ stigmata of liver disease: spider angioma, palmar erythema, gynecomastia, testicular atrophy
➢ portal hypertension: ascites splenomegaly, caput medusae, epigastric venous hum,
➢ hepatic encephalopathy: confusion, asterixis, fetor hepaticus
➢ jaundice, parotid enlargement, scant chest or axillary hair
❖ Severity Assessment:
➢ Stage 1 – (-) varices, (-) ascites
➢ Stage 2 – (+) varices without bleed, (-) ascites
➢ Stage 3 – (+) ascites, (+/-) variceal bleed
➢ Stage 4 – (+) variceal bleeding, (+/-) varices -→ triage to level 3 hospital with ICU
▪ Stage 1 and 2 → Compensated liver disease
▪ Stage 3 and 4 → Uncompensated liver disease: (+) ascites, (+) variceal bleed, (+)
encephalopathy, (+) jaundice, hepatocellular cancer
❖ Management:
➢ IVF: PLR x (rate dependent on hydration status), if with ascites give as KVO. Otherwise 80cc/hr
as maintenance. Or Fast drip in severe bleeding.
➢ Labs:
- CBC with PLT
- Na, K, Crea, BUN,
- SGPT, SGOT, Total bilirubin (Direct and Indirect), Albumin, PT APTT INR, Alkaline
phosphatase
- WA USD/CT scan or Fibroscan
- Lipid profile
- HbsAg, Anti-HCV
- FOBT if now gross melena or UGIB
➢ Compute APRI score if without USD
- AST in IU/L / (AST upper limit of normal in IU/L) x (100 / Platelet in 103/mm3)
a. Score of > 1.0 predict cirrhosis 76% sensitivity and 72% specificity
b. Score of > 2.0 has 91% specificity but 46% sensitivity.
❖ Medications (case to case basis):
➢ Esophageal varies:
- Screening endoscopy for PLT < 150
- Primary prophylaxis:
a. Propranolol 20mg 1 tab BID then titrate to keep HR 55-60bpm
b. Carvedilol 12.5mg BID for Child A cirrhosis, 6.25mg 1 tab BID for Child B
c. Endoscopic variceal ligation
- Acute Variceal bleed
a. Transfer to level 3 hospital with ICU capability
b. Stabilize BP with IVF fast drip or volume expander such as voluven or albumin
c. NGT (siliconized insertion prior to endoscopy)
d. Antibiotic prophylaxis: Fluoroquinolone or 3rd gen cephalosporin
i. Ie. Ceftriaxone 2gm IV OD x 7 days then ciprofloxacin 500mg BID x 7
days.
e. O2 support
f. Octreotide 100mcg slow IV bolus ( x 10 mins) then 50mcg per hour infusion
(500mcg in 250cc NSS to run at 25cc/hr) for 2-5 days.
i. Alternative: Terlipressin 1 mg slow IV then 1mg slow IV every 4-6 hrs
g. pRBC for Hg < 70g/L with goal Hg 70-90 g/L except for those with coronary
heart disease (goal Hg 100 g/L) or ongoing active bleeding)
h. PLT for PLT <50k
i. FFP or ideally cryoprecipitate
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j. Vit K 5mg IV q8 for abnormal INR value

k. Endoscopic ligation or sclerotherapy
- Ascites
a. IVF: PLR x KVO
b. Diet: Salt and fluid restriction
c. Diuretics:
i. Furosemide 40mg 1 tab OD (up to 400mg/d)
ii. Spironolactone 50mg 1 tab BID (up to 160mg/d)
1. Keep Furosemide : Spironolactone ratio to 40:100 daily
2. Stop diuretics in uncontrolled encephalopathy or recurrent
encephalopathy, ser Na < 120 meq/L despite fluid
restriction or serum Crea > 2.0 mg/dl.
d. Avoid NSAID, propranolol in refractory ascites
e. Paracentesis if 4-5L is needed to be drained due to tense ascites significantly
causing respiratory restrictions
i. Give albumin infusion during paracentesis if >5.5L peritoneal fluid is
to be removed to avoid hypotension

- Spontaneous Bacterial Peritonitis

a. IVF: PLR x KVO or maintenance rate if septic
b. Empiric antibiotics:
i. Indications: Fever, abdominal pain or tenderness, altered mental
status, ascitic fluid PMN count > 250 cells/uL
1. Cefotaxime 2gm IV q8 (preferred) or Ceftriaxone 2gm IV
OD
2. Oral: Ciprofloxacin 500mg 1 tab q12 x 5 days.
3. Carbapenems for critically ill
- Hepatic Encephalopathy
a. Types:
i. Type 1 – acute liver failure
ii. Type 2 – portal systemic bypass without intrinsic hepatocellular
disease
iii. Type 3 – cirrhosis with portal hypertension or systemic shunt
b. Severity:
i. Minimal (OPD) – abnormal psychometric test but w/o clinical
manifestation
ii. Grade 1 (OPD/admit) – changes in behavior, mild confusion, slurred
speech, disordered sleep (sleep-wake reversal)
iii. Grade 2 (admit) – lethargy, moderate confusion
iv. Grade 3 (ICU) – marked confusion or stupor, incoherent speech,
sleeping but arousable
v. Grade 4 (ICU) – coma, unresponsive to pain
c. Triggers:
i. GI bleed, infection, hypokalemia, renal failure, hypovolemia,
hypoxia, sedatives, hypoglycemia, constipation, HCC or vascular
occlusion
d. Treatment:
i. IVF: PLR x 100cc/hr if not contraindication such as severe ascites
ii. Nutrition: 35-40 kcal/kg/day, protein 1.2-1.5g/kg/day with late
snack. Small frequent feedings. May supplement branched chain
amino acids (Aminoleban) for protein intolerant patients
iii. Lower ammonia level by:
1. Lactulose 30-45ml 2-4x a day to achieve 2-3 soft stools a
day. May be given as enema if cannot tolerate PO intake
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2. Rifaximin 200mg/tab 2 tabs TID x 10 days. Alternative

metronidazole 500mg 1 tab TID
3. Prebiotics (lactulose or fermentable fiber) and probiotics
(lactobacillus and bifidobacterial)
iv. Treat the trigger
- Other complications of liver cirrhosis:
a. Muscle cramps
i. Branched chain amino acids 4gm granules TID
ii. Vitamin E 200mg TID
iii. Taurine 3gm OD
iv. Zinc 220mg BID
b. Hyponatremia (significant Na < 125meqs/L)
i. d/c beta blockers, alpha blockers and other antihypertensives
ii. correct hypokalemia
iii. NSS or hypertonic saline for severe hyponatremia
iv. Albumin infusion
v. Goal Na > 125 meqs/L
c. Thrombocytopenia or elevated INR
i. PLT goal > 50k (moderate risk procedures) or 100k high risk or in
active bleeding
ii. FFP or Vitamin K as needed for elevated INR (see UGIB part of this
protocol)
II. SCHISTOSOMIASIS
❖ Clinical: symptoms depend on organ involved. Exposure to farms, spring, ponds in high risk areas
➢ Seizures and neuro deficit in neuroschistosomiasis, may also involve spinal cord
➢ Liver: hepatomegaly, abdominal pain, blood in stool
❖ Laboratory:
➢ CBC, liver function test – thrombocytopenia, SGPT and SGOT usually normal
➢ Abdominal ultrasound – hepatosplenomegaly, lacelike pattern
➢ Katokatz smear
➢ Rectal biopsy
➢ CT or MRI for neuroschistosomiasis
❖ Medications:
➢ Acute phase (Katayama fever – allergy like reaction)
- Prednisolone 1mg/kg/day until symptoms resolves or 3-10days
- After 6-12 weeks, give praziquantel 40mg/kg once plus prednisolone 1mg/kg/day for 1-3
days
- After 4-6 weeks, give praziquantel 40mg/kg once
- Eg. For a 60kg patient, 40mg x 60 kg = 2400/600mg = 4 tabs divided doses (2 tabs 4 hrs
apart)
➢ Chronic Infection/Endemic area residents
- Test 6-12 weeks after infection
- Praziquantel 60mg/kg in divided doses
a. Eg. 60kg patient, 60mg x 60kg = 3600/600mg = 6 tabs. 3 tabs 4 hrs apart x 2
doses.
- Repeat stool katokatz after 3-6 months in nonendemic areas, after > 6 weeks in endemic
areas.
➢ Neuroschistosomiasis
- Prednisone 1-2mg/kg/day or 30mg tab BID then after few days may give Praziquantel
60mg/kg per day for 3 days
- Antiseizure meds if needed

III. NONALCOHOLIC FATTY LIVER DISEASE

❖ Diagnosis requires:
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➢ Hepatic steatosis on imaging

➢ Exclusion of significant alcohol consumption
➢ Exclusion of other causes of hepatic steatosis
➢ Absence of coexisting chronic liver disease
❖ Mild to moderate elevation in AST and ALT
❖ AST/ALT ratio < 1
➢ (unlike Alcoholic fatty liver disease in which AST/ALT ratio is >2)
❖ Important to request for hepatitis panel, plasma iron, ferritin, TIBC, ANA, Anti-Sm Ab, anti-LKM etc.
❖ Management:
➢ Abstain from alcohol
- MEN: Avoid >14 drinks per week or >4 drinks per day
- WOMEN: Avoid >7 drinks per week or >3 drinks per day
➢ Immunizations
- (Hepa-A and B, other standard immunizations)
➢ Modify cardiovascular risk factors
- (HPN, DM, Dyslipidemia)
➢ Weight loss
- for BMI >25 kg/m2 with goal 0.5-1kg loss per week to 7-10% of body weight
- then repeat ALT (must be <20 for women and <30 for men)
➢ For those with NASH w/o DM:
- Vitamin E 800 IU OD (discuss safety concerns with Px)
a. Avoid in male patients with family history of prostate CA
➢ For those with NASH w/ DM:
- Metformin + Pioglitazone or liraglutide as options
➢ Others with questionable benefit
- Atorvastatin (?), Omega 3 (promising), aspirin (promising), Silymarin (promising)
- Essentiale forte (phospholipids)?, Godex (B complex, carnitine, amino acids)?
- Monitor ALT and AST every 3-6 months while on weight loss regimen, see if ALT
improves otherwise look for other causes

IV. HEPATITIS B
➢ Acute Hep B Dx: (+) HBsAg and (+) Anti-HBc
- Treatment:
a. Give vaccine to all household and sexual contacts
b. Treatment mainly supportive
c. Antiviral Treatment for:
i. INR > 1.5,
ii. persistent symptoms or
iii. marked jaundice bilirubin >3mg/dl
iv. Symptoms more than 4 weeks
d. Medications:
i. TAF (Tenofovir alafenamide) 25mg 1 tab OD x 1 yr minimum
ii. ETV (Entecavir) 0.5mg tab OD. 1mg OD for decompensated liver
disease
➢ Chronic Hep B Dx: (+) HbsAg > 6 months
- Treatment indications:
a. (+) moderate to severe fibrosis or cirrhosis OR
b. ALT > 2x ULN (upper limit of normal) OR
c. HBV DNA > 2,000 IU/mL AND HbeAg (-) AND ALT ≥ 1x ULN OR FIBROSIS,
d. HBV DNA > 20,000 AND HbeAg (+) AND ALT > 2x ULN
e. Otherwise: repeat ALT, HBeAg, HBV DNA every 3-6 months and see if
treatment indicated
- Medications
a. TAF (Tenofovir alafenamide) 25mg 1 tab OD x 1 yr minimum
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b. TDF (Tenofovir disoproxil fumarate) 300mg 1 tab OD

c. ETV (Entecavir) 0.5mg tab OD. 1mg OD for decompensated liver disease
d. Use TAF or ETV over TDF if with renal disease or bone mineral disease
- Monitoring
a. HBV DNA and ALT every 3 months until undetectable for 2 consecutive visits
then every 6 mo’s thereafter
b. HbsAg yearly if undetectable HBV DNA.
c. Monitor Creatinine and phosphate in TDF use

V. HEPATITIS C
❖ Screening: Anti-HCV Ab
➢ (+) HCV RNA test as confirmatory
❖ Treatment indication:
➢ Detectable HCV viral level for 6 months
❖ Many regimens depending on viral genotype
➢ Refer to liver specialist or IDS

VI. NONSPECIFIC TRANSAMINITIS

❖ Elevated ALT and AST without identifiable cause
❖ Diagnosis of exclusion
❖ Detail history especially food/alcohol/drug/herbal intake
❖ Treat the cause

VII. DRUG or HERBAL INDUCED LIVER INJURY (DILI OR HILI; PTB MEDICATIONS)
❖ Most common cause:
➢ Acetaminophen, Amoxiclav. Other antibiotics and antiepileptics

❖ Alkaline phosphatase (elevated in cholestasis)

➢ Acute: Erythromycin, Amoxiclav, ACEi
➢ Chronic: Amoxiclav, ACEi, Anabolic steroids, Statins, Rifampicin
❖ Aminotransferases (elevated in hepatitis)
➢ Acute (90%): Acetaminophen, Iron sulfate, Cocaine, Phenytoin, Methyldopa, Isoniazid,
Diclofenac
➢ Chronic: Amoxiclav, Atorvastatin, Amiodarone, Methotrexate, Hypervitaminosis A, Herbal
products, Valproic
❖ Compute for R Factor to determine possible mechanism of injury if hepatitis vs cholestasis vs mixed
➢ Essential to obtain ALT and alkaline phosphatase (ALP) during laboratories

❖ Management
o Primary: withdrawal of offending
o Medications with Glucocorticoids for:
▪ Hypersensitivity drug reactions (autoimmune, DRESS)
▪ Persistent cholestasis despite withdrawing drug
o Cholestatic disease with pruritus:
▪ Ursodeoxycholic acid 300mg 1 tab TID
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o Acetaminophen poisoning/other acute liver injury:

▪ N-Acetylcysteine 150 mg/kg IV over 60 minutes then 12.5 mg/kg per hour IV for four hours
then infusion at 6.25 mg/kg per hour IV for 16 hours
▪ OR A loading dose of 140 mg/kg PO, followed by 70 mg/kg PO every four hours for a total of
17 doses
o Valproic acid toxicity:
▪ L-carnitine 100 mg/kg IV over 30 minutes (maximum dose 6 g), followed by 50 mg/kg IV
(maximum dose 3 g) given every eight hours
o TB Medications
▪ Baseline monitoring 2-4 weeks after starting of anti-TB medications if:
• With risk of hepatotoxicity
• Abnormal liver function test
▪ Discontinue anti-TB meds if:
• Symptoms of jaundice, anorexia, nausea, vomiting, or abdominal pain
• Bilirubin > 3mg/dl
• AST or ALT > 5x ULN without symptoms, >3x ULN with symptoms
• Monitor liver function tests weekly until bilirubin < 2mg/dl and AST and ALT < 2x
ULN
▪ Rule out other culprits:
• HepA, B and C, assess for biliary disease, alcohol use, other hepatotoxic drugs
▪ Otherwise, observe for 3 days with medications and repeat LFTs.
▪ Treatment algorithm for suspected TB medications related liver injury:

* first you need to discontinue HRZE once liver injury is suspected and repeat AST, ALT and bilirubin
after 1 week. If on repeat LFT < 2x ULN, initiate RE (Rifampicin + Ethambutol) then repeat LFT after 3-5
days. If with elevation of LFT >5x w/o symptoms or >3x with symptoms then Rifampicin is likely culprit.
Proceed with HZE OR 2HES/10HE (ie. 2 months isoniazid + ethambutol + streptomycin and then 10
months isoniazid + ethambutol) OR E+FQN/LZD+S. The number mentioned in the algorithm corresponds
to the number of months to give such abbreviated drugs.
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XIX ANTIBIOTICS
(Mostly lifted from Dr. Dagoc’s lecture and other resources (guidelines, Mandell’s, uptodate)

I. BASIC PRINCIPLES
o Antimicrobial combinations
▪ Combine antibiotics of different class or mechanism of action
▪ Usually used as empiric therapy for health-care associated infections and serious infection
▪ Multiple target organisms
▪ Combine Abx with synergistic activity eg. Bacteriostatic + bactericidal
o Oral VS IV Therapy
▪ Oral: for mild to moderate infection, oral intake and GI absorption intact, clinically stable except in
infective endocarditis and CNS infections,
• Useful in Abx with excellent oral bioavailability compared with IV such as:
• fluoroquinolones
• linezolid, • clindamycin, • fluconazole,
• cotrimoxazole • doxycycline, • voriconazole,
• metronidazole, • rifampin, • azithromycin

▪ IV – Unstable patients, severe infections, IE, CNS infections.

▪ Criteria for switch from IV to PO antibiotics:
• Assess clinical status for 24hrs:
o afebrile,
o downward trend or normalization of CRP or WBC,
o stable VS
o oral intake and absorption not compromised
o Efficacy at the site of infection
▪ Achieve concentration equal to or greater than the MIC (minimum inhibitory concentration)
▪ Agents in the same class can differ from one another
▪ Low-oxygen
▪ High-protein environment of abscess
▪ Presence of foreign bodies at the site of infection

o Counting of antimicrobial days

▪ Antimicrobials administered once daily: day of first dose (is day 1) plus 6 days.

▪ Antimicrobials administered in divided doses or spaced more than 24hrs apart (q48hrs):
• If there are loading or missed doses with less than 24hrs between the given doses, it will still be
counted as “a day” of antibiotic use.
o Eg 1. Piptaz ordered to be given q6hr but due to compliance issue was only given once a
day every 6AM for 3 days but interval between the given doses is ≤ 24hrs, it will still be
counted as “day 3 of antibiotic”.
o Eg 2 below. Vancomycin given q12. If certain doses were missed but less than 24hrs until
the next dose are still counted as day of antibiotic.
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• Counting will reset if the order was put on hold or missed for > 24hrs
o Eg. Clindamycin supposed to be given q6 and is now on day 3 but the following dose was
missed for >24hrs, the counting will reset and next dose will be counted as “Day 1”.

• If the antibiotic order is every 48hrs, counting of days will include the day when antibiotic was not
given.
o Eg. Levofloxacin ordered to be given every 48hrs.

o Duration of antibiotics:
▪ Shorter duration: UTI, CAP
▪ Longer duration: endocarditis, osteomyelitis, intraabdominal abscesses, invasive fungal infection, CNS
infection

II. PNEUMONIA
a. Community Acquired Pneumonia (see CAP protocol for risk stratification)
i. Low risk (without comorbids)
✓ Amoxicillin 1gm 1 tab TID OR
✓ Clarithromycin 500mg 1 tab BID OR
✓ Azithromycin 500mg 1 tab OD
ii. Low risk (with stable comorbids)
✓ Oral beta lactams:
a. Coamoxiclav 500/125mg 1 tab TID OR 875/125mg 1 tab BID OR
b. Cefuroxime 500mg 1 tab BID
✓ PLUS or MINUS macrolides:
a. Clarithromycin 500mg 1 tab BID OR
b. Azithromycin 500mg 1 tab OD OR
c. Doxycycline 100mg 1 tab BID
iii. Moderate Risk without multidrug resistant organism (MDRO) risk
✓ Non-pseudomonal beta lactams:
a. Ampicillin-Sulbactam 1.5-3gm IV q6 OR
b. Cefotaxime 1-2gm IV q8 OR
c. Ceftriaxone 1-2gm IV OD OR
✓ PLUS macrolides:
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a. Azithromycin 500mg 1 tab OD OR

b. Clarithromycin 500mg 1 tab BID
iv. High Risk without MDRO risk
(Regimen same with Moderate Risk w/o MDRO) OR
✓ Non-pseudomonal beta-lactam antibiotic as above
✓ PLUS Azithromycin 500mg PO/IV OD OR respiratory fluoroquinolone:
a. Levofloxacin 750mg PO/IV OD OR
b. Moxifloxacin 400mg PO/IV OD (1 hr infusion)
v. High Risk with MRSA risk: (prior colonization or infection with MRSA within 1 yr; IV antibiotic therapy within
90 days)
✓ Non-pseudomonal Beta lactam antibiotic
a. Ceftriaxone 2gm IV OD
✓ PLUS Macrolide OR respiratory fluoroquinolone
✓ PLUS Vancomycin 15mg/kg IV q12 OR Linezolid 600mg IV q12 OR Clindamycin 600mg IV q8
vi. MDRO with ESBL risk: (prior colonization with ESBL producing organism w/in 1yr)
✓ Replace non-pseudomonal beta lactam with:
a. Ertapenem 1gm IV q24 OR Meropenem 1gm IV q8
✓ PLUS Macrolide OR respiratory fluoroquinolone
vii. MDRO with Pseudomonas risk: (prior colonization/infection within 1 yr, severe bronchopulmonary disease
(severe COPD, bronchiectasis, prior tracheostomy)
✓ Pseudomonal beta lactams:
a. Piperacillin-Tazobactam 4.5gm IV q6 OR
b. Cefepime 2gm IV q8 OR
c. Ceftazidime 2gm IV q8 OR
d. Aztreonam 2gm IV q8 OR
e. Meropenem 1gm IV q8 (esp with ESBL risk also)
✓ PLUS Macrolide OR respiratory fluoroquinolones
b. Nosocomial pneumonia
i. Ventilator-associated pneumonia (VAP) – pneumonia that develops 48hrs or more after intubation
ii. Hospital-acquired pneumonia (HAP) – pneumonia that develops 48hrs or more after admission to hospital
✓ Ventilated HAP (vHAP) – HAP that eventually requires ventilation

SUSPECTED NOSOCOMIAL PNEUMONIA

c. Empiric Antibiotic:
i. Early onset without previous antibiotic: 3rd generation cephalosphorin
ii. vHAP and/or prior antibiotic failure: Ceftolozane/Tazobactam + Aminoglycoside OR Fluoroquinolone
iii. VAP
✓ P. aeruginosa risk and/or P. aeruginosa colonization or MDR local incidence >5% and or (+) PCR for
P. aeruginosa: Ceftolozane/Tazobactam (CFT/TAZ) + Aminoglycoside (AMG) or Fluoroquinolone
(FQN)
✓ KPC (Kleb. pneumoniae carbapenemase) risk factors and/or KPC colonization and/or KPC local
incidence > 5%: Ceftazidime/Avibactam (CAZ/AVI) + AMG or FQN
✓ Unknown colonization. PCR (-). Unknown local MDR incidence: Piperacillin-Tazobactam OR
Carbapenem + AMG or FQN
✓ ADD Linezolid or Vancomycin according to MRSA local incidence or risk
d. Targeted Antibiotic:
i. S. aureus→ MSSA : Cloxacillin/Cefazolin; MRSA : Linezolid/Vancomycin
ii. P. aeruginosa and/or bacteremia → CFT/TAZ (3gm/q8)
iii. KPC or Oxa-48* → CAZ/AVI
iv. Metallo B-lactamase → CAZ/AVI + AZT or Colistin or Cefiderocol
v. Acinetobacter → Consider adding Colistin or Cefiderocol
vi. Other etiologies and no bacteremia → consider de-escalation
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III. SKIN AND SOFT TISSUE INFECTIONS (SSTIs)

e. Classifications
i. Mild: no systemic signs
ii. Moderate: with systemic signs (temperature >38°C, tachycardia (heart rate >90 bpm), tachypnea
(respiratory rate >24/min) or abnormal white blood cell count (>12 000 or <400 cells/µL).
iii. Severe: with systemic signs who failed oral therapy or failed incision and drainage, immunocompromised
host or deeper infection (bullae, hypotension, skin sloughing or evidence of organ dysfunction)

Dosage:

1. Cefazolin: 1 g every 8 h IV
2. Ceftaroline: 600 mg bid IV
3. Ceftazidime: 1gm IV q8
4. Ceftriaxone: 1gm IV OD. For vibrio vulnificus: 1gm IV qid or 2gm IV
5. Cephalexin: 500 mg PO q6h
6. Ciprofloxacin: Ciprofloxacin 400 mg IV every 12 h
7. Clindamycin: 600 mg every 8 h IV or 300mg cap PO QID
8. Daptomycin: 4 mg/kg every 24 h IV
9. Dicloxacillin: 500 mg qid PO
10. Doxycycline: 100 mg PO BID or 100mg IV TID (in vibrio vulnificus)
11. Linezolid: 600 mg IV/PO every 12 h
12. Nafcillin: 1-2 g every 4 h IV
13. Penicillin VK: 250–500 mg every 6 h PO
14. Penicillin: Penicillin 2–4 million units every 4–6 h IV
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15. Piperacillin-Tazobactam: 3.37 g every 6–8 h IV or 4.5gm IV q8

16. TMP/SMX: 800mg/160mg 1-2 tabs BID
17. Vancomycin: 30 mg/kg/d in 2 divided doses IV

See link for more details on different SSTIs including surgical site infections: https://academic.oup.com/cid/article-
pdf/59/2/e10/28951783/ciu296.pdf

IV. INTRAABDOMINAL INFECTIONS

Severity:
f. Mild to Moderate → features not mentioned in high risk/severe. Example includes perforated appendix or
appendiceal abscess.
i. Coverage: enteric streptococci, nonresistant Enterobacteriaceae, and anaerobes
g. High risk or Severe community acquired (CA) infection →
i. Features:
✓ advanced age (>70 years),
✓ delay in initial intervention >24 hours,
✓ inability to achieve adequate debridement or control of infection with drainage,
✓ other comorbidity (eg, renal or liver disease, malignancy),
✓ immunocompromising condition (eg, poorly controlled diabetes mellitus, chronic high-dose
corticosteroid use, use of other immunosuppressive agents, neutropenia, advanced HIV infection,
B or T lymphocyte defects),
✓ organ dysfunction,
✓ severe peritoneal involvement or diffuse peritonitis, low albumin level, and poor nutritional status.
ii. Coverage against: Pseudomonas aeruginosa, Enterobacteriaceae, enteric streptococci, and anaerobes.
h. Healthcare associated infections →
i. Features:
✓ postoperative infection,
✓ previously received cephalosporins or other antimicrobial agents selecting for Enterococcus
species,
✓ immunocompromised patients
✓ with valvular heart disease or prosthetic intravascular materials.
ii. Coverage against: P. aeruginosa, resistant Enterobacteriaceae, streptococci, enterococci, and anaerobes.
iii. Coverage against: Fungal is reasonable for patients with
✓ upper gastrointestinal perforations,
✓ recurrent bowel perforations,
✓ surgically treated pancreatitis,
✓ heavy colonization with Candida spp, or
✓ microbiologic evidence of yeast on intra-abdominal specimens.

Type of Therapy Mild to Moderately Severe Infections High-risk or Highly severe community acquired
(CA) or healthcare associated (HCA) infection
Single Agent
B-Lactam/B-Lactam Inhibitor Ticarcillin-clavulanic acid or
Piperacillin-Tazobactam
Combinations Piperacillin-tazobactam
Fluoroquinolone Moxifloxacin Moxifloxacin
Carbapenems (usually in Imipenem-cilastatin or Meropenem or
Ertapenem
healthcare associated) Doripenem or Meropenem-Vaborbactam
Glycylcyclines Tigecycline Tigecycline
Combination Therapy
3rd or 4th Gen Cephalosporins (cefepime or
ceftazidime) + Metronidazole (for severe CA),
Cefazolin, or Cefuroxime, or
Cephalosporin based Ceftazidime/Avibactam + Metronidazole, or
Cefotaxime, or Ceftriaxone
Ceftolozane/Tazobactam + Metronidazole, or
PLUS Metronidazole
Cefepime or Ceftazidime + Metronidazole +
Vancomycin or Ampicillin (for HCA)
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Ciprofloxacin or Levofloxacin
Fluoroquinolone based Ciprofloxacin + Metronidazole
PLUS Metronidazole
Aztreonam + Vancomycin or Clindamycin plus
Monobactam based
Metronidazole
Not severe or susceptible: Fluconazole
Candida Coverage
Otherwise: Echinocandin

Dosages:

1. Ampicillin 2gm IV q4h

2. Aztreonam 1 to 2 g every 8 hours IV
3. Caspofungin 70mg on day 1 then 50mg OD IV x ≥14 days
4. Cefazolin 1 to 2 g every 8 hours
5. Cefepime 2 g every 8 to 12 hours
6. Cefotaxime 2gm IV q8
7. Ceftazidime 2gm IV q8
8. Ceftazidime/Avibactam 2.5 g over 2hrs every 8 hours in combination with metronidazole
9. Ceftolozane/Tazobactam 1.5 to 3 g every 8 hours IV
10. Ceftriaxone 1-2gm IV OD
11. Cefuroxime 1.5 g every 8 hours
12. Cephalosporins:
13. Ciprofloxacin 400mg IV BID or 500mg tab BID with metronidazole
14. Clindamycin 600mg IV q8
15. Doripenem 500 mg IV every 8h
16. Ertapenem 1gm IV OD
17. Fluconazole 12mg/kg or 800mg on day 1, then 400mg (or 6mg/kg) OD PO/IV x ≥14 days
18. Imipenem/cilastatin 500 mg every 6 h
19. Levofloxacin 750mg OD IV/PO with metronidazole
20. Meropenem 1gm over 3 hrs IV q8
21. Metronidazole 500mg IV q8
22. Moxifloxacin 400 mg OD PO/IV
23. Piperacillin/tazobactam 4.5 over 4 hrs every 6 h
24. Tigecycline 100 mg LD, then 50 mg every 12 h (not active against Pseudomonas aeruginosa)
25. Vancomycin 15 to 20 mg/kg/dose every 8 to 12 hours IV (HCA)

V. URINARY TRACT INFECTIONS

A. Choice of Agents:
 Upper tract (such as pyelonephritis): B-lactams, fluoroquinolones, trimethoprim-sulfamethoxazole (TMP-SMX),
aminoglycosides
 Lower tract (cystitis): nitrofurantoin or Fosfomycin
B. Duration:
a. Uncomplicated cystitis
i. Nitrofurantoin 5 days, TMP-SMX 800/160mg x 3 days or
ii. Fosfomycin 3gm x 1 dosoe
iii. Avoid fluoroquinolones (risk of ecological collateral damage)
iv. Extend treatment to 7-10 on nursing homes (risk of upper tract infection)
b. Pyelonephritis:
i. Ciprofloxacin 500mg tab or 400mg IV x 7 days or
ii. Levofloxacin 750mg 1 tab OD x 5 days
* if local resistance to FQN is > 10%, administer with IV 3rd gen cephalosporin (ceftriaxone 1-2gm IV OD)
c. Complicated UTI: drug resistant organism (DM cases), infected stone or foreign body (stent), men (unless
obstruction has been rule out)
i. Drug resistance: extended B-lactamase
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ii. Lower tract infection (susceptible): TMP-SMX, Nitrofurantoin, Fosfomycin, FQN x 7 days
iii. Polycystic kidney disease TMP-SMX or FQN will penetrate cyst/closed space
C. Resistance:
a. 35% isolates from community resistant to amoxicillin
b. 20% isolates resistant to TMP-SMX
c. Approaching 10% FQN resistance
d. Nitrofurantoin and Fosfomycin maintain activity.

RECOMMENDATIONS
PARAMETER ORAL PARENTERAL (switch to oral when
response occurs)
Uncomplicated Pyelonephritis
GNB (gram negative bacilli) or no urine Ciprofloxacin 500mg BID x7 days, FQN 7 days or extended spectrum B-
gram stain available Levofloxacin 750mg OD x 5 days, lactam such as Ceftriaxone 1gm OD x 14
if cannot use FQN, TMP-SMX days ± Aminoglycoside (gentamicin
160/800mg BID x 14 days + 1 dose of 5mg/kg/day) or Carbapenem
Ceftriaxone or Aminoglycoside (ertapenem or meropenem)
GPC (gram positive cocci) in chains Amoxicillin 875mg BID x 14 days Ampicillin 2gm q4h x 14 days
GPC (gram positive cocci) in clusters Linezolid or TMP-SMX x 14 days Vancomycin 15mg/kg x 14 days
Complicated Pyelonephritis
Nonpregnant women or men Same as uncomplicated Abx for 10-14 FQN (Cipro 400mg IV q12 or Levo
days 750mg IV OD) + Extended spectrum B-
lactam ± Aminoglycoside; OR
Carbapenem (ertapenem or
meropenem)
Pregnant women Extended spectrum B-lactam (eg. Co- Extended spectrum B-lactam
amox, 3rd gen cephalosporin such as (eg. Ceftriaxone 1gm OD, Cefepime 1gm
cefixime 200mg BID, cefpodoxime q12 in mild-moderate; Pip-taz 3.375g
200mg BID) q6, Merop 1g q8, Ertap 1g OD in severe
infection)
Uncomplicated Cystitis
Nonpregnant women Nitrofurantoin 100mg BID x 5 days, or
fosfomycin 3gm x 1 dose or TMP-SMX x
3 days, or pivmecillinam 400mg BID x 3-
7 days
Complicated Cystitis
Women or men FQN (see dose) or nitrofurantoin 100mg
BID x 7 days or Fosfomycin 3gm x 1 dose
Pregnant women Cephalexin 500mg QID 3-5 days, or
Fosfomycin 3gm x 1 dose or
nitrofurantoin 100mg BID x 7 days
See also UTI recommendations based on PSMID guideline in the protocol.

D. Catheter associated UTI (CAUTI)

a. Considerations for empirical agent
i. Collect urine culture prior to treatment to guide therapy
ii. Severity of illness and comorbidities – choose a broader agent for a more severely ill patients or those
who are immunocompromised
iii. Antimicrobial susceptibility of bacteriuria strains within past 2 years
iv. Antibiotic exposure within 6 months
v. Local resistance data
vi. Hospitalizations or stay in a long term care facility in past 6 months
vii. Travel to an area with high prevalence of drug resistance in prior 12 months
viii. Consider adding vancomycin if gram-positive organism is suspected
ix. Use carbapenem if an ESBL strain is known or suspected
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x. Tailor regimen based on susceptibility data and transition to oral medications as soon as condition
allows.
b. Empiric therapy:
i. Mild to moderate illness, can tolerate oral therapy (Duration 5-10 days)
1. Ciprofloxacin 500mg PO BID or 1gm extended release PO OD
2. Levofloxacin 750mg PO OD
3. Cefpodoxime 200mg PO q12 (or other 3rd gen cephalosporin)
4. Trimethoprim-Sulfamethoxazole (TMP-SMX) 160/800 mg PO q8
5. Co-amoxiclav immediate release 875mg BID OD
ii. Severe illness or unable to tolerate oral therapy (Duration 5-14 days)
1. Ciprofloxacin 400mg IV q12
2. Levofloxacin 750mg IV OD
3. Ceftriaxone 1-2gm IV OD
4. Cefepime 1gm IV BID
5. Piperacillin-Tazobactam 3.375 gm (as piperacillin) IV q6hr
6. Meropenem 1gm IV q8h
7. Imipenem-Cilastatin 500mg IV q6
8. Ertapenem 1gm IV OD
9. Gentamicin 5-7 mg/kg IV OD ± ampicillin 1-2gm IV q6h
10. Ceftolozane-tazobactam 1.5gm IV q8
11. Ceftazidime-avibactam 2.5mg IV q8
12. Meropenem-Vaborbactam 4gm IV q8
13. Plazomicin 15mg/kg IV OD

VI. CENTRAL NERVOUS SYSTEM INFECTIONS

A. ACUTE MENINGITIS (<4 weeks)

Predisposing factor Antimicrobial therapy
Age
<1 mo Ampicillin plus cefotaxime; or ampicillin plus an aminoglycoside
1-23 mo Vancomycin plus a 3rd gen Cephalosporin
2-50 yr Vancomycin plus a 3rd gen Cephalosporin
>50 yr Vancomycin plus ampicillin plus 3rd gen Cephalosporin
Immunocompromised state Vancomycin plus ampicillin plus either cefepime or meropenem
Basilar skull fracture Vancomycin plus a 3rd generation cephalosporin
Head trauma; after neurosurgery Vancomycin plus either ceftazidime, cefepime or meropenem
Note: Ideally start Dexamethasone 15-20mins prior to Antibiotic administration 10mg IV q6 x 4 days

Dose:
Ampicillin 2gm IV q4
Cefepime 2gm IV q8
Cefotaxime 1.5-3gm IV q4-6
Ceftazidime 2gm IV q8
Ceftriaxone 2gm IV q12-24
Meropenem 2gm IV q8
Vancomycin 15-30 mg/kg q8-12h

B. CHRONIC MENINGITIS (>4 weeks)

o Mostly due to tuberculous meningitis (unique features):
▪ Symptoms onset to clinical presentation majority within 1-3 weeks to more than 4 weeks
▪ Neurologic symptoms and altered sensorium (stage 3), personality changes
▪ Cranial II and VI palsies (in stage 2), multiple cranial ner, visual loss
o Treatment: HRZ+Streptomycin (or Levoflox/Ethionamide) x 2 months then HR 7-10 months.
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o Also start steroid: Dexamethasone 0.3 to 0.4 mg/kg/day intravenously (IV) for 2 weeks, then 0.2 mg/kg/day IV week
3, then 0.1 mg/kg/day IV week 4, then 4 mg per day orally and taper 1 mg off the daily dose each week; total duration
approximately eight weeks. In conscious patients, oral prednisolone 0.5 mg/kg (up to 40 mg/day) may be given for
four weeks and then tapered over the following four weeks

C. BRAIN ABSCESS:
PREDISPOSING CONDITION ANTIMICROBIAL REGIMEN
Otitis media or mastoditis Metronidazole + third-generation cephalosporin
Sinusitis (frontoethmoid or sphenoid) Metronidazole + third-generation cephalosporin
Dental infection Penicillin + Metronidazole ± (Vancomycin if MRSA suspected)
Penetrating trauma or postneurosurgical Vancomycin + 3rd or 4th generation cephalosporin (if
pseudomonas suspected)
Lung abscess, empyema, bronchiectasis Penicillin + metronidazole + sulfonamide (nocardia
suspected)
Bacterial endocarditis Vancomycin (± other agents based on likely microbiologic
etiologies)
Congenital heart disease 3rd generation cephalosporin
Unknown Vancomycin + metronidazole + 3rd or 4th gen cephalosporins
3rd gen to use: Cefotaxime or ceftriaxone
4th gen to use: Cefepime or ceftazidime

Dose:
Ampicillin 2gm IV q4
Cefepime 2gm IV q8
Cefotaxime 1.5-3gm IV q4-6
Ceftazidime 2gm IV q8
Ceftriaxone 2gm IV q12-24
Meropenem 2gm IV q8
Metronidazole 7.5 mg/kg IV q6
Penicillin 4 million U q4
Trimethoprim-Sulfamethoxazole 5-10mg/kg q6-12
Vancomycin 15-30 mg/kg q8-12h

D. VIRAL ENCEPHALITIS
o Empiric therapy: no specific therapies but in most cases may treat as HSV1 if none other can be associated with it.
Acyclovir 10mg/kg IV q8.

VII. JOINTS AND OSTEOMYELITIS

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(lifted from Mandell et.al Principles and Practice of Infectious Diseases)