IM On Call (LANGE On Call) PDF
IM On Call (LANGE On Call) PDF
IM On Call (LANGE On Call) PDF
Adenosine 6-mg bolus over 1–3 sec, followed by 20 mL saline Narrow or wide complex SVT
flush. Repeat 12-mg bolus over 1–3 sec after 1–2 min
Amiodarone Usual: 150 mg IV over 10 min, followed by 1 mg/min Ventricular tachycardia, cardiac arrest Dilute bolus 20–30 mL saline or dextrose in water.
IV × 6 hrs, then 0.5 mg/min (pulseless ventricular fibrillation or
ventricular tachycardia), ventricular
Cardiac Arrest: 300 mg IV push; may follow with 150 fibrillation, paroxysmal supraventricular
mg; max 2 mg over 24 hr tachycardia, atrial tachycardia, atrial
fibrillation/flutter, junctional tachycardia
Atropine Asystole 1 mg IV Q 3–5 min; bradycardia, 0.5–1 mg Sinus bradycardia, AV block, asystole If no response with 2 mg total, use dopamine or
IV Q 3–5 minutes to max 0.04 mg/kg epinephrine. Total dose of 3 mg causes full vagal
blockade.
Calcium 2–4 mg/kg of 10% solution IV Q 10 min Hypocalcemia, hyperkalemia, calcium Flush line before giving sodium bicarbonate.
chloride channel blocker toxicity
Defibrillation 1st attempt 200 joules (J) Ventricular fibrillation, pulseless For V fibrillation or pulseless V tachycardia, be sure
2nd attempt 200–300 J ventricular tachycardia synchronizer is in off position, or unit may not fire.
3rd attempt 360 J immediately If initial 3 shocks fail to defibrillate, continue CPR,
IVF, drugs, and repeat.
Diltiazem 0.25 mg/kg over 2 min, after 15 min 0.35 mg/kg over Atrial fibrillation/flutter, MAT, narrow Give slowly over 2 min (3 min in elderly); use
2 min, maintenance 10–20 mg/hr SVT, junctional tachycardia carotid massage before administering diltiazem.
Dopamine 2.5–20 mcg/kg/min, infusion titration Nonhypovolemic shock (cardiogenic Add norepinephrine if more than 20 mcg/kg is
septic). Hypotension with significant needed to maintain blood pressure. Flush line
bradycardia before giving NaHCO3.
Epinephrine 1.0 mg IV Q 3–5 min (10 mL of 1:10,000) follow Asystole, ventricular fibrillation, Flush line before giving sodium bicarbonate; can
with 20 mL flush, 2–10 mcg/min infusion bradycardia give via ET tube if no IV. ET tube dose needs to
be at least 2–2.5 times the peripheral dose.
Esmolol 0.5 mg IV over 1 min, then 50 mcg/kg/min × 4 min; if Paroxysmal supraventricular tachycardia, Maximum duration of infusion is 48 hrs.
necessary, another 0.5 mg over 1 min, with infusion atrial tachycardia, atrial fibrillation/flutter,
increased to 100 mcg/kg; infusion may be increased up polymorphic ventricular tachycardia
to 200 mcg/kg/min (maximum dose) following pacing
INTERNAL
MEDICINE
ON CALL
Fourth Edition
Edited by
John B. Robbins, MD
General Internist
Private Practice
Internal Medicine Associates
Bozeman, Montana
Series Editor
Leonard G. Gomella, MD
The Bernard W. Godwin, Jr. Professor and Chair
Department of Urology
Jefferson Medical College
Thomas Jefferson University Medical Center
Philadelphia, Pennsylvania
ISBN: 978-0-07-178135-0
MHID: 0-07-178135-8
The material in this eBook also appears in the print version of this title: ISBN: 978-0-07-143902-2,
MHID: 0-07-143902-1.
All trademarks are trademarks of their respective owners. Rather than put a trademark symbol after every
occurrence of a trademarked name, we use names in an editorial fashion only, and to the benefit of the trademark
owner, with no intention of infringement of the trademark. Where such designations appear in this book, they
have been printed with initial caps.
McGraw-Hill eBooks are available at special quantity discounts to use as premiums and sales promotions, or for
use in corporate training programs. To contact a representative please e-mail us at bulksales@mcgraw-hill.com.
Notice
Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge,
changes in treatment and drug therapy are required. The authors and the publisher of this work have checked
with sources believed to be reliable in their efforts to provide information that is complete and generally in
accord with the standards accepted at the time of publication. However, in view of the possibility of human error
or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved
in the preparation or publication of this work warrants that the information contained herein is in every respect
accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained
from use of the information contained in this work. Readers are encouraged to confirm the information contained
herein with other sources. For example and in particular, readers are advised to check the product information
sheet included in the package of each drug they plan to administer to be certain that the information contained in
this work is accurate and that changes have not been made in the recommended dose or in the contraindications
for administration. This recommendation is of particular importance in connection with new or infrequently
used drugs.
TERMS OF USE
This is a copyrighted work and The McGraw-Hill Companies, Inc. (“McGrawHill”) and its licensors reserve all
rights in and to the work. Use of this work is subject to these terms. Except as permitted under the Copyright Act
of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse
engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish
or sublicense the work or any part of it without McGraw-Hill’s prior consent. You may use the work for your own
noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may
be terminated if you fail to comply with these terms.
THE WORK IS PROVIDED “AS IS.” McGRAW-HILL AND ITS LICENSORS MAKE NO GUARANTEES
OR WARRANTIES AS TO THE ACCURACY, ADEQUACY OR COMPLETENESS OF OR RESULTS TO BE
OBTAINED FROM USING THE WORK, INCLUDING ANY INFORMATION THAT CAN BE ACCESSED
THROUGH THE WORK VIA HYPERLINK OR OTHERWISE, AND EXPRESSLY DISCLAIM ANY
WARRANTY, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO IMPLIED WARRANTIES OF
MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. McGraw-Hill and its licensors do not
warrant or guarantee that the functions contained in the work will meet your requirements or that its operation
will be uninterrupted or error free. Neither McGraw-Hill nor its licensors shall be liable to you or anyone else
for any inaccuracy, error or omission, regardless of cause, in the work or for any damages resulting therefrom.
McGraw-Hill has no responsibility for the content of any information accessed through the work. Under no
circumstances shall McGraw-Hill and/or its licensors be liable for any indirect, incidental, special, punitive,
consequential or similar damages that result from the use of or inability to use the work, even if any of them
has been advised of the possibility of such damages. This limitation of liability shall apply to any claim or cause
whatsoever whether such claim or cause arises in contract, tort or otherwise.
Dedicated to Meg, Sarah and Will, and Mary. Our inspiration
for everything we do. We also want to thank all of our former
teachers who instilled in us the importance of knowledge and
scholarship and our former, current, and future students
who inspire our continued learning.
This page intentionally left blank
Contents
v
vi CONTENTS
James A. Barker, MD
Professor and Chief,
Pulmonary and Critical Care Medicine
University of South Carolina School of Medicine
Columbia, South Carolina
Dianna S. Howard, MD
Assistant Professor
Division of Hematology and Oncology
Department of Internal Medicine
University of Kentucky
Lexington, Kentucky
viii
ASSOCIATE EDITORS ix
James A. Barker, MD
Professor and Chief,
Pulmonary and Critical Care Medicine
University of South Carolina School of Medicine
Columbia, South Carolina
Donald R. Barnett, MD
Service Line Manager for Primary Care
Veterans Administration Eastern Kansas Health Care System
Topeka, Kansas
P. Ricky Bass, MD
Assistant Professor
Department of Internal Medicine and
Department of Pediatrics
Louisiana State University—Shreveport
Shreveport, Louisiana
David J. Bensema, MD
General Internist
Private Practice
Lexington, Kentucky
x
CONTRIBUTORS xi
Rolando Berger, MD
Professor of Medicine
Division of Pulmonary and Critical Care Medicine
Department of Internal Medicine
University of Kentucky
Lexington, Kentucky
Eric W. Byrd, MD
General Internist
Private Practice
Carolina Mountain Internal Medicine
Hendersonville, North Carolina
William Coble, MD
Fellow
Division of Cardiology
Department of Internal Medicine
Medical College of Virginia
Richmond, Virginia
Thadis C. Cox, MD
Fellow
Division of Gastroenterology
Department of Internal Medicine
University of Kentucky
Lexington, Kentucky
Robert T. Davis, MD
Associate Professor of Medicine
Division of General Internal Medicine
Department of Internal Medicine
University of Kentucky
Lexington, Kentucky
David W. Dozer, MD
Gastroenterologist
Private Practice
Milwaukee Digestive Diseases Consultants, SP
Milwaukee, Wisconsin
xii CONTRIBUTORS
G. Paul Eleazer, MD
Professor of Medicine and Director
Division of Geriatrics
University of South Carolina School of Medicine
Columbia, South Carolina
Kim R. Emmett, MD
Assistant Professor
Department of Medicine
University of Tennessee Graduate School of Medicine
Knoxville, Tennessee
David K. Goebel, MD
Hematologist/Oncologist
Private Practice
Tri-State Regional Cancer Center
Ashland, Kentucky
CONTRIBUTORS xiii
John J. Gohmann, MD
Medical Oncologist
Private Practice
Central Baptist Hospital
Lexington, Kentucky
Leonard G. Gomella, MD
The Bernard W. Godwin, Jr. Professor and
Chair
Department of Urology
Jefferson Medical College
Thomas Jefferson University Medical Center
Philadelphia, Pennsylvania
Tricia L. Gomella, MD
Assistant Professor, Part-time
Division of Neonatology
Department of Pediatrics
Johns Hopkins University
Baltimore, Maryland
David M. Hiestand, MD
Fellow
Division of Pulmonary and Critical Care Medicine
Department of Internal Medicine
University of Kentucky Lexington, Kentucky
xiv CONTRIBUTORS
Alan T. Lefor, MD
Director, Surgical Education and Academic Affairs
Director, Division of Surgical Oncology
Cedars-Sinai Medical Center
Professor of Clinical Surgery
Department of Surgery
University of California, Los Angeles
Los Angeles, California
Jerry J. Lierl, MD
Associate Professor of Medicine
Director, Cardiac Cath Lab
Director of Interventional Cardiology Fellowship
University of Cincinnati
Cincinnati, Ohio
Shantae L. Lucas, MD
Hematologist/Oncologist
Private Practice
Cancer Care of Western North Carolina
Asheville, North Carolina
Andrew D. Massey, MD
Associate Professor of Medicine
Department of Internal Medicine
Department of Psychiatry
Department of Neurology—Kansas City
University of Kansas School of Medicine–Wichita
Wichita, Kansas
CONTRIBUTORS xv
Thomas B. Montgomery, MD
Professor of Medicine
Division of Medical Education
Department of Internal Medicine
University of South Alabama
Mobile, Alabama
William C. Moore, MD
General Internist
Private Practice
Ferrell Duncan Clinic, Inc.
Springfield, Missouri
Rita M. Kramer, MD
Associate Professor
The Breast Center
Baylor College of Medicine
Houston, Texas
Brain Murphy, MD
Fellow
Division of Infectious Diseases
Department of Internal Medicine
University of Kentucky
Lexington, Kentucky
xvi CONTRIBUTORS
John C. Parker, MD
Endocrinologist
Hanover Medical Specialists, PA
Wilmington, North Carolina
Consulting Associate in Medicine
Duke University
Durham, North Carolina
Carol B. Peddicord, MD
General Internist
Private Practice
Albany, Kentucky
John B. Robbins, MD
General Internist
Private Practice
Internal Medicine Associates
Bozeman, Montana
David W. Rudy, MD
Associate Professor of Medicine
Division of General Internal Medicine
Department of Internal Medicine
University of Kentucky Lexington, Kentucky
Steven I. Shedlofsky, MD
Marcos Lins Andrade Professor of Medicine
Division of Digestive Diseases and Nutrition
Department of Internal Medicine
University of Kentucky Medical Center and Veteran’s Administration
Hospital
Lexington, Kentucky
CONTRIBUTORS xvii
Michael H. Sifford, MD
Fellow
Division of Gastroenterology
Department of Internal Medicine
University of Kentucky
Lexington, Kentucky
R. Douglas Strickland, MD
Gastroenterologist
Private Practice
Holston Valley Hospital
Gastroenterology Associates
Kingsport, Tennessee
Timothy A. Winchester, MD
General Internist
Private Practice
Lexington, Kentucky
This page intentionally left blank
Preface
xix
xx PREFACE
want to thank Janet Foltin, our editor at McGraw-Hill, whose support and
guidance has been invaluable through the third and fourth editions of this
book.
Finally, we want to thank Lindsey Sutton and Mary Robbins, RN, for their
efforts in the completion of this book. Without their assistance, hard work
and support, the completion of this manual would not have been possible.
We sincerely hope that this manual will enhance your training and help
you to provide the best care for your patients.
Steven A. Haist, MD, MS, FACP
Lexington, Kentucky
John B. Robbins, MD
Bozeman, Montana
June 2005
I. On-Call Problems
1
2 I: ON-CALL PROBLEMS
C. Does the pain radiate? Pain that becomes rapidly generalized im-
plies perforation and leakage of fluid into the peritoneal cavity. Biliary
pain can radiate from the right upper quadrant to the right inferior
scapula. Pancreatic and abdominal aneurysmal pain may radiate to
the back. Ureteral colic classically is referred to the groin and thigh.
D. When did the pain begin? Sudden onset suggests perforated ulcer,
mesenteric occlusion, ruptured aneurysm, or ruptured ectopic preg-
nancy. A more gradual onset (> 1 hour) implies an inflammatory con-
dition such as appendicitis, cholecystitis, diverticulitis, or an
obstructed viscus such as bowel obstruction.
E. What is the quality of the pain? Intestinal colic occurs as cramping
abdominal pain interspersed with pain-free intervals. Biliary colic is
not a true colicky pain in that it usually presents as sustained persis-
tent pain. Unfortunately, the terms sharp, dull, burning, and tearing,
although used by patients to describe pain, seldom assist in deter-
mining the cause.
F. What relieves the pain or makes it worse? Pain with deep inspira-
tion is associated with diaphragmatic irritation, such as with pleurisy
or upper abdominal inflammation. Patients with intestinal or ureteral
colic tend to be restless and active, whereas patients with peritonitis
attempt to avoid all motion. Coughing frequently exacerbates abdom-
inal pain from peritonitis.
G. Are there any associated symptoms? Vomiting may result from in-
testinal obstruction or may result from a visceral reflex caused by
pain. In conditions causing an acute surgical abdomen, the vomiting
usually follows rather than precedes the onset of pain. Hematemesis
suggests gastritis or peptic ulcer disease. Diarrhea may result from
gastroenteritis, but may also result from ischemic colitis or inflamma-
tory bowel disease. Obstipation (absence of passage of stool or fla-
tus) suggests mechanical bowel obstruction. Hematuria indicates
genitourinary disease such as nephrolithiasis. Cough and sputum
production might occur if lower lobe pneumonia is present.
H. For women, what is the patient’s menstrual history? A missed
period in a sexually active woman suggests ectopic pregnancy. A
foul vaginal discharge may indicate pelvic inflammatory disease.
I. What is the patient’s medical history? Is there a history of peptic
ulcer disease, gallstones, diverticulosis, alcohol abuse, abdominal
operations suggesting adhesions, or an abdominal aortic aneurysm?
Is there any known history of cardiac arrhythmias or other cardiac
disease that could result in embolization to a mesenteric artery? Is
there a history of a hypercoagulable state?
J. What medications is the patient taking? Is the patient already on
chronic pain medications or steroids that mask the clinical picture?
Does the patient use nonsteroidal anti-inflammatory agents or other
1. ABDOMINAL PAIN, ACUTE 3
TABLE I–1. COMMON CAUSES OF ACUTE ABDOMEN: CONDITIONS IN ITALIC TYPE OFTEN
REQUIRE SURGERY.
Doherty GM, Boey JH: The Acute Abdomen. In Way LW, Doherty GM, eds. Current Surgical Diagnosis
and Treatment. 11th ed. McGraw-Hill; 2003.
4 I: ON-CALL PROBLEMS
Condition Signs
Perforated viscus Scaphoid, tense abdomen; diminished bowel sounds (late); loss of liver
dullness; guarding or rigidity
Peritonitis Motionless, absent bowel sounds (late); cough and rebound tender-
ness; guarding or rigidity
Inflamed mass Tender mass (abdominal, rectal, or pelvic); punch tenderness; special
or abscess signs (Murphy’s, psoas, or obturator)
Intestinal obstruction Distention; visible peristalsis (late); hyperperistalsis (early) or quiet
abdomen (late); diffuse pain without rebound tenderness; hernia or
rectal mass (some)
Paralytic ileus Distention; minimal bowel sounds; no localized tenderness
Ischemic or Not distended (until late); bowel sounds variable; severe pain but little
strangulated bowel tenderness; rectal bleeding (some)
Bleeding Pallor, shock; distention; pulsatile (aneurysm) or tender (eg, ectopic
pregnancy) mass; rectal bleeding (some)
Reproduced with permission from Doherty GM, Boey JH: The Acute Abdomen. In Way LW, Doherty GM,
eds. Current Surgical Diagnosis and Treatment. 11th ed. McGraw-Hill; 2003.
IV. Database
A. Physical examination key points. See Table I-2.
1. Vital signs and general appearance. Does the patient appear
uncomfortable? (See Section II.A.) Is the patient jaundiced? Is
there a position that provides some relief of the pain? Patients
with peritonitis resist movement, whereas patients with colic
writhe in pain.
2. Lungs. Percuss for dullness at the bases, which suggests a
pleural effusion or consolidation. In addition to dullness, crackles
or bronchial breath sounds suggest a pneumonia, infarction, or at-
electasis associated with decreased inspiratory effort because of
pain. A friction rub suggests pleuritis as a cause of upper abdomi-
nal pain.
3. Heart. Look for jugular venous distention, S3 gallop, or a dis-
placed apical impulse indicative of congestive heart failure that
might predispose to passive congestion of the liver or mesenteric
ischemia. An irregular pulse could indicate atrial fibrillation, which
might result in mesenteric artery embolism. Pericarditis is sug-
gested by a friction rub and could be associated with upper ab-
dominal discomfort.
4. Abdomen
a. Inspection. Examine for distention (obstruction, ileus, ascites),
ecchymoses (hemorrhagic pancreatitis), caput medusae (portal
hypertension), and surgical scars (adhesions).
6 I: ON-CALL PROBLEMS
TABLE I–3. INDICATIONS FOR URGENT OPERATION IN PATIENTS WITH ACUTE ABDOMEN.
■ Physical findings
Involuntary guarding or rigidity, especially if spreading
Increasing or severe localized tenderness
Tense or progressive distention
Tender abdominal or rectal mass with high fever or hypotension
Rectal bleeding with shock or acidosis
Equivocal abdominal findings along with
Septicemia (high fever, marked or rising leukocytosis, mental changes, or increasing
glucose intolerance in a diabetic patient)
Bleeding (unexplained shock or acidosis, falling hematocrit)
Suspected ischemia (acidosis, fever, tachycardia)
Deterioration on conservative treatment
■ Radiologic findings
Pneumoperitoneum
Gross or progressive bowel distension
Free extravasation of contrast material
Space-occupying lesion on CT scan with fever
Mesenteric occlusion on angiography
■ Endoscopic findings
Perforated or uncontrollably bleeding lesion
■ Paracentesis findings
Blood, bile, pus, bowel contents, or urine
1
Reproduced with permission from Doherty GM, Boey JH: The Acute Abdomen. In Way LW, Doherty GM,
eds. Current Surgical Diagnosis and Treatment. 11th ed. McGraw-HIll; 2003.
REFERENCES
Balthazar EJ, Birnbaum BA, Yee J et al: Acute appendicitis: CT and ultrasound correla-
tion in one hundred patients. Radiology 1997;202:137.
Fishman MB, Aronson MD: Approach to the patient with abdominal pain. In: Fletcher
SW, Fletcher RH, Aronson MD, eds. UpToDate [CD-ROM]. Version 8.2. Wellesley,
MA;2000. www.uptodate.com
Jung PJ, Merrell PC: Acute abdomen. Gastroenterol Clin North Am 1988;17:227.
Ray BS, Neill CL: Abdominal visceral pain in man. Ann Surg 1947;126:709.
Silen W: Cope’s Early Diagnosis of the Acute Abdomen. 20th ed. Oxford University
Press;2000.
Wagner JM, McKinney P, Carpentar JL: Does this patient have appendicitis? JAMA
1996;276:1589.
10 I: ON-CALL PROBLEMS
2. ACIDOSIS
I. Problem. A 30-year-old man is brought into the emergency room uncon-
scious. A friend found him at home. No other history is available. Physi-
cal examination is unremarkable except for rapid, shallow breathing.
Arterial blood gas (ABG) reading reveals a pH of 7.10.
HCO 3−
pH = pK a + log
H2 CO 3
2. ACIDOSIS 11
pCO 2
H + = 24 ×
HCO 3−
20
H + = 24 ×
6
H + = 80
Does a pH of 7.10 equal a [H+] of 80 nmol/L? There are some simple
rules to help convert pH to [H+]. At a pH of 7.40, the [H+] = 40 nmol/L.
pH is a log scale, and for every 0.3 change in pH, the [H+] doubles or
is halved. For instance, if pH = 7.70, [H+] = 20 nmol/L, and at pH =
8.00, [H+] = 10 nmol/L. In this patient, if pH = 7.10, then [H+ = 80
nmol/L. Also, around a pH of 7.40 (7.25–7.48), the [H+] changes 1
nmol/L for every 0.01 change in pH. Lastly, on the back of many ABG
slips, there may be a scale showing the relation between pH and
[H+]. If the numbers do not fit reasonably well (± 10%) into the equa-
tion
pCO 2
[H + ] = 24 ×
HCO 3−
45
50 = 24 ×
30
50 ≠ 36
The pH, the pCO2, or the HCO2− is in error. For instance, if the blood
was not transported on ice to the laboratory, the pH would be falsely
low.
F. Is the compensation appropriate? Checking to see whether the
compensation is appropriate may unmask mixed disturbances.
1. For respiratory acidosis, immediate compensation is through
buffers. In the short term, one expects the HCO3− to increase by 1
mmol/L for every 10 mm Hg increase in pCO2 over normal (40
12 I: ON-CALL PROBLEMS
The normal anion gap is 8–12 mmol/L. An increase in anion gap may
result from an increase in an unmeasured anion. Other causes of an
elevated anion gap include dehydration; alkalosis; use of penicillin
antibiotics that contain large amounts of sodium, such as carbeni-
cillin; and therapy with sodium salts or organic acids such as sodium
lactate, acetate, and citrate. Sodium citrate is used in whole blood
and packed red cells as an anticoagulant. However, only a metabolic
acidosis causes an appreciable increase in the anion gap.
1. Normal anion gap (metabolic nongap acidosis)
a. Loss of bicarbonate through the GI tract
i. Diarrhea
ii. Small bowel fistula
iii. Pancreatocutaneous fistula
iv. Ureterosigmoidostomy
v. Chloride-containing exchange resins, such as cholestyra-
mine; or with calcium chloride or magnesium chloride
14 I: ON-CALL PROBLEMS
IV. Database
A. Physical examination key points
1. Vital signs. A low respiratory rate suggests hypoventilation; a
high rate points toward respiratory failure or compensation for a
metabolic acidosis. Hypotension suggests hypoperfusion.
2. Skin. Changes, which characterize scleroderma, indicate a re-
strictive defect. Cool, clammy, and mottled skin on the extremities
suggests shock.
3. HEENT. Ketosis or fruity odor on breath suggests diabetic ke-
toacidosis. Look for tracheal shift from a space-occupying lesion
or venous distention (congestive heart failure or tension pneu-
mothorax). Pinpoint pupils are consistent with drug overdose.
4. Lungs. Evaluate for absent or decreased breath sounds, stridor
in upper airway obstruction, wheezes, and rales.
5. Abdomen. Peritoneal signs indicate an acute abdomen; marked
distention may inhibit respiration.
6. Neuromuscular examination. Generalized weakness or focal
neurologic signs, depressed level of consciousness, obtundation,
and coma should be noted.
B. Laboratory data
1. Hemograms. Anemia may be associated with renal failure. Ane-
mia may cause ischemia resulting in lactic acidosis. Leukocytosis
with a left shift may suggest sepsis.
2. Electrolytes. Serum chloride is usually elevated in metabolic
nongap acidosis. Serum potassium is usually increased with aci-
dosis, but may be low in diabetic ketoacidosis or renal tubular aci-
dosis. The serum potassium may be especially helpful in
predicting the acid–base status before the ABG analysis. For in-
stance, a serum bicarbonate of 34 mmol/L could indicate a pri-
mary metabolic alkalosis, or compensation for a chronic
respiratory acidosis. If the potassium were 5.6 mmol/L, this would
argue that the bicarbonate of 34 mmol/L was from compensation
for a chronic respiratory acidosis. If the potassium were 3.1
mmol/L, this would argue that the bicarbonate of 34 mmol/L was
from a metabolic alkalosis. The potassium, blood urea nitrogen
(BUN), and creatinine may be elevated with renal failure. The cre-
atinine may be falsely elevated with ketoacidosis.
2. ACIDOSIS 17
REFERENCES
Adrogue HJ, Madias NE: Management of life-threatening acid-base disorders. N Engl J
Med 1998;338:26.
Brent J, McMartin K, Phillips S, Aaron C, Kulig K: Fomepizole for the treatment of
methanol poisoning. N Engl J Med 2001;344:424.
Kaehny WD: Pathogenesis and management of respiratory and mixed acid-base disor-
ders. In: Schrier RW, ed. Renal and Electrolyte Disorders. 6th ed. Lippincott Williams
& Wilkins;2003:154.
Narins RG, Emmett A: Simple and mixed acid-base disorders: A practical approach.
Medicine 1980;59:161.
Shapiro JI, Kaehny WD: Pathogenesis and management of metabolic acidosis and al-
kalosis. In: Schrier RW, ed. Renal and Electrolyte Disorders. 6th ed. Lippincott
Williams & Wilkins;2003:115.
3. ALKALOSIS
I. Problem. You are consulted to see a 60-year-old man with a pH of 7.65,
who is 3 days status postcholecystectomy.
II. Immediate Questions
A. Is the alkalemia from a metabolic, respiratory, or mixed alkalo-
sis? A quick look at the pCO2 on the arterial blood gas (ABG) slip will
reveal whether the disturbance is a primary metabolic or respiratory
alkalosis. If the pCO2 is > 40 mm Hg, the primary disturbance is a
metabolic alkalosis with at least partial respiratory compensation. If
20 I: ON-CALL PROBLEMS
IV. Database
A. Physical examination key points
1. Vital signs. Tachypnea may indicate pulmonary disease, pul-
monary edema, or CNS respiratory stimulation. Bradypnea sug-
gests a metabolic alkalosis. An elevated temperature may
indicate an infection or sepsis.
2. Chest. Examination must be thorough; look for evidence of pneu-
mothorax, pleural effusion, pneumonia, bronchospastic disease,
and pulmonary edema.
3. Abdomen. Look for evidence of chronic liver disease such as as-
cites and caput medusae.
4. Skin. Check for evidence of chronic liver disease such as palmar
erythema, Dupuytren’s contractures, and spider angiomas. Also,
look for changes associated with Cushing’s syndrome, such as
buffalo hump, purple striae, and easy bruisability.
5. Neurologic exam. Check for focal abnormalities as evidence for
tumor, cerebrovascular accident, and infection. Tremor and hy-
perreflexia may suggest hyperthyroidism.
B. Laboratory data
1. Anion gap. May unmask a mixed metabolic gap acidosis and
metabolic alkalosis. See Section I, Chapter 2, Acidosis, III.B, p 13.
2. Serum electrolytes. Hypokalemia and hypomagnesemia may
cause a metabolic alkalosis. Hypokalemia, hypomagnesemia,
hypocalcemia, and hypophosphatemia may result from alkalosis.
3. Respiratory alkalosis
a. Salicylate level. If elevated, check serum and urine drug
screen for other ingested substances.
b. Liver function tests
c. Thyroid function studies
d. Blood cultures
24 I: ON-CALL PROBLEMS
V. Plan. It is essential to identify the cause of the alkalemia and treat it.
A. Respiratory alkalosis
1. If hypoxic, give supplemental oxygen.
2. If anxious, give sedative. Diazepam 1–5 mg PO or 1–2 mg IV; or
lorazepam 1–2 mg PO or 0.5 mg IV.
3. If nonintubated, increase FiCO2 (fraction of inspired carbon diox-
ide). Use a rebreathing mask (or a paper bag). Would consider for
pH > 7.55.
4. If the patient is intubated, decrease minute ventilation. De-
crease the rate or tidal volume. Be sure the tidal volume is set for
8–10 mL/kg. The respirator may need to be changed from assist
control to intermittent ventilation. Increasing the amount of dead
space would also increase the pCO2.
5. Salicylate overdose. Consider alkalinization of urine. Alkaliniza-
tion of urine should be done cautiously in a patient who is already
alkalotic. Follow serum pH and serum bicarbonate closely. See
Section I, Chapter 2, Acidosis, Section V, p 17, for instructions on
alkalinization of urine. Hemodialysis may be required.
B. Metabolic alkalosis
1. In the presence of severe alkalemia with seizures or ventricular
arrhythmias, prompt, immediate action is needed. Treatment in-
cludes increasing the pCO2, or administering an acid such as hy-
drochloric acid. HCl 0.1–0.2 N solution (100–200 mmol of H+ per
liter) is administered slowly through a central line. The amount of
required HCl to be administered can be calculated by taking the
desired change in HCO3− and multiplying by the weight in kg and
by 0.50 (bicarbonate space). For instance, in a 80-kg man with a
pH of 7.68, if the actual bicarbonate is 52 mmol/L and the desired
bicarbonate is 40 mmol/L, the required amount of HCl would be
(52 mmol/L − 40 mmol/L) × 80 kg × 0.5 = 480 mmol, or about 2.5
liters of 0.2 N solution.
2. Ammonium chloride and arginine hydrochloride. Both are pre-
cursors to HCl; however, there is significant risk (an increase in
ammonia with ammonium chloride in patients with liver failure and
hyperkalemia with arginine hydrochloride with renal failure).
4. ANAPHYLACTIC REACTION 25
REFERENCES
Adrogue HJ, Madias NE: Management of life-threatening acid-base disorders. N Engl J
Med 1998;338:107.
Kaehny WD: Pathogenesis and management of respiratory and mixed acid-base disor-
ders. In: Schrier RW, ed. Renal and Electrolyte Disorders. 6th ed. Lippincott Williams
& Wilkins;2003:154.
Narins RG, Emmett A: Simple and mixed acid–base disorders: A practical approach.
Medicine 1980;59:161.
Shapiro JI, Kaehny WD: Pathogenesis and management of metabolic acidosis and al-
kalosis. In: Schrier RW, ed. Renal and Electrolyte Disorders. 6th ed. Lippincott
Williams & Wilkins;2003:115.
Wilson RF, Gibson D, Percinel AK et al: Severe alkalosis in critically ill surgical patients.
Arch Surg 1972;105:197.
4. ANAPHYLACTIC REACTION
I. Problem. Within 10 minutes of receiving an intramuscular injection, a
patient develops diffuse pruritus, wheezing, and shortness of breath.
REFERENCES
Bochner BS, Lichtenstein LM: Anaphylaxis. N Engl J Med 1991;324:1785.
Ellis A, Day J: Diagnosis and management of anaphylaxis. CMAJ 2003;169:4.
Freeman TM: Anaphylaxis: Diagnosis and treatment. Primary Care 1998;25:809.
Ring J, Behrendt H: Anaphylaxis and anaphylactoid reactions. Clin Rev Allergy Im-
munol 1999;28:723.
Winbery SL, Lieberman PL: Anaphylaxis. Immunol Allergy Clin North Am 1995;15:447.
5. ANEMIA
I. Problem. A 50-year-old man is admitted for pneumonia. Laboratory test-
ing reveals a hemoglobin of 11.2 g/dL (7.0 mmol/L).
5. ANEMIA 29
IV. Database
A. Physical examination key points
1. Vital signs. Make sure the patient is not hypotensive. The patient
may be orthostatic. Look for a decrease in systolic blood pressure
of 10 mm Hg and/or an increase in heart rate of 20 bpm on move-
32 I: ON-CALL PROBLEMS
4. B12 and folate. Order these tests for any patient suspected of
having B12 and folate deficiency before transfusion. If folate defi-
ciency is secondary to malnutrition, a serum folate may be normal
after one or two well-balanced meals. If folate deficiency is sus-
pected and the patient has recently eaten, then consider checking
an RBC folate.
5. Haptoglobin and urine hemosiderin. A low haptoglobin and a
positive urine hemosiderin are indicative of hemolysis. When hap-
toglobin is low, free hemoglobin in the serum or urine and/or in-
creased lactate dehydrogenase are also suggestive of hemolysis.
6. Direct and indirect Coombs’ test. These tests may indicate that
the hemolysis is immunologic. A direct Coombs’ test measures
the presence of antibody or complement on the RBC; an indirect
Coombs’ test detects antibody in the plasma that has dissociated
from the RBC but is directed at the RBC. Direct Coombs’ is the
more valuable test in evaluating the possibility of immunohe-
molytic disease, whereas indirect Coombs’ is primarily of value as
a blood banking procedure. Detection of an antibody in the
plasma but not on the RBC indicates that it is an alloantibody
rather than an autoantibody. Most immunohemolytic anemias are
due to warm-reacting antibodies, usually IgG. These are manifest
by a direct Coombs’ test result that is positive for IgG with or with-
out complement. Cold-reacting antibodies may be induced by in-
fections such as mycoplasma.
7. Platelet count. May be elevated in early iron deficiency. De-
creased in folate and vitamin B12 deficiency as well as with mar-
row replacement.
C. Radiologic studies. Not usually needed unless GI blood loss is sus-
pected; then order as clinically indicated.
D. Pathologic evaluations. A bone marrow aspirate and biopsy are
generally indicated in all but the very straightforward explanations for
anemia. Even when iron deficiency anemia is suspected, absence of
iron stores in the marrow supports the diagnosis.
V. Plan
A. Anemia with hemodynamic compromise or complications
1. If the patient is hemodynamically unstable or is having angina, a
transfusion is urgently indicated. In such cases, the source of
blood loss is usually obvious. For specific information on transfu-
sion, consult Section V, Blood Component Therapy, p 465.
2. Be sure the patient has adequate intravenous access if there is
evidence of acute bleeding.
B. Anemia without hemodynamic compromise or complications. If
the patient is not hemodynamically compromised, proceed with the
workup in an orderly fashion. In many cases, the cause of the anemia
is not obvious. Furthermore, laboratory testing is not always diagnos-
34 I: ON-CALL PROBLEMS
REFERENCES
Beutler E, Lichtman MA, Coller RS et al, eds. Williams Hematology. 6th ed. McGraw-
Hill;2001.
Bolinger A: Anemias. In: Koda-Kimbel MA, Young LY, eds. Applied Therapeutics: The
Clinical Use of Drugs. 7th ed. Lippincott Williams & Wilkins;2001.
Izaks GJ, Westendorp RGJ, Knook DL: The definition of anemia in older persons.
JAMA 1999;281:1714.
36 I: ON-CALL PROBLEMS
Lux SE: Introduction to anemia. In: Handin RI, Lux SE, Stossel TP, eds. Blood: Princi-
ples and Practice of Hematology. Lippincott;1995:1383.
Toh B-H, van Driel IR, Gleeson PA: Pernicious anemia. N Engl J Med 1997;337:1441.
I. Problem. You are called to the intensive care unit to see a patient in
whom a low, dampened arterial line pressure is being obtained.
4. The catheter has punctured the arterial wall, causing bleeding and
compression of the catheter.
IV. Database
A. Physical examination key points
1. Blood pressure. If the arterial line pressure is low, perform a
brachial artery cuff pressure. If the reading confirms hypotension,
prompt action is indicated. The manual blood pressure is usually
within 10–20 mm Hg of the arterial line pressure, unless severe
vasoconstriction is present; in which case indirect measurement
may underestimate direct measurement by 20–30 mm Hg.
2. Pulses. Check at once for distal pulses and for swelling or tender-
ness in the area of the catheter insertion. Failure to find a pulse or
finding a decrease in the pulse, with significant swelling at the
catheter site, represents a potentially serious vascular compro-
mise.
3. Inspection of the equipment
a. Check for air in the lines or the transducer. The search must
be thorough and almost certainly requires the assistance of
the nursing staff.
b. Have nursing staff confirm that the electrical equipment is
working properly.
c. Attempt to withdraw blood through the catheter. Inability to do
so suggests either that the catheter tip is poorly positioned or
that there is a kink or a thrombus in the catheter, at the
catheter tip, or in the artery. Caution: Do not attempt to flush a
catheter through which blood cannot be drawn!
V. Plan
A. Maintaining perfusion to the extremity. A limb may be susceptible
to ischemic injury as the result of systemic hypotension, a large
catheter-to-vessel ratio, bleeding into surrounding tissues, inade-
quate flushing techniques, or prolonged catheter indwelling time.
1. Failure of the pulse to return will probably necessitate a surgical
attempt at thrombus removal or repair of the artery. Consult a
vascular surgeon immediately.
2. If bleeding from the artery into the surrounding tissue seems
likely, watch carefully for compartmental syndrome (pain, pain
with extension of the digits, pallor, hypesthesia, and loss of motor
function). Surgical evacuation of the blood may be necessary.
Consult a vascular surgeon at once if compartmental syndrome is
suspected.
3. Search for evidence of infection. If infection is present, culture and
treat appropriately, and remove the catheter.
B. Monitoring apparatus problems
1. Flush the transducer and tubing thoroughly.
38 I: ON-CALL PROBLEMS
7. ASPIRATION
I. Problem. After a generalized seizure, a patient is observed to vomit and
subsequently develops acute respiratory distress.
II. Immediate Questions
A. What are the vital signs? On the basis of the history, it must be as-
sumed that the patient has aspirated gastric contents. This can result
in acute respiratory compromise from lodging of particulate matter in
the larynx or trachea, by induction of laryngospasm, or through the
rapid onset of pulmonary edema. Both tachycardia and tachypnea
are often present. In severe episodes of respiratory compromise,
respiratory arrest or shock may also occur.
B. Is the patient able to communicate? Aphonia may result from lodg-
ing of particulate matter in the larynx or trachea; it requires immedi-
ate intervention to dislodge the bolus by either the Heimlich
maneuver or forceful coughing.
C. Is the patient cyanotic? Cyanosis would indicate severe respiratory
compromise and probable need for emergent intubation.
D. Does the patient need to be repositioned? To prevent further aspi-
ration of gastric contents, the patient should be placed in a lateral de-
cubitus position with the head down.
III. Differential Diagnosis. Aspiration is defined as the entry of oropharyn-
geal contents into the larynx below the vocal cords. Three distinct aspi-
ration syndromes are recognized: (1) acidic gastric contents; (2)
nonacidic and/or particulate material; and (3) oropharyngeal bacterial
pathogens. These syndromes should be distinguished from one another
7. ASPIRATION 39
portant because death from respiratory failure can occur if the condition
is not recognized early. Ideally, the best treatment is prevention.
A. Prevention
1. For patients being administered tube feedings, gastric empty-
ing should be confirmed and the head of the bed elevated to
45 degrees. Flexible, small-bore feeding tubes are preferable
to stiffer large-bore tubes. Duodenal placement of the tube may
confer a reduction in risk of aspiration compared to gastric feeding.
2. Unconscious patients should be placed in a lateral, slightly head-
down position whenever possible.
3. When not being used for enteral feedings, nasogastric tubes
should be placed only when continuous suction is required.
4. Up to one-third to one-half of patients presenting with acute cere-
brovascular accidents will experience aspiration. Consider order-
ing videofluoroscopy in these patients to determine aspiration risk
and appropriate feeding.
B. Oxygenation. Supplemental oxygen should be given in an amount
sufficient to ensure oxygen saturation greater than 90%.
C. Intubation and positive pressure breathing. This is required in the
patient for whom supplemental oxygen therapy is not sufficient to
maintain adequate oxygenation, or in the patient who is obtunded
and unable to protect her or his airway.
D. Medications
1. Bronchodilators such as albuterol 0.5 mL with 3 mL normal saline
may relieve bronchospasm.
2. Prophylactic corticosteroids have not been shown to decrease
subsequent morbidity and mortality from aspiration and are not in-
dicated.
3. Prophylactic antibiotics likewise have not been shown to diminish
morbidity and mortality. Antibiotics should be administered only if
the patient continues to manifest fever, leukocytosis, purulent
sputum, and infiltrates 2–3 days after the initial aspiration. For pa-
tients with in-hospital aspiration, a regimen that provides cover-
age for gram-negative aerobes and Staphylococcus aureus is
more important than anaerobic coverage.
E. Fiberoptic bronchoscopy. This procedure is indicated when lobar
or segmental collapse is present, when foreign body aspiration is
suspected, or when abscess drainage is required.
REFERENCES
Bartlett JG: Aspiration pneumonia. In: Rose BD, ed. UpToDate, Wellesley, MA,2003.
Elpern E: Pulmonary aspiration in hospitalized adults. Nutr Clin Pract 1997;12:5.
Marik PE: Aspiration pneumonitis and aspiration pneumonia. N Engl J Med
2001;344:665.
42 I: ON-CALL PROBLEMS
Marom E, McAdams HP, Erasmus JJ et al: The many faces of pulmonary aspiration.
Am J Radiol 1999;172:121.
Teofilo L: Pulmonary aspiration. Comp Ther 1997;23:371.
Tietjen PA, Kaner RD, Quin CE: Aspiration emergencies. Clin Chest Med 1994;15:117.
8. BRADYCARDIA
I. Problem. A nurse on the telemetry unit notifies you that a 66-year-old
woman has a heart rate of 40 beats per minute (bpm). She was admitted
earlier in the day with syncope.
IV. Database
A. Physical examination key points
1. Vital signs. Obtain the patient’s BP during the bradycardic
rhythm, and assess the patient’s level of consciousness.
2. Neck veins. Intermittent cannon “A” waves in the jugular venous
pulsations are observed in the presence of complete AV dissocia-
tion. A cannon A wave is an exaggerated A wave in the jugular
venous pulse that results from right atrial contraction on an al-
ready closed tricuspid valve, caused by simultaneous atrial and
ventricular contraction. This results in backward ejection of right
atrial blood into the superior vena cava and jugular veins.
3. Lungs. Rales during periods of bradycardia suggest congestive
heart failure from inadequate left ventricular cardiac output.
4. Heart. Listen for murmurs and gallops. An S4 gallop may be pre-
sent during an acute myocardial infarction. A new cardiac murmur
may be seen in myocardial infarction, acute rheumatic fever, and
myocarditis. See Section I, Chapter 26, Heart Murmur, p 159.
5. Skin. Cool, pale extremities suggest an inadequate cardiac output.
6. Mental status. Inadequate cerebral perfusion may result in an al-
tered level of consciousness.
B. Laboratory data
1. Electrolytes. Exclude hypokalemia if the patient is on digoxin.
2. Digoxin level. Bradycardia can be a sign of digitalis intoxication.
3. Thyroid hormone levels. Rule out hypothyroidism as a cause.
C. Electrocardiogram and rhythm strip
1. Identify P waves and their timing and relation to the QRS com-
plexes. Leads I, II, aVR, aVF, and V1 demonstrate the morphology
of the P waves best. The absence of P waves suggests an AV
nodal rhythm, or atrial fibrillation with a slow ventricular response,
as the cause of the bradycardia.
2. An increasing PR interval with a dropped QRS complex, recurring
in a cyclical pattern, indicates Mobitz type I second-degree heart
block.
3. P waves that occur intermittently without an associated QRS com-
plex, but with an otherwise constant PR interval, suggest Mobitz
8. BRADYCARDIA 45
REFERENCES
Mangrum JM, DiMarco JP: The evaluation and management of bradycardia. Primary
Care 2000;342:703.
Miller JM, Zipes DP: Management of patient with cardiac arrhythmias. In: Braunwald E,
Zipes DP, Libby P, eds. Heart Disease: A Textbook of Cardiovascular Medicine. 6th
ed. Saunders;2001:700.
Wagner GS, ed: Marriott’s Practical Electrocardiography. 9th ed. Williams &
Wilkins;1994.
9. CARDIOPULMONARY ARREST
I. Problem. You are the first member of a code team to arrive at the bed-
side of a patient found unresponsive by the nurse.
B. Pulmonary
1. Acute pulmonary embolism (usually massive)
2. Acute respiratory failure
3. Aspiration
4. Tension pneumothorax (large)
C. Hemorrhagic. Acute severe hemorrhage such as from a ruptured
aortic aneurysm or rapid gastrointestinal bleeding.
D. Metabolic
1. Electrolyte disturbances. Hypokalemia, hyperkalemia, and hy-
pomagnesemia can induce arrhythmias. Hypophosphatemia can
induce respiratory failure.
2. Acidosis and alkalosis
3. Hypothermia and rewarming. During the treatment of acute hy-
pothermia, rewarming may induce ventricular fibrillation or other
arrhythmias as body temperature increases.
E. Drug overdoses. Especially tricyclic antidepressants, digitalis, and
beta and calcium channel blockers.
IV. Database
A. Physical examination key points. The initial assessment of airway,
breathing, and circulation is described in Section II, p 369. Resuscita-
tion should be initiated before a detailed physical examination is per-
formed. Other signs to watch for are:
1. Tracheal deviation. This indicates the possibility of tension pneu-
mothorax.
2. Distended neck veins. May indicate a tension pneumothorax or
a hemodynamically significant pericardial effusion.
3. Cannon A waves on jugular venous pulsations. May indicate
third-degree heart block.
B. Laboratory data. These should be obtained early in resuscitation ef-
forts but should not delay initiation of specific therapy.
1. Arterial blood gases. Acidosis could be the cause of an arrhythmia
or result from prolonged hypoperfusion. A low pO2 can result from a
variety of causes, including pulmonary edema and pulmonary embo-
lus, or it may be the result of prolonged hypoperfusion.
2. Serum electrolytes. Particularly potassium, magnesium, and ion-
ized calcium.
3. Complete blood count. Keep in mind that with massive hemor-
rhage the hematocrit may not have had sufficient time to equili-
brate and therefore may not be an accurate indicator of the
severity of blood loss.
C. Radiologic and other studies
1. Continuous cardiac monitoring. Three-lead monitoring is ac-
ceptable; however, a 12-lead electrocardiogram (ECG) should be
obtained as early as possible.
9. CARDIOPULMONARY ARREST 49
Check responsiveness
Call for code team
Call for crash cart/defibrillator
Assess ABCs
Perform CPR until defibrillator attached
(including positive pressure ventilation)
Defibrillate up to 3 times if needed for
persistent VF/VT 200 J, 200–300 J, 360 J
Epinephrine 1 mg IV
push, repeat every 3–
5 minutes (2) or
vasopressin 40 U IV ×
1 (3)
Defibrillate 360 J
within 30–60 s
Figure I–1. Algorithm for ventricular fibrillation and pulseless ventricular tachycardia (VF/VT).
(Reproduced with permission from American Heart Association: Guidelines 2000 for cardiopul-
monary resuscitation and emergency cardiovascular care. Circulation 2000[August 22]:102.)
9. CARDIOPULMONARY ARREST 51
Check responsiveness
Call for code team
Call for crash cart/defibrillator
Assess ABCs
Perform CPR (including positive pressure ventilation)
Confirm asystole
Assess for, and shock, if present VF or pulseless VT
Figure I–2. Asystole treatment algorithm. (Reproduced with permission from American Heart As-
sociation: Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care.
Circulation 2000[August 22]:102.)
Check responsiveness
Call for code team
Call for crash cart/defibrillator
Assess ABCs
Perform CPR until defibrillator attached
(including positive pressure ventilation)
Defibrillate up to 3 times if needed for persistent VF/VT 200 J,
200–300 J, 360 J
Continue CPR
Intubate at once
Obtain IV access
Identify rhythm
Administer appropriate drugs
Identify and treat underlying cause
Figure I–3. Algorithm or pulseless activity. PEA, rhythm on monitor without detectable pulse.
(Reproduced with permission from American Heart Association: Guidelines 2000 for cardiopul-
monary resuscitation and emergency cardiovascular care. Circulation 2000[August 22]:102.)
9. CARDIOPULMONARY ARREST 55
REFERENCES
American Heart Association: Guidelines 2000 for cardiopulmonary resuscitation and
emergency cardiovascular care. Circulation 2000;August 22:102.
Wenzel V, Krismer AC, Arntz HR et al: A comparison of vasopression and epinephrine
for out-of-hospital cardiopulmonary resuscitation. N Engl J Med 2004;350:105.
IV. Database
A. Physical examination key points
1. Vital signs. An elevated temperature suggests an infection. If the
catheter has been in place more than 3 days, you must assume
the central venous catheter is the source of the fever.
2. Extremities. Look for evidence of deep venous thrombosis, such
as unilateral edema and venous engorgement.
3. Skin. Examine the insertion site for evidence of tissue infiltration,
bleeding, catheter kinking, or leakage. Also, erythema around the
insertion site may result from a localized infection.
B. Laboratory data
1. Complete blood count with differential. An elevated white
blood count with an increase in banded neutrophils is often pre-
sent with catheter-related sepsis.
2. Prothrombin time (PT), partial thromboplastin time (PTT),
platelet count. These values should be obtained if a central line
58 I: ON-CALL PROBLEMS
REFERENCES
Fares LG, Block PH, Feldman SD: Improved house staff results with subclavian cannu-
lation. Am Surg 1986;52:108.
Gil RT, Kruse JA, Thill-Baharozian MC et al: Triple- vs. single-lumen central venous
catheters. Arch Intern Med 1989;149:1139.
Maki DG, Stolz SM, Wheeler S et al: Prevention of central venous catheter-related
bloodstream infection by use of an antiseptic-impregnated catheter. Ann Intern Med
1997;127:257.
60 I: ON-CALL PROBLEMS
Mansfield PF, Hohn DC, Fornage BD et al: Complications and failures of subclavian-
vein catheterization. N Engl J Med 1994;331:1735.
McGee DC, Gould MK: Preventing complications of central venous catheterization. N
Engl J Med 2003;348:1123.
Raad I, Darouiche R, Dupuis J et al: Central venous catheters coated with minocycline
and rifampin for the prevention of catheter-related colonization and bloodstream in-
fections. Ann Intern Med 1997;127:267.
IV. Database
A. Physical examination key points
1. Vital signs
a. Hypotension. An ominous sign that may result from any one
of several potentially catastrophic causes, including massive
MI, cardiac tamponade, tension pneumothorax, acute massive
64 I: ON-CALL PROBLEMS
V. Plan. In assessing any patient with acute chest pain, the overriding goal
is to exclude the presence of the previously mentioned life-threatening
conditions. In the acute setting, it is better to maintain a high index of
suspicion for these conditions.
A. Emergency management (for all patients with chest pain)
1. Oxygen. Administer oxygen therapy with 2–4 μL/min by nasal
cannula. If the patient has a history of chronic obstructive airway
disease, it is preferable to administer 24% O2 by Venturi face
mask initially.
2. Intravenous access. Establish at least one intravenous line for
administration of medications if the patient’s condition deteriorates.
3. Nitroglycerin. If chest pain is still present and the systolic blood
pressure is above 90 mm Hg, 0.4 mg nitroglycerin may be admin-
istered sublingually.
11. CHEST PAIN 67
4. 12-lead ECG
5. Stat portable chest x-ray and ABGs. Obtain if your initial as-
sessment suggests any evidence of a pneumothorax, pneumonia,
or heart failure.
B. Myocardial ischemia. If your initial assessment suggests the possi-
bility of acute MI, the following are brief guidelines offered for the ini-
tial treatment. A full discussion of acute MI is beyond the scope of
this section.
1. Aspirin. Administer two chewable 81-mg aspirin (consider ticlopi-
dine [Ticlid] if there is a history of aspirin hypersensitivity).
2. Nitrates
a. Nitroglycerin in a dose of 0.4–0.6 mg may be administered
sublingually every 5 minutes, provided that the systolic blood
pressure remains above 90 mm Hg. It is preferable to adminis-
ter the nitroglycerin while the patient is recumbent. This may
provide relief for angina pectoris and possibly unstable angina
pectoris.
b. The pain of acute MI is seldom relieved by sublingual nitro-
glycerin and requires treatment with either intravenous nitro-
glycerin or morphine. If the nitroglycerin is effective but pain
recurs, begin a nitroglycerin infusion initially at 10 μg/min and
increase by 10 μg/min every 10 minutes until relief of pain or
to a maximum dose of 200 μg/min. The systolic blood pres-
sure must be maintained above 90 mm Hg during the adminis-
tration of nitroglycerin. Hemodynamic monitoring with a
pulmonary artery catheter (see Section III, Chapter 12, Pul-
monary Artery Catheterization p 449) is often necessary if hy-
potension develops.
3. Morphine sulfate. If pain is not relieved by nitroglycerin sublin-
gually or intravenously, 3–5 mg of morphine IV every 5–10 min-
utes can be administered for relief. Close monitoring of the
patient’s blood pressure and respirations is necessary, because
hypotension and respiratory suppression may occur. These ad-
verse effects may be reversed with naloxone (Narcan) 0.4 mg IV.
4. Beta-blockers. Administration should strongly be considered.
Metoprolol 5 mg every 2–5 minutes for 3 doses intravenously; or
atenolol 5 mg every 5 minutes for 2 doses intravenously. Watch
for bradycardia and acute heart block (second- or third-degree),
especially in a patient with suspected right ventricular infarction.
5. Heparin. Unfractionated heparin 70 U/kg bolus, followed by 15
U/kg/hr continuous infusion. Dose is titrated to a partial thrombo-
plastin time (PTT) 1.5–2 times the control value (usually 50–60
seconds); some cardiologists prefer the PTT to be 2–2.5 times the
control value. Low molecular weight heparins may also be used.
Dalteparin (Fragmin) 120 U/kg SC Q 12 hr, to a maximum of
10,000 units per dose, or enoxaparin (Lovenox) 1 mg/kg SC Q 12
68 I: ON-CALL PROBLEMS
REFERENCES
Raschke RA, Reilly BM, Guidry JR et al: The weight-based heparin dosing nomogram
compared with a “standard care” nomogram. Ann Intern Med 1993;119:874.
Silverman ME: Examination of the Heart: The Clinical History. 3rd ed. American Heart
Association;1990.
70 I: ON-CALL PROBLEMS
12. COAGULOPATHY
I. Problem. After cardiac catheterization, a patient has oozing from the
femoral arterial puncture site.
A. Thrombocytopenia
1. Use random donor platelet transfusion, usually 5–10 U at a time
(often a “six-pack” is ordered), for a platelet count below 20,000 or
with higher platelet counts if there is ongoing bleeding. Platelet
transfusions are generally not indicated in immune thrombocy-
topenias unless there is active bleeding. Patients receiving multi-
ple platelet transfusions may develop HLA antibodies, and they
will have better incremental increases in the platelet count with
HLA-matched single-donor platelets. Immunocompromised pa-
tients should receive irradiated single-donor platelets that are
leuko-filtered to avoid a transfusion-induced graft-versus-host re-
action and to avoid sensitivity to alloantigens. Such patients in-
clude bone marrow transplant patients and possibly patients with
acute leukemia or lymphoma who are undergoing aggressive
therapy.
2. For a drug reaction, discontinue the drug and transfuse platelets if
necessary.
3. In the presence of ITP, no treatment is usually needed until the
platelet count is below 10,000 unless there is bleeding. For counts
below 10,000, IV immunoglobulin (for Rh-negative patients) or
WinRho (for Rh-positive patients) with or without prednisone may
be used. Chronic ITP is treated with prednisone, cyclophos-
phamide, azathioprine, or danazol. The best long-term results are
obtained with splenectomy. Platelet transfusions before splenec-
tomy are very short-lived in ITP.
4. Document functional defect with bleeding time and treat the un-
derlying condition, such as uremia. Deamino-8-D-arginine vaso-
pressin (DDAVP; desmopressin), a vasopressin analogue, may
be useful in uremic patients whose bleeding time is prolonged.
The usual dose is 0.3 μg/kg IV. Discontinue drugs adversely af-
fecting function.
5. TTP and HUS are treated with plasmapheresis.
B. von Willebrand’s disease (vWD)
1. Cryoprecipitate or fresh-frozen plasma is the plasma product of
choice. (See Section V, Blood Component Therapy, p 465.)
2. DDAVP increases von Willebrand factor (vWF) levels by releasing
stores from endothelium. DDAVP can be effective for certain
types of vWD with mild bleeding, but is contraindicated in type IIb
because it may exacerbate thrombocytopenia.
C. Hemophilia A. Specific recommendations for factor replacement de-
pend on site of bleeding and severity of factor deficiency and are be-
yond the scope of this book. The reader is referred to a standard
hematology text for this information. The half-life of factor VIII is
about 8–12 hours. Because many factor VIII concentrates are now
available, treatment of choice should be only with genetically engi-
neered products that minimize risk of transmission of viral hepatitis
12. COAGULOPATHY 75
REFERENCES
Rodgers GM: Acquired coagulation disorders. In: Greer JP, Foerster J, Lukens J et al,
eds. Wintrobe’s Clinical Hematology. 11th ed. Lippincott Williams & Wilkins;
2004:1668.
Rodgers GM: Diagnostic approach to the bleeding disorders. In: Greer JP, Foerster J,
Lukens J et al, eds. Wintrobe’s Clinical Hematology. 11th ed. Lippincott Williams &
Wilkins;2004:1511.
76 I: ON-CALL PROBLEMS
d. Vitamin deficiencies
i. Thiamine (vitamin B1). Wernicke’s encephalopathy is
often seen in alcoholics but also occurs in patients with
hyperemesis gravidarum, AIDS, peritoneal dialysis, mal-
nutrition, and eating disorders. Mental status changes
range from mild confusion to coma. Patients presenting
in coma with Wernicke’s encephalopathy are often not di-
agnosed until autopsy. Ataxia, bilateral horizontal nys-
tagmus, or other ophthalmoplegias are frequently present.
Korsakoff’s psychosis is a part of Wernicke’s encephalo-
pathy and is characterized by anterograde amnesia, im-
paired ability to learn, and confabulation. Recovery from
Korsakoff’s psychosis can be expected in only 50% of
cases.
ii. Cobalamin (vitamin B12). Symptoms include forgetful-
ness, dementia, irritability, and psychosis. Neurologic man-
ifestations can precede macrocytic anemia.
iii. Niacin (vitamin B3). In pellagra, fatigue and insomnia
often precede an encephalopathic syndrome of memory
loss, confusion, and psychosis. Other symptoms include
dermatitis and diarrhea.
e. Alteration in body temperature
i. Hypothermia. Occurs most commonly from exposure and
is frequently observed in patients with alcohol or barbitu-
rate intoxication, extracellular fluid deficit, sepsis, adrenal
insufficiency, and myxedema. See Section I, Chapter 43,
Hypothermia, p 243.
ii. Hyperthermia. Most commonly seen from heat stroke. Hy-
perthermia also occurs with neuroleptic malignant syn-
drome in patients taking phenothiazines and as malignant
hyperthermia secondary to inhaled anesthetics or succinyl-
choline. It may be seen in hyperthyroidism (thyroid storm).
See Section I, Chapter 22, Fever, p 133.
f. Miscellaneous
i. Porphyria. Anxiety, depression, disorientation, and hallu-
cinations can occur in attacks of acute intermittent por-
phyria.
ii. Reye’s encephalopathy. This rare syndrome can follow
influenza or varicella upper respiratory infections in chil-
dren less than 15 years old. It is classically associated with
salicylate use (salicylate use not necessary).
C. Infection
1. Central nervous system infections. Consider meningitis, en-
cephalitis, tertiary syphilis, and stage 3 Lyme disease.
2. Sepsis
3. Infections in the elderly. Especially urinary or respiratory.
80 I: ON-CALL PROBLEMS
D. Tumors
1. Primary or metastatic to CNS
2. Hypercalcemia from metastatic disease
3. Paraneoplastic syndromes.
a. Parathyroid hormone–related peptide. Secretion by squa-
mous cell bronchogenic carcinoma causes hypercalcemia.
b. Syndrome of inappropriate antidiuretic hormone. Inappro-
priate secretion of antidiuretic hormone by small cell lung can-
cer can cause symptomatic hyponatremia.
c. Cushing’s syndrome. This can be due to ectopic adrenocorti-
cotropic hormone (ACTH) production by small cell lung cancer
or carcinoid.
d. Paraneoplastic neurologic syndromes. These include para-
neoplastic encephalomyelitis and limbic encephalitis, both as-
sociated with small cell lung cancer.
E. Psychiatric causes
1. Psychogenic coma. In pseudocoma, patients appear unarous-
able and unresponsive but have no structural, metabolic, or toxic
disorder.
2. Catatonia. State of muteness characterized by drastically de-
creased motor activity with preserved ability to sit, stand, and
maintain body posture. Catatonia is usually psychiatric in etiology
(schizophrenia), but frontal lobe dysfunction and drug effects can
mimic.
3. Depression. May mimic dementia or cause vegetative state, es-
pecially in the elderly.
4. ICU psychosis. This form of delirium classically occurs in the ICU
but can occur with any hospitalization, particularly in the elderly
patient.
F. Miscellaneous
1. Hypotension. See Section I, Chapter 42, Hypotension, p 237.
2. Hypertensive encephalopathy. Blood pressure is markedly ele-
vated. Funduscopic exam is notable for exudates, hemorrhages,
and papilledema.
3. Seizures. Non–tonic-clonic seizures as well as postictal confusion.
4. Cerebrovascular accident
a. Ischemic infarction. The most common causes include ath-
erosclerosis with thromboembolism and cardiogenic embolism
from mural thrombus or endocarditis. Also, consider vasculitis
and vasospasm.
b. Intracranial hemorrhage. Causes include hypertension,
trauma, ruptured aneurysm, arteriovenous malformation, co-
agulopathy, tumor, and cocaine.
5. Locked-in syndrome. In this de-efferented state, bilateral pon-
tine lesions cause quadriplegia and lower cranial nerve palsies.
Patients are alert and awake but mute.
13. COMA, ACUTE MENTAL STATUS CHANGES 81
IV. Database
A. Physical examination key points
1. Vital signs
a. Blood pressure. Hypotension can cause decreased cerebral
perfusion and is a common finding in acute mental status
changes due to ethanol or barbiturate intoxication, GI hemor-
rhage, myocardial infarction, dissecting aortic aneurysm, Addi-
son’s disease, and gram-negative sepsis. Hypertension
occurs with hypertensive encephalopathy, cerebral or brain
stem infarction, subarachnoid hemorrhage, or increased in-
tracranial pressure.
b. Heart rate. Tachycardia may be secondary to many causes of
mental status alteration such as sepsis, pulmonary embolus,
hypoglycemia, and myocardial infarction. Bradycardia in asso-
ciation with hypertension and respiratory irregularity may indi-
cate increased intracranial pressure (Cushing’s reflex).
c. Respiratory rate and pattern. Bradypnea may indicate
ethanol, narcotic, or barbiturate intoxication. Tachypnea may
indicate significant hypoxia or sepsis. Hyperpnea causing hy-
perventilation can be compensation for metabolic acidosis
(Kussmaul respiration). A normal breathing pattern suggests
the absence of brain stem damage. Cheyne-Stokes respira-
tion, characterized by periods of waxing and waning hyperp-
nea alternating with shorter periods of apnea, implies an intact
brain stem and may be present in bilateral hemispheric lesions
or metabolic disturbance. Apneustic or ataxic breathing
strongly suggests brain stem damage.
d. Temperature. In the comatose patient, temperature should be
measured with a rectal probe. A fever suggests infection, thy-
roid storm, anticholinergic toxicity, heat stroke, malignant hy-
perthermia, or neurogenic hyperthermia due to subarachnoid
hemorrhage or hypothalamic pathology. The elderly may not
82 I: ON-CALL PROBLEMS
V. Plan
A. General. Although the therapy of altered mental status must be di-
rected at the underlying cause, certain steps should be taken immedi-
ately: Ensure adequate airway, breathing, and circulation (the ABCs
of basic life support). In the comatose patient with normal respiration,
an oropharyngeal airway is usually adequate. However, intubation
may be necessary to protect the airway. If trauma is known or sus-
pected, stabilize the neck until radiographic clearance is obtained.
B. Metabolic causes. Treat the underlying defect. Refer to the specific
abnormality in the index. Any patient in coma should receive thiamine
100 mg slow IV push. Empiric dextrose administration is controversial.
Because the administration of D50 has been associated with a poorer
outcome in patients with anoxic or ischemic coma, some experts rec-
ommend intravenous dextrose only if an immediate finger-stick glu-
cose is low. If dextrose is given, it should be in conjunction with
thiamine to avoid precipitation of acute Wernicke’s syndrome.
C. Exogenous causes. Any suspicion of narcotic-induced somnolence
can be safely treated with naloxone 0.4–0.8 mg IV push. A repeat
dose may be necessary (up to 4–5 ampules are commonly given in
this situation). Consider gastric aspiration and lavage if toxic ingestion
is suspected. If indicated, administer the appropriate antidote (see
Section I, Chapter 52, Overdoses, p 292) such as ethanol for methanol
or ethylene glycol ingestion, 100% FiO2 for carbon monoxide poison-
ing, amyl nitrite and sodium nitrite followed by sodium thiosulfate for
cyanide poisoning, and digitalis antibody for “digitalis delirium.”
D. Tumor. Altered mental status in the presence of metastatic or primary
CNS tumors can require emergent radiation therapy. Intracranial
pressure should be acutely decreased with steroids, hyperventilation,
and osmotic diuresis. Give dexamethasone 0.1–0.2 mg/kg IV bolus.
The patient should be intubated to protect the airway and can be hy-
perventilated by increasing the ventilator rate to achieve a pCO2 of
20–25 mm Hg. Osmotic diuresis with mannitol 50 g in a 20% solution
over 20 minutes is also beneficial if cerebral edema is associated.
E. Infection. Treat with appropriate antibiotics. Gram’s stain may help
direct initial antibiotic therapy prior to culture results.
F. Cardiac syncope or low cardiac output. Treat the underlying car-
diac problem.
G. Intracranial hemorrhage. Consult neurosurgery immediately. In-
creased intracranial pressure should be emergently treated as out-
lined above.
86 I: ON-CALL PROBLEMS
REFERENCES
Berger JR: Clinical approach to stupor and coma. In: Bradley WG, ed: Neurology in
Clinical Practice. 3rd ed. Butterworth-Heinemann;2000:37.
Mendez Ashla MF: Delirium. In Bradley WG, ed: Neurology in Clinical Practice. 3rd ed.
Butterworth-Heinemann;2000:25.
Victor M, Ropper AH: Coma and related disorders of consciousness. In: Adams and
Victor’s Principles of Neurology. 7th ed. McGraw-Hill;2001:366
Victor M, Ropper AH: Delirium and other acute confusional states. In: Adams and Vic-
tor’s Principles of Neurology. 7th ed. McGraw-Hill;2001:431.
14. CONSTIPATION
I. Problem. A 75-year-old bedridden woman from a nursing home was ad-
mitted with dehydration and a urinary tract infection. She has not had a
bowel movement in 7 days.
II. Immediate Questions
A. What are the patient’s normal bowel habits? Normal bowel habits
vary from three stools per day to three stools per week. Constipation
can be defined as infrequent defecation, but one also needs to in-
clude excessive straining, passage of hard stools, and a sensation of
incomplete evacuation.
B. What medications is the patient taking? Constipation is a side ef-
fect of many drugs. A careful medication history including use of vita-
mins and herbal products is necessary.
C. Is the abdomen distended, tender, or tense? Is the patient pass-
ing flatus or vomiting? Intestinal obstruction (obstipation) from sig-
moid volvulus, intussusception, and hernia can lead to constipation.
Mechanical obstruction often has other symptoms. Flatus signifies an
intact, functioning gastrointestinal tract. Obstipation can result in
tremendous abdominal distention.
D. Does the patient have a history of hemorrhoids or rectal bleed-
ing? Rectal lesions, including hemorrhoids, proctitis, and fissures,
may induce constipation. The patient suppresses bowel movements
to avoid discomfort.
E. Has the patient undergone any recent radiographic or surgical
procedures? Barium from radiologic studies can cause constipation.
Many postoperative patients have an ileus resulting in constipation.
F. What is the patient’s fluid status? Decrease in fluid intake or in-
crease in diuretic use, especially in the elderly patient, can cause
constipation.
III. Differential Diagnosis
A. Systemic disorders
1. Drugs. Constipation is a side effect of many medications, in-
cluding analgesics (inhibitors of prostaglandin synthesis, opiates);
14. CONSTIPATION 87
REFERENCES
Arce DA: Evaluation of constipation. Am Fam Physician 2002;65:2283.
Camilleri M, Thompson WG, Fleshman JW et al: Clinical management of intractable
constipation. Ann Intern Med 1994;121:520.
Harari D, Gurwitz JH, Minaker KL: Constipation in the elderly. J Am Geriatr Soc
1993;41:1130.
Lange RL, DiPiro JT: Diarrhea and constipation. In: DiPiro JT, Talbert RL, Hayes PE et
al, eds. Pharmacotherapy: A Pathophysiologic Approach. 2nd ed. Appleton &
Lange;1993:566.
Lennard-Jones JE: Constipation. In: Feldman M, Friedman LS, Sleisenger MH, eds.
Gastrointestinal and Liver Diseases: Pathophysiology/Diagnosis/Management. 7th
ed. Saunders;2002:181.
Locke GR III, Pemberton JH, Phillips SF: AGA technical review on constipation. Gas-
troenterology 2000;119:1161.
Rao S: Constipation: Evaluation and treatment. Gastroenterol Clin North Am
2003;32(2):659.
Wald A: Constipation in elderly patients. Drugs Aging 1993;3:220.
15. COUGH
I. Problem. A nurse notifies you that one of your patients is unable to
sleep because of a persistent cough.
IV. Database
A. Physical examination key points
1. Vital signs. Fever occurs with infection and pulmonary infarction.
Tachypnea and use of accessory respiratory muscles suggest
significant underlying pulmonary disease.
2. Ears. Examine for impacted cerumen, foreign body, or hair in the
external auditory canal.
3. Mouth. Examine posterior pharynx for evidence of sinusitis or
rhinitis (postnasal drip or cobblestoning resulting from lymphoid
hyperplasia). Look for evidence of head and neck cancer.
4. Sinuses. Check for tenderness or opacification.
5. Lungs
a. Stridor. This is a manifestation of upper airway obstruction re-
sulting from conditions such as laryngeal edema or epiglottitis.
Stridor also frequently occurs after extubation or after an aspi-
ration event.
b. Rhonchi. Occur with bronchitis and inhalation injuries.
c. Signs of consolidation. Peripheral bronchial breath sounds,
egophony, and increased tactile fremitus occur with pneumo-
nia.
d. Crackles. Occur in congestive heart failure, pneumonia, and
interstitial lung disease.
e. Wheezing. Occurs in asthma. If localized, wheezing may sig-
nify a foreign body or obstructing neoplasm.
6. Heart. Jugular venous distention, laterally displaced point of maxi-
mal impulse, and left third heart sound (S3) gallop indicate con-
gestive heart failure.
7. Lymph nodes. Lymphadenopathy suggests metastatic carci-
noma, a lymphoproliferative disorder, or a granulomatous disease
such as sarcoidosis or tuberculosis.
8. Extremities. Clubbing occurs in patients with bronchiectasis,
bronchogenic carcinoma, or usual interstitial pneumonitis.
B. Laboratory data
1. Hemogram. Leukocytosis with left shift occurs with infectious dis-
eases. Thrombocytosis may result from underlying malignancy.
2. Arterial blood gases. Important to evaluate in patients who ap-
pear tachypneic or cyanotic.
C. Radiologic and other studies
1. Chest x-ray. Look for congestive heart failure, neoplasm, pneu-
monia, interstitial lung disease, hilar adenopathy, and thoracic
aortic aneurysm.
2. Sputum. Examine for color, viscosity, odor, and amount. A good
quality Gram’s stain with PMNs and few epithelial cells may guide
antibiotic therapy for pneumonia.
15. COUGH 93
REFERENCES
Bryant BG, Lombardi TP: Cold, cough, and allergy products. In: Covington TR, Lawson
LC, Young LL et al, eds. The Handbook of Non-Prescription Drugs. 10th ed. Ameri-
can Pharmaceutical Association;1993:89.
Infectious Diseases Society of America: Update of practice guidelines for the manage-
ment of community-acquired pneumonia in immunocompetent adults. Clin Infect Dis
2003;37:1405.
Irwin RS, Corrao WM, Pratter MR: Chronic persistent cough in the adult: Spectrum and
frequency of causes and successful outcome of specific therapy. Am Rev Respir Dis
1981;123:413.
Irwin RS, Madison JM: The diagnosis and treatment of cough. N Engl J Med
2000;343:1715.
Poe RH, Harder RV, Israel RH et al: Chronic persistent cough: Experience in diagnosis
and outcome using an anatomic diagnostic protocol. Chest 1989;95:723.
V. Plan
A. Strategies. There are four treatment strategies for minor or moder-
ate alcohol withdrawal:
1. Supportive care. A calm environment with frequent assessment
and nursing care is all that is required for many patients with mild
alcohol withdrawal. Individuals with a history of alcohol withdrawal
seizures or DTs, or a coexisting acute illness, require medical
management in addition to supportive care.
2. Front-load dosing. A long-acting benzodiazepine is given every
1–2 hours until symptoms abate; for example, diazepam (Valium)
10–20 mg PO every 1–2 hours (or 5 mg IV every 5 minutes) until
symptoms subside or lorazepam (Ativan) 2 mg PO every 2 hours
can be used. Symptoms are alleviated faster, and the total dose
of benzodiazepines required is less than the conventional sched-
uled dosing method.
3. Symptom-triggered dosing. The benzodiazepines are adminis-
tered according to the patient’s symptoms. This method requires
frequent assessment using a validated withdrawal symptom scale
(a common example is the Clinical Institute Withdrawal Assess-
ment for Alcohol). Symptom-triggered therapy has been shown to
require less medication and to require a shorter duration of treat-
ment compared with scheduled dosing regimens. Initially, di-
azepam (Valium) 10–20 mg PO or chlordiazepoxide (Librium)
50–100 mg PO is given; or lorazepam (Ativan) 2–4 mg PO initially
with additional doses every 1–2 hours if assessment indicates a
need for more medication.
4. Scheduled dosing. A fixed dose of a benzodiazepine is given on a
regular schedule and tapered over several days, for example, di-
azepam (Valium) 10–20 mg every 4–6 hours for 1–3 days, decreas-
ing the dose by half every day. An as-needed dose of 5–10 mg
every 2–4 hours is made available. Chlordiazepoxide (Librium)
50–100 mg every 6 hours can be given for 1–3 days, decreasing the
dose by half every day with an additional 25–50 mg every 2–4 hours
as needed. Lorazepam (Ativan) or oxazepam (Serax) PO or IM
should be considered with moderate to severe hepatic dysfunction.
B. Delirium tremens
1. ICU setting
2. Thiamine replacement. Thiamine 100 mg IV or IM should be
given before the administration of any IV fluids containing glu-
100 I: ON-CALL PROBLEMS
REFERENCES
Chang PH, Steinberg MB: Alcohol withdrawal. Med Clin North Am 2001;85:1191.
Hall W, Zador D: The alcohol withdrawal syndrome. Lancet 1997;349:1897.
Kosten TR, O’Connor PG: Management of drug and alcohol withdrawal. N Engl J Med
2003;348:1786.
Kraus ML, Gottlieb LD, Horwitz RI et al: Randomized clinical trial of atenolol in patients
with alcohol withdrawal. N Engl J Med 1985;313:905.
Mayo-Smith MF: Pharmacological management of alcohol withdrawal: A meta-analysis
and evidence based practice guideline. JAMA 1997;278:144.
Saitz R, O’Malley SS: Pharmacotherapies for alcohol abuse: Withdrawal and treatment.
Med Clin North Am 1997;81:881.
Turner RC, Lichstein PR, Peden JG et al: Alcohol withdrawal symptoms: A review of
pathophysiology, clinical presentations, and treatment. J Gen Intern Med 1989;4:432.
Williams D, McBride AJ: The drug treatment of alcohol withdrawal symptoms: A sys-
tematic review. Alcohol Alcohol 1998;33:103.
17. DIARRHEA
I. Problem. A 50-year-old woman is admitted after having 36 hours of di-
arrhea.
sites that can cause diarrhea in HIV patients. Other nonparasitic eti-
ologies associated with HIV infection include S typhimurium, which
often results in bacteremia; C jejuni, Mycobacterium avium-intracel-
lulare, and cytomegalovirus. Often the diarrhea is idiopathic and as-
sociated with fever and weight loss.
IV. Database
A. Physical examination key points
1. General. Cachexia suggests a chronic process such as carci-
noma, AIDS, IBD, or malabsorption.
2. Vital signs. Hypotension or postural changes suggest sepsis or
significant volume depletion. Tachycardia implies volume deple-
tion or infection, or could be secondary to pain. Tachypnea may
indicate fever, anxiety, pain, or sepsis or may represent compen-
sation for a metabolic acidosis from a variety of causes including
sepsis and bowel infarction.
3. HEENT. Aphthous ulcers are associated with IBD. Glossitis,
cheilitis, or stomatitis can be seen with vitamin deficiencies sec-
ondary to malabsorption, especially the B vitamins. An enlarged
thyroid suggests hyperthyroidism or medullary carcinoma.
4. Abdomen. Look for surgical scars. Distention may be from carbo-
hydrate malabsorption. Absent bowel sounds suggest bowel in-
farction or associated peritoneal inflammation. Metastatic cancer
can result in hepatomegaly.
5. Rectum. Rule out rectal carcinoma. Look for fissures suggesting
CD. Patients with fecal impaction can present with diarrhea.
Sphincter tone should be evaluated, since many patients with
fecal incontinence associated with poor tone actually report “diar-
rhea” because of embarrassment.
6. Musculoskeletal exam. Arthritis is associated with IBD, Whip-
ple’s disease, and infection by Yersinia enterocolitica.
7. Skin. Hyperpigmentation can be seen with Addison’s disease.
Erythema nodosum and pyoderma gangrenosum point to IBD.
Dermatitis herpetiformis suggests celiac sprue, a relatively com-
mon cause of chronic diarrhea.
B. Laboratory data: The laboratory evalaution is more commonly re-
quired in chronic diarrheas. The number of studies that can be done is
extensive. It is useful to categorize the diarrhea as completely as possi-
ble with history and physical examinations before proceeding with diag-
nostic tests. If history and physical do not suggest a specific cause, then
lab tests aimed at placing a diarrhea into one of three categories—wa-
tery, fatty, or inflammatory—are helpful in narrowing the evaluation.
C. Blood tests
1. Electrolytes. With severe diarrhea, various electrolyte abnormali-
ties can occur, including hypokalemia, metabolic acidosis, hyper-
natremia, and hyponatremia.
106 I: ON-CALL PROBLEMS
REFERENCES
Aranda-Michel J, Giannella RA: Acute diarrhea: A practical review. Am J Med
1999;106:670.
Centers for Disease Control and Prevention: Outbreak of gastroenteritis associated
with an interactive water fountain at a beachside park—Florida, 1999. MMWR 2000;
49:565.
Cimolai N, Carter JE, Morrison BJ, Anderson JD: Risk factors for the progression of Es-
cherichia coli O157:H7 enteritis to hemolytic-uremic syndrome. J Pediatr 1990;
116:589.
Fine KD: Diarrhea. In: Feldman M, Scharschmidt BF, Sleisenger MH, eds. Gastroin-
testinal and Liver Diseases: Pathophysiology/Diagnosis/Management. 6th ed. Saun-
ders;1998:128.
Guerrant RL, Araujo V, Soares E et al: Measurement of fecal lactoferrin as a marker of
fecal leukocytes. J Clin Microbiol 1992;30:1238.
Lebwohl B, Deckelbaum RJ, Green PHR: Giardiasis. Gastrointest Endosc 2003;
57:906.
Schiller LR, Sellin, JH: Diarrhea. In: Feldman M, Friedman LS, Sleisenger MH, eds.
Gastrointestinal and Liver Diseases: Pathophysiology/Diagnosis/Management. 7th
ed. Saunders;2004:131.
18. DIZZINESS
I. Problem. You are called by the nurse to evaluate a 65-year-old woman
complaining of dizziness.
IV. Database
A. Physical examination key points
1. Vital signs. See above Section II.B.
2. Ears. The external auditory canal should be evaluated for ceru-
men impaction or foreign body. The tympanic membrane should
be examined for evidence of fluid, infection, or perforation. Do a
simple assessment for hearing loss through whispered voice or
finger rub. If hearing loss is suspected, then distinguish between
sensorineural and conductive hearing loss (Weber and Rinne
tests). Sensorineural hearing loss is suggestive of Ménière’s dis-
ease or an acoustic neuroma, whereas conductive hearing loss is
often due to middle ear disease interfering with conduction, such
as otitis media.
3. Eyes. Eyes should be examined for nystagmus, which is com-
monly associated with vertigo. Assess pupils and extraocular
muscles for cranial nerve dysfunction, which may be due to a
CNS lesion. Do a funduscopic exam to evaluate for papilledema
(increased intracranial pressure). A quick check of visual acuity
should also be done.
4. Neck. Auscultate for carotid/vertebral bruits, which may suggest
possible cerebrovascular disease. Determine whether head and
neck movement precipitates dizziness.
5. Cardiac. Assess cardiac rate and rhythm to determine presence
of arrhythmia. Auscultate for heart murmurs suggestive of aortic
stenosis or idiopathic hypertrophic subaortic stenosis.
6. Neurologic exam. A careful neurologic exam is essential.
a. Mental status exam. May give evidence of underlying psychi-
atric disorder. Altered mental status associated with non-
vestibular dizziness may be attributed to drug toxicity,
metabolic abnormalities, or CNS infection, whereas altered
mental status with vertigo is often associated with life-threaten-
ing CNS disorders such as cerebellar hemorrhage or infarction.
b. Cranial nerves. Cranial nerve abnormalities suggest a CNS
disorder. Sensory: peripheral neuropathy, especially of lower
extremities, contributes to disequilibrium.
c. Cerebellar. Observe gait. Evaluate for limb ataxia and gait
ataxia.
B. Diagnostic physical tests
1. Nystagmus. The presence of nystagmus suggests that dizziness
is caused by vertigo. It may be the only objective finding in the ex-
amination of a patient with vertigo. Nystagmus associated with a
peripheral lesion is different from that seen with a central lesion.
Peripheral lesions cause only horizontal or rotary nystagmus; cen-
tral lesions may cause nystagmus in any direction. Vertical nys-
tagmus is seen only with central lesions. Visual fixation tends to
suppress nystagmus that is due to peripheral but not central le-
114 I: ON-CALL PROBLEMS
sions. Changing the direction of gaze does not change the direc-
tion of nystagmus with peripheral lesions, but it may change the
direction of nystagmus with central lesions.
2. Nylen-Barany (Hallpike-Dix) maneuver. Indicated with a history
of vertigo. This maneuver helps to differentiate peripheral positional
vertigo from central vertigo. The physician moves the patient from a
sitting to a supine position, with the head rotated 45 degrees to one
side and hanging off the table at 45 degrees. The patient is then ob-
served for vertigo and nystagmus. The maneuver is repeated with
the head turned to the other side. With peripheral positional vertigo
(benign positional vertigo), the maneuver produces vertigo and ro-
tary nystagmus after a latency of 2–20 seconds, which diminishes
in intensity within 30 seconds and fatigues with repetitive testing.
Variation of these features often indicates a central disorder.
3. Romberg test. The patient stands with feet together, without sup-
port from the arms. Monitor the patient with his eyes open and
then closed. Pronounced imbalance with eyes closed compared
with eyes open suggests proprioceptive impairment. A positive
Romberg test is common with disequilibrium.
4. Hyperventilation maneuver. The patient hyperventilates for 2–3
minutes. Monitor for reproduction of dizziness.
C. Laboratory data
1. Complete blood count. To rule out anemia or infection.
2. Glucose. To rule out hypoglycemia.
3. Serum electrolytes. To rule out electrolyte abnormalities such as
hypokalemia or hypocalcemia.
4. Thyroid function tests. If hypothyroidism is suspected.
5. Urine drug screen/drug levels. If illicit drug use or drug toxicity
is suspected.
6. Serologic test for syphilis (RPR/VDRL). If tertiary syphilis is
suspected.
D. Special tests
1. Brain imaging. Not all patients with dizziness need neuroimag-
ing. If a patient’s findings on exam are suggestive of a CNS disor-
der, neuroimaging is indicated. MRI is more sensitive than CT in
diagnosing posterior fossa lesions and acoustic neuromas.
2. Electronystagmogram. Testing of vestibular function by evaluat-
ing nystagmus. This test is able to confirm nystagmus when the
physical examination is equivocal. It detects peripheral and cen-
tral vestibular disorders and should be considered when the
cause of vertigo is uncertain.
3. Audiometry. Should be considered with hearing complaints or
with hearing loss on examination. It may help with the diagnosis
of peripheral vertigo (ie, Ménèire’s disease or acoustic neuroma).
4. Brain stem–evoked audiometry. Very sensitive in the detection
of acoustic neuromas.
18. DIZZINESS 115
D. Lightheadedness
1. Treat any underlying psychiatric disorder (ie, give anxiolytics
or antidepressants).
2. Supportive psychotherapy.
3. Teach relaxation techniques.
4. Teach breathing techniques to relieve symptoms.
REFERENCES
Branch WT: Approach to the patient with dizziness. In: Fletcher SW, Fletcher RH, Aron-
son MD, eds. UpToDate [CD-ROM]. Version 8.2. Wellesley, MA;2000. www.upto-
date.com
Hoffman RM, Einstadter D, Kroenke K: Evaluating dizziness. Am J Med 1999;107:468.
Warner EA, Wallach PM, Adelman HM et al: Dizziness in primary care patients. J Gen
Intern Med 1992;7:454.
19. DYSPNEA
I. Problem. A patient admitted to the coronary care unit to rule out a my-
ocardial infarction (MI) complains of difficulty breathing.
IV. Database
A. Physical examination key points
1. Vital signs. Fever may signify infection, but also occurs with PE
and MI. Tachypnea occurs in most cases of dyspnea; however,
19. DYSPNEA 119
V. Plan
A. Emergent therapy
1. Oxygen supplementation. The initial goal of treatment for acute
dyspnea should be to ensure adequate oxygenation; thus, most
patients should be treated with 100% oxygen therapy. In patients
with a history of COPD in whom one is concerned about the pos-
sibility of suppression of their hypoxic ventilatory drive, therapy
should be initiated with 24–28% oxygen by Venturi mask. In either
case, ABG values should be obtained to direct subsequent adjust-
ments of the oxygen. Continuous oxygen saturation monitoring by
pulse oximetry can be helpful.
2. Stat portable chest x-ray, ECG, and ABG. Indicated in any pa-
tient who complains of acute dyspnea.
B. Asthma/acute exacerbation of chronic bronchitis
1. Albuterol. Request a stat nebulizer treatment with albuterol 0.5
mL in 23 mL normal saline or give 4 puffs albuterol by metered-
dose inhaler via a spacer device.
2. Epinephrine. For anaphylaxis or in young patients with acute
asthma, epinephrine 0.250.4 mL of a 1:1000 concentration can be
given SC.
3. Methylprednisolone (Solu-Medrol). 125 mg stat IV will provide
relief of bronchospasm in 36 hours as the effectiveness of the al-
buterol dissipates.
C. Anaphylaxis. (See Section I, Chapter 4, Anaphylactic Reaction, V, p
27.)
D. Myocardial ischemia. If initial assessment suggests myocardial is-
chemia, administer aspirin 325 mg (chewable) and nitroglycerin 0.4
mg SL, provided the systolic blood pressure is > 100. (See Section I,
Chapter 11, Chest Pain, V, p 66.)
E. Acute congestive heart failure. Furosemide (Lasix) 40–80 mg IV
may be given, provided the patient is not hypotensive. Morphine sul-
fate 25 mg IV may also be helpful initially for acute pulmonary
edema. Invasive monitoring via pulmonary artery catheter, IV in-
otropes, and angiotensin-converting enzyme inhibitor therapy may
be warranted.
122 I: ON-CALL PROBLEMS
REFERENCES
Burki NK: Acute dyspnea: Is the cause cardiac or pulmonary—or both? Consultant
2000;40:542.
DeGowin RL, Brown DD: DeGowin’s Diagnostic Examination. 7th ed. McGraw-
Hill;2000:247.
Gillespie DJ, Staats BA: Concise review for primary-care physicians: Unexplained dys-
pnea. Mayo Clin Proc 1994;69:657.
Gulsun M, Goodman LR: CT for the diagnosis of venous thromboembolic disease. Curr
Opin Pulm Med 2003;9:367.
Mahler DA: Acute dyspnea. In: Mahler DA, ed. Dyspnea. Futura Publishing
Co.;1990:127.
Maisel AS, Krishnaswamy P, Nowak RM et al: Rapid measurement of B-type natriuretic
peptide in the emergency diagnosis of heart failure. N Engl J Med 2002;347:161.
Manning HL, Schwartzstein RM: Pathophysiology of dyspnea. N Engl J Med
1995;327:1547.
Salzman GA: Evaluation of dyspnea. Hosp Pract 1997;195.
Task Force on Pulmonary Embolism, European Society of Cardiology: Guidelines on
diagnosis and management of acute pulmonary embolism. Eur Heart J
2000;21:1301.
Ware LB, Matthay MA: Medical progress: The acute respiratory distress syndrome. N
Engl J Med 2000;342:1334.
20. DYSURIA
I. Problem. A 36-year-old sexually active woman complains of pain with
urination.
II. Immediate Questions
A. How long have the symptoms been present? Acute onset of
symptoms of dysuria, frequency, and urgency within 1–2 days indi-
cates lower urinary tract infection (UTI). Patients with symptoms for
more than 1 week are more likely to have a more serious infection
(upper tract involvement). A gradual onset of several days’ duration
suggests a chlamydial or gonorrheal infection. Prostatitis can also
present with several days of symptoms.
B. Are there any associated symptoms? Fever, chills, nausea, vomit-
ing, and back pain are often signs of upper UTIs such as
pyelonephritis. Dysuria, frequency, urgency, and suprapubic pain are
20. DYSURIA 123
lower UTI signs and symptoms and can occur with cystitis, prostati-
tis, and urethritis. A vaginal discharge suggests a vaginitis, such as
that caused by Gardnerella vaginalis in bacterial vaginosis, Candida
albicans, or Trichomonas vaginalis, as a cause of dysuria. Also, re-
member that other sexually transmitted diseases such as chlamydia
and gonorrhea can cause urethritis. In men, ask about a recent pe-
nile discharge.
C. Does the patient have a history of UTIs or urologic abnormality?
Women and patients with a urinary tract abnormality are predisposed
to recurrent UTIs. Patients with recurrent UTIs (> 2 UTIs per year)
are managed with longer courses of antibiotics and possibly prophy-
lactic antibiotics. Bladder cancer can sometimes present with dy-
suria.
D. Has the patient recently had a Foley catheter removed? Catheter
placement may result in an infection or transient urethral irritation.
E. What types of contraception or sexual protection are used by
the patient? Use of diaphragm and spermicide enhance UTI sus-
ceptibility in women. In men, unprotected anal intercourse, inter-
course with an infected partner, and an uncircumcised penis all are
risk factors for UTIs.
III. Differential Diagnosis. The principal causes of dysuria differ for men
and women.
A. Women. Women presenting with acute dysuria are likely to have one
of seven conditions, each of which may require different manage-
ment.
1. Acute pyelonephritis. Suggested by fever, rigors, flank pain,
nausea, and vomiting with or without lower UTI symptoms.
2. Complicated UTI. Seen in patients with diabetes, immunosup-
pression, pregnancy, abnormal genitourinary tracts, resistant or-
ganisms, and history of relapsing infections. These patients can
present only with signs of lower UTI but can have an upper UTI as
well (subclinical pyelonephritis).
3. Lower UTI. These patients have either cystitis or urethritis, with
bacteria confined to either the bladder or urethra.
4. Chlamydial urethritis. This is characterized by a gradual onset
over several days. The patient often reports intercourse with a
partner with similar symptoms. An associated mucopurulent en-
docervical secretion may be noted on pelvic exam.
5. Other urethral infections. Urethritis may also be caused by
Neisseria gonorrhoeae and T vaginalis.
6. Vaginitis. In contrast to the internal sensations of dull pain asso-
ciated with dysuria caused by cystitis, vaginitis causes external
burning pain as the urine stream flows over the inflamed labia.
The most common causes include bacterial vaginosis, candida
vulvovaginitis, and trichomoniasis.
124 I: ON-CALL PROBLEMS
V. Plan
A. Acute pyelonephritis
1. Suspected sepsis or intolerance to oral medications. Admin-
ister a fluoroquinolone IV (Cipro 200–400 mg IV Q 12 hr). A third-
generation cephalosporin such as ceftriaxone 1 g IV Q 24 hr is an
alternative. If you suspect Enterococcus (more common with re-
currence or in the presence of structural abnormalities), use ampi-
cillin 1.5–2.0 g Q 4–6 hr and gentamicin 1.5–2.0 mg/kg IV loading
dose; then give about 1.5 mg/kg IV Q 8–24 hr, depending on renal
function (see aminoglycoside dosing, Section VII, Table 7–18, p
630). Once antibiotic susceptibility tests are known, the patient
can be switched to oral medications after being afebrile for 24–48
hours. Duration of therapy should be 14 days.
2. Hospitalization indications. Include dehydration; inability to tol-
erate oral medications; concern about compliance; uncertainty
about diagnosis; and severe illness with high fever, severe pain,
and marked debility.
3. Acute uncomplicated pyelonephritis. A 7-day outpatient course
of a fluoroquinolone antibiotic such as ciprofloxacin 500 mg PO
bid. Other possibilities include amoxicillin/potassium clavulanate
(Augmentin) and oral cephalosporins for 14 days. Trimethoprim
(Bactrim) has fallen out of favor due to the high rate of resistance.
4. Follow-up. Urine cultures should be checked 2–3 weeks after
therapy is completed.
B. Complicated UTI. These patients should be treated with a 7- to 14-
day course of the same oral or IV agents as described above for un-
complicated pyelonephritis.
C. Lower UTI. In patients presenting with acute dysuria who are noted
to have pyuria and bacteriuria on urinalysis, but do not have the clini-
cal picture of acute pyelonephritis, an uncomplicated lower UTI (most
20. DYSURIA 127
likely cystitis) can be presumed and treated. A urine culture is not re-
quired in these patients. Studies indicate that trimethoprim-sul-
famethoxazole (Bactrim) is the most efficacious treatment if local E
coli resistance is < 20%. A 3-day regimen of Bactrim DS, 1 tablet PO
bid, is sufficient for uncomplicated lower UTIs in women. A 7-day
regimen should be considered for patients with diabetes mellitus, > 7
days of symptoms, a recent UTI, UTI with associated use of a di-
aphragm or spermicide, and UTIs in men. Alternative antibiotics for
patients with a history of intolerance to sulfa are oral cephalosporins
for 3 days or nitrofurantoin 100 mg qid for 7 days. If local E coli resis-
tance to Bactrim > 20% ciprofloxacin and other fluoroquinolones are
appropriate for a 3-day course. Otherwise, they are reserved as sec-
ond-line agents for patients who have recurrences and treatment fail-
ures. A follow-up culture is also not necessary for acute
uncomplicated lower UTIs unless they occur frequently.
D. Vaginitis. Therapy is directed to the specific cause of the vaginitis.
For patients with bacterial vaginosis, metronidazole 500 mg PO bid
for 7 days or metronidazole vaginal gel 1 application a day for 5 days
is effective. For candida vaginitis, miconazole (Monistat) cream topi-
cally for 7 days is effective. An alternative is a single 150-mg oral
dose of fluconazole (Diflucan). For trichomonal vaginitis, metronida-
zole 2 g PO in a single dose is recommended for the sex partner as
well as the patient. Alternatively, treatment can be metronidazole 500
mg PO bid for 7 days. Topical Premarin cream is effective for at-
rophic vaginitis. The cream should be applied daily for 1 week and
then 2–3 times a week thereafter.
E. Chlamydial urethritis. This should be suspected when dysuria and
pyuria but no bacteriuria is present, and when the partner has symp-
toms. Doxycycline 100 mg bid for 7 days is effective. An alternative
therapy is azithromycin 1 g PO in a single dose or ofloxacin 300 mg
PO bid for 7 days. The partner should be evaluated and treated. Ver-
ify that women are not pregnant before prescribing doxycycline.
F. Gonococcal urethritis. With the emergence of penicillin resistance,
ceftriaxone 125 mg IM or ofloxacin 400 mg PO is now recom-
mended. Because of the frequent coexistence of chlamydial urethri-
tis, azithromycin 1 g PO 1 dose or doxycycline 100 mg PO twice a
day for 7 days should also be given. The patient’s partner(s) should
be evaluated and treated.
G. Acute prostatitis. Patients who are septic should be admitted and
broad antibiotic coverage administered IV. If Gram’s stain shows
gram-positive cocci in chains, patients should be treated with intra-
venous ampicillin and gentamicin to cover Enterococcus. Patients
with gram-negative rods in their urine should be treated with intra-
venous ceftriaxone and either a fluoroquinolone (PO or IV) or an
aminoglycoside. Once the patient has been afebrile for 24–48 hours,
the patient may be switched to oral antibiotics for a total of 2-4
128 I: ON-CALL PROBLEMS
REFERENCES
Claudius HI: Dysuria in adolescents. West J Med 2000;172:201.
Gilbert DN, Moellering RC, Sande MA: The Sanford Guide to Antimicrobial Therapy.
33rd ed. Antimicrobial Therapy, Inc. (Hyde Park, VT);2003:15-23.
Hooton TM, Stamm WE: Diagnosis and treatment of uncomplicated urinary tract infec-
tion. Infect Dis Clin North Am 1997;11:551.
Johnson RE, Newhall WJ: Screening tests to detect Chlamydia trachomatis and Neis-
seria gonorrhoeae infections—2002. MMWR 2002;51:RR-15.
Lipsky BA: Urinary tract infections in men. Ann Intern Med 1989;110:138.
Orenstein R, Wong ES: Urinary tract infections in adults. Am Fam Physician
1999;59:1225.
Pappas PG: Laboratory in the diagnosis and management of urinary tract infections.
Med Clin North Am 1991;75:313.
Stamm WE, Hooton TM: Management of urinary tract infection in adults. N Engl J Med
1993;329:1328.
21. FALLS
I. Problem. You are called to evaluate an 84-year-old woman with pneu-
monia who has fallen on her way to the bathroom.
III. Differential Diagnosis. With younger patients, the cause of the fall may
be easily apparent. However, the differential diagnosis with an older pa-
tient may be extensive. The elderly frequently have many contributing
causes of a fall.
A. Extrinsic causes. These result from the environment.
1. Slippery floors. From water or urine.
2. Inadequate lighting. Older patients may have cataracts or other
ophthalmologic problems that impair vision.
3. Transfers. A weakened patient attempting to make a transfer
from the bed to a wheelchair may fall.
4. Bed side rails. If side rails are placed up, a delirious patient at-
tempting to climb over them can fall.
5. Walking aids not available. A hospitalized patient may not have
his or her cane or walker immediately available and may attempt
to walk to the bathroom unaided.
B. Intrinsic causes
1. “Normal” aging. Such as visual impairment (eg, presbyopia or
cataracts). Patients with visual or hearing loss may be unable to
move well in a new environment.
2. Neurologic
a. Cerebrovascular accident with hemiparesis. May result in
decreased mobility.
b. Parkinson’s disease. May cause decreased mobility.
c. Dementia. From any number of causes such as multi-infarct
dementia, Alzheimer’s disease, or hypothyroidism. The patient
130 I: ON-CALL PROBLEMS
with dementia may have poor judgment about his or her ability
to move in a new environment.
d. Seizures. The patient usually functions normally after the
seizure episode. Look for evidence of tongue biting or urinary
incontinence.
e. Carotid sinus hypersensitivity
f. Peripheral neuropathy. Vitamin B12 deficiency is more com-
mon among the elderly. Also, consider peripheral neuropathy
in a patient with a history of diabetes mellitus, thyroid disor-
ders, or alcohol abuse.
g. Vestibular dysfunction. Inner ear problems may have asso-
ciated attacks of vertigo, affecting balance.
3. Cardiovascular. See Section I, Chapter 59, Syncope, p 337.
a. Orthostatic hypotension. Should be considered with dehy-
dration, acute infections, gastrointestinal bleeding, or auto-
nomic dysfunction (diabetes mellitus).
b. Arrhythmias. Tachyarrhythmias or bradyarrhythmias should
be considered, especially in the elderly or those with a history
of heart disease. See Section I, Chapter 60, Tachycardia, p
345, and Section I, Chapter 8, Bradycardia, p 42.
c. Angina or MI. Syncope or hypotension can be a sign of is-
chemic heart disease.
d. Vagal response disorders. Valsalva (due to defecation, mic-
turition, or other cause) may cause an increase in vagal tone,
resulting in a decrease in heart rate and blood pressure, which
then may result in a fall.
4. Fluid/volume loss. From any cause, including diuretic use, diar-
rhea, vomiting or nasogastric suction, GI hemorrhage, high fever,
or decreased oral intake.
5. Musculoskeletal disorders. Degenerative joint disease or os-
teoarthritis is very common in the elderly. Deconditioning can be a
problem, especially during hospitalization. In addition, a fall can
cause a hip fracture, predisposing the patient to fall again. Proxi-
mal muscle weakness is common in the elderly.
6. Metabolic disorders
a. Hyperthyroidism. Associated arrhythmias such as atrial fibril-
lation may affect function.
b. Hypoglycemia. There may be associated diaphoresis, tachy-
cardia, or syncope.
c. Electrolyte imbalance. Hypokalemia or hypomagnesemia
can lead to muscle weakness or arrhythmias. Hypercalcemia
can cause confusion.
d. Diabetes mellitus. Uncontrolled diabetes mellitus can cause
an osmotic diuresis leading to volume depletion. Peripheral
neuropathy and autonomic insufficiency causing orthostatic
hypotension can result from longstanding diabetes mellitus.
21. FALLS 131
IV. Database
A. Physical examination key points
1. Vital signs. Look for hypotension, tachycardia or bradycardia,
tachypnea, or an increase or decrease in the temperature from
baseline. Check for orthostatic changes, a decrease in systolic
blood pressure of 10 mm Hg, and/or an increase in heart rate of
20 bpm (16 bpm in the elderly) 1 minute after going from supine to
a standing position.
2. HEENT. Look for evidence of trauma from the fall, such as soft
tissue swelling and tenderness. Look for cataracts, which may im-
pair vision.
3. Extremities. Look for evidence of fractures, such as an externally
rotated and flexed hip, deformity of long bones, or swelling over
these sites.
4. Neurologic exam. Examine for evidence of peripheral neuropa-
thy or movement disorder (eg, Parkinson’s disease). Perform a
brief mental status exam and check for localizing findings to as-
sess for possible subdural hematoma.
B. Laboratory data. If there are obvious clues from the history and/or
physical examination, an extensive laboratory evaluation may not be
indicated.
132 I: ON-CALL PROBLEMS
REFERENCES
Fuller GF: Falls in the elderly. Am Fam Physician 2000;61:2159.
Kiel DP: The evaluation of falls in the emergency department. Clin Geriatr Med
1993;9:591.
King MB: Falls. In: Hazzard WR, Blass JP, Halter JB et al, eds. Principles of Geriatric
Medicine and Gerontology. 5th ed. McGraw-Hill;2003:1517.
Mahoney JE: Immobility and falls. Clin Geriatr Med 1998;14:699.
Tinetti M, Speechley M: Prevention of falls among the elderly. N Engl J Med
1989;320:1055.
22. FEVER
I. Problem. You are called to see a 57-year-old man who has been hospi-
talized for 3 days and now has a fever of 39.5 °C (103.1 °F).
ficile colitis. Also consider a drug-induced fever and review all med-
ications.
F. Have any recent procedures such as bronchoscopy been car-
ried out, or has the patient recently received blood? A fever up to
38.3 °C (101 °F) is common after bronchoscopy and transfusions.
G. Are there any factors relating to the patient’s psychosocial his-
tory that need to be assessed? Inquire about recent travel, espe-
cially to countries with poor sanitation; HIV risk factors (intravenous
drug use; homosexual or bisexual male; promiscuous sexual activity;
or sexual intercourse with a prostitute, a person with AIDS, or HIV-
positive persons); exposure to dogs, cats, birds, ticks, and cattle; and
health of family members.
H. Does the patient have significant valvular heart disease includ-
ing a prosthetic valve? Significant valvular heart disease predis-
poses the patient to bacterial endocarditis. Be sure to inquire about
recent procedures, including dental work.
III. Differential Diagnosis. An exhaustive list is extraordinarily long; only
the major categories are presented here:
A. Infections
1. Bacterial
2. Viral
3. Mycobacterial
4. Fungal
5. Parasitic
6. Protozoal
7. Rickettsial
B. Neoplasms. Solid tumors, especially with metastasis to the liver;
lymphoma; Hodgkin’s disease; multiple myeloma; leukemia;
myelodysplastic syndromes. Fever with leukemia is often due to in-
fection but may be caused by the primary disease, especially in
chronic myelogenous leukemia. Solid tumors causing fever include
renal cell and hepatocellular carcinoma, osteogenic sarcoma, and
atrial myxoma.
C. Connective tissue disease
1. Acute rheumatic fever
2. Rheumatoid arthritis
3. Adult Still’s disease
4. Systemic lupus erythematosus (SLE)
5. Vasculitis. Including hypersensitivity vasculitis, polymyalgia
rheumatica, temporal arteritis, and polyarteritis nodosa.
D. Thermoregulatory disorders. Heat stroke, malignant hyperthermia,
thyroid storm, and malignant neuroleptic syndrome. Thyroid storm
may be a postoperative complication in a hyperthyroid patient. Fea-
tures of malignant neuroleptic syndrome include hyperthermia, hy-
22. FEVER 135
IV. Database
A. Physical examination key points
1. General appearance. This factor can help determine whether the
patient should receive empiric antibiotic therapy based on the
most likely cause.
2. Vital signs. Take both oral and rectal temperatures. Neutropenia
is a contraindication to taking rectal temperature. A rectal tem-
perature should be taken to make sure the oral temperature is
not falsely elevated secondary to recent consumption of a hot liq-
uid or smoking. Check pulse and blood pressure to make sure
136 I: ON-CALL PROBLEMS
REFERENCES
Balk RA: Conundrums in the management of critically ill patients: Steroids for Septic
Shock. Back from the dead? Chest 2003;124:1733.
Bohr D: Fever of unknown origin. In: Fletcher SW, Fletcher RH, Aronson MD, eds. Up-
ToDate [CD-ROM]. Version 8.1. Wellesley, MA;2000. www.uptodate.com
de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. N Engl J
Med 2002;347:1549.
Hughes WT, Armstrong D, Bodey GP et al: 1997 Guidelines for the use of antimicrobial
agents in neutropenic patients and unexplained fever. Clin Infect Dis 1997;25:551.
Infectious Diseases Society of America: Update of practice guidelines for the manage-
ment of community-acquired pneumonia in immunocompetent adults. Clin Infect Dis
2003;37:1405.
Mackowiak PA: Temperature regulation and the pathogenesis of fever. In: Mandell GL,
Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 5th ed.
Churchill Livingstone;2000:604.
O’Grady NP, Barie PS, Bartlett JG et al: Practice guidelines for evaluating new fever in
critically ill adult patients. Clin Infect Dis 1998;26:1042.
Quagliarello VJ, Scheld MW: Treatment of bacterial meningitis. N Engl J Med
1997;336:708.
III. Differential Diagnosis. There are multiple causes of fever in this set-
ting. The HIV-positive patient is a special problem because you must
consider not only opportunistic infections seen frequently in this popula-
tion but also other causes of fever that occur in non–HIV-positive pa-
tients. (See Section I, Chapter 22, Fever, p 133.) Most opportunistic
infections occur when the CD4 count is < 200/mL; they are especially
common when the CD4 count is < 50/mL.
A. Drug fever. Antiretroviral agents rarely cause a fever, but zidovudine
(AZT) and zalcitabine (ddC) may cause fever. Fever while on aba-
cavir may represent a life-threatening hypersensitivity reaction. An-
timicrobials, such as sulfonamides and beta-lactams, are common
causes of fever. Relative bradycardia is the cardinal finding in drug
fever (be sure to eliminate other causes of relative bradycardia [eg,
use beta-blockers in the presence of another source of fever] in
febrile patients before applying this in your differential).
B. Sinusitis. Bacterial sinusitis may occur at any time during the course
of HIV infection but is more severe in the later stages. Presentation
23. FEVER IN THE HIV-POSITIVE PATIENT 143
G. Gastrointestinal disease
1. Esophagitis generally presents with dysphagia. Candida
esophagitis may or may not present with fever. Other common
causes of esophagitis are CMV and herpes simplex virus.
2. Diarrhea. Often fever and abdominal pain accompany low-vol-
ume diarrhea and mucoid stools. Depending on the etiologic
agent, blood may be present. S typhi often causes recurrent bac-
teremia and diarrhea. Other bacterial pathogens may include
Campylobacter jejuni, Shigella flexneri, Clostridium difficile, and
MAI, as well as enterotoxigenic Escherichia coli. CMV and a vari-
ety of parasites including Cryptosporidium, Isospora belli, and Mi-
crosporidia may cause diarrhea and fever. Histoplasma
capsulatum can also cause diarrhea in HIV-positive patients.
H. Hepatobiliary/pancreatic disease
1. Sclerosing cholangitis-like syndrome. Fever, right upper quad-
rant pain, and progressive cholangitis have been described in pa-
tients with Cryptosporidium, CMV, Microsporidia, and Cyclospora
infection involving the biliary tract.
2. Hepatitis A, B, or C
3. Cholestatic hepatitis. Secondary to MAI, TB, H capsulatum, C
neoformans.
4. Pancreatitis. May occur as a result of an opportunistic infection,
increased triglycerides, or drug toxicity (eg, pentamidine, didano-
sine, and stavudine, TMP-SMX).
I. Skin. Bacillary angiomatosis thought to be secondary to Bartonella
(Rochalimaea) henselae causes firm purplish-to-reddish papules,
subcutaneous nodules, or cellulitis-like plaques. Fever is unlikely un-
less there is a secondary infection. Herpes simplex virus type I or II
may cause primary or recurrent erythematous/vesicular lesions with
ulceration.
J. Neurologic disease. Many agents can cause a variety of neurologic
complications, including meningitis, encephalitis, and mass lesions.
1. Meningitis. HIV can initially cause an aseptic meningitis. C neo-
formans is a common cause of meningitis. Presenting symptoms
include fever, night sweats, and headaches. M tuberculosis as
well as S pneumoniae, H influenzae, and Neisseria meningitidis
need to be considered as etiologic agents.
2. Encephalitis. T gondii causes altered mental status, headache,
fever, and focal neurologic findings.
3. Mass lesions can be caused by a variety of infectious agents (T
gondii, M tuberculosis, Nocardia asteroides, C neoformans, H
capsulatum) and noninfectious agents (primary CNS lymphoma,
metastatic lymphoma, and Kaposi’s sarcoma).
K. Malignant disease. Malignancies, including B-cell non-Hodgkin’s
lymphoma, Kaposi’s sarcoma, and Hodgkin’s lymphoma, may have
associated fever.
23. FEVER IN THE HIV-POSITIVE PATIENT 145
REFERENCES
Bartlett JG, Gallant JE: Medical Management of HIV Infection, 2003 ed. Johns Hop-
kins;2003.
Bissuel F, Leport C, Perronne C et al: Fever of unknown origin in HIV-infected patients:
A critical analysis of a retrospective series of 57 cases. J Intern Med 1994;236:529.
Carrier J: MAC infections in HIV infected patients. In: Fletcher SW, Fletcher RH, Aronson
MD, eds. UpToDate [CD-ROM]. Version 8.1. Wellesley, MA;2000. www.uptodate.com
Falloon J: Pulmonary manifestations of human immunodeficiency virus infection. In:
Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases.
5th ed. Churchill Livingstone;2000:1415.
Holloway RG, Kieburtz KD: Neurologic manifestations of human immunodeficiency
virus infection. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of
Infectious Diseases. 5th ed. Churchill Livingstone;2000:1432.
148 I: ON-CALL PROBLEMS
Jones BE, Young SM, Antoniskis D, Davidson PT, Kramer F, Barnes PF: Relationship
of the manifestations of tuberculosis to CD4 cell counts in patients with human im-
munodeficiency virus infection. Am Rev Respir Dis 1993;148:1292.
Keiper MD, Beumont M, Elshami A, Langlotz CP, Miller WT: CD4 T lymphocyte count
and the radiographic presentation of pulmonary tuberculosis. A study of the relation-
ship between these factors in patients with human immunodeficiency virus infection.
Chest 1995;107:74.
Sande M, Volberding P: Medical Management of AIDS. 6th ed. Saunders;1999.
Sepkowitz K, Talzak E, Carrow M et al: Fever among outpatients with advanced human
immunodeficiency virus infection. Arch Intern Med 1993;153:1909.
Sulkowski MS, Chaisson RE: Gastrointestinal and hepatobiliary manifestations of
human immunodeficiency virus infection. In: Mandell GL, Bennett JE, Dolin R, eds.
Principles and Practice of Infectious Diseases. 5th ed. Churchill Living-
stone;2000:1426.
Vander Els N: Clinical features and diagnosis of TB in HIV infected patients. In:
Fletcher SW, Fletcher RH, Aronson MD, eds. UpToDate [CD-ROM]. Version 8.1.
Wellesley, MA;2000. www.uptodate.com.
IV. Database
A. Physical examination key points
1. Vital signs. Check for tachycardia or hypotension, which is char-
acteristic of hypovolemia and may explain the low urine output.
2. Abdominal exam. Determine whether the bladder is distended
(suprapubic dullness to percussion with or without tenderness).
This may be indicative of an obstructed Foley catheter. Percuss
the bladder to help identify distention.
3. Genital exam. Bleeding at the meatus suggests urethral trauma
or partial removal of the catheter with the balloon inflated.
4. Rectal exam. A “floating prostate” suggests urethral disruption.
5. General. Look for signs of hypovolemia causing low urine output,
such as poor skin turgor (which may be a normal variant in the el-
derly) and dry mucous membranes.
B. Laboratory data. Most problems are usually mechanical in nature,
so laboratory data are somewhat limited in this setting.
150 I: ON-CALL PROBLEMS
REFERENCE
Shahbandi M, Parulkar BG: Foley catheter problems. In: Gomella LG, ed. 5 Minute
Urology Consult. Lippincott Williams & Wilkins;2000:50.
25. HEADACHE 151
25. HEADACHE
I. Problem. You are called to the emergency room to evaluate a 58-year-
old man who complains of a severe headache that has lasted for several
hours.
II. Immediate Questions
A. Has the patient experienced similar headaches before? If the
headache is similar to previous tension or migraine headaches, then
the situation is unlikely to be urgent; however, if the headache is new
or deviates from a previous pattern, several potentially serious condi-
tions should be considered, including acute glaucoma, sinusitis, sub-
arachnoid hemorrhage, meningitis, neoplasm, temporal arteritis, and
early hypertensive encephalopathy.
B. What are the patient’s vital signs? Although essential hyperten-
sion by itself is an infrequent cause of headache, it may exacerbate a
preexisting vascular or tension headache. Diastolic blood pressures
> 140 mm Hg can cause severe headache. A fever should alert the
clinician to the possibility of subarachnoid hemorrhage, meningitis,
temporal arteritis, or acute sinusitis.
C. Is the patient taking any anticoagulants? Does the patient have a
predisposition to bleeding? Aspirin or coumadin increases the risk for
an intracranial hemorrhage, especially with minor head trauma.
Spontaneous intracranial bleeding occurs with platelet counts of less
than 20,000/μL.
III. Differential Diagnosis. A detailed, well-focused history is the most im-
portant tool for evaluating headache. Most headaches are secondary to
either tension-type or migraine headaches. A headache may also be the
only symptom of a more serious condition, such as an intracranial mass,
temporal arteritis, meningitis, and subarachnoid hemorrhage.
A. Tension-type headache
1. Episodic tension-type headache. This is frequently described
as a squeezing, “bandlike” tightness that is usually felt bilaterally.
It may occur in the occipital, frontal, or bitemporal regions. Occa-
sionally, patients with tension-type headaches describe a “throb-
bing” pain. This form of headache may last 30 minutes to 7 days;
it is generally described as having a mild to moderate intensity.
There is usually no aggravation from walking stairs or similar rou-
tine activities and no associated nausea or vomiting. Photophobia
and phonophobia are absent, or only one is present.
2. Chronic tension-type headache. Same as tension-type
headache, except for the number of days with such headaches: at
least 15 days per month for at least 6 months
B. Migraine headache. Although the precise pathophysiology has not
been fully ascertained, migraine is thought to be secondary to cerebral
152 I: ON-CALL PROBLEMS
IV. Database
A. Physical examination key points
1. Vital signs. See II.B.
2. HEENT
a. Scalp. Patients with both migraine and chronic tension
headaches frequently complain of scalp tenderness, which
may also suggest temporal arteritis.
b. Temporal arteries. A diminished pulse or tender temporal ar-
teries suggests arteritis; however, temporal arteries may feel
normal to palpation in 30–40% of patients with temporal arteri-
tis.
c. Eyes. Examine for injected conjunctivae and excessive
lacrimation, which occur with cluster headaches. Miosis and
ptosis suggest carotid artery dissection as the cause of the
headache. Examine the fundi for any signs of papilledema or
optic nerve atrophy resulting from an intracerebral mass. Reti-
nal hemorrhage may be observed after subarachnoid hemor-
rhage. Subhyaloid hemorrhages may be seen trapped behind
25. HEADACHE 155
REFERENCES
Abramowicz M, ed: Drugs for migraine. Med Lett Drug Ther 1995;37:17.
Bartleson JD: Treatment of migraine headaches. Mayo Clin Proc 1999;74:702.
Dalessio DJ: Diagnosing the severe headache. Neurology 1994;44:S6.
Dresser GK, Spence JD, Bailey DG: Pharmacokinetic-pharmacodynamic conse-
quences and clinical relevance of cytochrome P450 3A4 inhibition. Clin Pharma-
cokinet 2000;38:41.
Edlow JA, Caplan LR: Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N
Engl J Med 2000;342:29.
Evans RW: Diagnostic testing for headache. Med Clin North Am 2001;85:865.
Gallagher RM, Dennish G, Spierings ELH et al: A comparative trial of zolmitriptan and
sumatriptan for the acute oral treatment of migraine. Headache 2000;40:119.
26. HEART MURMUR 159
IV. Database
A. Physical examination key points
1. General. Inability to lie flat suggests pulmonary edema, pericardi-
tis, or pericardial effusion.
2. Vital signs
a. Temperature. Elevated temperature may indicate infection
(endocarditis), although myocardial infarction can cause fever
for up to a week. Also, any fever can cause or intensify a flow
murmur.
b. Heart rate and rhythm. Tachycardia is often associated with
CHF, pain, infection, pericarditis, and perhaps arrhythmias (see
Section I, Chapter 60, Tachycardia, p 345). Irregular rhythm
may suggest atrial fibrillation or frequent premature atrial or
ventricular beats as well as second-degree atrioventricular
block (see Section I, Chapter 45, Irregular Pulse, p 251).
c. Blood pressure. Hypertension or hypotension is often associ-
ated with angina or MI. Hypotension could occur with sepsis or
hemodynamic collapse. A widened pulse pressure may sug-
gest aortic insufficiency. Pulsus paradoxus (a difference of 10
mm Hg in systolic blood pressure between tidal inspiration and
expiration) indicates pericardial tamponade.
d. Tachypnea. Suggests CHF, or decreased perfusion or hy-
poxia from any cause such as a VSD with a right-to-left shunt.
162 I: ON-CALL PROBLEMS
3. Neck
a. Elevated jugular venous distention. Suggests right-sided
ventricular failure or pericardial tamponade.
b. A decrease in the carotid upstroke. Suggests significant
aortic stenosis. Also, the murmur of aortic stenosis radiates to
the carotids bilaterally and should not be confused with bilat-
eral carotid bruits, a venous hum, or a thyroid bruit.
4. Cardiovascular. Careful cardiac examination is essential. Pal-
pate the carotid pulsations for the presence of a palpable thrill,
and palpate the chest for displacement of the apical impulse. First
(S1) and second (S2) heart sounds and splitting of S2 must be
characterized. The presence of a fourth heart sound (S4) may
suggest a recent MI, hemodynamically significant aortic stenosis,
or longstanding hypertension. A third (S3) heart sound is consis-
tent with ventricular dysfunction.
a. Flow murmur. A midsystolic murmur with normal carotid up-
stroke is present.
b. Aortic insufficiency. A diastolic blowing murmur heard best
at the right second intercostal space down to the left lower
sternal border with the patient leaning forward in full expira-
tion. This may occur with acute aortic dissection or acute bac-
terial endocarditis, or it may be chronic. The aortic component
of S2 may be soft or absent. The murmur of acute aortic insuf-
ficiency is usually soft in intensity and short in duration, is
heard best at the left lower sternal border, and can easily be
missed. The carotid upstroke is sharp, followed by a rapid
downstroke (Corrigan’s, or water-hammer, pulse).
c. Aortic stenosis. This systolic murmur is crescendo-de-
crescendo and harsh in character; it is heard best at the right
second intercostal space. Critical aortic valve stenosis is char-
acterized by the absence of the aortic component of S2, a pal-
pable S4 gallop at the apex, late peaking of the maximal
intensity of the murmur, a palpable carotid thrill (usually over
the left carotid artery), and a diminished and delayed carotid
upstroke (pulsus parvus et tardus).
d. Mitral regurgitation. It is heard best as a blowing pansystolic
murmur at the apex, radiating to the axilla and occasionally
into the midback. An intermittent murmur of mitral regurgitation
may suggest intermittent papillary muscle dysfunction sec-
ondary to ischemia or other causes. The murmur of acute, se-
vere mitral regurgitation may be short in duration and soft in
intensity. Other findings associated with severe mitral regurgi-
tation include an S3 gallop, tachycardia, pulmonary rales, and
signs of poor peripheral perfusion.
e. Mitral valve prolapse. A midsystolic click followed by a late
systolic murmur suggests mitral valve prolapse. A click or mur-
26. HEART MURMUR 163
REFERENCES
Banning AP: Valvular disease: The GP’s key role. Practitioner 1999;243:740.
Braunwald E, Perloff JK: Physical examination of the heart and circulation. In: Braun-
wald E, Zipes DP, Libby P, eds. Heart Disease: A Textbook of Cardiovascular Medi-
cine. 6th ed. Saunders;2001:45.
DeGowin RL, Brown DD: DeGowin’s Diagnostic Examination. 7th ed. McGraw-
Hill;2000:247.
Maisel A: B-type natriuretic peptide levels: Diagnostic and prognostic in congestive
heart failure. What’s next? Circulation 2002;105:2328.
IV. Database
A. Physical examination key points
1. Vital signs. Including orthostatic blood pressure and heart rate.
Orthostatic changes are a decrease in systolic blood pressure of
10 mm Hg and/or an increase in heart rate of 20 bpm 1 minute
after changing from supine to standing position. Vital signs need
to be checked frequently until the patient is stable.
168 I: ON-CALL PROBLEMS
V. Plan
A. Monitoring. The first step in management is to determine whether
the patient should be monitored in an ICU. The following are guide-
lines for admission to the ICU.
1. Clearly documented frank hematemesis.
2. Coffee-ground emesis and either melena or hematochezia.
3. Hemodynamic instability, either hypotension, tachycardia, or or-
thostatic hypotension.
4. A drop in hematocrit of 5 points after fluid resuscitation.
5. A significant unexplained increase in the BUN when GI bleeding
is suspected.
6. High-risk patient: advanced age, inpatient status at time of bleed,
recurrent or evidence of persistent bleeding, major comorbidity
(hepatic, renal, pulmonary, or cardiac disease).
B. Volume resuscitation. If massive bleeding is evident, place two
large-bore (14- or 16-gauge) IV lines. Begin IV fluids containing nor-
170 I: ON-CALL PROBLEMS
REFERENCES
Besson I, Ingrand P, Person B et al: Sclerotherapy with and without octreotide for acute
variceal bleeding. N Engl J Med 1995;333:555.
Cappell MS, ed: High risk gastrointestinal bleeding, Part I. Gastroenterol Clin North Am
2000;29:1.
Cappell MS, ed: High risk gastrointestinal bleeding, Part II. Gastroenterol Clin North Am
2000;29:275.
Consensus Conference: Therapeutic endoscopy and bleeding ulcers. JAMA
1989;262:1369.
Gisbert JP, Gonzalez L, Calvet X et al: Proton pump inhibitors versus H2-antagonists:
A meta-analysis of their efficacy in treating bleeding peptic ulcer. Aliment Pharmacol
Ther 2001;15:917.
Khuroo MS, Yattoo GN, Javid G et al: A comparison of omeprazole and placebo for
bleeding peptic ulcer. N Engl J Med 1997;336:1054.
Laine L, Cook D: Endoscopic ligation compared with sclerotherapy for treatment of
esophageal variceal bleeding: A meta-analysis. Ann Intern Med 1995;123:280.
28. HEMATOCHEZIA 171
28. HEMATOCHEZIA
I. Problem. A 38-year-old man comes to the emergency room and states,
“I have just passed a lot of blood from my bowels.”
II. Immediate Questions
A. What are the patient’s vital signs? Is there supine hypotension (indi-
cates 30% volume loss)? Is there resting tachycardia (indicates 20%
volume loss)? Are there orthostatic changes in his pulse or blood pres-
sure (indicates 10% volume loss)? If the patient has supine hypoten-
sion or resting tachycardia, resuscitation must begin immediately.
B. Does the patient have IV line access? With no indication of hemo-
dynamic instability, one 16- to 18-gauge IV line is adequate. In the
presence of hemodynamic compromise, two large-bore IVs should
be in place.
C. Is there a history of previous gastrointestinal (GI) bleeding? Ask
about a history of diseases associated with lower GI bleeding, such
as diverticular disease, colon polyps or carcinoma, inflammatory
bowel disease, hemorrhoids, and other anal diseases. Inquire about
prior upper GI bleeding and also peptic ulcer disease (PUD).
D. What medications is the patient taking? Ask specifically about
steroids, nonsteroidal anti-inflammatory drugs (NSAIDs), and antico-
agulants.
E. Does the patient have a history of alcohol abuse? This suggests
the possibility of an upper GI source of bleeding such as varices or
gastritis.
F. What is the most recent hematocrit? Obtain this information from
previous visits. This will establish the baseline value with which to
compare future hematocrits.
G. What is the volume of bright red blood per rectum? Ask the
nurse to save the specimen or specimens for your inspection. This is
important for establishing the presence and volume of blood loss. A
large volume of blood suggests the need for immediate action.
H. Has there been hematemesis? Acute severe upper GI blood loss
may result in hematochezia.
III. Differential Diagnosis
A. Anorectal (hemorrhoids/fissures/rectal ulcers). These account for
4% of all episodes of hematochezia and are usually not brought to
172 I: ON-CALL PROBLEMS
can detect very slow bleeding (0.5 mL/min). Localization is only fair
and needs to be documented with endoscopy or angiography.
6. Angiography. Localization is very good, but patients must be
bleeding fairly rapidly (1–2 mL/min) for the source to be detected
by angiography. This procedure can also treat with selective intra-
arterial infusion of vasopressin.
V. Plan
A. Monitoring. The primary question in managing bleeding patients is
the necessity of ICU monitoring. The following are guidelines for ad-
mission to the ICU:
1. Clearly documented frank hematochezia (> 100 mL).
2. Coffee-ground emesis or positive NG aspirate and hematochezia.
3. Any indication of hemodynamic instability (tachycardia, hypoten-
sion, or orthostasis).
4. Drop in hematocrit > 5 percentage points after fluid resuscitation.
5. Significant increase in BUN when GI bleeding is suspected.
6. High-risk patient: advanced age, inpatient status at time of bleed,
recurrent or evidence of persistent bleeding, major comorbidity
(hepatic, renal, pulmonary, or cardiac disease).
B. Volume resuscitation. If massive bleeding is evident, place two
large-bore (18-gauge or larger) peripheral or central lines. Begin IV
fluids containing normal saline at a rate to maintain hemodynamic
stability. With massive bleeding, transfuse PRBCs when available.
Blood should be given to maintain a hematocrit above 30%.
C. Surgical consultation. Contact early in the management, especially
if brisk bleeding is encountered.
D. Establish source of bleeding. The source of bleeding must be
identified to institute specific therapy.
1. If bleeding is brisk, start with NG aspirate. If positive, evaluate for
upper GI source. If negative, proceed with colonoscopy. If en-
doscopy is negative and bleeding remains brisk, proceed to an-
giography and then bleeding scan. Angiography may also be a
therapeutic modality. If all tests fail to reveal the site, and the
bleeding remains brisk, then the patient requires laparotomy. A
negative NG aspirate for blood should not dissuade evaluation of
the upper GI tract for the bleeding source (usually by upper GI en-
doscopy) before surgical exploration for hematochezia.
2. If the bleeding has stopped and the NG aspirate is negative, pro-
ceed first with colonoscopy after prep. Colonoscopy is rarely help-
ful during brisk bleeding. If the colonoscopy is negative, do an
upper GI endoscopy and then angiography. Note: If at any point
the patient becomes unstable and is difficult to stabilize with IV
fluids and blood, surgery is indicated.
3. The tempo of the evaluation is dictated by the rate of the patient’s
bleeding and overall stability.
29. HEMATURIA 175
REFERENCES
Brandt LJ, Boley SJ: Intestinal ischemia. In: Feldman M, Friedman LS, Sleisenger MH,
eds. Gastrointestinal and Liver Diseases Pathophysiology/Diagnosis/Management.
7th ed. Saunders;2004:2321.
Cappell MS, ed: High risk gastrointestinal bleeding, Part I. Gastroenterol Clin North Am
2000;29:1.
Cappell MS, ed: High risk gastrointestinal bleeding, Part II. Gastroenterol Clin North Am
2000;29:275.
Dusold R, Burke K, Carpentier W, Dyck WP: The accuracy of technetium-99m-labeled
red cell scintigraphy in localizing gastrointestinal bleeding. Am J Gastroenterol
1994;89:345.
Jensen DM, Machicado GA: Diagnosis and treatment of severe hematochezia: The role
of urgent colonoscopy after purge. Gastroenterology 1988;95:1569.
Jensen DM, Machicado GA, Jutabha R et al: Urgent colonoscopy for the diagnosis and
treatment of severe diverticular hemorrhage. N Engl J Med 2000;340:78.
Rockey DC: Gastrointestinal bleeding. In: Feldman M, Friedman LS, Sleisenger MH,
eds. Gastrointestinal and Liver Diseases: Pathophysiology/Diagnosis/Management.
7th ed. Saunders;2002:211.
Rogers BH. Endoscopic diagnosis and therapy of mucosal vascular abnormalities of
the gastrointestinal tract occurring in elderly patients and associated with cardiac,
vascular, and pulmonary disease. Gastrointest Endosc 1980;26:134.
Zuccaro G Jr: Management of the adult patient with acute lower gastrointestinal bleed-
ing. Am J Gastroenterol 1998;93:1202.
Zuckerman DA, Bocchini TP, Birnbaum EH: Massive hemorrhage in the lower gastroin-
testinal tract in adults: Diagnostic imaging and intervention. AJR Am J Roentgenol
1993;161:703.
Zuckerman GR, Prakash C: Acute lower intestinal bleeding. Part II: Etiology, therapy,
and outcomes. Gastrointest Endosc 1999;49:228.
29. HEMATURIA
I. Problem. A 51-year-old man has red blood cells noted on urinalysis 3
days after undergoing a total hip replacement.
3. Infections
a. Pyelonephritis
b. Tuberculosis. Characterized by sterile pyuria.
4. Malformations
a. Cystic. Familial polycystic kidney disease, ruptured solitary
cysts, medullary sponge kidney.
b. Vascular. Suggested by findings of hemangiomas or telang-
iectasias elsewhere.
5. Neoplasms. Particularly renal cell carcinoma and more rarely
transitional cell carcinoma.
6. Ischemia
a. Embolism. Aortic atherosclerosis, cardiac arrhythmias, ma-
nipulation of the aorta (aortography, coronary angiography).
b. Thrombosis. Nephrotic syndrome, neoplastic disease, coagu-
lation disorders (antithrombin III, protein-C or protein-S defi-
ciencies, lupus anticoagulant, and factor V Lieden).
7. Trauma
C. Postrenal
1. Mechanical
a. Kidney stones. Nephrolithiasis and urolithiasis.
b. Obstruction. Prostatic hypertrophy (common cause in men
over 50 years), posterior urethral valves, retroperitoneal fibro-
sis, ureteropelvic junction abnormalities, strictures.
2. Inflammatory. Infection or regional inflammation.
a. Periureteritis. Diverticulitis, pelvic inflammatory disease.
b. Cystitis. Infectious or inflammatory, such as cyclophos-
phamide-induced hematuria, which is a medical emergency.
c. Prostatitis
d. Urethritis
3. Neoplasm. Transitional cell carcinoma, adenocarcinoma of the
prostate, squamous cell carcinoma of the penis.
4. Exercise. Especially in marathon runners.
D. False hematuria
1. Vaginal/rectal bleeding
2. Factitious. Most common in patients demonstrating drug-seeking
behavior and requesting narcotics for nephrolithiasis.
IV. Database
A. Physical examination key points
1. Abdomen. Examine for palpable masses indicative of tumors,
polycystic kidneys, or diverticular abscess. Tenderness accompa-
nies infection, infarction, sickle cell crisis, inflammatory
processes, and obstruction.
2. Urethral meatus. Look for gross blood, especially in trauma pa-
tients, and evidence of recent instrumentation or superficial le-
sions.
178 I: ON-CALL PROBLEMS
V. Plan. Treatment depends on the cause. Keep in mind that apart from
gross hematuria with or without clots (trauma, severe coagulopathy, cy-
clophosphamide-induced hematuria), the causes of hematuria are rarely
emergencies; a thoughtful and careful evaluation can therefore be pur-
sued over several days.
A. Urinary tract infection. See Section I, Chapter 20, Dysuria, V, p
126. The infection must be eradicated and a repeat urinalysis per-
formed to rule out continued hematuria. If hematuria persists, further
evaluation is necessary.
B. Urolithiasis. If the stone is expected to pass spontaneously (usually
< 1 cm) and there are no complicating factors (infection, obstruction),
expectant therapy with analgesics and hydration is appropriate. The
urine should be strained.
C. Neoplasms. A complete urologic evaluation is recommended for as-
sessing gross hematuria.
D. Tuberculosis. Treat appropriately with antibiotics. Initial therapy is
usually with isoniazid (INH) 300 mg PO Q day, rifampin 600 mg PO Q
day, and pyrazinamide 15–30 mg/kg with a maximum dose of 2 g Q
day and ethambutol 15–25 mg/kg/day. The American Thoracic Soci-
ety and the Centers for Disease Control and Prevention recommend a
four-drug regimen for treatment until the results of drug susceptibility
studies are available; or unless there is < 4% primary resistance to
INH within the community. If so, an initial three-drug regimen is rec-
ommended. Long-term follow-up with IV pyelograms is necessary, be-
cause strictures are late sequelae and can lead to obstruction.
E. Collecting system abnormality. Usually requires surgical referral
and repair.
F. Coagulopathy. Correct clotting factor deficiencies or adjust antico-
agulant dose. Frequently, the coagulopathy induces bleeding from a
preexisting abnormality. A thorough evaluation is usually indicated in
a patient who has hematuria and a coagulopathy.
G. Glomerulonephritis. Most cases require a biopsy for definitive diag-
nosis, with therapy as appropriate for the underlying illness.
H. Hemorrhagic cystitis. Treat with continuous saline irrigation and oc-
casionally a 1% alum irrigation. Also, hyperbaric oxygen can be
180 I: ON-CALL PROBLEMS
REFERENCES
Cohen RA, Brown RS: Clinical practice, microscopic hematuria. N Engl J Med
2003;48:2330.
Mazhari R, Kimmel PL: Hematuria: An algorithmic approach to finding the cause. Cleve
Clin J Med 2002;69:870.
Miller OF, Rineer SK, Reichard SR et al: Prospective comparison of unenhanced spiral
computed tomography and intravenous urogram in the evaluation of acute flank pain.
Urology 1998;52:982.
30. HEMOPTYSIS
I. Problem. A 60-year-old male smoker comes to the emergency room
complaining of “spitting up blood” for 1 week.
2. Autoimmune diseases
a. Wegener’s granulomatosis. Look for renal changes (red cell
casts, hematuria, proteinuria) and sinus disease. The chest x-
ray often is abnormal. Bilateral nodular densities and cavita-
tion are common.
b. Goodpasture’s syndrome. This disease also involves the
kidney. Proteinuria, hematuria, and red cell casts may be pre-
sent. Diffuse alveolar infiltrates are often present.
c. Systemic lupus erythematosus (SLE). Lupus more fre-
quently involves the pleura, but patients may develop life-
threatening hemoptysis from lupus pneumonitis.
IV. Database
A. Physical examination key points
1. Vital signs. Look particularly for fever and signs of impending
respiratory failure: respiratory rate above 30 per minute, abdomi-
nal paradox with inspiration, and accessory muscle use.
2. HEENT. Look carefully for a nasal or oropharyngeal source of
bleeding.
3. Chest. Inspect and palpate for signs of trauma such as rib or clav-
icle fractures. Listen for a pleural rub, localized rales, or signs of
consolidation.
4. Heart. An irregularly irregular pulse signifies atrial fibrillation and
suggests mitral stenosis as a possible cause. Pulmonary embolus
can also cause atrial fibrillation. An S3 and jugular venous disten-
tion suggest congestive heart failure as a possible cause. Always
listen carefully for the low diastolic rumble of mitral stenosis at the
apex with the bell.
5. Abdomen. Palpate the epigastrium, liver, and spleen. Peptic
ulcer disease or alcoholic liver disease could certainly cause GI
bleeding, which might mimic hemoptysis.
6. Extremities. Examine lower extremities for signs of deep venous
thromboses or edema. Look for cyanosis and clubbing. Clubbed
fingers associated with hemoptysis generally imply either
bronchiectasis or a pulmonary neoplasm.
7. Skin. Inspect the skin for petechiae, ecchymoses, angiomata, and
rashes.
B. Laboratory data
1. Complete blood count. May reveal an anemia that could be caused
by hemoptysis or, more likely, is related to hemoptysis. A normocytic
anemia with a normal or low reticulocyte count may be secondary to
anemia of chronic disease (eg, cancer). An elevated reticulocyte
count indicates hemolytic anemia possibly secondary to SLE. An iron
deficiency may indicate Goodpasture’s syndrome.
2. Platelet count, prothrombin time, and partial thromboplastin
time. All are indicated to rule out coagulopathy as a cause. See
30. HEMOPTYSIS 183
V. Plan
A. Intensive care unit
1. Massive hemoptysis
2. Present or impending hypoxemic or hypercarbic respiratory
failure
B. Establish IV access. Death comes from asphyxia rather than hem-
orrhage, but IV medications are needed.
C. Always protect the airway. This may require early intubation.
D. Correct any coagulopathy. See Section I, Chapter 12, Coagulopa-
thy, V, p 73.
E. Fiberoptic bronchoscopy. Arrange early if the diagnosis is in doubt
or hemoptysis continues.
F. Consult. Obtain a thoracic surgery consultation if the patient has
massive or continuous hemoptysis. Medical management of massive
hemoptysis is associated with a high mortality rate.
G. Cough suppression. Retard the cough reflex with codeine-based
drugs, and place the patient on quiet bed rest.
H. Treat the underlying disease state
1. Lung cancer. Can be treated surgically if there are no metas-
tases and the pulmonary reserve is adequate. Otherwise, radia-
tion or laser therapy can rapidly control bleeding.
2. Infections. Treat with antibiotics as dictated by Gram’s stain and
clinical picture. If a necrotizing pneumonia is present, consider
methicillin-resistant Staphylococcus aureus or Pseudomonas in-
fection and treat accordingly.
3. Pulmonary emboli. Treat acutely with heparin. See Section I,
Chapter 11, Chest Pain, V, p 66.
4. Diffuse alveolar hemorrhage or a pulmonary-renal syndrome.
1000 mg methylprednisolone (Solu-Medrol) IV may control bleed-
ing, pending definitive workup.
5. Nonsurgical patients with localized bleeding. Bronchial arteri-
ography followed by embolism may be lifesaving. However, collat-
eral circulation to the spinal arteries or carotids must be excluded
before embolization.
REFERENCES
Cahil BC, Ingbar DH: Massive hemoptysis-assessment and management in clinics. Clin
Chest Med 1994;15:147.
Ryu JH, Swensen SJ, Olson EJ et al: Diagnosis of pulmonary embolism with use of
computed tomographic angiography. Mayo Clin Proc 2001;76:59.
31. HYPERCALCEMIA 185
31. HYPERCALCEMIA
I. Problem. A 60-year-old man is admitted for severe diffuse bone pain
and is found to have a calcium level of 5.5 mEq/L or 2.75 mmol/L (nor-
mal: 4.2–5.1 mEq/L or 2.10–2.55 mmol/L).
REFERENCES
Case Records of the Massachusetts General Hospital (Case 38-2002). N Engl J Med
2002;347:1952.
Edelson GW, Kleerekoper M: Hypercalcemic crisis. Med Clin North Am 1995;79:79.
Marx SJ: Hyperparathyroid and hypoparathyroid disorders. N Engl J Med
2000;343:1863.
Mundy GR, Guise TA. Hypercalcemia of malignancy. Am J Med 1997;103:134.
Popovtzer MM: Disorders of calcium, phosphorus, vitamin D and parathyroid hormone
activity. In: Schrier RW, ed. Renal and Electrolyte Disorders. 6th ed. Lippincott-
Raven;2003:216.
190 I: ON-CALL PROBLEMS
32. HYPERGLYCEMIA
I. Problem. A 44-year-old man is admitted because of chest pain. His glu-
cose is 428 mg/dL, or 23.79 mmol/L.
II. Immediate Questions
A. What are the patient’s vital signs? Fever may indicate sepsis,
which can exacerbate hyperglycemia. Hypotension or tachycardia
may indicate volume depletion common in diabetic ketoacidosis
(DKA) and hyperosmolar syndromes. Tachypnea may be due to
Kussmaul respirations in DKA.
B. Is the patient known to be diabetic? A history of diabetes should
make the clinician consider factors such as noncompliance with med-
ication/diet, sepsis, acute stress, glucocorticoid use, and myocardial
infarction (MI), which can result in poor control of hyperglycemia. The
absence of a history of diabetes should make one consider all of the
preceding factors as unmasking latent carbohydrate intolerance, as
well as the possibility of laboratory error.
C. If the patient is diabetic, what medications is he or she taking and
when was the last meal in relation to the time of phlebotomy? Be-
fore one modifies the regimen, it is important to know whether the pa-
tient is receiving large or small amounts of insulin and whether he or
she is receiving oral hypoglycemic agents. In addition, it is important to
know whether the blood sugar was drawn randomly (and therefore
could be postprandial) or whether it represents a fasting level.
III. Differential Diagnosis
A. Diabetes mellitus
1. Type 1 (previously called juvenile diabetes or insulin-depen-
dent diabetes). Patients with type 1 diabetes require insulin even
when not eating, although in lower doses. They are more likely to
be thin or normal in weight, young, and “brittle” and are prone to
DKA. Diabetic ketoacidosis may be defined as a blood sugar level
> 300 mg/dL (16.68 mmol/L), urine ketones that are strongly posi-
tive, and a serum bicarbonate < 17 mmol or a pH < 7.30.
2. Type 2 (previously called adult-onset diabetes or non–in-
sulin-dependent diabetes mellitus). Patients with type 2 dia-
betes tend to be obese and older and are more prone to
hyperosmolar hyperglycemic syndromes than to ketoacidosis.
Weight loss may normalize carbohydrate metabolism initially.
Some patients can be managed with diet and exercise alone, al-
though data from the United Kingdom Prospective Diabetes Study
indicate that type 2 diabetes usually progresses to require oral
agents and eventually insulin.
3. Gestational diabetes. Glucose intolerance associated with preg-
nancy. Close monitoring and tight control are important to improve
outcome of mother and infant.
32. HYPERGLYCEMIA 191
IV. Database
A. Physical examination key points
1. Vital signs. Include orthostatic blood pressure and pulse to eval-
uate volume status. A decrease in systolic blood pressure of 10
mm Hg and/or an increase in heart rate of 20 bpm suggest vol-
ume depletion in younger patients. In patients over 75 years there
may be up to 25 mm systolic orthostatic drop normally, and a
pulse increase of 16 bpm signifies volume depletion. Fever im-
plies sepsis. Kussmaul respirations (deep, regular respirations,
whether slow or fast) suggest DKA.
2. HEENT. Fruity odor on breath suggests ketones and DKA. Fun-
duscopic exam may show diabetic retinopathy, which suggests
long-standing disease and increases the likelihood of other dia-
betic complications such as nephropathy and neuropathy.
3. Lungs. Evaluate for signs of pneumonia. Follow-up lung exams
for rales are important in assessing volume.
4. Heart. Listen for associated findings of ischemia/MI, such as a third
(S3) or fourth (S3) heart sound, or murmur of mitral insufficiency.
5. Peripheral vascular system. Listen for bruits.
6. Abdomen. Evaluate for cause of sepsis. Rebound tenderness
suggests peritonitis. A positive Murphy’s sign (see Section I,
Chapter 1, Abdominal Pain, p 1) suggests acute cholecystitis,
which is more common in diabetics.
7. Extremities. Check for foot ulcers and cellulitis.
8. Neurologic exam. A clouded sensorium suggests more severe
disease (ketoacidosis or hyperosmolar syndrome).
B. Laboratory data
1. Serum glucose. Significantly elevated finger-stick glucose should
be further evaluated with a serum glucose.
192 I: ON-CALL PROBLEMS
REFERENCES
American Diabetes Association: Clinical practice recommendations. Diabetes Care
2001;24(entire suppl 1).
American Diabetes Association: Standards of medical care for patients with diabetes
mellitus. Diabetes Care 2000;23(suppl 1):S32.
Brown G. Dodek P: Intravenous insulin nomogram improves blood glucose control in
the critically ill. Crit Care Med 2001;29:1714.
DeFronzo RA: Pharmacologic therapy for type 2 diabetes mellitus. Ann Intern Med
1999;131:281.
Finney SJ, Zekveld C, Elia A, Evans TW: Glucose control and mortality in critically ill
patients. JAMA 2003;15;290:2041.
Lebovitz HE: Oral therapies for diabetic hyperglycemia. Endocrinol Metab Clin North
Am 2001;30:909.
Nathan DM: Clinical practice. Initial management of glycemia in type 2 diabetes melli-
tus. N Engl J Med 2002;347:1342.
The Diabetes Control and Complications Trial Research Group: The effect of intensive
treatment of diabetes on the development and progression of long-term complica-
tions in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977.
33. HYPERKALEMIA
I. Problem. A 64-year-old man with diabetes admitted for a myocardial in-
farction is found to have a potassium (K+) level of 7.1 mmol/L.
IV. Database
A. Physical examination key points
1. Cardiovascular exam. The conduction system of the heart is
most vulnerable to hyperkalemia, which may result in bradycardia,
ventricular fibrillation, or asystole.
2. Neuromuscular exam. Skeletal muscle paralysis may occasion-
ally dominate and result in weakness, tingling, and hyperactive
deep tendon reflexes.
B. Laboratory data
1. Electrolytes. Low bicarbonate may indicate a metabolic acidosis.
Low sodium may result from aldosterone deficiency.
2. Plasma potassium. Obtain if the serum level is in doubt.
3. Blood urea nitrogen (BUN) and creatinine. Assess renal func-
tion.
4. Arterial blood gases (ABG). Along with a serum bicarbonate, an
ABG is essential in establishing the acid–base status.
5. Platelets and white blood cell count. Marked elevations may
cause factitious hyperkalemia.
6. Serum creatine phosphokinase. To detect rhabdomyolysis.
7. Digoxin level. If indicated.
8. Serum aldosterone level. Indicated after initial workup. Lack of
stimulation with volume depletion is consistent with mineralocorti-
coid deficiency.
C. Other studies. An ECG is a must! The cardiac abnormalities that
occur with hyperkalemia are initially tall, peaked T waves in the pre-
cordial leads, followed by decreased amplitude of the R wave,
widened QRS complex, prolongation of the PR interval, and then de-
creased amplitude and disappearance of the P wave. Finally, the
QRS blends into the T wave, forming the classic sine wave. Ventricu-
lar fibrillation and asystole may follow.
REFERENCES
Acker CG, Johnson JP, Palevsky PM et al: Hyperkalemia in hospitalized patients. Arch
Intern Med 1998;158:917.
Black RM : Disorders of acid base and potassium balance. In: Dale DC, ed. ACP Medi-
cine 2001. Section 10, Nephrology.
Greenberg S, Reiser IW, Chou S-Y et al: Trimethoprim-sulfamethoxazole induces re-
versible hyperkalemia. Ann Intern Med 1993;119:291.
Perazella MA: Drug-induced hyperkalemia: Old culprits and new offenders. Am J Med
2000;109:307.
Perazella MA, Mahnensmith RL: Hyperkalemia in the elderly. J Gen Intern Med
1997;12:646.
Velazquez H, Perazella MA, Wright FS et al: Renal mechanism of trimethoprim induced
hyperkalemia. Ann Intern Med 1993;119:296.
34. HYPERNATREMIA
I. Problem. The clinical chemistry lab calls to tell you that the 65-year-old
female patient admitted with pneumonia has a serum sodium of 155
mmol/L (normal: 136–145 mmol/L).
II. Immediate Questions
A. Is the patient awake, alert, and oriented? Or, is the patient
lethargic and confused? The major signs and symptoms of hyper-
natremia are lethargy, which may lead to coma or convulsions; and
neuromuscular irritability, including tremors, rigidity, and hyper-
reflexia. Mortality and symptoms are related to the level and acuity of
the hypernatremia. Mortality in adults is increased with the sodium
levels above 160 mmol/L.
202 I: ON-CALL PROBLEMS
IV. Database
A. Physical examination key points
1. Vital signs. Check for orthostatic changes in blood pressure and
heart rate. A decrease in systolic blood pressure of 10 mm Hg
and/or an increase in heart rate of 20 bpm 1 minute changing
from a supine to a standing position points to volume depletion.
Also, a decrease in weight suggests volume depletion.
2. Skin. Check turgor; poor turgor suggests volume depletion. Re-
member that poor skin turgor can be a normal variant in the elderly.
3. Mouth. Dry mucous membranes suggest volume depletion.
4. Neurologic exam. Look for signs of irritability, muscle twitching, hy-
perreflexia, or seizures. A thorough neurologic examination needs
to be done, since CNS trauma, infection, or tumor can cause DI.
B. Laboratory data
1. Serum sodium. Normal 136–145 mmol/L. Follow closely, espe-
cially if sodium is > 160 mmol/L.
2. Urine osmolality. > 700 mOsm/L suggests insufficient water intake
with or without extrarenal water losses or an osmoreceptor defect.
A urine osmolality between 700 mOsm/L and the serum osmolality
suggests partial central DI, osmotic diuresis, diuretic therapy, ac-
quired (partial) nephrogenic DI, or renal failure. A urine osmolality <
serum osmolality suggests complete central DI or nephrogenic DI.
3. Spot urine sodium. In hypernatremia with water and sodium
loss, a level < 20 mmol/L suggests extrarenal loss. In hyperna-
tremia with water loss without loss of sodium, the spot sodium in
extrarenal losses is variable.
4. Water deprivation/vasopressin. If you suspect DI. The patient is
fluid-deprived until the plasma osmolality is 295 mOsm/kg or
greater; or if, on three consecutive hourly urines, the osmolality
does not increase; or, if the patient loses 3% to 5% of his or her
body weight. Five units of aqueous vasopressin is then given, ei-
ther IM or SC.
a. Normal subjects. Urine concentrates with fluid deprivation
and no change occurs with vasopressin.
b. Complete central DI. Urine does not concentrate with fluid
deprivation. There is a significant increase in urine osmolality
after vasopressin.
c. Nephrogenic DI. Urine does not concentrate with deprivation,
and there is no change in urine osmolality with vasopressin.
C. Radiologic and other studies. A computed tomography scan of the
head to rule out a CNS lesion may be helpful if central DI is sus-
pected.
35. HYPERTENSION 205
V. Plan. The overall plan is to slowly decrease the serum sodium toward
normal. Only hyperacute hypernatremia (hypernatremia < 12 hours) may
be treated rapidly. Too rapid a correction of the sodium in hypernatremia
may result in cerebral edema, seizures, and herniation, leading to death.
The rate of correction of the sodium should not exceed 0.7 mmol/L/hr or
about 10% of the serum sodium concentration per day. Specific treat-
ment depends on whether there is a loss of sodium and water, a loss of
water, or an increase in total body sodium.
A. Water and sodium loss. Represents significant volume depletion. With
shock, replenish volume with normal saline. If the patient is hemodynam-
ically stable, replace volume with hypotonic saline (half-normal saline).
B. Water loss without loss of sodium. Calculate the free water deficit:
Weight (kg) × 0.60 = total body water
Water deficit = total body water × 1 −[desired (Na1)/Measured (Na+)]
Give half of the calculated free water deficit in the first 12 hours and
the remainder in the next 24 hours. Include maintenance fluids.
C. Increase in total body sodium. Remove excess sodium, either by
giving free water and diuretics or by dialysis with hypotonic dialysate.
D. Treatment of underlying cause
1. Central DI. After correction of free water deficit, begin vasopressin.
2. Diabetes mellitus. Treat with insulin and IV fluids (see Section I,
Chapter 32, Hyperglycemia, V, p 193).
3. Nephrogenic DI. After correction of free water deficit, begin thi-
azide diuretic and low-salt diet. Remove offending agent, if appro-
priate.
REFERENCES
Adrogue HJ, Madias NE: Hypernatremia. N Engl J Med 2000;342:1493.
Berl T, Schrier RW: Disorders of water metabolism. In: Schrier RW, ed. Renal and
Electrolyte Disorders. 6th ed. Lippincott-Raven;2003:1.
Palvevsky PM, Bhagrath R, Greenberg A: Hypernatremia in hospitalized patients. Ann
Intern Med 1996;124:197.
35. HYPERTENSION
I. Problem. A 37-year-old woman complains of having a severe occipital
headache for the past 6 hours. Her blood pressure is 220/140.
10. Drugs
a. Estrogens
b. Other prescription medications. Cyclosporine, nonsteroidal
anti-inflammatory drugs, corticosteroids, and erythropoietin oc-
casionally cause hypertension.
c. Over-the-counter medications containing sympath-
omimetics. For example, decongestants (pseudoephedrine)
and weight loss medications (ephedrine and ephedra) may el-
evate the blood pressure.
d. Illicit drugs. Phencyclidine (PCP), amphetamines, and co-
caine.
11. Postoperative conditions. Multifactorial, including hypoxia,
pain, anxiety, volume overload, hypothermia, and medications.
12. Gestational
13. Hyperparathyroidism
C. Miscellaneous diseases. Other diseases can cause a marked ele-
vation in blood pressure; or they may be the consequence of long-
standing, poorly controlled hypertension.
1. Cerebrovascular accident. If the patient has had a stroke result-
ing in marked elevation of blood pressure, the physician is not
quite as aggressive in lowering the blood pressure. A sudden
marked drop in blood pressure can extend a stroke, so blood pres-
sure should be lowered cautiously in the acute phase of stroke.
2. Subarachnoid hemorrhage. Patients classically complain of the
worst headache of their life.
3. Aortic dissection. “Tearing” chest pain, often radiating to the
back, and most severe at onset. There is usually a history of hy-
pertension.
4. Congestive heart failure/pulmonary edema
5. Angina pectoris/myocardial infarction. See Section I, Chapter
11, Chest Pain, p 60.
D. Accelerated hypertension. Markedly elevated blood pressure with
no current life-threatening problem secondary to the hypertension.
E. Malignant hypertension. Usually a markedly elevated blood pres-
sure with an associated serious complication, such as hypertensive
encephalopathy, angina pectoris, myocardial infarction, aortic dissec-
tion, or cerebrovascular accident; proteinuria, hematuria, and red
blood cell casts may be present.
IV. Database
A. Physical examination key points
1. Vital signs. Take blood pressure in both arms, feel both radial
pulses, and check for a radial-femoral pulse lag. Such maneuvers
may point to aortic dissection or coarctation.
2. Eyes. Look for evidence of papilledema, hemorrhages, exudates,
severe arteriolar narrowing, and arteriovenous nicking. Pa-
208 I: ON-CALL PROBLEMS
V. Plan
A. Hypertensive emergency. Treatment must be initiated within min-
utes if possible. Hospitalization and parenteral drug therapy is neces-
sary.
1. Admission to an ICU. Intravenous (IV) and arterial lines should
be placed.
2. Appropriate therapy. Initiated once therapeutic goals are estab-
lished. The goal of immediate therapy is to reduce mean arterial
35. HYPERTENSION 209
REFERENCES
Coates ML, Rembold CM, Farr BM: Does pseudoephedrine increase blood pressure in
patients with controlled hypertension? J Fam Pract 1995;40:22.
Kaplan NM: Clinical Hypertension. 6th ed. Williams & Wilkins;1994.
The Seventh Report of the Joint National Committee on Detection, Evaluation, and
Treatment of High Blood Pressure. JAMA 2003;289,2560.
210 I: ON-CALL PROBLEMS
36. HYPOCALCEMIA
I. Problem. A 54-year-old man admitted for an acute myocardial infarction
(MI) has a calcium of 3.5 mEq/L, or 1.75 mmol/L (normal: 4.2–5.1
mEq/L, or 2.10–2.55 mmol/L).
III. Differential Diagnosis. The causes of low ionized serum calcium can
be categorized as parathyroid hormone deficits, vitamin D deficits, and
loss or displacement of calcium.
A. Parathyroid hormone (PTH) deficits
1. Decreased PTH level
a. Surgical excision or injury. Including thyroid surgery.
b. Infiltrative diseases of the parathyroid gland. For example,
hemochromatosis, amyloid or metastatic cancer.
c. Idiopathic
d. Irradiation. To the neck to treat lymphoma.
2. Decreased PTH activity
a. Congenital. Pseudohypoparathyroidism: resistance to PTH at
the tissue level.
b. Acquired. Hypomagnesemia.
B. Vitamin D deficiency
1. Malnutrition
2. Malabsorption
a. Pancreatitis
b. Postgastrectomy
c. Short-gut syndrome
d. Laxative abuse
e. Sprue
f. Hepatobiliary disease with bile salt deficiency
36. HYPOCALCEMIA 211
3. Defective metabolism
a. Liver disease. Failure to synthesize 25-hydroxyvitamin D.
b. Renal disease. Failure to synthesize 1,25-dihydroxyvitamin D.
c. Anticonvulsant treatment with phenobarbital or phenytoin
(Dilantin). Possibly from an increase in the metabolism of vita-
min D in the liver leading to a vitamin D deficiency.
C. Calcium loss or displacement
1. Hyperphosphatemia. Increases bone deposition of calcium.
a. Acute phosphate ingestion
b. Acute phosphate release by rhabdomyolysis or tumor
lysis
c. Renal failure
2. Acute pancreatitis
3. Osteoblastic metastases. Especially breast and prostate can-
cer.
4. Medullary carcinoma of the thyroid. Increased calcitonin.
5. Decreased bone resorption. Overuse of actinomycin, calcitonin,
or mithramycin.
6. Miscellaneous disorders. Sepsis, massive transfusion, hungry
bone syndrome, toxic shock syndrome, and fat embolism.
IV. Database
A. Physical examination key points
1. Skin. Dermatitis with chronic hypocalcemia.
2. HEENT. Cataracts with chronic hypocalcemia. Laryngospasm is
rare but life-threatening. Look for surgical scars on the neck.
3. Neuromuscular exam. Confusion, spasm, twitching, facial gri-
macing, and hyperactive deep tendon reflexes all indicate symp-
tomatic hypocalcemia.
4. Specific tests for tetany of hypocalcemia
a. Chvostek’s sign. Present in 5–10% of normocalcemic pa-
tients. Tapping on the facial nerve near the zygoma will elicit a
twitch in hypocalcemic patients.
b. Trousseau’s sign. Inflate a blood pressure cuff above the
systolic pressure for 3 minutes and watch for carpal spasm.
B. Laboratory data
1. Serum electrolytes. Particularly calcium, phosphate, potassium,
and magnesium. Calcium must be interpreted in terms of the
serum albumin (see II.B, p 210). Hypomagnesemia and hyper-
kalemia may potentiate the effects of hypocalcemia.
2. Serum albumin. See II.B.
3. Blood urea nitrogen and creatinine. To rule out renal failure.
4. Parathyroid hormone level. A low normal level is inappropriately
low in the presence of true hypocalcemia.
5. Vitamin D levels. 25-hydroxyvitamin D and 1,25-dihydroxyvita-
min D.
212 I: ON-CALL PROBLEMS
REFERENCES
Bushinsky DA, Monk RD: Calcium. Lancet 1998;352:306.
Carlstedt F, Lind L: Hypocalcemic syndromes. Crit Care Clin 2001;17:139.
Marx SJ: Hyperparathyroid and hypoparathyroid disorders. N Engl J Med
2000;343:1863. (See correction of Figure 2: N Engl J Med 2001;344:240.)
37. HYPOGLYCEMIA
I. Problem. A 33-year-old woman was admitted for diabetic ketoacidosis
(DKA) 24 hours ago. The patient’s finger-stick glucose is now 50 mg/dL,
or 2.78 mmol/L.
glucoses are prone to error secondary to strips that have been ex-
posed to air, inappropriate preparation of the finger with povidone-
iodine (Betadine), presence of alcohol on the finger, incorrect
timing, or an uncalibrated machine. In the presence of symptoms,
blood should be obtained immediately, but treatment should not be
withheld pending results or because of a delay in obtaining blood.
2. Electrolytes, blood urea nitrogen and creatinine, liver func-
tion studies, complete blood count, urinalysis. In the setting of
hypoglycemia with no history available, obtain these test results to
evaluate for common causes listed in the differential diagnosis.
3. Drug screens. Look specifically for oral hypoglycemics as well as
for ethanol, salicylates, acetaminophen, and antipsychotics (eg,
haloperidol).
4. Serum insulin. Results may indicate either exogenous insulin ad-
ministration or insulinoma.
5. C-peptide. Helps to differentiate between insulinoma and exoge-
nous insulin administration. The C-peptide level is elevated with
an insulinoma and low with the administration of exogenous in-
sulin.
C. Radiologic and other studies. These may be indicated in specific
circumstances to rule out infection, insulinoma, malignancy, or pitu-
itary lesion.
V. Plan
A. Administer glucose. Do not wait for the results of the serum glu-
cose if you strongly suspect the diagnosis. It is best to draw blood
before administering glucose; however, you should proceed with
treatment if there will be a significant delay before blood can be ob-
tained and the patient is markedly symptomatic. If the patient is
awake and able and willing to take fluids, glucose should be given
orally. Otherwise, administer IV glucose.
1. Orange juice with added sugar is usually readily available. Spe-
cific glucose-containing liquids are stocked on most hospital floors
and may be substituted for orange juice. For mild hypoglycemia, 8
ounces of 2% milk or a package of saltines with juice may be ade-
quate and may not result in “overshoot” hyperglycemia. If glucose
tablets are used, 15–30 g are administered orally.
2. Give 25–50 g (1⁄2 to 1 ampule) of 50% dextrose (D50) IV push; re-
peat in 5 minutes if no response. If there is no response after the
second ampule, the diagnosis should be seriously questioned and
other causes for the symptoms should be considered, such as hy-
poxia, transient ischemic attack, and ethanol or drug intoxication
or overdose.
3. If the patient is unable to take glucose PO, and IV access is not
immediately available, give glucagon 0.5–1 mg IM or SC (may in-
duce vomiting; be prepared to protect the patient’s airway).
38. HYPOKALEMIA 217
REFERENCES
Cryer PE, Davis SN, Shamoon H: Hypoglycemia in diabetes. Diabetes Care
2003;26:1902.
Cryer PE, Fisher JN, Shamoon H: Hypoglycemia. Diabetes Care 1994;17:734.
Service FJ: Hypoglycemia. Endocrinol Metab Clin North Am 1997;26:937.
38. HYPOKALEMIA
I. Problem. A 72-year-old woman with hypertension develops profound
muscle weakness after 3 days of vomiting and diarrhea. Her serum
potassium is 2.5 mmol/L (2.5 mEq/L).
IV. Database
A. Physical examination key points
1. Cardiovascular. Irregular pulse may represent an arrhythmia
(PACs or PVCs), or digitalis toxicity.
2. Abdomen. Look for distention and the presence of bowel sounds.
Ileus secondary to hypokalemia may be present. Abdominal ex-
amination may reveal a cause of vomiting.
3. Neurologic exam. Weakness, blunting of reflexes, paresthesias,
and paralysis may be seen.
B. Laboratory data
1. Serum electrolytes. Hypomagnesemia may coexist or may
cause the hypokalemia.
2. Arterial blood gases. Look for alkalosis.
3. Urine potassium, chloride, and sodium. If the patient is not tak-
ing diuretics, a low urine sodium or chloride indicates volume de-
pletion. A relatively high urine potassium in the face of
hypokalemia indicates renal losses.
4. Digoxin level. A must if the patient is on digoxin. Hypokalemia
may potentiate digoxin toxicity.
C. Radiologic and other studies. An electrocardiogram may show dig-
italis effect or manifestations of hypokalemia ranging from PACs and
PVCs to life-threatening ventricular arrhythmias. A U wave is a com-
mon finding.
38. HYPOKALEMIA 221
REFERENCES
Black RM: Disorders of acid base and potassium balance. In: Dale DC, ed. ACP Medi-
cine 2001;Section 10: Nephrology.
Cohn JN, Kowey PR, Whelton PK, Prisant M: New guidelines for potassium replace-
ment in clinical practice. Arch Intern Med 2000;160:2429.
Gennari FJ: Hypokalemia. N Engl J Med 1998;339:451.
39. HYPOMAGNESEMIA
I. Problem. A 40-year-old man complaining of chest pain is admitted to
rule out myocardial infarction. A magnesium level returns at 0.8 mEq/L
(normal: 1.5–2.1 mEq/L).
V. Plan. The urgency of treatment depends on the clinical setting. The pa-
tient who is having neurologic or cardiac manifestations should be
treated urgently with parenteral IV therapy. Asymptomatic individuals
may be treated with oral magnesium, although many clinicians treat
magnesium levels < 1.0 mEq/L with parenteral magnesium even though
there is not always a good correlation between serum levels and intra-
cellular levels.
A. IV magnesium sulfate. Magnesium sulfate 1 g (2 mL of a 50% solu-
tion of MgSO4) equals 98 mg of elemental magnesium, which is
equal to 8 mEq MgSO4 or 4 mmol Mg++. With tetany, status epilepti-
cus, or significant cardiac arrhythmias, then 2 g of magnesium sul-
fate (16 mEq) can be given IV over 10–20 min. For slightly less
39. HYPOMAGNESEMIA 225
REFERENCES
Agus ZS: Hypomagnesemia. J Am Soc Nephrol 1999;10:1616.
Antman EM: Early administration of intravenous magnesium to high-risk patients with
acute myocardial infarction in the Magnesium in Coronaries (MAGIC) Trial: a ran-
domised controlled trial. Lancet 2002;360:1189.
40. HYPONATREMIA
I. Problem. A 50-year-old man is admitted for evaluation of a right pul-
monary hilar mass. The serum sodium is 118 mmol/L (normal: 136–145
mmol/L).
II. Immediate Questions
A. Is the patient symptomatic from the hyponatremia? Patients with
hyponatremia may be asymptomatic, or they may have central ner-
vous system (CNS) symptoms or signs ranging from lethargy,
anorexia, nausea, vomiting, agitation, and headache to marked dis-
orientation, seizures, and death. Muscle cramps, weakness, and fa-
tigue are also common.
B. Are there any recent sodium levels to document the chronicity
of the hyponatremia? The rate of development and magnitude of
hyponatremia correlates directly with the severity of the symptoms.
Acute changes in sodium levels are more likely to produce more se-
vere symptoms.
C. Is there any evidence of volume depletion? Orthostatic changes
in blood pressure and heart rate suggest volume depletion.
D. Does the patient have a history of vomiting or diarrhea? Vomit-
ing and diarrhea can cause wasting of sodium and extracellular fluid,
resulting in hyponatremia.
E. Is there any history of renal disease, congestive heart failure
(CHF), cirrhosis, or nephrotic syndrome? Any of these edema-
tous states suggests an excess of sodium accompanied by an even
greater excess of total body water.
F. Is there any history of hypothyroidism or adrenal insufficiency?
Hypothyroidism and hypoadrenalism cause renal wasting of sodium,
even in the face of hyponatremia.
G. Is the patient taking any medications that could cause the hy-
ponatremia? Diuretics can cause hyponatremia by inducing sodium
deficits in excess of water deficits. Chlorpropamide, clofibrate, nico-
tine, narcotics, cyclophosphamide, vincristine, nonsteroidal anti-in-
flammatory drugs (NSAIDs), antipsychotic medications (eg,
haloperidol and thioridazine), tricyclic antidepressants, selective
serotonin reuptake inhibitors (SSRIs), angiotensin-converting en-
zyme (ACE) inhibitors and anticonvulsants such as carbamazepine
(Tegretol) may cause hyponatremia. Mannitol used to treat elevated
40. HYPONATREMIA 227
SIADH
Hypothyroidism Psychogenic
Extrarenal Renal Pain Cirrhosis Acute & polydipsia
Vomiting Diuretics Pain meds Nephrosis chronic Beer potomania
Lab Error CHF renal failure
Diarrhea Addison’s Other meds
Pseudo Na+ Severe bilat (tubulointerstitial)
Third space Salt waste neph carbamazepine,
Essential Na+ RAS
Burns Med cystic dz HCTZ etc)
Pancreatits Polycystic dz Post Colonoscopy GN (with JG apparatus
( ADH) & tubules intact) BUN/Cr ≤20
Traumatized muscle Chronic int neph
Urine Na+ >20
RTA
FENa+ >1
Cerebral salt waste
Urine Osm—low
BUN/Cr >20 BUN/Cr <20 (appropriately
BUN/Cr >20 BUN/Cr >20 BUN/Cr ≤20 Urine Na+ <20 Urine Na+ >20
Urine Na− <20 Urine Na >20 Urine Na+ >20 FENa+ <1 FENa+ >1
low)
FENa+ <1 FENa >1 FENa+ > 1
Urine Osm-high
Inappropriately
high)
Figure I–4. Differential diagnosis of hyponatremia. ADH, antidiuretic hormone; BUN, blood urea nitrogen;
CHF, congestive heart failure; Chron int neph, chronic interstitial nephritis; Cr, creatinine; GN, glomeru-
lonephritis; HCTZ, hydrochlorothiazide; JG, juxtaglomerular; Med cystic dz, medullary cystic disease;
Pseudo, pseudohyponatremia; RAS, renal artery stenosis; RTA, renal tubular acidosis; SIADH, syndrome
of inappropriate antidiuretic hormone.
40. HYPONATREMIA 229
V. Plan. The cause and the presence and severity of symptoms guide ther-
apy. Aggressive treatment of severe symptoms (eg, coma) is discussed
below, as are specific therapies for certain diagnoses.
A. Emergency treatment. Usually for severe CNS symptoms (eg,
seizures or coma).
1. Normal saline (NS) and furosemide 1 mg/kg. Use a combina-
tion of NS and diuretics to achieve a net negative free water
deficit in hyponatremia associated with euvolemic or hyperv-
olemic conditions. Use NS by itself if the hyponatremia is associ-
ated with volume depletion. Carefully document fluid intake and
output. Supplement fluids with potassium as needed. Too-rapid
correction of sodium can be deleterious, resulting in central pon-
tine myelinolysis. Correct sodium level rapidly (> 1.0 mmol/L/hr) to
120–125 mmol/L; then slowly correct sodium level (< 0.5
mmol/L/hr) over the next 24–48 hours to normal.
For hypovolemic states, calculate the total amount of sodium
required to increase the sodium to a desired level, use the follow-
ing formula:
Sodium required (mmol) =
(desired sodium [Na] − actual serum [Na]) × TBW
REFERENCES
Adrogue HJ, Madias NE: Hypernatremia. N Engl J Med 2000;342:1493.
Ayus CJ, Varon J, Arieff AI: Hyponatremia, cerebral edema, and noncardiogenic pul-
monary edema in marathon runners. Ann Intern Med 2000;132:711.
Berl T, Schrier RW: Disorders of water metabolism. In: Schrier RW, ed. Renal and
Electrolyte Disorders. 6th ed. Lippincott-Raven;2003:1.
Cohen CD, Keuneke C, Schiemann U et al: Hyponatremia as a complication of
colonoscopy. Lancet 2001;357:282.
Fabian TJ, Amico JA, Kroboth PD et al: Paroxetine-induced hyponatremia in older
adults. Arch Intern Med 2004;164:327.
Van Amelsvoort T, Bakshi R, Devaux CV et al: Hyponatremia associated with carba-
mazepine and oxcarbazepine therapy: A review. Epilepsia 1994;35:181.
Weisberg LS: Pseudohyponatremia: A reappraisal. Am J Med 1989;86:315.
41. HYPOPHOSPHATEMIA
I. Problem. A 26-year-old male with type 1 diabetes was admitted 6 hours
ago for treatment of diabetic ketoacidosis (DKA) and now has a serum
phosphate level of 1.0 mg/dL.
II. Immediate Questions
A. Are there any symptoms related to the low phosphate? Serum
phosphate levels below 1.0 mg/dL require prompt treatment regard-
less of symptoms. Above that level, check for symptoms related to
low phosphate, such as numbness or tingling, muscle weakness,
anorexia, confusion, irritability, seizures, and skeletal pain. Muscle
234 I: ON-CALL PROBLEMS
V. Plan. If the phosphate level is < 1.0 mg/dL, start IV replacement therapy
immediately. If the level is 1.0–1.5 mg/dL and the patient is sympto-
matic, start IV replacement therapy. Otherwise, oral treatment is usually
sufficient.
A. Intravenous treatment
1. If the hypophosphatemia is recent and uncomplicated, give 0.08
mmol/kg (2.5 mg/kg) IV over 6 hours. Sodium phosphate and
potassium phosphate IV solutions both contain 3 mmol of phos-
phate per milliliter.
2. If the hypophosphatemia is longstanding or complicated, give
0.16 mmol/kg (5.0 mg/kg) IV over 6 hours.
3. In either case, consider using 25–50% higher doses if the patient
is symptomatic, but do not exceed 0.24 mmol/kg (7.5 mg/kg) or
16.9 mmol (525 mg) for a 70-kg patient.
4. Recheck the phosphate level promptly after the 6-hour infusion,
and reassess the patient’s need for further replacement.
B. Oral replacement
1. Neutra-Phos tablets contain 250 mg phosphorus (8 mmol) per
tablet; Neutra-Phos powder contains 0.1 mmol phosphate per mil-
liliter.
2. Milk contains modest amounts of phosphate. Skim milk has
slightly more phosphate and may be better tolerated for those
who are lactose intolerant (Table I–8).
3. Fleet enema solution and Fleet Phospho-Soda contain buffered
sodium phosphate and can be administered orally. Fleet enema
solution contains 1.4 mmol/mL. Administer 15–30 mL, tid–qid
(50–150 mmol/24 hr). Fleet Phospho-Soda contains 4.15
mmol/mL phosphate. An estimated two-thirds of orally adminis-
tered phosphate is absorbed.
C. Precautions
1. It may be necessary to give calcium supplements to hypocalcemic
patients who are being given phosphate.
2. Do not give calcium and phosphate through the same IV line.
3. Beware of causing hyperphosphatemia, hypotension, hyper-
kalemia, osmotic diuresis, or hypernatremia.
Phosphorus1
Milk (mg/8-oz. serving)
Skim 247
Whole 227
1
250 mg of elemental phosphorus = 8 mmol phosphate.
42. HYPOTENSION (SHOCK) 237
REFERENCES
Shiber JR, Mattu A: Serum phosphate abnormalities in the emergency department. J
Emerg Med 2002;23:395.
Subramanian RMB, Khardori R: Severe hypophosphatemia: Pathophysiologic implica-
tions, clinical presentations, and treatment. Medicine 2000;79:1.
REFERENCES
Hollenberg SM, Kavinsky CJ, Parrillo JE: Cardiogenic shock. Ann Intern Med
1999;131:47.
Jansen RWMM, Lipsitz LA: Postprandial hypotension: Epidemiology, pathophysiology,
and clinical management. Ann Intern Med 1995;122:286.
43. HYPOTHERMIA
I. Problem. You are called to the emergency room to see a patient with a
temperature of 32.0 °C (89.6 °F).
II. Immediate Questions
A. Does the patient have any possible source of infection? Septic
patients may be hypothermic. Look for evidence of pneumonia, uri-
nary tract infection, or any other cause of bacteremia. One study
found that 41% of patients admitted for hypothermia had a serious in-
fection.
B. Is there a history of other medical problems? Hypothyroidism, hy-
poglycemia, hypopituitarism, and hypoadrenalism all may present
with hypothermia. Alcohol also predisposes humans to environment-
induced hypothermia.
C. What is the clinical setting? Does the patient have a history of
exposure to cold weather or inadequate heating or clothing?
The very young and very old are susceptible to hypothermia as a re-
sult of environmental exposure.
D. Is the patient taking any medications? Barbiturates and phenoth-
iazines impair hypothalamic thermoregulation. Alcohol is a vasodila-
tor and central nervous system (CNS) depressant, thus increasing
the risk for hypothermia from environmental exposure. The use of in-
sulin, thyroid medication, or steroids may also suggest a cause.
Beta-blockers and clonidine can impair the body’s ability to compen-
sate for hypothermia.
244 I: ON-CALL PROBLEMS
IV. Database
A. Physical examination key points
1. Vital signs. Record the core temperature accurately with a rectal
or bladder thermometer; make sure that it is a low-recording ther-
mometer. Standard thermometers may not record temperatures
lower than 34.4 °C (93.8 °F). Keep in mind that hypotension and
bradycardia frequently occur in hypothermia.
43. HYPOTHERMIA 245
V. Plan
A. General support
1. For moderate/severe hypothermia (< 32 °C), admit to an in-
tensive care unit. Make sure the patient is hemodynamically sta-
ble. If ventricular fibrillation occurs, cardiopulmonary resuscitation
should be instituted and continued until the core temperature rises
(see Section I, Chapter 9, Cardiopulmonary Arrest, V, p 49). In
this clinical setting, the statement “A patient is not dead until they
are warm and dead” applies.
2. If you suspect hypothermia secondary to environmental exposure,
place an IV line to replace fluids because chronic hypothermia
leads to volume depletion. The IV fluids can be warmed to 43 °C
(109.4 °F).
3. Other therapeutic measures depend on the clinical setting. If sep-
sis is a possibility, begin antibiotics immediately.
4. Give IV steroids if you suspect Addison’s disease or IV thyroxine
if you suspect possible myxedema coma.
5. Some clinicians advocate administration of 100 mg thiamine IV,
an ampule (50 mL) of 50% dextrose solution (D50), and 2 mg of
naloxone (Narcan) to all comatose hypothermic patients. Narcotic
overdose should be suspected with bradypnea and pin-point
pupils. Empiric dextrose administration is controversial because
the administration of D50 has been associated with poorer out-
comes in patients with anoxic or ischemic coma. Some experts
recommend IV dextrose only if an immediate finger-stick glucose
is low.
B. Rewarming techniques
1. In cases of environmental exposure, remove the patient from the
cold environment and use some insulating material such as blan-
kets. Patients with mild hypothermia (body temperature, 32.2 ° to
35 °C) and no circulatory compromise can be treated with passive
rewarming.
2. Patients with moderate (body temperature, 28 ° to < 32.2 °C) or
severe hypothermia (temperature, < 28 °C) should be treated with
active rewarming. Some aggressive rewarming techniques are
44. INSOMNIA 247
REFERENCES
Browning RG, Olson DW, Stueven HA et al: 50% dextrose: Antidote or toxin? Ann
Emerg Med 1990;19:683.
Danzl DF, Pozos RS: Accidental hypothermia. N Engl J Med 1994;331:1756.
Lazar HL: The treatment of hypothermia. N Engl J Med 1997;337:1545.
Lewin S, Brettman LR, Holzman RS: Infections in hypothermic patients. Arch Intern
Med 1981;141:920.
Reuler JB: Hypothermia: Pathophysiology, clinical settings and management. Ann In-
tern Med 1978;89:519.
Scott MG, Heusel JW, LeGrys VA et al: Electrolyte and blood gases. In: Burtis CA, Ash-
wood ER, eds. Tietz Textbook of Clinical Chemistry. 3rd ed. Saunders;1999:1056.
Walpoth BH, Walpoth-Aslan BN, Mattle HP et al: Outcome of survivors of accidental
deep hypothermia and circulatory arrest treated with extracorporeal blood warming.
N Engl J Med 1997;337:1500.
Weinberg AD: Hypothermia. Ann Emerg Med 1993;22:370.
44. INSOMNIA
I. Problem. A patient hospitalized for lower-extremity cellulitis complains
of lying awake for hours at night.
II. Immediate Questions
A. What is the patient’s mental status? Delirium and dementia both
can present with sleep disturbance. Delirium frequently results in a
reversal of the normal sleep–wake cycle. It is important to avoid
treatment with sedatives or hypnotics because they may actually
worsen the symptomatology. Because some causes of delirium are
potentially life-threatening, aggressive evaluation of delirious patients
is warranted. (See Section I, Chapter 13, Coma, Acute Mental Status
Changes, p 76.)
B. Is the patient kept awake by pain? Painful stimuli result in a state
of increased arousal that interferes with sleep and escalates the
cycle of sleep disturbance and pain. Common examples include
rheumatoid arthritis, in which a worsening of morning stiffness is as-
sociated with sleep disturbance, and fibrositis, in which symptoms
can be reproduced by disturbing delta sleep in normal subjects.
248 I: ON-CALL PROBLEMS
(REM) sleep and lower abuse potential than with older benzo-
diazepines. Other older, rapidly absorbed, short half-life
agents such as triazolam (Halcion) 0.125–0.25 mg PO every
night; or temazepam (Restoril) 15–30 mg PO and flurazepam
(Dalmane) 15–30 mg PO every night can be used.
b. Chloral hydrate. Available in both oral and rectal forms; the
dose is 500–1000 mg by either route. Do not use in patients
with hepatic or renal failure.
c. Antihistamines. Be conscious of anticholinergic side effects,
particularly in the elderly.
i. Diphenhydramine (Benadryl) 25–50 mg PO or IM.
ii. Hydroxyzine (Vistaril) 25–50 mg PO or IM.
d. Antidepressants. Many have significant anticholinergic side
effects and should be used with caution in the elderly. Also, be
aware of cardiac side effects.
i. Amitriptyline (Elavil). Give 25–50 mg PO Q HS. Has sig-
nificant anticholinergic side effects; most useful when
chronic pain syndromes accompany sleep disturbance.
ii. Imipramine (Tofranil). Give 75 mg PO Q HS. Requires
the same precautions as with amitriptyline but is less use-
ful in chronic pain.
iii. Desipramine (Norpramin). Give 50 mg PO every night. It
may have fewer anticholinergic side effects.
iv. Trazodone (Desyrel). Give 25–50 mg PO Q HS.
2. Alternative therapies. Valerian, kava, and others are not to be
recommended because of inadequate research regarding their ef-
fectiveness and because of concerns over the quality and consis-
tency of concentration of the preparations of the various
manufacturers. Melatonin, which has been extensively studied,
has vasoconstrictive properties, and cardiovascular disease is a
contraindication.
REFERENCES
Hardman JG, Limbird LE, eds: Goodman & Gilman’s The Pharmacological Basis of
Therapeutics. 10th ed. McGraw-Hill;1996.
McCrae CS, Lichstein KL: Secondary insomnia: diagnostic challenges and intervention
opportunities. Sleep Med Rev 2001;5:47.
Meyer TJ: Evaluation and management of insomnia. Hosp Pract 1998;33:75.
Morin CM, Daley M, Ouellet MC: Insomnia in adults. Curr Treat Options Neurol
2001;3:9.
IV. Database
A. Physical examination key points
1. Vital signs. Palpate the brachial or carotid pulses to determine the
heart rate and assess the degree of cardiac irregularity. The brachial,
254 I: ON-CALL PROBLEMS
carotid, and femoral artery pulses are preferred for palpation over
more peripheral pulses. Be careful to avoid mistaking a heartbeat
with a variable pulsation amplitude from an irregular cardiac rhythm.
Variations in pulsation amplitude can be seen during severe pul-
monary bronchospasm, during an extensive MI, with decompen-
sated congestive heart failure, with acute aortic insufficiency, or with
pericardial tamponade. Prompt action must be taken if hypotension
is present. A fever may suggest an infection, which can have associ-
ated PVCs or PACs. Several specific infections (eg, acute rheumatic
fever and acute Lyme disease) can cause AV node block.
2. Heart. AV node block with an associated murmur might suggest
acute rheumatic fever. An S4 gallop suggests acute MI. Several
cardiac arrhythmias may be present with an acute MI, including
PVCs and PACs, variable degrees of AV block, atrial fibrillation,
and atrial flutter. If atrial fibrillation is present, listen for the dias-
tolic rumble of mitral stenosis at the cardiac apex. It is best heard
using the bell of the stethoscope, with the patient in the left lateral
decubitus position.
B. Laboratory data
1. Electrolytes. Rule out hypokalemia. A low serum bicarbonate
suggests metabolic acidosis.
2. Arterial blood gases. If PVCs are present, exclude hypoxemia
and severe acidemia or alkalemia.
3. Medications. A recent serum digoxin level is imperative if the pa-
tient is taking this medication. Digitalis intoxication can cause
PVCs, sinoatrial exit block, or second-degree heart block. Con-
sider measuring serum levels of other medications, such as quini-
dine, procainamide, and theophylline. An elevated digoxin level
can occur if the level is obtained while the drug is in the distribu-
tion phase (6–8 hours).
C. Electrocardiogram (ECG) and rhythm strip
1. Be sure to include a long rhythm strip to catch the pattern of the
responsible arrhythmia.
2. Identify all the P waves that are present and note their timing and
their relation to the QRS complexes. P waves are best seen in leads
I, II, aVR, aVF, and V1. You may need to examine several rhythm
strips from different leads to correctly identify the cardiac rhythm.
3. Be certain to examine the ECG for evidence of myocardial is-
chemia; drug effects such as prolongation of the QT interval; and
for the electrocardiographic changes of pulmonary embolism (S1,
Q3, T3, acute right bundle branch block, acute right-axis devia-
tion), and for pericarditis (diffuse ST-elevation with upward con-
cavity, T-wave inversion, and PR-segment depression).
REFERENCES
Cardiac Arrhythmia Suppression Trial (CAST) Investigators: Preliminary report: Effect
of encainide and flecainide on mortality in a randomized trial of arrhythmia suppres-
sion after myocardial infarction. N Engl J Med 1989;321:406.
Falk RH: Atrial fibrillation. N Engl J Med 2001;344:1067.
Miller JM, Zipes DP: Management of the patient with cardiac arrhythmias. In: Braun-
wald E, Zipes DP, Libby P, eds. Heart Disease: A Textbook of Cardiovascular Medi-
cine. 6th ed. Saunders;2001:700.
Wagner GS, ed: Marriott’s Practical Electrocardiography. 9th ed. Williams &
Wilkins;1994.
46. JAUNDICE
I. Problem. A 66-year-old woman is admitted because of icteric sclerae
and abdominal pain.
II. Immediate Questions
A. What are the patient’s vital signs? Fever and tachycardia with or
without hypotension can indicate sepsis associated with ascending
cholangitis. This is a medical emergency and requires immediate ag-
gressive intervention.
256 I: ON-CALL PROBLEMS
REFERENCES
Frank BB: Clinical evaluation of jaundice. JAMA 1989;262:3031.
Friedman LS, Emmett BK, eds. Handbook of Liver Disease. Churchill Livingstone;1998.
Kamath PS: Clinical approach to the patient with abnormal liver function tests. Mayo
Clin Proc 1996;71:1089.
Lidofsky S: Jaundice. In: Feldman M, Friedman LS, Sleisenger MH, eds. Gastrointesti-
nal and Liver Diseases: Pathophysiology/Diagnosis/Management. 7th ed. Saun-
ders;2002:249.
Moseley RH: Evaluation of abnormal liver function tests. Med Clin North Am
1996;80:887.
Rösch T et al: A prospective comparison of the diagnostic accuracy of ERCP, MRCP,
CT and EUS in biliary strictures. Gastrointest Endosc 2002;55:870.
IV. Database
A. Physical examination key points. Physical exam must be com-
plete. Systemic disease must be ruled out as the cause of the arthri-
tis; there can be no shortcuts.
1. Skin. A rash may indicate the cause of the joint swelling. For evi-
dence of psoriasis, frequently overlooked areas include under the
264 I: ON-CALL PROBLEMS
REFERENCES
Baker DG, Schumacher HR: Acute monarthritis. N Engl J Med 1993;329:1013.
Klippel JH, ed: Primer on the Rheumatic Diseases. 12th ed. Arthritis Foundation;2001.
48. LEUKOCYTOSIS
I. Problem. A 63-year-old woman is admitted for hypoxemia, bilateral pul-
monary infiltrates, and fever. Broad-spectrum intravenous (IV) antibiotics
are begun after appropriate cultures are obtained. Her white blood cell
(WBC) count remains about 25,000–30,000/μL.
B. Chronic
1. Persistent infections. Often the same infection that caused the
acute leukocytosis.
2. Partially treated or occult infections. Osteomyelitis, subacute
bacterial endocarditis, and intra-abdominal abscess often present
as chronic leukocytosis.
3. Mycobacterial or fungal infections. These are notorious for pro-
moting a sustained leukocytosis, often with little other clinical
pathology at initial evaluation.
4. Chronic inflammatory states. Rheumatic fever, connective tis-
sue disease such as systemic lupus erythematosus (SLE), thy-
roiditis, myositis, drug reactions, and pancreatitis all can
chronically elevate the WBC count.
5. Neoplastic processes. Solid tumors and lymphoproliferative dis-
orders can have an associated chronic leukocytosis.
6. Primary hematologic disorders. These include myeloprolifera-
tive disorders (eg, polycythemia vera), myelodysplasia, leuke-
mias, chronic hemolysis, and asplenic states.
7. Congenital disorders (including Down’s syndrome). May be
associated in rare cases with chronic leukocytosis.
8. Drugs. These are less common causes. Potential offending
agents include glucocorticoids and lithium.
9. Overproduction of adrenocorticotropic hormone or thyrox-
ine. May cause chronic elevation of the baseline WBC count.
IV. Database
A. Physical examination key points
1. Vital signs. Be especially careful to check for fever or hypother-
mia, which suggests infection or sepsis. Fever can also indicate a
neoplastic process, infarction of various tissues, or a connective
tissue disorder. (See Section I, Chapter 22, Fever, p 133.) Hy-
potension may occur with sepsis.
2. General. Look for evidence of acute distress or a chronic disease
state (cachexia, digital clubbing, bitemporal wasting).
3. Lymph nodes. Check for palpable lymph nodes and note their
character. Soft and tender nodes are most consistent with an in-
fectious cause. Rubbery and generalized nodes are most often
seen with lymphoproliferative disorders such as lymphoma. Hard,
fixed, and localized nodes suggest carcinoma.
4. Skin/mucosa. Petechiae or ecchymoses suggest sepsis with dis-
seminated intravascular coagulation, primary bone marrow
pathology with altered platelet number or function, or a clotting
disorder or vasculitis.
5. Lungs. Inspiratory rales imply pneumonitis or pneumonia. Dimin-
ished breath sounds and dullness to percussion suggest a pleural
effusion or empyema. A pleural rub may accompany infectious or
48. LEUKOCYTOSIS 269
REFERENCES
Arnold SM, Patchell R, Lowy AM et al: Paraneoplastic syndrome. In: Devita VT, Hell-
man S, Rosenberg SA, eds. Cancer: Principles and Practice of Oncology. 6th ed.
Lippincott Williams & Wilkins;2001:2511.
Curnutte JT, Coates TD: Leukocytosis and leukopenia. In: Hoffman R, Benz EJ, Shattil
SJ et al, eds. Hematology: Basic Principles and Practice. 3rd ed. Churchill Living-
stone;2000:720.
Dale DC: Neutropenia and neutrophilia. In: Beutler E, Lichtman MA, Coller BS et al,
eds. William’s Hematology. 6th ed. McGraw-Hill;2001:823.
49. LEUKOPENIA
I. Problem. A 39-year-old man with a history of schizophrenia is placed on
clozapine. Two months later, he returns with complaints of fever and
chills. He appears toxic, and his white blood cell (WBC) count is
1000/μL.
49. LEUKOPENIA 271
IV. Database
A. Physical examination key points
1. Vital signs. Fever suggests infection. Hypotension may be a sign
of sepsis.
2. Skin. Petechiae are consistent with Rocky Mountain spotted fever
or disseminated intravascular coagulation. Rash may be seen in
connective tissue diseases or with certain bacterial infections
such as Neisseria gonorrhoeae and N meningitidis.
3. HEENT. Temporal wasting and oral thrush may occur in acquired
immunodeficiency syndrome (AIDS). Nuchal rigidity suggests
meningitis.
4. Lymph nodes. Lymphadenopathy can be seen in both malignant
and infectious processes, including HIV infection.
5. Lungs. Pneumonia with overwhelming sepsis may cause or be
secondary to neutropenia. Inspiratory crackles, increased tactile
and vocal fremitus, and egophony suggest pneumonia.
6. Abdomen. Hepatosplenomegaly can be a sign of malignancy
(leukemia or lymphoma), infection, or hypersplenism.
7. Joints. Look for classic findings of rheumatoid arthritis, such as
symmetric swelling of the proximal interphalangeal and metacar-
pophalangeal joints. Rheumatoid nodules on the extensor surface
of the arms near the elbows are also a classic sign.
B. Laboratory data
1. Complete blood count with differential. The presence of ane-
mia and thrombocytopenia along with leukopenia may suggest
B12 or folate deficiency, aplastic anemia, PNH, ethanol abuse, or
leukemia. The mean corpuscular volume is increased with B12 or
folate deficiency.
274 I: ON-CALL PROBLEMS
the cause and duration of the neutropenia and any other ongoing
medical problems.
3. Identify any potential drugs or chemicals that may have in-
duced the neutropenia; discontinue them.
4. Always wash your hands before touching the patient. The
patient should avoid exposure to fresh fruits or vegetables, flow-
ers, live plants, and persons with active infections. Avoid rectal
manipulation such as with digital examination or rectal tempera-
ture.
B. Definitive care. After the patient has had a complete history and
physical exam, the cause of the neutropenia can usually be placed in
one of the three broad categories discussed earlier (see III). Subse-
quent tests can be obtained to confirm a specific diagnosis. In gen-
eral, regardless of the cause, supportive care is indicated for most of
these patients (ie, antibiotics for infections and blood products for as-
sociated severe anemia or thrombocytopenia).
1. Bone marrow failure. For drug-induced neutropenia, remove the
offending agent and give supportive care until the counts increase
to normal or at least above the neutropenic range (generally
within 1–2 weeks). Colony-stimulating factors (CSFs) are now
available that can be used for drug-induced (ie, by chemotherapy)
neutropenia to speed recovery. Specific guidelines have been es-
tablished by the American Society of Clinical Oncology for the use
of CSFs in cancer patients receiving chemotherapy for primary
and secondary prophylaxis. In general, the CSFs are used as pri-
mary prevention with chemotherapeutic regimens that are signifi-
cantly myelosuppressive to help decrease the incidence of febrile
neutropenia. The CSFs are started approximately 24–72 hours
after completion of the chemotherapy and are given until the ANC
is > 10,000 following the neutrophil nadir. For use in the febrile
patient with neutropenia, the CSFs may be used if the patient has
clinical features of deterioration, profound neutropenia (ANC
< 100), pneumonia, sepsis, hypotension, or a fungal infection.
They are usually continued until ANC is > 10,000. The usual
dosage is 5 μg/kg/day for G-CSF (filgrastim) and 250 μg/m2/day
for GM-CSF (sargramostim). The treatment for viral etiology or
myelodysplastic syndromes is generally supportive care. The use
of CSFs can be considered in myelodysplastic patients if patients
are experiencing neutropenic infections.
2. Consumption. Treat bacterial infections as indicated. Immune-
mediated consumption may require steroids. The patient with
Felty’s syndrome generally requires no specific treatment for the
neutropenia unless he or she has recurrent infections. Then,
splenectomy may be required.
3. Redistribution. Patients with hypersplenism are generally able to
immobilize the sequestered neutrophils and thus fight off infec-
tion; subsequently, they do not require any specific therapy.
50. NAUSEA & VOMITING 277
REFERENCES
American Society of Clinical Oncology: 2000 Update of recommendations for the use of
hematopoietic colony-stimulating factors: Evidence-based, clinical practice guide-
lines. J Clin Oncol 2000;18;3558.
Baehner R. Overview of neutropenia. In: UpToDate, Rose, BD, ed. UpToDate. Welles-
ley, MA;2004.
Bodey GP, Buckley M, Sathe YS et al: Quantitative relationships between circulating
leukocytes and infection in patients with acute leukemia. Ann Intern Med
1966;64:328.
Elting LS, Rubenstein EB, Rolston KV et al: Outcomes of bacteremia in patients with
cancer and neutropenia: Observations from two decades of epidemiological and clini-
cal trials. Clin Infect Dis 1997;25:247.
Hughes WT, Armstrong D, Bodey GP et al: 1997 Guidelines for the use of antimicrobial
agents in neutropenic patients and unexplained fever. Clin Infect Dis 1997;25:551.
Shoenfeld Y, Alkan ML, Asaly A et al. Benign familial leukopenia and neutropenia in dif-
ferent ethnic groups. Eur J Haematol 1988;41:273.
III. Differential Diagnosis. Disorders that are associated with nausea and
vomiting can be grouped as follows:
A. Intra-abdominal or thoracic etiology
1. Gastric outlet obstruction. Occurs in patients with a history of
peptic ulcer disease (PUD), prior abdominal surgery, or neo-
plasms.
2. Small or large bowel obstruction. May be caused by fibrous
bands and adhesions (usually after surgery), primary or sec-
ondary metastatic neoplasms, impacted feces, active inflamma-
tory bowel disease (IBD)–related stricture, postoperative
strictures, intestinal parasites, gallstones, incarcerated hernia,
intussusception, or a volvulus.
3. Pseudo-obstruction or functional (paralytic) ileus. Results
from failure of normal intestinal peristalsis. Causes include ab-
dominal surgery; retroperitoneal or intra-abdominal hematomas;
severe infections; renal disease; metabolic disturbances such as
hypokalemia; or drugs, particularly anticholinergics. Chronic
cases of pseudo-obstruction can result from abnormalities in ei-
ther the enteric nervous system or the gut smooth muscle.
4. PUD. Local irritation or edema surrounding a pyloric channel
ulcer can cause a mechanical obstruction.
5. Pancreatitis. Usually associated with abdominal pain that fre-
quently (in > 50% of cases) radiates to the back. A computed to-
mography (CT) scan is helpful in demonstrating inflammation
and pseudocyst formation. Retroperitoneal abscess formation
can complicate pancreatitis.
6. Biliary colic. From distention of smooth muscle in bile ducts
secondary to stones, inflammation, or neoplasms.
7. Intestinal ischemia. From local vascular compromise or from re-
duced cardiac output. Guaiac-positive stools are common findings.
50. NAUSEA & VOMITING 279
8. Pyelonephritis or nephrolithiasis
9. Hepatitis. May be either viral or drug-induced.
10. Appendicitis. Often associated with right lower quadrant pain,
fever, and leukocytosis with a left shift.
11. Diverticulitis. Lower abdominal pain and fever are common.
12. Perforated viscus. Usually presents as an acute abdomen.
13. Pelvic inflammatory disease (PID)
14. Acute myocardial infarction (MI). MI, especially involving the
inferior wall, can present with nausea and vomiting; chest pain
may be absent.
B. Intracranial etiology
1. Tumor or mass lesions leading to increased intracranial
pressure. Consider an acute cerebral vascular accident, neo-
plasm, or subdural hematoma.
2. Bacterial and viral meningitis
3. Migraine headache. Usually a unilateral headache, with photo-
phobia and history of similar headache. The affected patient may
have a prodrome (eg, aura).
4. Labyrinthitis
C. Metabolic etiology
1. Uremia. Often associated with weight loss, lethargy, and intense
pruritus.
2. Hepatic failure. From a variety of causes including cirrhosis, hy-
poxic injury, and drug-induced states such as acetaminophen
overdose.
3. Adrenal insufficiency. Can occur in patients on chronic corticos-
teroid therapy that is suddenly discontinued or in such patients
when stressed (surgery, serious infection) and the steroid dose is
not increased. Associated symptoms include weakness, fatigue,
hypotension, and abdominal pain.
4. Metabolic acidosis. See Section I, Chapter 2, Acidosis, p 10.
5. Electrolyte abnormalities. Hypercalcemia, hyperkalemia, and
hypokalemia can cause nausea.
6. Hypothyroidism with decreased intestinal motility or thyroid
storm. Weight gain, constipation, mental status changes, and dry
skin suggest hypothyroidism. Weight loss, hyperdefecation, moist
skin, hyperthermia, and mental status changes as well as a pre-
cipitating event are consistent with thyroid storm.
D. Miscellaneous etiology
1. Drug-induced. Major offenders are dopamine agonists such as L-
dopa and bromocriptine (Parlodel), opiate analgesics such as mor-
phine, digoxin (Lanoxin), and certain chemotherapy agents such
as cisplatin (Platinol). Also consider alcohol, NSAIDs, and aspirin.
2. Acute gastroenteritis. Common in the outpatient setting with
“food poisoning” from bacterial endotoxins. Diarrhea is often pre-
sent. (See Section I, Chapter 17, Diarrhea, p 101.)
280 I: ON-CALL PROBLEMS
REFERENCE
Makau L: Nausea and vomiting. In: Feldman M, Friedman LS, Sleisenger MH, eds.
Gastrointestinal and Liver Diseases: Pathophysiology/Diagnosis/Management. 7th
ed. Saunders;2002:119.
51. OLIGURIA/ANURIA 283
51. OLIGURIA/ANURIA
I. Problem. You are called because a 68-year-old man admitted with
pyelonephritis and diabetes mellitus type 2 has had only 100 mL of urine
output over the last 8 hours.
II. Immediate Questions. A medical history and review of the patient’s
chart and hospital course are essential in evaluating and treating olig-
uria.
A. Are there any serious or life-threatening conditions? Oliguria
may be associated with shock, hypotension, pulmonary edema, ure-
mia, hyperkalemia, uncompensated metabolic acidosis, other elec-
trolyte disorders, or the accululation of toxic levels of medications
and/or metabolites.
B. Is the patient in distress? Does he appear ill? Is he hemodynam-
ically stable? Oliguria may be an early manifestation of impending
shock.
C. What are the patient’s serum chemistries and blood urea nitro-
gen (BUN) and creatinine levels? Review the patient’s lab results
in the chart. What is the patient’s baseline serum creatinine? Has the
creatinine changed during hospitalization? An elevated creatinine
suggests different causes compared with a normal or only slightly el-
evated creatinine, especially with an elevated BUN:creatinine ratio.
Because of the reciprocal nature of serum creatinine in the estimate
of glomerular filtration rate (GFR), small changes in low values of
serum creatinine reflect a large loss of renal function. For example, if
a patient with a baseline creatinine of 0.6 mg/dL develops a creati-
nine level of 1.2 mg, he or she has lost half of the renal function.
Other factors besides a decreased GFR may contribute to an ele-
vated creatinine. Accelerated muscle breakdown as is seen in rhab-
domyolysis increases creatinine production. At lower levels of GFR,
the proportion of creatinine cleared by tubular secretion increases.
Certain medications that compete for creatinine for tubular secretion
such as cimetidine and trimethoprim raise serum creatinine without
affecting GFR. An elevated BUN:creatinine ratio is seen in patients in
the prerenal state and in those with increased catabolism, increased
protein intake such as total parenteral nutrition, and gastrointestinal
(GI) bleeding, and with the administration of glucocorticoids.
D. What is the cause of the oliguria? Prompt identification of the un-
derlying cause or causes is essential to prevent or attenuate renal in-
jury.
E. What is the urine output? Oliguria is defined as a 24-hour urine
output of 100–400 mL. As a general rule, the minimal acceptable
urine output is 0.5–1.0 mL/kg/hr. Anuria, less than 100 mL/day of
urine, may indicate complete urinary obstruction, a catastrophic renal
vascular event, bilateral cortical necrosis, severe rapidly progressive
284 I: ON-CALL PROBLEMS
III. Differential Diagnosis. The differential diagnosis for acute oliguria and
acute renal failure is identical and may be divided into prerenal, renal,
and postrenal causes. Keep in mind that multiple causes may frequently
contribute to the development of ARF.
A. Prerenal causes. Relating to renal hypoperfusion. Prompt recogni-
tion and correction of prerenal azotemia are important in that renal
hypoperfusion may lead to ischemic ATN. Prerenal ARF and is-
chemic ATN together account for about 75% of cases of ARF in hos-
pitalized patients.
1. Shock/hypovolemia
a. Hemorrhage. From GI bleeding or trauma, or as a postopera-
tive complication.
b. Inadequate fluid administration. Fever, diarrhea, vomiting,
poor oral intake without adequate fluid administration.
c. Sepsis. Causes decreased renal perfusion from a decreased
systemic vascular resistance.
2. Apparent intravascular hypovolemia. A relative decrease in the
effective circulating volume.
a. Third-space losses. Pancreatitis, major burns, and after
major operations.
b. CHF
c. Cirrhosis. Hepatorenal syndrome may be associated.
d. Nephrotic syndrome
3. Vascular
a. Renal artery occlusion (acute or chronic)
b. Aortic dissection
c. Emboli (such as cholesterol)
B. Renal causes
1. Acute tubular necrosis
a. Ischemia. Secondary to shock from any cause, including sep-
sis.
b. Toxins. These may include medications (aminoglycosides,
amphotericin B), contrast media, and heavy metals.
c. Transfusion reaction. Causes intravascular hemolysis.
d. Myoglobinuria. Secondary to rhabdomyolysis; often seen in
alcoholics. Muscle tenderness, elevated creatine phosphoki-
nase, and pigmented casts point to myoglobinuria.
2. AIN
a. Drugs. Beta-lactamase–resistant penicillins (eg, methicillin);
also sulfonamides, fluoroquinolones, NSAIDs, and many others.
b. Hypercalcemia
c. Uric acid. Tumor lysis syndrome (chemotherapy for leukemia
or lymphoma).
286 I: ON-CALL PROBLEMS
V. Plan
A. Management of specific causes of oliguria/ARF
1. Prerenal
a. Monitor volume replacement. Give crystalloid to increase
central venous pressure above 10 mm Hg or pulmonary capil-
lary wedge pressure above 12–14 mm Hg. A hematocrit
> 25–30% is adequate.
b. Follow hourly urine output. Give specific criteria, such as
having the house officer called if urine output is < 0.5
mL/kg/hr. Remove potassium and magnesium from IV solu-
tions. If hypokalemia or hypomagnesemia is present, replace
judiciously, preferably by the oral route.
2. Postrenal
a. Bladder outlet obstruction. Manage acutely with a Foley
catheter. There are several concerns with this therapy, includ-
ing acute bladder decompression, postobstructive diuresis,
and increased risk of infection. Rapid bladder decompression
has been a concern in the past because of possibly triggering
a vasovagal episode or bladder hemorrhage. However, stud-
ies have demonstrated that large changes in bladder pressure
occur with the first 100–250 mL of urine output. Thus, intermit-
tent clamping of the catheter is probably unnecessary.
b. Postobstructive diuresis. Occasionally, relief of obstruction
is followed by a brisk diuresis. This is thought to be the result
of volume overload and is physiologic. Volume depletion and
electrolyte disturbances may occur. The usual therapy is IV
maintenance fluids such as 1⁄2 normal saline or 0.45% NaCl at
75 mL/hr. Replacement of urine output with IV fluids milliliter
per milliliter should be avoided.
c. Risk of infection. Intermittent, rather than continuous, bladder
catheterization should be considered to reduce infection risk.
51. OLIGURIA/ANURIA 291
REFERENCES
Cadnapaphornchai P, Alavalapti RK, McDonald FD: Differential diagnosis of acute
renal failure. In: Jacobson HR, Striker GE, Klahr S, eds. The Principles and Practice
of Nephrology. 2nd ed. Mosby;1995:555.
Esson ML, Schrier RW: Diagnosis and treatment of acute tubular necrosis. Ann Intern
Med 2002;137:744.
Holley JL: Clinical approach to the diagnosis of acute renal Failure. In: Greenberg A,
ed. Primer on Kidney Diseases. 3rd ed. Academic Press;2001:245.
Klahr S, Miller SB: Current concepts: Acute oliguria. N Engl J Med 1998;338:671.
Post TW, Rose BD: Approach to the patient with renal disease including acute renal
failure. In: Fletcher SW, Fletcher RH, Aronson MD, eds. UpToDate [CD-ROM]. Ver-
sion 8.2. Wellesley, MA;2000. www.uptodate.com
Rose BD: Optimal dosage of loop diuretics. In: Fletcher SW, Fletcher RH, Aronson MD,
eds. UpToDate [CD-ROM]. Version 8.2. Wellesley, MA;2000. www._uptodate.com.
Rose BD: Rate of decompression of an enlarged bladder. In: Fletcher SW, Fletcher RH,
Aronson MD, eds. UpToDate [CD-ROM]. Version 8.2. Wellesley, MA;2000. www.up-
todate.com.
Rose BD: Urine output in urinary tract obstruction and postobstructive diuresis. In:
Fletcher SW, Fletcher RH, Aronson MD, eds. UpToDate [CD-ROM]. Version 8.2.
Wellesley, MA;2000. www.uptodate.com
Singri N, Ahya SN, Levin ML: Acute renal failure. JAMA 2003;289:747.
Thadhani R, Pascual M, Bonventre JV: Acute renal failure. N Engl J Med
1996;334:1448.
52. OVERDOSES
I. Problem. You are called to the emergency room to evaluate a 38-year-
old woman who was found unconscious by her husband, with an empty
pill bottle lying on the floor near her.
III. Differential Diagnosis. The possible causes of acute overdoses are nu-
merous. One method of simplifying the classification of overdoses is to
group toxins by their effects. Six toxic syndromes encompass most of
the common agents causing overdoses. A small group of additional
agents do not fit any of the categories and are considered separately.
Remember that even though causes of overdoses are grouped by com-
mon effects, there are characteristics and toxicities unique to individual
agents even within the same group.
A. Anticholinergic agents. The anticholinergics cause delirium, choreo-
athetosis, hypertension, tachypnea, tachycardia, and hyperthermia.
Other characteristic signs include dry mouth, reduced bowel sounds,
flushing of skin, dilated pupils, and urinary retention. Examples are tri-
cyclic antidepressants (also commonly cause arrhythmias), antihista-
mines, phenothiazines, cyclobenzaprine, and belladonna alkaloids.
B. Sympathomimetic agents. These toxins cause hyperalert and delu-
sional mental states. Hyperthermia, hypertension, tachypnea, and
tachycardia are common. Other signs include tremor, dilated pupils,
diaphoresis, hyperreflexia, and, on occasion, seizures. Examples are
cocaine, amphetamines, methamphetamines, pseudoephedrine, and
theophylline.
C. Sedatives/hypnotics/opiates. These agents cause CNS depression
and, in extreme cases, coma. Vital signs show hypothermia, brady-
cardia, bradypnea, and hypotension. Reflexes are depressed, and
noncardiogenic pulmonary edema is common. Examples are opiates
(morphine, oxycodone, heroin), benzodiazepines (diazepam, lo-
razepam, oxazepam, alprazolam), barbiturates and alcohols
(ethanol, methanol, isopropyl alcohol, ethylene glycol).
D. Cholinergic agents. The mnemonic SLUDGE describes the symp-
toms of cholinergic overdose. Salivation, Sweating, Lacrimation, Uri-
294 I: ON-CALL PROBLEMS
REFERENCES
Brent J, McMartin K, Phillips S et al: Fomepizole for the treatment of methanol poison-
ing. N Engl J Med 2001;344:424.
Burns M, Schwartzstein R: General approach to drug intoxications. In: Fletcher SW,
Fletcher RH, Aronson MD, eds. UpToDate [CD-ROM]. Version 8.2. Wellesley,
MA;2000. www.uptodate.com
Ellenhorn MJ, Schonwald S, Ordog G et al, eds: Ellenhorn’s Medical Toxicology. 2nd
ed. Williams & Wilkins;1997.
Graeme K: New drugs of abuse. Emerg Med Clin North Am 2000;18:625.
Kulig K: Initial management of ingestions of toxic substances. N Engl J Med
1992;326:1677.
Rosen P, ed: Emergency Medicine Concepts and Clinical Practice. 4th ed. Mosby-Year
Book;1998.
Toll LL, Hurlbut KM, eds: POISINDEX System. Englewood, CO: MICROMEDEX,
Inc.;2001.
Zimmerman J: Poisonings and overdoses in the intensive care unit: General and spe-
cific management issues. Crit Care Med 2003;31:2794.
Figure I–5. Failure to capture. The rhythm is a nodal rhythm at 40 beats per minute. The pace-
maker spikes occur at 72 beats per minute. The pacemaker spikes are not associated with the ven-
tricular depolarizations.
53. PACEMAKER TROUBLESHOOTING 303
Figure I–6. Failure to sense. A pacemaker spike is seen immediately after the 3rd, 4th, 5th, and
6th QRS complexes. The pacemaker should have been inhibited by the QRS complexes. (Photo-
graph courtesy of Alberto Mazzoleni, MD.)
304 I: ON-CALL PROBLEMS
REFERENCES
Emergency cardiac pacing. In: Cummins RO, ed. Textbook of Advanced Cardiac Life
Support. American Heart Association;1994:5.
Narula OS: Clinical concepts of spontaneous and induced atrioventricular block. In:
Mandel WJ, ed. Cardiac Arrhythmias: Their Mechanisms, Diagnosis and Manage-
ment. Lippincott;1995:441.
Watanabe Y, Dreifus LS, Mazyalev T: Atrioventricular block: Basic concepts. In: Man-
del WJ, ed. Cardiac Arrhythmias: Their Mechanisms, Diagnosis and Management.
Lippincott;1995:417.
Wood M: Temporary cardiac pacing. In: Ellenbogen KA, Kay GN, Wilkoff BL, eds. Clini-
cal Cardiac Pacing. Saunders;1995:687.
Wood M, Ellenbogen KA: Temporary cardiac pacing. In: Ellenbogen KA, ed. Cardiac
Pacing. 2nd ed. Blackwell Science;1996:168.
of chronic pain (pain that has lasted longer than 3 months) is not dis-
cussed here. Pain in a patient with cancer may be caused by primary or
metastatic disease, or it may occur as a complication of treatment
(surgery, radiation, chemotherapy, immobility, or infections).
A. Pain caused directly by tumors
1. Tumor invasion of bone and pathologic fracture
2. Infiltration/compression of nerves
3. Obstruction of a hollow viscus
4. Expansion of a viscus or its capsule. For example, liver metas-
tases.
5. Tissue ischemia after tumor invasion of lymphatics and
blood vessels
6. Paraneoplastic syndromes. Hypertrophic osteoarthropathy and
neuropathy.
B. Iatrogenic causes of cancer pain
1. Surgery. Incisions; phantom limb pain.
2. Chemotherapy. May cause infectious, gastrointestinal, and neu-
rologic pain.
3. Radiation. Colitis, esophagitis.
C. Psychological pain. Anxiety, depression, spiritual distress, and a
feeling of loss of control are frequently associated with malignancy
and may intensify the patient’s perception of pain.
IV. Database
A. Physical examination key points
1. Vital signs. Tachycardia occurs with a variety of causes of acute
pain and therefore is too nonspecific to suggest a specific cause.
Fever suggests an infectious cause or acute venous thrombosis.
2. Skin. Chemotherapy and hematologic malignancies can predis-
pose to herpes zoster infections; therefore, ascertain whether the
pain is in the distribution of a specific dermatome. Look for vesicles
on an erythematous base that would suggest shingles. Pain may
precede the development of the typical vesicular rash by 2–3 days.
3. HEENT. Papilledema suggests increased intracranial pressure
from cerebral metastases.
4. Neck. Nuchal rigidity could indicate infectious or carcinomatous
meningitis causing back or neck pain.
5. Chest. In addition to auscultating the lungs for evidence of pneu-
monia, palpate the ribs and sternum for evidence of bone pain
suggesting metastases.
6. Abdomen. In a patient with abdominal pain, examine for he-
patomegaly, which could indicate liver metastases. Bowel ob-
struction could result from the underlying malignant process itself,
or it could occur as a result of decreased bowel motility from the
administration of narcotics. A pulsatile epigastric mass would sug-
gest an abdominal aortic aneurysm.
308 I: ON-CALL PROBLEMS
1
Transdermal fentanyl given every 72 hours is equivalent to 1/2 of daily oral morphine dose
2
Important note: Equivalent doses for methadone and morphine may change at morphine doses
greater than 300 mg per day.
3
Not recommended for routine use
Reproduced with permission from Lawson AP, Smith LM. Are all opioids created equal? Orthope-
dics 2004;27:1.
REFERENCES
Abramowicz M, ed: Drugs for pain. Med Lett Drugs Ther 2000;42:73.
Acute Pain Management Guideline Panel: Acute Pain Management: Operative or Med-
ical Procedures and Trauma. Clinical Practice Guideline No. 1. US Dept of Health
and Human Services, Public Health Service, Agency for Health Care Policy and Re-
search;1992.
Bruera E, Kim HN: Cancer pain. JAMA 2003;290:2476.
Ducharne J: Acute pain and pain control: State of the art. Ann Emerg Med
2000;35:592.
Martin JJ, Moore GP: Pearls, pitfalls, and updates for pain management. Emerg Med
Clin North Am 1997;15:399.
Moynihan TJ: Use of opioids in the treatment of severe pain in terminally ill patients.
Mayo Clin Proc 2003;78:1397.
312 I: ON-CALL PROBLEMS
55. POLYCYTHEMIA
I. Problem. A 65-year-old man is admitted because of chest pain; his
hematocrit is 62%.
II. Immediate Question. Are there any medical conditions that require
the prompt institution of therapy directed at the elevated hemat-
ocrit? Usually, the finding of an elevated hematocrit is incidental, being
discovered during the evaluation of a nonacute problem. You should de-
termine that there is no evidence of decompensated congestive heart
failure and cardiac or cerebral ischemia that might benefit acutely from
phlebotomy. Evidence of profound intravascular volume depletion re-
quiring fluid replacement should be noted.
III. Differential Diagnosis. When you are confronted with an elevated hemat-
ocrit (> 50% for men, > 45% for women), you can simplify the differential di-
agnosis by separating polycythemia into three broad diagnostic categories.
A. Relative (or apparent) polycythemia. This condition is a conse-
quence of a decrease in the plasma volume and is generally asymp-
tomatic. Patients can, however, present with venous thrombosis,
which can occur with severe volume depletion. Relative poly-
cythemia is associated with obesity, hypertension, and smoking.
B. Polycythemia vera. Onset is usually insidious, often found on rou-
tine blood counts for other reasons. Patients with polycythemia vera
may present with major venous thrombosis or hemorrhage. Possible
symptoms include headache, dizziness, vertigo, tinnitus, diplopia,
blurred vision, claudication, angina, symptoms of peptic ulcer dis-
ease, pruritus, mucosal bleeding, epistaxis, ecchymoses, and symp-
toms of deep venous thrombosis, pulmonary embolism, or cerebral
vascular thrombosis. Polycythemia vera is usually a disease of mid-
dle and later years of life with a peak incidence in the sixth and sev-
enth decades. There is a slight male predominance.
1. Clinical criteria for diagnosis have been defined by the Poly-
cythemia Vera Study Group (PVSG). The diagnosis is made
by meeting three major criteria, or the first two major criteria
and two minor criteria.
a. Major criteria
• Elevated red blood cell (RBC) mass (≥ 36 mL/kg in a
male; ≥ 32 mL/kg in a female)
• Arterial oxygen saturation > than 92% in the presence of
erythrocytosis.
• Splenomegaly
b. Minor criteria
• Platelet count > 400,000/mL
• Elevated leukocyte alkaline phosphatase (LAP) score
• Elevated vitamin B12
• Leukocytosis > 12,000/mL
55. POLYCYTHEMIA 313
IV. Database
A. Physical examination key points
1. Vital signs. Hypertension is indicative of possible renal vascular
disease or pheochromocytoma and may be present with poly-
cythemia vera. Respiratory rate helps to assess the presence of
cardiac or pulmonary disease. Fever may indicate underlying sys-
temic illness that may have caused volume depletion or may be a
sign of underlying malignancy.
314 I: ON-CALL PROBLEMS
REFERENCES
Berk PD et al: Therapeutic recommendations in polycythemia vera based on Poly-
cythemia Vera Study Group Protocol. Semin Hematol 1986;23:132.
Berlin NI: Polycythemia vera. Hematol/Oncol Clin North Am 2003;17:1191.
Beutler E, Lichtman MA, Coller RS et al, eds. Williams Hematology. 6th ed. McGraw-
Hill;2001.
Gruppo Italiano Studio Policitemia: Polycythemia vera: The natural history of 1213 pa-
tients followed for 20 years. Ann Intern Med 1995;123:656.
Hoffman R, Benz EJ, Shattil SJ et al, eds. Hematology: Basic Principles and Practice.
2nd ed. Churchill Livingstone;1995.
Means RT: Erythrocytosis. In: Greer JP, Foerster J, Lukens F et al, eds. Wintrobe’s
Clinical Hematology. 11th ed. Lippincott Williams & Wilkins;2004:1495.
Means RT: Polycythemia vera. In: Greer JP, Foerster J, Lukens F et al, eds. Wintrobe’s
Clinical Hematology. 11th ed. Lippincott Williams & Wilkins;2004:2259.
56. PRURITUS
I. Problem. A 25-year-old man is admitted for lethargy and a hematocrit of
21%. He also complains of severe generalized itching (pruritus).
B. Laboratory data
1. Hemogram and differential. An elevated hematocrit/hemoglobin,
white blood cell (WBC) count, and platelet count suggest poly-
cythemia vera. A low mean cell volume and a low mean cellular
hemoglobin indicate iron deficiency anemia. A low hematocrit/he-
moglobin, WBC count, and platelet count may be seen with lym-
phoma or carcinoma. Eosinophilia occurs with occult parasitic
infection. An elevated WBC count (or decreased WBC count) with
blasts, monoclonal lymphocytosis, or granulocytes at all stages of
development suggests leukemia as the cause.
2. Liver function tests. Total bilirubin, alkaline phosphatase, γ-glu-
tamyltransferase, alanine aminotransferase, and aspartate amino-
transferase should be obtained.
3. Blood urea nitrogen and creatinine. Uremia needs to be ruled
out.
4. Thyroid function tests. Thyroid-stimulating hormone to assess
for hypothyroidism or hyperthyroidism.
5. Glucose. To rule out diabetes mellitus.
6. Calcium. To rule out hyperparathyroidism.
7. Uric acid. If gout is considered. However, the diagnosis of gout is
made by aspiration of joint fluid and examination of the fluid for
crystals.
8. Stool test for ova and parasites. Consider especially with gas-
trointestinal symptoms and eosinophilia.
9. Other tests. Specific tests such as serum and urine histamine
(systemic mastocytosis) and 24-hour urine for 5-HIAA (carcinoid)
may be helpful. An arterial blood gas test, leukocyte alkaline
phosphatase (LAP) score, and vitamin B12 level are helpful if poly-
cythemia vera is considered (see Section I, Chapter 55, Poly-
cythemia, p 312).
C. Radiologic and other studies
1. Chest x-ray. May reveal hilar adenopathy (lymphoma), a lung
mass, or infiltrates (transient infiltrates seen with several parasitic
infections).
2. KOH (potassium hydroxide) preparation of skin scrapings.
Any rash suspected to be fungal in origin should be scraped with
a #15 blade. Scrapings should fall on a microscopic slide recently
wiped with an alcohol pad (which will help keep the scrapings on
the slide). Add 1 drop of KOH (10–20%), place a coverslip over
the scrapings and KOH, and view under the microscope at magni-
fications of 10× and 40×. Heating the slide under an alcohol flame
may facilitate visualization of fungal elements.
3. Wood’s ultraviolet light. Erythrasma has a coral-red or pink
color.
4. Skin biopsy. May be very helpful in establishing the diagnosis in
systemic mastocytosis and various dermatologic conditions. The
56. PRURITUS 323
REFERENCES
Greco PJ, Ende J: Pruritus: A practical approach. J Gen Intern Med 1992;7:340.
Fleisher AB: Pruritus in the elderly. Adv Dermatol 1995;10:41.
Kantor GR, Lookingbill DP: Pruritus. In: Sams WM, Lynch PJ, eds. Principles and Prac-
tice of Dermatology. Churchill Livingstone;1990:861.
Yosipovitch G, David M: The diagnostic and therapeutic approach to idiopathic general-
ized pruritus. Int J Dermatol 1999;38:881.
pressure, the same effect may occur as the pulmonary vascular bed
shrinks relative to the catheter position. The catheter may end up
wedged with its balloon deflated, a situation analogous to a pul-
monary embolus. The catheter position must be corrected as soon
as possible. Careful evaluation is needed to ensure that the problem
is really a case of permanent wedge and not a kink or system mal-
function. If all else fails to help distinguish the various causes of a flat
tracing, wedge position can be confirmed with blood gas sampling,
showing saturation in the arterial range, as opposed to the mixed ve-
nous range usually found when blood gases are sampled from the
PA position.
E. Can a wedge tracing be obtained with the balloon inflated? If
not, the balloon may have ruptured or the catheter may have been
partially removed. Do not continue to inject air if the balloon has rup-
tured, because the air is injected directly into the PA.
F. Are there any associated symptoms? Chest pain may result from
a PA catheter in permanent wedge, resulting in a pulmonary infarc-
tion. Hemoptysis can result from pulmonary infarction or from PA
rupture or erosion. This is usually associated with inflation of the bal-
loon in a vessel smaller than the balloon, rupturing the PA with entry
of blood into the airways. Hemoptysis usually results and can some-
times be severe, but is rarely life-threatening. A fever may be sec-
ondary to catheter infection, catheter sepsis, or pulmonary infarction.
G. What is the relative necessity of the PA catheter? If critical mea-
surements are being made, such as hourly PA wedge pressure read-
ings, the situation is more serious than if the line has outlived its
usefulness and can be removed.
the monitor is set on the proper pressure scale for the measure-
ments being made.
3. Monitor-related problems. Perhaps the most common monitor-
related problems arise when the monitor is set on an improper
scale or when the transducer/monitor setup is not properly zero-
balanced.
B. Inside the patient
1. Catheter migration. The catheter may have moved from its origi-
nal insertion position, migrating either distally or proximally. Distal
migration may result in a permanent wedge.
2. Thrombosis. A blood clot in the pressure-monitoring lumen may
preclude good-quality pressure recordings.
3. Kinks. The most common sites for kinking are at the skin surface,
under the clavicle, and at the proximal and distal ends of the
sheath. Kinks are another cause of poor-quality tracings.
4. Malfunctioning balloon. If the catheter does not wedge, the bal-
loon may have ruptured or the catheter may have migrated proxi-
mally. Do not continue to inject air into the catheter system if a
wedge tracing does not appear, because a ruptured balloon may
be the cause.
IV. Database
A. Physical examination key points
1. General exam. As in most technical areas of medicine, be sure
that the information provided by your technology correlates with
your clinical assessment.
2. Vital signs. The presence of fever suggests catheter infection or
sepsis, especially if the catheter has been in place longer than 3
days.
B. Laboratory data
1. Blood gases. A blood gas sample obtained from the distal port of
the catheter can be helpful in determining whether a PA catheter is
in permanent wedge position. If the catheter is wedged, the oxygen
saturation will approximate arterial oxygen saturation, whereas
mixed venous saturation is found in pulmonary artery locations.
2. Blood cultures. These should be obtained in the presence of a
fever or elevated white cell count with an increase in segmented
and banded neutrophils.
C. Radiologic and other studies
1. Chest x-ray. A chest x-ray is useful in determining whether the
catheter is kinked or is in the correct position. Permanent wedge
may be suggested by a markedly distal location of the catheter
tip. After injection with air, a deflated balloon also points to balloon
rupture.
2. Culture of PA catheter. If catheter-related sepsis or infection is
suspected, the PA catheter and the introducer sheath must be re-
57. PULMONARY ARTERY CATHETER PROBLEMS 327
V. Plan. For replacement of a PA catheter, see Section III, Chapter 12, Pul-
monary Artery Catheterization, p 449.
A. Problems outside the patient. If simple tapping on the catheter
does not result in a waveform, the cause clearly resides outside the
patient. Faulty line connections and stopcocks that are improperly set
up, as well as transducer, cable, and monitor-related problems,
should be addressed first.
B. Problems inside the patient. When a good waveform is obtained by
tapping the catheter, the problem most likely resides within the pa-
tient.
1. Permanent wedge. This problem is reported much more fre-
quently than actually exists. Often, a well-placed PA catheter is
withdrawn when the position is fine.
a. System inspection. Thoroughly inspect the PA catheter sys-
tem before you attempt to move the catheter. The transducer
should be evaluated for proper functioning. The system should
be evaluated for leaks, loose connections, and similar me-
chanical problems, before any manipulation of the catheter.
b. Chest x-ray. For PA catheter positioning and evaluation of the
balloon. If the catheter is truly stuck in wedge, the chest x-ray
will show the catheter to be in the distal pulmonary circulation.
Less commonly, the balloon will not deflate because the
catheter is kinked.
c. Check the oxygen saturation. As mentioned earlier, the oxy-
gen saturation will be close to arterial when obtained from a
truly wedged catheter.
d. Catheter withdrawal. If the catheter is really wedged and the
waveform cannot be returned to the expected waveform by
manual aspiration or flushing of the catheter, withdraw the
catheter centimeter by centimeter while flushing between each
withdrawal using a pressure-bag flush system. During catheter
withdrawal, the balloon must always be completely deflated.
When an appropriate waveform for PA position returns, the
balloon should be reinflated to be certain that the catheter will
wedge when desired. With most properly placed PA catheters,
the balloon needs to be inflated with only 1–1.5 mL of air to
obtain the wedge tracing. Once the balloon is deflated, the
original PA pressure waveform should return within 3–5 heart-
beats.
2. A balloon that will not wedge. In most cases, the catheter has
been pulled back too far, or the balloon is not functioning. The
328 I: ON-CALL PROBLEMS
REFERENCES
Davidson CJ, Bonow RO: Cardiac catheterization. In: Braunwald E, Zipes DP, Libby P,
eds. Heart Disease: A Textbook of Cardiovascular Medicine. 6th ed. Saun-
ders;2001:359.
Sprung CL, ed: The Pulmonary Artery Catheter: Methodology and Clinical Applications.
2nd ed. Critical Care Research Associates;1993.
58. SEIZURES
I. Problem. A 65-year-old man experiences a seizure-like episode the day
after being admitted for a fractured hip.
IV. Database
A. Physical examination key points. Although a detailed history and
general physical examination are necessary for all patients who pre-
sent with an epileptic seizure, key points include the following:
1. Vital signs. The blood pressure is often normal after a seizure,
but hypotension in an elderly person may signal a recent myocar-
dial infarction due to the profound muscular exertion accompany-
ing a generalized tonic-clonic seizure. Hypertension may suggest
a cause of the seizure, such as hypertensive encephalopathy,
toxemia, or a recent stroke.
2. Skin. Skin changes of neurocutaneous syndromes including
tuberous sclerosis, Sturge–Weber syndrome, ataxia-telangiecta-
sia, von Hippel–Lindau syndrome, and neurofibromatosis can
give clues regarding the cause of an epileptic seizure. Inspection
of the skin for needle tracks might indicate illegal drug use, and a
rash could suggest an underlying vasculitis or connective tissue
disease. Enlarged lymph nodes could imply HIV or other infec-
tions, malignancy, sarcoidosis, or systemic lupus erythematosus.
3. HEENT. A deeply bitten and bleeding tongue is strongly associ-
ated with generalized tonic-clonic seizures and rarely if ever oc-
curs in psychogenic seizures. Inspection of the skull for recent or
remote head injuries, burr holes, or craniotomy scar can provide
significant clues regarding the cause of the patient’s seizure. Pa-
pilledema on funduscopic examination implies intracranial hyper-
tension from a tumor, infection, hemorrhage, or brain edema.
Measuring head circumference is important to detect microcephaly
and an associated disorder of maldevelopment, which can cause
epileptic seizures. Meningismus, or nuchal rigidity, could signify a
neck injury, meningitis, or a subarachnoid hemorrhage.
4. Heart and lungs. A cardiac dysrhythmia or valvular abnormality
could suggest syncope rather than an epileptic seizure. After a
58. SEIZURES 333
V. Plan. Support life functions with the ABCs (airway, breathing, and circu-
lation) of cardiopulmonary resuscitation and protect the patient from self-
inflicted injury during the seizure.
A. Emergency management. Place the patient in a lateral decubitus
position with a suction device to prevent aspiration if vomiting occurs.
Move objects away from the patient or place padding between the
patient and the floor or other immovable items. Do not place objects
in the patient’s mouth or try to force the mouth open because these
measures are unnecessary and may lead to injury to the patient or
yourself.
B. Seizure control. See Section VII, Therapeutics, for a discussion of
drugs listed here.
1. Most seizures are self-limited, last no more than 2–3 minutes, and
may not need immediate treatment until a detailed evaluation is
completed. Status epilepticus is recurrent seizures without com-
plete recovery between seizures. Any seizure type can evolve into
status epilepticus, but generalized tonic-clonic status epilepticus
is a medical emergency requiring prompt treatment to prevent se-
rious morbidity and mortality. In clinical practice, a generalized
tonic-clonic seizure lasting more than 5–10 minutes or two gener-
alized tonic-clonic seizures occurring in quick succession without
the patient fully recovering between seizures should be treated as
status epilepticus.
2. Immediately establish IV access and collect a serum specimen for
laboratory tests. If hypoglycemia is a suspected cause, do not
wait for the results of the laboratory tests. Promptly give 50 mL of
50% dextrose IV. If there is clinical suspicion of chronic alcohol
abuse or another disorder associated with nutritional deprivation,
give 50 mg thiamine IV with dextrose to prevent precipitation of
Wernicke’s encephalopathy.
3. For generalized tonic-clonic status epilepticus with the patient in
an active seizure, give lorazepam 0.1 mg/kg at 1–2 mg/min IV,
and repeat, if necessary, in 15 minutes (maximum dose 0.2 mg/kg
or 5–10 mg total; doses > 0.2 mg/kg are usually unnecessary or
ineffective). Diazepam may also be used at doses of 5–10 mg at
1–2 mg/min IV, and repeated, if necessary, in 15 minutes (maxi-
mum dose 20–40 mg). However, lorazepam may be preferred be-
cause of its longer effect. Both drugs may cause respiratory
depression (especially if given with phenobarbital) and may re-
quire intubation and ventilatory support.
336 I: ON-CALL PROBLEMS
seizure type would not predict serious harm to the patient if re-
leased from the hospital (eg, absence or brief myoclonic seizure,
or some complex partial or simple partial seizures).
9. Not all isolated seizures need to be treated with an anticonvul-
sant. Epileptic seizures due to alcohol or drug withdrawal, drug
abuse, severe sleep deprivation, or seizures associated with
acute illness such as hypoglycemia do not need to be treated. If
the patient has a history of brain injury, a structural lesion of the
brain such as a tumor or arteriovenous malformation, or an abnor-
mal EEG with epileptiform activity, or if the presentation with sta-
tus epilepticus is at the onset, treatment with an anticonvulsant to
prevent further seizures is recommended.
REFERENCES
Blum AS: Recurrent generalized and partial seizures. In: Johnson RT, Griffin JW,
McArthur JC, eds. Current Therapy in Neurologic Disease. 6th ed. Mosby;2002:46.
Browne TR, Holmes GL: Epilepsy. N Engl J Med 2001;344:1145.
Delanty N, Vaughan CJ, French JA: Medical causes of seizures. Lancet 1998;352:383.
Leppik IE: Contemporary Diagnosis and Management of the Patient with Epilepsy. 5th
ed. Handbooks in Health Care;2000.
Manno EM: New management strategies in the treatment of status epilepticus. Mayo
Clin Proc 2003;78:509.
Pedley TA: The epilepsies. In: Goldman L, Ausiello D, eds. Cecil Textbook of Medicine.
22nd ed. Saunders;2004:2257.
59. SYNCOPE
I. Problem. A patient admitted for palpitations and chest pain loses con-
sciousness while ambulating to the bathroom.
SYNCOPE
+ Echocardiography
and exercise
treadmill test
+ OHD
Holter (2)
– OHD
Normal sinus Arrhythmia Nondiagnostic
rhythm with symptoms
with symptoms
Consider
Treat electrophysiologic studies
Stop workup
for arrhythmia
–
+
Treat
A
Recurrent First episode
Figure I–7. Algorithm for diagnosing syncope (1) Carotid massage can be performed in an office
setting only in the absence of bruits, ventricular tachycardia, recent stroke, and myocardial infarc-
tion. (2) Holter monitoring may be replaced by inpatient telemetry if there is a concern about ar-
rhythmias. OHD, organic heart disease. (Reprinted, with permission, from Linzer M, Yang EH,
Estes M et al: Diagnosing syncope: Part I. Value of history physical examination, and electrocar-
diography. Ann Intern Med 1997;126:989.)
59. SYNCOPE 343
REFERENCES
Kapoor WN: Evaluation and management of the patient with syncope. JAMA
1992;268:2553.
Linzer M, Yang EH, Estes M et al: Diagnosing syncope part 1: Value of history, physical
examination, and electrocardiography. Ann Intern Med 1997;126:989.
Linzer M, Yang EH, Estes M et al: Diagnosing syncope part 2: Unexplained syncope.
Ann Intern Med 1997;127:76.
60. TACHYCARDIA
I. Problem. You are asked to evaluate an 18-year-old woman with sudden
onset of chest pain, palpitations, and dizziness. Cardiac monitoring re-
veals a rapid, regular, narrow-complex tachycardia at a rate of 180 beats
per minute (bpm).
IV. Database
A. Physical examination key points
1. Vital signs. Hypotension requires rapid action. Palpation of
carotid, brachial, or femoral pulses can give the examiner a rapid
estimate of the adequacy of systolic pressure.
2. Neck. Distended jugular veins are present with acute decompen-
sation of congestive heart failure, exacerbations of chronic pul-
monary disease, pneumothorax, and pericardial tamponade. The
presence of cannon “A” waves in the jugular venous pulsations
suggests the presence of AV dissociation.
3. Chest. Rales and wheezes can be present in many of the associ-
ated cardiopulmonary diseases that predispose to tachyarrhythmias.
4. Heart. Listen in particular for S3 or S4 heart sounds or a murmur
that might suggest mitral valve disease.
5. Abdomen. Localized or rebound tenderness pinpoint a source of
infection as the cause of the tachyarrhythmia.
6. Extremities. Examine for signs of peripheral perfusion as an as-
sessment of the adequacy of cardiac output.
B. Laboratory data
1. Serum electrolytes. Hypokalemia and hypomagnesemia can be
responsible for sustained arrhythmias, particularly in patients tak-
ing digoxin. Both supraventricular and ventricular arrhythmias can
result from potassium and magnesium deficiencies.
60. TACHYCARDIA 351
REFERENCES
Falk RH: Atrial fibrillation. N Engl J Med 2001;344:1067.
Horowitz LN, ed: Current Management of Arrhythmias. Decker;1991.
Miller JM, Zipes DP: Management of patient with cardiac arrhythmias. In: Braunwald E,
Zipes DP, Libby P, eds. Heart Disease: A Textbook of Cardiovascular Medicine. 6th
ed. Saunders;2001:700.
61. THROMBOCYTOPENIA 355
Wagner GS, ed: Marriott’s Practical Electrocardiography. 9th ed. Williams &
Wilkins;1994.
Wellens HJJ, Bar FWH, Lie K: The value of the electrocardiogram in the differential di-
agnosis of tachycardia with widened QRS complex. Am J Med 1978;64:27.
61. THROMBOCYTOPENIA
I. Problem. You are called to see a 73-year-old patient admitted to the
cardiology service with unstable angina. His admission laboratory data
reveal a platelet count of 32,000/μL.
V. Plan
A. Bleeding. Initially, it is important to determine whether there is life-
threatening bleeding, in which case platelet transfusion is indicated.
(See Section V, Blood Component Therapy, p 465.) If there is no ac-
tive bleeding and the thrombocytopenia is immunologic, platelet
transfusions are to be avoided. In this situation, transfusions are fre-
quently ineffective and may actually worsen the thrombocytopenia
with further immunologic challenge.
B. Immune-mediated destruction. If this situation is suspected, all
nonessential medicines should be stopped. Do not overlook heparin
flush from catheters and Hep-Locks, as well as heparin-banded cen-
tral venous catheters.
C. Treatment of underlying cause. Especially important for leukemias,
lymphomas, infections, and DIC.
D. ITP
1. High-dose steroids (1–2 mg/kg prednisone) daily is the initial
treatment for ITP. IV immunoglobulins can also be used in
steroid-unresponsive ITP or when steroids are contraindicated.
2. Splenectomy may be required in chronic ITP or acute ITP that is
unresponsive to steroids or immunoglobulins. If the platelet count
is consistently > 50,000/μL, close observation may be best, de-
pending on the underlying medical condition(s). Before splenec-
tomy, be sure the patient receives appropriate vaccinations,
including pneumococcal vaccine (if possible, at 2 weeks before
splenectomy).
E. TTP
1. Plasmapheresis. Considered standard treatment, although the
mechanism of action is unknown. It may be related to removal of
an offending agent or replacement of missing factor(s).
2. High-dose prednisone. Frequently used treatment; however,
there is no proven benefit.
F. Prophylactic platelet transfusion. This may be indicated with
myeloproliferative disorders or bone marrow suppression from
myelotoxic drugs. Frequently, transfusions are given for platelet
counts < 20,000/μL. Three units per meter squared, or approximately
6 units, should give an adequate increment in most adults. Pheresed
or single-donor platelets are often given to those who require re-
peated transfusion to decrease donor exposure and risk of develop-
62. TRANSFUSION REACTION 361
REFERENCES
Beutler E: Platelet transfusions: The 20,000/microliter trigger. Blood 1993;81:1411.
George JN: Drug-induced thrombocytopenia: A systemic review of published case re-
ports. Ann Intern Med 1998;129:886.
George JN, Rizvi MA: Thrombocytopenia. In: Beutler E, Lichtman MA, Coller BS et al,
eds. William’s Hematology. 6th ed. McGraw-Hill;2001:1495.
George JN, Vesely SK. Immune thrombocytopenia purpura—let the treatment fit the
patient. N Engl J Med 2003;349:903.
Rizvi MA, Kojouri K, George JN. Drug-induced thrombocytopenia: An updated system-
atic review. Ann Intern Med 2001;134:346.
Rodgers G: Thrombocytopenia. In: Kjeldsberg C, ed. Practical Diagnosis of Hemato-
logic Disorders. 3rd ed. ASCP Press;2000:739.
IV. Database
A. Physical examination key points
1. Vital signs. If the constellation of hypotension, fever, and tachy-
cardia is present, the transfusion reaction must be considered to
be a severe hemolytic reaction.
2. Skin and mucous membranes. Generalized bleeding may be
part of a severe hemolytic reaction.
3. Chest. Wheezing or rales is consistent with a life-threatening re-
action.
B. Laboratory data
1. Hemogram. May point to contaminated blood or show evidence
of hemolysis.
2. Prothrombin time, partial thromboplastin time, thrombin
time, fibrinogen, and fibrin split products. To rule out DIC.
3. Peripheral smear. Look for schistocytes as evidence of DIC.
4. Urine for hemoglobinuria. Supports the diagnosis of a severe
transfusion reaction.
5. Serum for free hemoglobin. If positive, indicates hemolysis.
6. Post-transfusion direct antiglobulin testing. A negative study
in the absence of serum-free hemoglobin supports that an acute
hemolytic transfusion has not occurred.
364 I: ON-CALL PROBLEMS
REFERENCES
Cookson ST, Arduino MJ, Aguero SM et al: Yersinia enterocolitica-contaminated red
blood cells: An emerging threat to blood safety. 1996 Interscience Conference on An-
timicrobial agents and Chemotherapy. ABS:2352.
Goodnough LT. Risks of blood transfusion. Crit Care Med 2003;31:S678.
Jeter EK, Spivey MA. Noninfectious complications of blood transfusion. Hematol Oncol
Clin North Am 1995;9:187.
Linden JV, Wagner K, Voytovich AE et al: Transfusion errors in New York State: An
analysis of 10 years’ experience. Transfusion 2001;40:1207.
Red blood cell transfusions contaminated with Yersinia enterocolitica—United States,
1991-1996, and initiation of a national study to detect bacteria-associated transfusion
reactions. MMWR 1997;46:553.
63. WHEEZING
I. Problem. You are asked to evaluate a recently admitted patient who de-
velops respiratory distress and wheezing.
C. Localized wheezing
1. Tumors. May obstruct one bronchus, leading to localized wheez-
ing.
2. Mucous plugging
3. Aspirated foreign body
IV. Database
A. Physical examination key points. Localization of wheezing allows
categorization, as outlined in the differential diagnosis (see III).
1. Vital signs. A fever may indicate an infectious cause. A pulsus
paradoxus > 16 mm Hg indicates severe respiratory distress. Hy-
potension requires immediate assessment and action.
2. HEENT. Check the mouth carefully. Examine the neck and
tongue for angioedema, which may be precipitated by an-
giotensin-converting enzyme (ACE) inhibitors. Palpate the stern-
ocleidomastoid muscles to assess accessory muscle use in
obstructive lung diseases. Auscultate over the mouth and larynx
in an effort to identify upper airway wheezing (stridor).
3. Chest. Carefully auscultate for localized wheezing. Listen for
bibasilar rales, which may be present in pulmonary edema. Rales,
increased fremitus, and egophony suggest pneumonia.
4. Heart. Check carefully for evidence of an S3 gallop or jugular ve-
nous distention, which points to cardiogenic pulmonary edema.
5. Extremities. Clubbing may indicate underlying lung cancer.
Cyanosis indicates underlying hypoxemia. Edema may signify
chronic congestive heart failure.
6. Skin. Urticaria suggests an acute allergic reaction.
B. Laboratory data
1. Arterial blood gases. An elevated paCO2 indicates significant
ventilatory failure. Hypoxemia is commonly present during bron-
chospasm because of V̇/ Q̇ mismatch. It may worsen after beta-
agonist aerosols.
2. Complete blood count. An increased white blood cell (WBC)
count may indicate an underlying infection; however, an increase
in WBCs without a left shift can be seen with an acute MI or PE.
Eosinophilia suggests an allergic or asthmatic cause of the
wheezing.
C. Radiologic and other studies
1. Electrocardiogram (ECG). An ECG may show an acute MI or is-
chemia. Occasionally, it is suggestive of a PE, showing an S
wave in lead I, a Q wave in III, T-wave inversion in lead III
(S1Q3T3), new right bundle branch block, and right-axis shift. It
may also show a change in rhythm.
2. Chest radiograph. A PE (with infarction) severe enough to cause
wheezing may be evident on the chest film. Look for a pleural-
63. WHEEZING 367
REFERENCES
Aboussouan LS, Stoller JK: Diagnosis and management of upper airway obstruction.
Clin Chest Med 1994;15:35.
Leatherman J: Life-threatening asthma. Clin Chest Med 1994;15:453.
NHLBI Expert Panel Report 2: Guidelines for the Diagnosis and Management of
Asthma. NIH Publication # 97-4051; April 1997.
II. Laboratory Diagnosis
Notes: The ranges of normal values are given below each test, first in con-
ventional units such as metric (eg, milligrams per liter) and then in interna-
tional units if there is a difference. Reference ranges for each laboratory may
vary from the values given; therefore, you should interpret the results of a
patient’s laboratory value in light of an individual facility’s range.
■ ACID-FAST STAIN
Positive: Mycobacterium species (tuberculosis and atypical mycobacteria
such as M avium-intracellulare) and Nocardia.
■ ALBUMIN, SERUM
3.5–5.0 g/dL or 35–50 g/L.
369
370 II: LABORATORY DIAGNOSIS
■ ALBUMIN, URINE
Normal = < 30 mg/day.
Microalbuminuria 30–300 mg/day (a sign of early renal damage in dia-
betes mellitus, hypertension, and other diseases affecting the kidney. Its
presence helps identify patients at risk for renal failure, neuropathy,
retinopathy, and coronary artery disease. Renal function may be preserved
with the use of an angiotensin-converting enzyme [ACE] inhibitor or an-
giotensin-receptor blocker [ARB]). Microalbuminuria can be detected by de-
termining the albumin to creatinine ratio by obtaining a spot urine for albumin
and creatinine. Normal is < 30 μg of albumin per milligram of creatinine, and
microalbuminuria is defined as 30–300 μg of albumin per milligram of creati-
nine.
Note: Microalbuminuria can be seen with prolonged exercise, hematuria,
fever, or prolonged upright posture.
Nephrotic proteinuria > 3.5 g/day.
■ ALDOSTERONE
Serum—supine: 3–10 g/dL or 0.083–0.28 nmol/L early AM, normal sodium
intake; upright: 5–30 g/dL or 0.138–0.83 nmol/L.
Urinary—2–16 μg/24 hr or 5.4–44.3 nmol/day.
■ ALKALINE PHOSPHATASE
Adults: 20–70 U/L.
A γ-glutamyltransferase (GGT) is often useful to differentiate whether an
elevated alkaline phosphatase originates from bone or liver. A normal GGT
suggests bone origin.
■ ALPHA-FETOPROTEIN (AFP)
< 30 ng/mL or < 30 μg/L.
■ AMMONIA
Arterial: 15–45 μg/dL or 11–32 μmol N/L.
■ AMYLASE
25–125 U/L.
■ ANION GAP
8–12 mmol/L.
Note: The anion gap is a calculated estimate of unmeasured anions and
is used to help differentiate the cause of metabolic acidosis.
■ ANTICARDIOLIPIN ANTIBODIES
See Antiphospholipid Antibodies, p 373.
372 II: LABORATORY DIAGNOSIS
■ ANTIPHOSPHOLIPID ANTIBODIES
Note: There are two basic categories of antiphospholipid antibody—anticar-
diolipin and lupus anticoagulant. Both are associated with recurrent arterial
or venous thrombosis or fetal demise.
Lupus anticoagulant\eh4\
Negative = normal.
Positive = presence.
Should be suspected with an isolated elevated partial thromboplastin time
(PTT) with no other likely cause.
■ BASE EXCESS/DEFICIT
See Table II–1, p 374. A decrease in base (bicarbonate) is termed base
deficit; an increase in base is termed base excess.
■ BENCE–JONES PROTEINS—URINE
Negative: Normal.
Metabolic acidosis ↓ ↓↓ ↓
Metabolic alkalosis ↑ ↑↑ ↑
Acute respiratory acidosis ↓ slight↑ ↑↑
Chronic respiratory acidosis slight↓ ↑ ↑↑
Acute respiratory alkalosis ↑ slight↓ ↓↓
Chronic respiratory alkalosis slight↑ ↓ ↓↓
■ BILIRUBIN
Total: < 0.2–1.0 mg/dL or 3.4–17.1 μmol/L;
■ BLEEDING TIME
Duke, Ivy: < 6 min; Template: < 10 min.
Decreased ratio: (< 10:1): Acute tubular necrosis, low-protein diet, starva-
tion, malnutrition, liver disease, syndrome of inappropriate antidiuretic hor-
mone, pregnancy, and rhabdomyolysis.
Note: The ratio may not be appropriate if the patient is in diabetic ketoaci-
dosis or receiving drugs such as cephalosporin.
The ratio can be altered by interferences in the chemical methods used to
measure the creatinine or the BUN, resulting in spurious results. The pres-
ence of ketones may seriously elevate the serum creatinine level. Drugs
such as cephalosporins, ascorbic acid, and barbiturates may also interfere
with the serum creatinine measurement.
■ CALCITONIN
< 100 pg/mL or < 100 g/L.
■ CALCIUM, SERUM
8.4–10.2 mg/dL (4.2–5.1 mEq/L) or 2.10–2.55 mmol/L;
Ionized: 4.5–4.9 mg/dL (2.2–2.5 mEq/L) or 1.1–1.2 mmol/L.
CARCINOMA MARKERS 377
Note: To interpret a total calcium value, you must know the albumin level.
If the albumin is not within normal limits, a corrected calcium can be roughly
calculated with the following formula. Values for ionized calcium need no
special correction.
■ CALCIUM, URINE
Average calcium diet: 100–300 mg per 24-hour urine.
■ CARBOXYHEMOGLOBIN
Nonsmoker: < 2%.
Smoker: < 6%.
Toxic: > 15%.
■ CARCINOMA MARKERS
CA 125.
0–35 m/L.
378 II: LABORATORY DIAGNOSIS
Her2/neu-
Positive result is abnormal. This means that the gene is overexpressed in
the breast carcinoma, suggesting an aggressive breast carcinoma that tends
to be resistant to hormonal therapy and chemotherapy. Some patients may
respond to Herceptin.
■ CATECHOLAMINES, FRACTIONATED
Note: Values are variable and depend on the lab and method of assay used.
Normal levels listed in Table II–3 are based on high-performance liquid chro-
matography technique.
■ CHLORIDE, SERUM
98–106 mEq/L.
■ CHLORIDE, URINE
110–250 mmol per 24-hour urine.
See Urinary Electrolytes, p 411.
■ CHOLESTEROL (TOTAL)
140–240 mg/dL or 3.63–6.22 mmol/L.
Desired level: < 200 mg/dL or 5.18 mmol/L.
dial infarction in the next 10 years (> 10 %), desired LDL is < 100 mg/dL or
2.58 mmol/L (optimal < 70 mg/dL).
Triglycerides
See Triglycerides, p 407.
■ COLD AGGLUTININS
Normal = < 1:32.
■ COMPLEMENT C3
80–155 mg/dL or 800–1550 ng/L.
> 60 years: 80–170 mg/dL or 80–1700 ng/L.
Note: Normal values may vary greatly depending on the assay used.
■ COMPLEMENT C4
20–50 mg/dL or 200–500 ng/L.
■ CORTISOL
Serum—8 AM: 5.0–23.0 μg/dL or 138–635 nmol/L; 4 PM: 3.0–15.0 μg/dL or
83–414 nmol/L.
Urine (24-hour): 10–100 μg/day or 27.6–276 nmol/day.
■ COUNTERIMMUNOELECTROPHORESIS (CIE)
Normal = negative.
CIE is an immunologic technique that allows rapid identification of infec-
tious organisms from body fluids, including serum, urine, cerebrospinal fluid,
and others. Organisms that can be identified include Neisseria meningitidis,
Streptococcus pneumoniae, Haemophilus influenzae, and group B strepto-
coccus.
CREATINE PHOSPHOKINASE (CK) 383
■ C-PEPTIDE
Fasting: ≤ 4.0 g/mL or = 4.0 μg/L;
Males > 60 years: 1.5–5.0 g/mL or 1.5–5.0 μg/L;
Females: 1.4–5.5 g/mL or 1.4–5.5 μg/L.
High-sensitivity C-reactive protein: Not widely used but several labs are
now performing. Check your lab for reference ranges. Elevated levels are
associated with increased risk of cardiovascular disease such as myocardial
infarction and possibly unstable atherosclerotic plaques of carotid arteries.
This is an important predictor at all levels of LDL.
This test is used to predict a healthy person’s risk for cardiovascular con-
ditions such as heart attack. Since it measures CRP, people with inflamma-
tory diseases such as rheumatoid arthritis should not be evaluated based on
this test.
CK isoenzymes MM, MB, BB: MB (normal < 6%) increased in acute my-
ocardial infarction (increases in 4–8 hours, peaks at 24 hours), cardiac
surgery; BB not useful.
384 II: LABORATORY DIAGNOSIS
■ CREATININE CLEARANCE
Males: 100–135 mL/min or 0.963–1.300 mL/s/m2.
Females: 85–125 mL/min or 0.819–1.204 mL/s/m2.
A concurrent serum creatinine and a 24-hour urine creatinine are needed.
A shorter time interval can be used and corrected for in the formula. A quick
formula for estimation is also found in Table VII–18, Aminoglycoside Dosing,
p 630.
■ CREATININE, SERUM
Males: 0.7–1.3 mg/dL.
Females: 0.6–1.1 mg/dL.
■ CREATININE, URINE
Male total creatinine: 14–26 mg/kg/24 hr or 124–230 μmol/kg/day.
Females: 11–20 mg/kg/24 hr or 97–177 μmol/kg/day. See Creatinine
Clearance, p 384.
■ CRYOCRIT
≤ 0.4%. (Negative if qualitative.) Cryocrit, a quantitative measure, is pre-
ferred over the qualitative method. It should be collected in nonanticoagu-
lated tubes and transported at body temperature. Positive samples can be
analyzed for immunoglobulin class, and light-chain type on request.
> 0.4%. (Positive if qualitative.) Monoclonal—Multiple myeloma, Walden-
ström’s macroglobulinemia, lymphoma, chronic lymphocytic leukemia.
Mixed polyclonal or mixed monoclonal—Infectious diseases (viral, bacter-
ial, parasitic) such as subacute bacterial endocarditis and malaria, SLE,
ETHANOL LEVEL 385
■ ERYTHROPOIETIN (EPO)
Normal = 5–30 mU/mL.
There is an inverse relationship between erythropoietin and hematocrit.
■ ETHANOL LEVEL
See Drug Levels, Table VII–16, p 629.
386 II: LABORATORY DIAGNOSIS
■ FERRITIN
Males: 15–200 ng/mL or 15–220 μg/L.
Females: 12–150 ng/mL or 12–150 μg/L.
■ FIBRINOGEN
150–450 mg/dL or 150–450 g/L.
■ FUNGAL SEROLOGIES
Negative (< 1:8). Complement-fixation fungal antibody screen that usually
detects antibodies to Histoplasma, Blastomyces, Aspergillus, and Coccid-
ioides.
■ γ-GLUTAMYLTRANSFERASE (GGT)
Males: 9–50 U/L.
Females: 8–40 U/L. Generally parallels changes in serum alkaline phos-
phatase and 5′-nucleotidase in liver disease.
■ GASTRIN
Males: < 100 pg/mL or < 100 ng/L.
Females: < 75 pg/mL or < 100 ng/L.
■ GLUCOSE
Fasting: 70–105 mg/dL or 3.89–5.83 nmol/L.
2 hours postprandial: 70–120 mg/dL or 3.89–6.67 mmol/L.
■ GRAM’S STAIN
Rapid Technique
388 II: LABORATORY DIAGNOSIS
Spread a thin layer of specimen onto a glass slide and allow it to dry. Fix
with heat. Apply Gentian violet (15–20 seconds); follow with iodine (15–20
seconds), then alcohol (just a few seconds until effluent is barely decol-
orized). Rinse with water and counterstain with safranin (15–20 seconds).
Examine under oil immersion lens: gram-positive bacteria are dark blue and
gram-negatives are red.
■ HAPTOGLOBIN
26–185 mg/mL.
■ HELICOBACTER ANTIBODIES
Normal = negative.
Serologic test to detect antibodies to Helicobacter pylori in patients with
peptic ulcer disease. High titers of IgG to Helicobacter are indicative of H py-
lori infection (sensitivity > 95% and specificity > 95%). More sensitive than
biopsy for detecting presence of H pylori. It may take 6 months or longer for
antibodies to decline appreciably after treatment.
■ HEMATOCRIT
See Table II–4, p 380, for normal values.
HEPATITIS TESTS 389
■ HEMOGLOBIN
See Table II–4, p 380, for normal values.
■ HEPATITIS TESTS
See Table II–5, p 390.
• Anti-HAV Tot: Total antibody to hepatitis A virus, both IgG and IgM.
Confirms previous exposure to hepatitis A virus and is also positive with
acute infection.
• Anti-HAV IgM: IgM antibody to hepatitis A virus. Indicates acute infec-
tion with hepatitis A virus.
• HBsAg: Hepatitis B surface antigen. Indicates either chronic or acute
infection with hepatitis B. Used by blood banks to screen donors and
part of routine hepatitis panel for evaluation of liver injury.
• Total Anti-HBc: IgG and IgM antibody to hepatitis B core antigen. Con-
firms either previous exposure to hepatitis B virus (HBV) or ongoing in-
fection. Used by blood banks to screen donors.
• Anti-HBc IgM: IgM antibody to hepatitis B core antigen. Early and best
indicator of acute infection with hepatitis B.
• HBeAg: Hepatitis Be antigen. When present, indicates high degree of
infectiousness. Order only when evaluating a patient with chronic HBV
infection.
• Anti-HBe: Antibody to hepatitis Be antigen. Order with HbeAg. Pres-
ence is associated with resolution of active viral proliferation, but often
means virus is integrated into host DNA, especially if host remains
HbsAg-positive.
• Anti-HBs: Antibody to hepatitis B surface antigen. Typically indicates
immunity associated with clinical recovery from an HBV infection or pre-
vious immunization with hepatitis B vaccine. Order only to assess effec-
tiveness of vaccine, and results will often be reported as a titer.
• HBV-DNA: Detects presence of viral DNA in serum (pg/mL) quantita-
tively to confirm infection and assess therapy with antivirals such as
lamivudine and adefovir. Relatively expensive assay.
• Anti-HDV: Antibody to delta-agent hepatitis. Order only in patients with
known chronic HBV infection who have flare of transaminase elevation.
• Anti-HCV: Antibody against hepatitis C. Order to evaluate both acute
and chronic hepatitis. Has a low false-positive rate. Used by blood
390 II: LABORATORY DIAGNOSIS
TABLE II–5. HEPATITIS PANEL TESTING.
■ Screening
Admission: High- HBsAg To screen for chronic or
risk patients Anti-HCV active infection.
(homosexuals,
IV drug users,
dialysis patients)
All pregnant women HBsAg To screen for chronic or
active infection.
Percutaneous HBsAg Test serum of patient
inoculation Anti-HCV (if known) for possible
infectivity. Start Hep B
vaccination if health care
worker not previously
immunized.
Anti-HBs Determine if vaccinated
health care worker is
immune and protected.
Pre-HBV vaccine in HBsAg To determine if an individual
high-risk patients Anti-HBc is infected or already has
antibodies and is immune.
■ Diagnosis
Differential diagnosis of Anti-HAV IgM To differentiate between
acute hepatitis HBsAg hepatitis A, hepatitis B, and
Anti-HBc IgM hepatitis C (Anti-HCV may
Anti-HCV take 4–8 weeks to become
positive)
Differential diagnosis of HBsAg To rule out chronic hepatitis
chronic hepatitis Anti-HCV (and B or C as a cause of
(Abnormal Liver RIBA or HCV RNA chronically elevated LFTs.
Function Tests if Anti-HCV is
[LFTs]) positive)
■ Monitoring
Chronic hepatitis B LFTs To test for activity, late
HBsAg seroconversion, or disease
HBeAg/Anti-HBe latency in known hepatitis B
Anti-HDV IgM carrier, superinfection with
α-fetoprotein HDV, development of hepatoma,
HBV DNA or resolution of infection after
therapy or spontaneously.
Chronic hepatitis C LFTs To test for activity of hepatitis
HCV RNA likelihood of response to inter-
α-fetoprotein feron, or development of hepatoma
Postvaccination screening Anti-HBs To ensure immunity after
vaccination
Sexual contact HBsAg To monitor sexual partners with
acute or chronic hepatitis B
HOMOCYSTEINE 391
banks to screen donors and part of routine hepatitis panel for evaluation
of liver injury.
• Anti-HCV RIBA: Measures antibody to four separate HCV antigens.
However, no longer used to confirm positive anti-HCV test.
• HCV-RNA: Detects presence of virus either qualitatively by sensitive
RT-PCR or quantitatively by one of a number of tests with varying sen-
sitivities and dynamic ranges. The qualitative test is used to confirm that
the HCV-Ab represents an active infection; it is also used to assess the
end-of-treatment response and the “sustained viral response” (RNA
negative at 24 weeks after therapy and likely cured) to interferon and
ribavirin antiviral therapies. The quantitative test (viral load, in Interna-
tional Units) is obtained only before instituting antiviral therapy and at 12
weeks into therapy. This is to determine whether there has been an
“early viral response” to therapy defined as ≥ 100-fold drop in IU or un-
detectable virus. Therapy is not continued beyond 12 weeks without an
early viral response. The HCV viral load does NOT correlate with
amount of liver injury.
• HCV-Genotype: Important for determining likelihood of the HCV infec-
tion responding to antiviral therapy with interferon and ribavirin. Geno-
type 1 patients with quantitative RNA values > 850,000 IU are less likely
to respond to therapy than genotypes 2 and 3 patients. Genotype 1 pa-
tients usually require 48 weeks of therapy to achieve a 40–50% chance
of cure; genotypes 2 and 3 patients require only 24 weeks of therapy to
achieve a 70–80% chance of cure.
■ HOMOCYSTEINE
5–12 mmol/mL.
Western Blot
The technique is used as the reference procedure for confirming the pres-
ence or absence of HIV antibody, usually after a positive HIV antibody by
ELISA determination.
• INR 2–3: Therapeutic range for most indications, including atrial fibrilla-
tion, deep venous thrombosis, pulmonary embolus, and transient is-
chemic attacks.
• INR 2.5–3.5: Prevention of arterial thromboembolism with mechanical
valves. This range may also be required in hypercoagulable states, or in
recurrent arterial or venous thromboembolic disease.
KOH PREP 393
■ IRON
Males: 65–175 μg/dL or 11.64–31.33 μmol/L.
Females: 50–170 μg/dL or 8.95–30.43 μmol/L.
Increased: Acute and chronic blood loss, iron deficiency anemia, hepatitis,
oral contraceptives.
■ 17-KETOSTEROIDS (17-KS)
Males: 9–22 mg or 31–76 μmol/24-hr urine.
Females: 6–15 mg or 21–52 μmol/24-hr urine.
■ KOH PREP
Negative: Normal.
■ LIPASE
Variable depending on the method; 10–150 U/L by turbidimetric method.
■ LUPUS ANTICOAGULANT
See Antiphospholipid Antibodies, p 373.
■ LYMPHOCYTES, TOTAL
1800–3000/mL.
Used to assess nutritional status. Calculated by multiplying the white
blood cell count by the percentage of lymphocytes: < 900, severe;
5′-NUCLEOTIDASE 395
■ MAGNESIUM
1.6–2.4 mg/dL or 0.80–1.20 mmol/L.
■ MAGNESIUM, URINE
6.0–10.0 mEq/day or 3.00–5.00 mmol/day.
■ METANEPHRINES, URINE
Total: < 1.0 mg or 0.574 mmol/24-hr urine;
Fractionated metanephrines-normetanephrines: < 0.9 mg or 0.517
mmol/24-hr urine;
Fractionated metanephrines: < 0.4 mg or 0.230 mg/24-hr urine.
■ MONOSPOT
Negative: Normal.
Positive: Mononucleosis.
■ MYOGLOBIN, URINE
Qualitative negative.
■ 5′-NUCLEOTIDASE
2–15 U/L.
■ OSMOLALITY, SERUM
275–295 mOsm/kg.
A rough estimation of osmolality is [2(Na) + BUN/2.8 + glucose/18]). The
calculation will not be accurate if foreign substances that increase the osmo-
lality (eg, mannitol) are present. If foreign substances are suspected, osmo-
lality should be measured directly.
■ OSMOLALITY, URINE
Spot 50–1400 mOsm/kg; > 850 mOsm/kg after 12 hours of fluid restriction.
Loss of the ability to concentrate urine, especially during fluid restriction, is
an early indicator of impaired renal function.
Decreased: . .
• Ventilation-perfusion (V/Q) abnormalities: Chronic obstructive pul-
monary disease, asthma, atelectasis, pneumonia, pulmonary embolus,
adult respiratory distress syndrome, pneumothorax, cystic fibrosis, ob-
structed airway.
• Alveolar hypoventilation: Skeletal abnormalities, neuromuscular dis-
orders, Pickwickian syndrome.
• Decreased pulmonary diffusing capacity: Pneumoconiosis, pul-
monary edema, pulmonary fibrosis.
• Right-to-left shunt: Congenital heart disease (tetralogy of Fallot, trans-
position, others).
■ PH, ARTERIAL
See Tables II–1 and II–2, pp 374, 375.
■ PHOSPHORUS
2.7–4.5 mg/dL or 0.87–1.45 mmol/L.
■ PLASMINOGEN
7–17 mg/dL.
Plasminogen activity: 75–140%.
■ PLATELETS
See Table II–4, p 380.
Platelet counts may be normal in number, but abnormal in function (eg,
aspirin therapy); platelet function with a normal platelet count can be as-
sessed by measuring bleeding time.
398 II: LABORATORY DIAGNOSIS
■ POTASSIUM, SERUM
3.5–5.1 mmol/L.
■ POTASSIUM, URINE
25–125 mmol/24-hr urine; varies with diet. See Urinary Electrolytes, p 411.
■ PROLACTIN
Females: 1–25 ng/mL.
Males: 1–20 ng/mL.
■ PROTEIN, SERUM
6.0–7.8 g/dL or 60–78 g/L.
■ PROTEIN, URINE
See also Albumin, Urine, p 370.
< 100 mg/24-hr urine;
Spot: < 10 mg/dL (< 20 mg/dL if early-morning collection);
Dipstick: negative.
■ PROTEIN C, PLASMA
Normal = 60–130%.
ALB α1 α2 β γ ALB α1 α2 β γ
ALB α1 α2 β γ ALB α1 α2 β γ
ALBα1 α2 β γ ALB α1 α2 β γ
ALB α β γ ALB α β γ
Bence–Jones Protein
ALB α β γ
Figure II–1. Protein electrophoresis patterns. Examples of (A) serum and (B) urine protein elec-
trophoresis patterns.
TABLE II–6. NORMAL SERUM PROTEIN COMPONENTS AND FRACTIONS AS DETERMINED BY ELECTROPHORESIS ALONG
WITH ASSOCIATED CONDITIONS.
Protein Percentage of
Fraction Total Protein Constituents Increased Decreased
Reproduced with permission from Gomella LG, ed. Clinician’s Pocket Reference. 10th ed.: McGraw-Hill; 2004.
401
402 II: LABORATORY DIAGNOSIS
■ PROTEIN S, PLASMA
Normal = 60–140%.
■ QUANTITATIVE IMMUNOGLOBULINS
IgG: 650–1500 mg/dL or 6.5–15 g/L;
IgM: 40–345 mg/dL or 0.4–3.45 g/L;
IgA: 76–390 mg/dL or 0.76–3.90 g/L;
IgE: 0–380 IU/mL or KIU/L;
IgD: 0–8 mg/dL or 0–80 mg/L.
■ RETICULOCYTE COUNT
0.5–1.5%.
If the patient’s hematocrit is abnormal, a corrected reticulocyte count
should be calculated as follows:
Corrected
reticulocyte count = % reticulocytes × patient' s hematocrit
45%
Increased: Hemolysis, acute hemorrhage, therapeutic response to treat-
ment for iron, vitamin B12, or folate deficiency.
■ SODIUM, SERUM
136–145 mmol/L.
■ SODIUM, URINE
40–210 mmol/24-hr urine. See Urinary Electrolytes, p 411.
■ T3 (TRIIODOTHYRONINE) RADIOIMMUNOASSAY
120–195 ng/dL or 1.85–3.00 nmol/L.
■ T3 RU (RESIN UPTAKE)
24–34%.
■ T4 TOTAL (THYROXINE)
5–12 μg/dL or 65–155 nmol/L.
Males: 5–10 μg/dL: 5–10 μg/dL or 65–129 nmol.
Females: 5.5–10.5 μg/dL or 71–135 nmol/L.
■ THROMBIN TIME
10–14 seconds.
■ THYROGLOBULIN
0–60 ng/mL or < 60 μg/L.
Used primarily to detect recurrence of nonmedullary thyroid carcinoma
after resection.
Increased: Hypothyroidism.
■ TRANSFERRIN
220–400 mg/dL or 2.20–4.00 g/L.
Increased: Acute and chronic blood loss, iron deficiency anemia, hepatitis,
oral contraceptives.
■ TRIGLYCERIDES
Males: 40–160 mg/dL or 0.45–1.81 mmol/L.
Females: 35–135 mg/dL or 0.40–1.53 mmol/L; may vary with age.
■ TROPONIN I
< 0.6 ng/mL or < 0.6 μg/L.
Increased: In myocardial injury levels > 1.5 ng/mL (1.5 μg/L) is consistent
with myocardial infarction. Sensitivity is similar to CK-MB (creatine kinase
MB fraction) but more specific. Does not tend to be elevated with skeletal
muscle injury nor chronic renal disease as much as the CK-MB. False-posi-
tives can be seen in clotted specimens and in the presence of heterophil an-
tibodies. Elevated within 4–8 hours of myocardial injury with peak at 12–16
hours, but remains elevated for 5–9 days unlike CK-MB, which begins to de-
crease after 24–36 hours.
408 II: LABORATORY DIAGNOSIS
■ TROPONIN T
< 0.1 ng/mL or < 0.1 μg/L.
■ TRYPTASE
5.6–13.5 μg/L.
■ URIC ACID
Males: 4.5–8.2 mg/dL or 0.27–0.48 mmol/L.
Females: 3.0–6.5 mg/dL or 0.18–0.38 mmol/L.
■ URINALYSIS, ROUTINE
Appearance
• Normal: Yellow, clear, straw-colored
• Pink/red: Blood, hemoglobin, myoglobin, food coloring, beets
• Orange: Pyridium, rifampin, bile pigments
• Brown/black: Myoglobin, bile pigments, melanin, cascara bark, iron, ni-
trofurantoin, metronidazole, sickle cell crisis
• Blue: Methylene blue, Pseudomonas urinary tract infection (rare),
hereditary tryptophan metabolic disorders
• Cloudy: Urinary tract infection (pyuria), blood, myoglobin, chyluria,
mucus (normal in ileal loop specimens), phosphate salts (normal in al-
kaline urine), urates (normal in acidic urine), hyperoxaluria
• Foamy: Proteinuria, bile salts
URINALYSIS, ROUTINE 409
pH
(4.6–8.0)
Basic: Urinary tract infection, involving Proteus; renal tubular acidosis; diet
(high vegetable, milk, immediately postprandial); sodium bicarbonate or ac-
etazolamide therapy; vomiting; metabolic alkalosis; chronic renal failure.
Specific Gravity
Normal: 1.001–1.035.
Bilirubin
Negative dipstick.
Blood (Hemoglobin)
Negative dipstick.
Glucose
Negative dipstick.
Ketones
Negative dipstick.
410 II: LABORATORY DIAGNOSIS
Microscopy
Note: Many laboratories no longer perform urine microscopy on a routine
basis when the dipstick is negative and the gross appearance is normal.
• RBCs: (Normal: 0–2/HPF.) Trauma, urinary tract infection, prostatic hy-
pertrophy, genitourinary tuberculosis, nephrolithiasis, malignant and be-
nign tumors, glomerulonephritis.
• WBCs: (Normal: 0–4/HPF.) Infection anywhere in the urinary tract, gen-
itourinary tuberculosis, renal tumors, acute glomerulonephritis, radiation
damage, interstitial nephritis (analgesic abuse). (Glitter cells represent
WBCs lysed in hypotonic solution.)
• Epithelial cells: (Normal: occasional.) Acute tubular necrosis, necrotiz-
ing papillitis.
• Parasites: (Normal: none.) Trichomonas vaginalis, Schistosoma
haematobium.
• Yeast: (Normal: none.) Candida albicans (especially in diabetics and
immunosuppressed patients, or if a vaginal infection is present).
• Spermatozoa: (Normal: after intercourse or nocturnal emission.)
• Crystals:
Normal:
Acid urine: Calcium oxalate (small square crystals with a central
cross), uric acid.
Alkaline urine: Calcium carbonate, triple phosphate (resemble
coffin lids).
Abnormal:
Cystine, sulfonamide, leucine, tyrosine, cholesterol, or exces-
sive amounts of the crystals noted earlier.
• Contaminants: Cotton threads, hair, wood fibers, amorphous sub-
stances (all usually unimportant).
• Mucus: (Normal: small amounts.) Large amounts suggest urethral dis-
ease. Ileal loop urine normally has large amounts.
• Hyaline cast: (Normal: occasional.) Benign hypertension, nephrotic
syndrome.
• RBC cast: (Normal: none.) Acute glomerulonephritis, lupus nephritis,
subacute bacterial endocarditis, Goodpasture’s disease, vasculitis, ma-
lignant hypertension.
• WBC cast: (Normal: none.) Pyelonephritis or interstitial nephritis.
• Epithelial cast: (Normal: occasional.) Tubular damage, nephrotoxin,
viral infections.
URINARY ELECTROLYTES 411
Nitrite
Negative dipstick.
Positive: Bacterial infection (a negative test does not rule out infection).
Protein
See also Albumin, Urine, p 370.
Negative dipstick.
Reducing Substance
Negative dipstick.
Urobilinogen
Negative dipstick.
■ URINARY ELECTROLYTES
These “spot urines” are of limited value because of large variations in daily
fluid and salt intake. Results are usually indeterminate if a diuretic has been
given. Sodium is most useful in the differentiation of volume depletion, olig-
uria, or hyponatremia. Chloride is useful in the diagnosis and treatment of
metabolic alkalosis. Urinary potassium levels are often used in the evalua-
tion of hypokalemia.
• Chloride < 10 mmol/L: Chloride-sensitive metabolic alkalosis. See
Section I, Chapter 3, Alkalosis, p 19.
• Chloride > 20 mmol/L: Chloride-resistant metabolic alkalosis. See
Section I, Chapter 3, Alkalosis, p 19.
• Potassium < 10 mmol/L: Hypokalemia, from extrarenal losses.
412 II: LABORATORY DIAGNOSIS
■ URINARY INDICES
The indices in Table II–7 are used in determining the cause of oliguria. See
Section I, Chapter 51, Oliguria/Anuria, p 283.
Neutrophils
40–70% segmented neutrophils, 5–10% banded neutrophils.
Lymphocytes
Normal: 24–44%.
Lymphocytes, Atypical
Normal: 0–3%.
> 20%: Infectious mononucleosis (Epstein-Barr virus), cytomegalovirus in-
fection, viral hepatitis, toxoplasmosis.
3–20%: Viral infections (mumps, rubeola, varicella), rickettsial infections,
tuberculosis.
414 II: LABORATORY DIAGNOSIS
Monocytes
Normal: 3–7%.
Eosinophils
Normal: 0–3%.
Basophils
Normal: 0–1%.
■ ZINC
60–130 μg/dL or 9–20 μmol/L.
REFERENCES
Burtis CA, Ashwood ER: Tietz’s Textbook of Clinical Chemistry. 3rd ed. Saun-
ders;1999.
Coudrey L: The troponins. Arch Intern Med 1998;158:1173.
Jurado R, Mattix H: The decreased serum urea nitrogen-creatinine ratio. Arch Intern
Med 1998;115:2509.
Henry JB, ed. Clinical Diagnosis and Management by Laboratory Methods. 20th ed.
WB Saunders;2001.
Pettijohn TL, Doyle T, Spiekerman AM et al: Usefulness of positive troponin-T and neg-
ative creatine kinase levels in identifying high-risk patients with unstable angina pec-
toris. Am J Cardiol 1997;80:510.
Tchetgen M-B, Song JT, Strawderman M et al: Ejaculation increases the serum
prostate-specific antigen concentration. Urology 1996;47:511.
III. Procedures
1. ARTERIAL LINE PLACEMENT
See also Section I, Chapter 6, Arterial Line Problems, p 36.
Procedure
1. The radial artery is most frequently used; this approach is described
here. Other sites, in decreasing order of preference, are the dorsalis
pedis, femoral, brachial, and axillary arteries. Axillary arteries are in-
frequently used; catheters in these arteries should be placed by an in-
tensivist or anesthesiologist.
2. Verify the patency of the collateral circulation between the radial and
ulnar arteries using the Allen test. See Section III, Chapter 2, Arterial
Puncture, p 417.
3. Place the extremity on an armboard with a roll of gauze behind the
wrist to hyperextend the joint. Prep with povidone-iodine and drape
with sterile towels. The operator should wear gloves and a mask.
4. Raise a very small skin wheal at the puncture site with 1% lidocaine
using a 25-gauge needle. Carefully palpate the artery and choose the
puncture site where it appears most superficial.
5. While palpating the path of the artery with your nondominant hand,
advance the 20-gauge catheter-over-needle assembly into the artery
at a 30-degree angle to the skin with the needle bevel up. Once a
“flash” of blood is seen in the hub, hold the needle steady and ad-
vance the entire unit 1–2 mm so that the needle and catheter are in
the artery. Advance the catheter over the needle into the artery. Re-
move the needle while briefly occluding the artery with manual pres-
sure and connect the pressure tubing. Penetration of both sides of the
vessel may occur; therefore, withdraw the catheter slowly while ob-
serving for blood return. Never reinsert the needle into a plastic
416
2. ARTERIAL PUNCTURE 417
catheter that lies beneath the skin. Finally, no more than three at-
tempts at cannulation should be performed at a single site.
6. Suture in place with 3-0 silk and apply a sterile dressing.
7. Splint the dorsum of the wrist to limit mobility and provide catheter
stability.
8. Kits are available with a needle and guidewire that allow the Seldinger
technique to be used. This is especially useful for femoral artery can-
nulation.
9. Arterial lines should be replaced using a different site every 4 days to
decrease risk of infection.
2. ARTERIAL PUNCTURE
Indications: Blood gas determination; need for arterial blood in certain
chemistry determinations.
Procedure
1. Use a heparinized syringe for blood gas and a nonheparinized syringe
for chemistry determinations. Obtain a blood gas kit (contains a pre-
heparinized syringe), or a small syringe (3–5 mL) with a small-gauge
needle (23- to 25-gauge for radial artery; 20- to 22-gauge is accept-
able for femoral artery). Heparinize the syringe (if not preheparinized)
by drawing up about 0.5–1 mL of heparin, pulling the plunger all the
way back, and discarding the heparin.
2. Arteries, in order of preference, are radial, femoral, and brachial. If
using the radial artery, perform the Allen test to verify collateral flow
from the ulnar artery (15–20% of patients have inadequate collateral
circulation to the hand). Have the patient make a tight fist. Occlude
both the radial and ulnar arteries at the wrist and have the patient
make a fist and release several times. Then have the patient open the
hand. The hand should appear pale. While maintaining pressure on
the radial artery, release the ulnar artery. If the ulnar–brachial arterial
arch is patent, the entire hand should flush red within 10 seconds. If
the Allen test is positive (the radial distribution remains white beyond
10 seconds), the artery should not be used.
3. Hyperextension of the wrist joint or elbow often brings the radial and
brachial arteries closer to the surface.
418 III: PROCEDURES
4. If you are using the femoral artery, the mnemonic NAVEL can aid in
locating the important structures in the groin. Palpate the femoral
artery just two fingerbreadths below the inguinal ligament. From lat-
eral to medial, the structures are nerve, artery, vein, empty space,
lymphatic. You may wish to inject 1% lidocaine subcutaneously for
anesthesia. Palpate the artery proximally and distally with two fingers,
or trap the artery between two fingers placed on either side of the ves-
sel.
5. Prep the area with either a povidone-iodine solution or an alcohol
swab. Hold the syringe like a pencil with the needle bevel up and
enter the skin at a 60- to 90-degree angle. Maintain slight negative
pressure on the syringe.
6. Obtain blood on the downstroke or on slow withdrawal. Aspirate very
slowly. A good arterial sample should require only minimal backpres-
sure. If a glass or blood-gas syringe is used, the barrel usually rises
spontaneously. You should obtain 2–3 mL.
7. If the vessel cannot be located, redirect the needle without taking it
out of the skin.
8. Withdraw the needle quickly and apply firm pressure at the site for at
least 5–10 minutes, even if the sample was not obtained, to avoid a
hematoma.
9. If the sample is for a blood gas, expel any air from the syringe, mix the
contents thoroughly by twirling the syringe between your fingers, and
make the syringe airtight with a cap. Place the syringe on ice before
the sample is taken to the laboratory.
of fluid present), a 3-mL syringe with a 25-gauge needle, and two hep-
arinized tubes for cell count and crystal examination.
Discuss with your microbiology laboratory staff their preference for trans-
porting fluid for bacterial, fungal, and acid-fast bacillus (AFB) cultures, and
Gram’s stain. A Thayer-Martin plate is needed if you suspect Neisseria gon-
orrhoeae (GC). A small syringe containing a long-acting corticosteroid such
as Depo-Medrol or triamcinolone is optional for therapeutic arthrocentesis.
Procedure
General
1. Obtain consent. Describe the procedure and complications including
bleeding, pain, infection. If injecting steroids, also include skin atro-
phy, tendon rupture, and systemic side effects of elevated blood pres-
sure and elevated serum glucose. Postinjection flare-ups of joint pain
and swelling can occur after steroid injection and can persist up to 48
hours. This complicatioon is thought to be a crystal-induced synovitis
from the crystalline suspension used in long-acting steroids.
2. Determine the optimal site for aspiration and mark with indelible ink.
Alternatively, make an indentation in the skin with the retracted tip of a
ballpoint pen.
3. Wear gloves (universal precautions) to protect yourself against hep-
atitis and HIV. When aspiration is to be followed by corticosteroid in-
jection, maintaining a sterile field with sterile implements minimizes
the risk of infection to the patient.
4. Clean the area with povidone-iodine, and dry and wipe over the aspi-
ration site with alcohol. Povidone-iodine can render cultures negative.
Let the alcohol dry before beginning the procedure.
5. Anesthetize the area with lidocaine using a 25-gauge needle, taking
care not to inject the solution into the joint space. Lidocaine is bacteri-
cidal. Avoid preparations containing epinephrine, especially in a digit.
Alternatively, spray the area with ethyl chloride just before needle as-
piration.
6. Insert the aspirating needle, applying a small amount of vacuum to
the syringe. Remove as much fluid as possible, repositioning the sy-
ringe if necessary.
7. If a corticosteroid is to be injected, remove the aspirating syringe from
the needle, which is still in the joint space. It is helpful to ensure that
the syringe can easily be removed from the needle before undertaking
step 6. Attach the syringe containing the corticosteroid, pull back on
the plunger to ensure that the needle is not in a vein, and inject con-
tents. Caution: Never inject steroids when there is a possibility that
the joint is infected. Remove the needle and syringe, and apply pres-
sure to the area. Generally, the equivalent of 40 mg of methylpred-
nisolone is injected into large joints such as the knee and 20 mg into
medium-sized joints such as the ankle or wrist. Preparations of intra-
articular steroids are equivalent in potency. Injections of 0.5 mL into
420 III: PROCEDURES
the knee or shoulder and 0.25 mL into the ankle or wrist are recom-
mended dosages.
8. Joint fluid is sent for cell count and differential, crystal exam, Gram’s
stain, and cultures for bacteria, fungi, and AFB as indicated. See Sec-
tion I, Chapter 47, Joint Swelling, p 260.
Arthrocentesis of the Knee
1. With the patient in the supine position, the knee should be slightly
bent with a small towel under it to help with relaxation. Wait until the
patient’s quadriceps muscle has relaxed, because its contraction
plants the patella against the femur, making aspiration painful.
2. Insert the needle posterior to the lateral portion of the patella into the
patellar-femoral groove. Direct the advancing needle slightly posteri-
orly and superiorly (Figure III–1).
Arthrocentesis of the Wrist. The easiest site for aspiration lies between the
navicular bone and the radius on the dorsal wrist.
1. Locate the distal radius between the tendons of the extensor pollicis
longus and the extensor carpi radialis longus of the second finger.
This site is just ulnar to the anatomic snuff box.
2. Direct the needle perpendicular to the mark (Figure III–2).
Arthrocentesis of the Ankle
1. The most accessible site lies between the tibia and the talus. The
angle of foot to leg is positioned at 90 degrees. Make a mark lateral
Extensor carpi
radialis longus
Extensor pollicis
longus
Tibialis anterior
tendon
Medial malleolus
and anterior to the medial malleolus and medial and posterior to the
tibialis anterior tendon. Direct the advancing needle posteriorly toward
the heel.
2. The subtalar ankle joint does not communicate with the ankle joint
and is difficult to aspirate even by an expert. Keep in mind that “ankle
pain” may originate in the subtalar joint rather than in the ankle (Fig-
ure III–3).
4. BLADDER CATHETERIZATION
See also Section I, Chapter 24, Foley Catheter Problems, p 148).
Procedure
1. Have the patient in a well-lit area in a supine position. With females,
knees should be flexed, hips internally rotated, and heels placed to-
gether to adequately expose the meatus.
2. Open the kit and put on the gloves. Prepare all the materials before
you attempt to insert the catheter. Open the prep solution and soak
the cotton balls; apply the sterile drapes.
3. Inflate and deflate the balloon of the Foley catheter with 5–10 mL of
sterile water to ensure proper functioning. Coat the end of the
catheter with sterile lubricant jelly.
4. In females, use one gloved hand to prep the urethral meatus in a
pubis-toward-anus direction; hold the labia apart with the other gloved
hand. With uncircumcised males, retract the foreskin to prep the
glans; use a gloved hand to hold the penis still.
5. The hand used to hold the penis or labia should not touch the catheter
while you are inserting it. You can use disposable forceps in the kit to
insert the catheter, or use the forceps to prep. You can then insert the
catheter with your gloved hand.
6. In males, stretch the penis upward perpendicular to the body to elimi-
nate any folds in the urethra that might create a false passage. Use
gentle pressure to slowly advance the catheter. Any significant resis-
tance that is encountered may represent a stricture and requires uro-
5. BONE MARROW ASPIRATION & BIOPSY 423
gloves and surgical drapes; iodine prep solution and alcohol; 22- and 26-
gauge needles; at least two 10-mL syringes; 1% lidocaine solution; no. 11
scalpel blade, 4 × 4 gauze pads; and several microscope slides for staining.
Procedure
1. Explain the procedure in detail to the patient or to the legally responsi-
ble person and obtain an informed consent.
2. Local anesthesia is usually all that is required; however, it is reason-
able to premedicate extremely anxious patients with an anxiolytic or
sedative such as diazepam (Valium) or lorazepam (Ativan) or with an
analgesic.
3. To obtain a bone marrow aspirate and biopsy from the posterior iliac
crest (safest and easiest location), position the patient either on the
abdomen or on the side opposite the biopsy site.
4. Identify the posterior iliac crest with palpation, and mark the desired
biopsy site with indelible ink. In most patients, the upper posterior su-
perior iliac spine can be identified by a dimple in the skin at the lateral
edge of the Michaelis’ rhomboid.
5. Use sterile gloves and follow strict aseptic technique for the remainder
of the procedure.
6. Prep the biopsy site with sterile iodine solution and allow the skin to
dry. Then wipe the site free of iodine with sterile alcohol. Next, cover
the surrounding areas with surgical drapes.
7. Using a 26-gauge needle, administer 1% lidocaine solution subcuta-
neously to raise a skin wheal. (The lidocaine may be buffered by 8.4%
sodium bicarbonate solution (1 mEq/mL) to decrease the burning as-
sociated with this part of the procedure (2 mL sodium bicarbonate
with 8 mL lidocaine). Then, with the 22-gauge needle, infiltrate the
deeper tissues with lidocaine until you reach the periosteum. At this
point, advance the needle just through the periosteum and infiltrate li-
docaine subperiosteally. An area approximately 2 cm in diameter
should be infiltrated, using repeated periosteal punctures.
8. Once local anesthesia has been obtained, use a no. 11 scalpel blade
to make a 2- to 3-mm skin incision over the biopsy site.
9. Insert the bone marrow needle through the skin incision; then ad-
vance it with a rotating motion that alternates between clockwise and
counterclockwise rotation and with gentle pressure until you reach the
periosteum. After the needle is firmly seated on the periosteum, ad-
vance it through the outer table of bone into the marrow cavity with
the same rotating motion and gentle pressure. Generally, a slight
change in the resistance to needle advancement signals entry into the
marrow cavity. At this point, advance the needle 2–3 mm.
10. Remove the stylet from the biopsy needle and attach a 10-mL syringe
to the hub of the biopsy needle. Withdraw the plunger on the syringe
briskly and aspirate 1–2 mL of marrow into the syringe. The patient
5. BONE MARROW ASPIRATION & BIOPSY 425
Procedure
1. Sterilize the site with chlorhexidine and drape with sterile towels.
2. Administer local anesthesia with lidocaine in the area to be explored.
3. Place the patient in Trendelenburg (head-down) position.
4. Use a small-bore thin-walled needle with syringe attached to locate
the internal jugular vein. It may be helpful to have a small amount of
anesthetic (1% lidocaine) in the syringe to inject during exploration for
the vein, if the patient notes some discomfort. Some operators find
the vein with a long 21-gauge needle, leave the needle in place off the
syringe, and pass the 19-gauge needle directly behind it, following the
same course to the deep vein puncture site.
5. The internal diameter of the needle used to locate the internal jugular
vein should be large enough to accommodate the passage of the
guidewire. Some operators prefer a “micro-puncture” kit, which uti-
lizes a smaller puncture needle, followed by a smaller-diameter
guidewire, followed by a small-caliber dilator. The dilator actually then
allows passage of the same guidewire usually passed via a 19-gauge
needle. Less trauma is felt to occur because of the smaller puncture
needle.
6. Percutaneous entry should be made at the apex of the triangle formed
by the two heads of the sternocleidomastoid muscle and the clavicle.
7. The needle should be directed slightly laterally toward the ipsilateral
breast and kept as superficial as possible.
8. Often a notch can be palpated on the posterior surface of the clavicle.
This actually can help locate the vein in the lateral/medial plane, as
the vein lies deep to this shallow notch.
9. Successful puncture of the vein is usually accomplished at a depth of
needle insertion of 2–4 cm and is heralded by sudden aspiration of
nonpulsatile venous blood.
10. After the needle is detached from the syringe, the guidewire should
pass with ease all the way to the right atrium. Once the wire is
passed, remove the needle.
11. Leave enough wire outside the patient to accommodate the length of
the intravascular catheter, sheath, etc, with an adequate amount to
allow control over the distal end of the guidewire at all times.
12. Nick the skin with a no. 11 scalpel blade just adjacent to the
guidewire.
428 III: PROCEDURES
13. The catheter or sheath should be introduced over the guidewire, while
the depth of the guidewire is kept relatively constant to avoid irritation
of the right atrium or ventricle and possible ventricular ectopy.
14. When the sheath or catheter is placed over the guidewire, the proxi-
mal end of the guidewire should be held until the catheter or sheath
completely passes over the distal end of the guidewire.
15. Then the distal end of the guidewire is controlled while the catheter or
sheath is advanced through the incised skin and into the vein.
16. Once the catheter or sheath is in place, the guidewire is removed.
17. An occlusive sterile dressing should be applied.
18. A chest x-ray should be obtained to verify position of the line and to
assess for a pneumothorax. The tip of the catheter should be posi-
tioned above the right atrium.
Complications
1. Central venous catheterization is relatively safe, with a low risk of
pneumothorax.
2. Errant attempts at internal jugular puncture are likely to end up in the
mediastinum. It is possible to perforate endotracheal tube cuffs by this
approach. This is usually not a subtle event and generally requires
prompt replacement of the now-faulty endotracheal tube before safe
deep line placement can proceed.
3. The other procedural miscue is inadvertent puncture of the carotid
artery. This commonly occurs if the needle is inserted medial to where
it should be on the middle approach; it is also common with the ante-
rior approach. With arterial puncture, the syringe fills without negative
pressure because of arterial pressure, and bright red blood pulsates
from the needle after the syringe is removed. The needle should be
removed and manual pressure applied for 10–15 minutes to ensure
adequate hemostasis.
Advantages: Central venous access from this site allows virtually every po-
tential use of the deep line, including hemodynamic assessment (both cen-
tral venous pressure and pulmonary artery measurements); temporary
pacemaker placement; endomyocardial biopsy; and administration of fluids,
drugs, and parenteral nutrition.
Disadvantages
1. The major disadvantage of this site is patient discomfort. The site is
difficult to dress and is uncomfortable for patients who have the ca-
pacity to turn their heads.
2. The risk of infectious contamination for this line is intermediate be-
tween that for femoral lines and that for subclavian lines and is proba-
bly related to the difficulty in keeping the site occlusively dressed.
Reports from centers in Europe have shown a markedly reduced inci-
dence of catheter infection by including at least an 8-cm subcuta-
6. CENTRAL VENOUS CATHETERIZATION 429
neous tunnel from the percutaneous venipuncture site to the skin exit
site of the catheter. The procedure is more demanding by virtue of
having to construct the tunnel (not described here).
available for bedside use or have not been associated with benefit in
trials evaluating patient safety.
9. Direct the needle under the clavicle, above the first rib and toward the
suprasternal notch (Figure III–4).
10. Apply constant negative pressure while the needle is advanced.
11. Successful entry is marked by free flow of nonpulsatile venous blood.
12. The patient’s head should be directed to face the operator while the
guidewire is inserted. This facilitates guidewire placement down the
superior vena cava as opposed to up the internal jugular vein.
13. Remove the syringe.
14. Advance the guidewire through the needle.
15. The guidewire should slide easily through the needle, essentially to
the hub of the needle.
16. If there is resistance to passage of the guidewire, it is important to reat-
tach the syringe and reposition the needle so that the blood flows freely.
17. If the resistance is more distal than the tip of the needle, the guidewire
is likely coursing cephalad at the internal jugular vein (an awake pa-
tient may remark that the ipsilateral ear hurts). Another pass of the
guidewire with the entry needle pulled back slightly is appropriate.
18. Once the guidewire is passed, remove the needle.
Subclavian vein
Clavicle
First rib
Figure III–4. Technique for catheterization of the subclavian vein. (Reproduced, with permission,
from Gomella L, ed: Clinician’s Pocket Reference. 10th ed. McGraw-Hill;2004.)
6. CENTRAL VENOUS CATHETERIZATION 431
19. Follow steps 11 through 18 for placement via the right internal jugular
vein approach.
Complications
1. Arterial puncture is usually obvious because bright red blood spurts from
the needle when the syringe is detached or the syringe spontaneously
fills without negative pressure. The needle is then withdrawn and manual
pressure applied to stop arterial bleeding. Significant bleeding deep to
the clavicle may occur and is heavily dependent on the patient’s coagu-
lation system and the size of the puncture. This underscores the impor-
tance of knowing the patient’s coagulation profile before making the
decision on which approach to use for central line placement.
2. Pneumothorax can be detected when a sudden gush of air is aspi-
rated instead of blood. A postprocedure chest x-ray should always be
done to rule out pneumothorax and check for line placement. A pneu-
mothorax requires chest tube placement in virtually all cases, espe-
cially when the patient is being supported on a ventilator. The
left-sided approach is associated with higher risk for pneumothorax
because of the higher dome of the left pleura compared with the right.
3. Hemothorax
4. Air embolus
Advantages
1. The left subclavian approach affords a gentle, sweeping curve to the
apex of the right ventricle and is the preferred entry site for placement
of a temporary transvenous pacemaker without fluoroscopic assis-
tance.
2. Hemodynamic measurements are often easier to record from the left
subclavian approach.
3. From the left subclavian vein approach, the catheter does not have to
negotiate an acute angle, as is commonly the case at the junction of the
right subclavian with the right brachiocephalic vein en route to the supe-
rior vena cava. This is also a common site for kinking of the deep line.
4. Lowest risk of infection of various central line sites.
Procedure
1. Place the patient in the supine position.
2. Use sterile preparation and appropriate draping. Administer local
anesthesia in the area to be explored.
432 III: PROCEDURES
Complications
1. The femoral deep line has the highest incidence of contamination and
sepsis. If an occlusive dressing can remain in place and remain free
from contamination, this is a safe option. Recent randomized series
from centers in Europe testify to the benefit of a 10-cm long subcuta-
neous tunnel between the vein puncture site to the skin exit site of the
catheter. A fourfold decrease in catheter-related infections was noted.
The procedure is still done at bedside but is more involved in that the
tunneling subcutaneously must be added to the percutaneous
venipuncture.
2. Deep venous thrombosis (DVT) has occurred from femoral vein
catheterization as well as with other sites. The risk for DVT increases
if the catheter remains in place for prolonged periods.
Advantages
1. The procedure is safe, in that arterial and venous sites are compress-
ible. This route or the median basilic vein approach is preferred in the
presence of a coagulopathy or severe lung disease.
2. It is impossible to cause pneumothorax from this site.
3. Placement can be accomplished without interrupting cardiopulmonary
resuscitation.
6. CENTRAL VENOUS CATHETERIZATION 433
Disadvantages
1. This approach has the highest rate of infection.
2. Fluoroscopy is required for placement of pulmonary artery catheters
or transvenous pacemakers.
Procedure
1. Use sterile preparation with appropriate draping.
2. Administer local anesthesia with lidocaine.
3. Place an Intracath needle into the vein through which the guidewire
will pass. Alternatively, the “micro-puncture” technique described
above is also applicable for use in the upper extremities as well.
4. Advance the guidewire through the Intracath/intermediate dilator.
5. Once the guidewire has passed into the median vein, remove the In-
tracath/intermediate dilator.
6. Incise the skin with a no. 11 scalpel. Advance the sheath/dilator system
or triple-lumen catheter over the wire and into the vein while control-
ling either the proximal or distal end of the guidewire at all times.
7. Follow steps 14 through 17 for the right internal jugular vein approach.
Advantages
1. Noncompressible bleeding is avoided. This route or the femoral route
is preferred in the presence of coagulopathy or severe lung disease.
2. No risk of pneumothorax.
Disadvantages
1. Cannot be used in all patients.
2. Fluoroscopy is required for placement of pulmonary artery catheters
or temporary pacemakers.
3. Uncomfortable and immobilizing.
434 III: PROCEDURES
REFERENCES
Maki DG, Stolz SM, Wheeler S et al: Prevention of central venous catheter-related
bloodstream infection by use of an antiseptic-impregnated catheter. Ann Intern Med
1997;127:257.
Raad I, Darouiche R, Dupuis J et al: Central venous catheters coated with minocycline
and rifampin for the prevention of catheter-related colonization and bloodstream in-
fections. Ann Intern Med 1997;127:267.
Timsit J-F, Bruneel F, Cheval C et al: Use of tunneled femoral catheters to prevent
catheter-related infection. Ann Intern Med 1999;130:729.
Timsit J-F, Sebille V, Farkas J-C et al: Effect of subcutaneous tunneling on internal
jugular catheter-related sepsis in critically ill patients. JAMA 1996;276:1416.
7. ENDOTRACHEAL INTUBATION
See also Section VI, Ventilator Management, p 470.
Epiglottis
Glottis
Epiglottis
Figure III–5. Endotracheal intubation. Advance blade to groove between base of tongue and
epiglottis. (Reproduced, with permission, from Vander Salm TJ, ed. Atlas of Bedside Procedures.
2nd ed. Little, Brown;1988:21.)
436 III: PROCEDURES
rior and superior to the epiglottis. Thrust the left arm upward at a 45-
degree angle from the horizontal and visualize the vocal cords or the
arytenoid cartilage. Avoid using the maxillary teeth as a fulcrum by
keeping the wrist rigid and lifting only with the arm and shoulder. If the
cords are not visualized, the straight blade may have progressed too
posterior and inferior into the esophagus. In that case, slowly retract
the laryngoscope while watching for the cords to appear. With either
type of blade, application of cricoid pressure by an assistant may be a
useful adjunct while attempting cord visualization.
8. While maintaining visualization of the cords, grasp the ETT in the right
hand, pass it into the right corner of the mouth, and advance the cuff
beyond the cords. With more difficult intubations, a malleable stylet can
be used to direct the tube. In average-sized individuals, the incisors
should be at the 23-cm mark for males and 21-cm mark for females.
9. Gently inflate the cuff with air until an adequate seal is obtained
(about 5 mL). Auscultate over the epigastrium (with ventilation; loud
gurgling over the epigastrium suggests a gastric intubation). Then
auscultate over the left and right anterior and midaxillary chest. If the
left side lacks breath sounds, a right mainstem bronchus intubation is
likely. In that case, deflate the cuff, retract the ETT 1–2 cm, reinflate
the cuff, and reassess breath sounds. End-tidal CO2 monitoring will
confirm tracheal intubation. Confirm the positioning with a stat chest
x-ray. The end of the ETT should be 3–4 cm superior to the carina.
10. Secure tube position with tape. Record the centimeter mark at the in-
cisors. Insert an oropharyngeal airway to prevent the patient from bit-
ing the ETT.
REFERENCES
Einarsson O, Rochester CL, Rosenbaum SH: Airway management in respiratory emer-
gencies. Clin Chest Med 1994;15:13.
Kaur S, Heard SO: Airway management and endotracheal intubation. In: Irwin RS,
Rippe JM, Cerra FB et al, eds. Procedures and Techniques in Intensive Care Medi-
cine. 2nd ed. Lippincott Williams & Wilkins;1999:3.
Pingleton SK: Management of complications of acute respiratory failure. In: Bone RC,
ed. Pulmonary and Critical Care Medicine. 6th ed. Mosby;1998:R11-6.
8. GASTROINTESTINAL TUBES
Indications: Gastrointestinal (GI) decompression (paralytic ileus, obstruc-
tion, postoperatively); lavage of the stomach for GI bleeding or drug over-
8. GASTROINTESTINAL TUBES 437
Procedure
1. Inform the patient of the nature of the procedure and encourage the
patient to cooperate. Choose the nasal passage that appears most
patent by occluding one nostril and having the patient sniff.
2. Lubricate the distal 3–4 inches of the tube with a water-soluble jelly
(K-Y Jelly or viscous 2% lidocaine), and insert the tube gently along
the floor of the nasal passageway. Maintain gentle pressure that will
allow the tube to pass into the nasopharynx. Running the tube under
warm water before lubrication makes it more pliable and may help fa-
cilitate its placement. Flexing the head also helps facilitate passage of
the tube.
3. When the patient can feel the tube in the back of the throat, ask him
or her to swallow small amounts of water through a straw as you ad-
vance the tube 2–3 inches at a time.
4. To be sure that the tube is in the stomach, aspirate gastric contents or
blow air into the tube and listen over the stomach with your stetho-
scope for a “pop” or “gurgle.”
438 III: PROCEDURES
5. Attach sump tubes (Salem sump) to “continuous low wall suction” and
the single-lumen tube (Levine) to “intermittent suction.”
6. Feeding tubes are more difficult to insert because they are more flexi-
ble. You can use a stylet or guidewire or attach the smaller tube to a
larger, stiffer tube by wedging both into a gelatin capsule. Pass the
tube in the usual fashion and allow it to remain in the stomach for
10–15 minutes. After this time, the capsule will dissolve and the larger
tube can be removed.
7. Always verify the position of feeding tubes by chest x-ray before be-
ginning feedings.
8. Tape the tube securely in place but do not allow it to apply pressure to
the nasal ala. Patients have been disfigured by ischemic necrosis of
the nose caused by a poorly positioned tube.
9. INTRAVENOUS TECHNIQUES
Indications: To establish intravenous (IV) access for the administration of
fluids, blood, or medications.
Procedure
1. An upper, nondominant extremity is the site of choice for an IV.
Choose a distal vein so that if the vein is damaged, you can reposition
the IV more proximally. Avoid veins that cross joint spaces. Also avoid
the leg, since there is a high incidence of superficial thrombophlebitis.
If no extremity vein can be found, try the external jugular vein. If all
these fail, the only alternative is a central line or a cutdown.
2. Apply a tourniquet above the proposed IV site. Techniques to help ex-
pose difficult-to-locate veins include (1) wrapping the extremity in a
warm towel; (2) leaving the arm in a dependent position for a few min-
utes after the tourniquet is applied; or (3) using a blood pressure cuff
as a tourniquet, inflated so that the arterial flow is still maintained.
Carefully clean the site with an alcohol or povidone-iodine swab. If a
large-bore IV is to be used (16F or 14F), local anesthesia with 1% li-
docaine may be helpful.
3. Stabilize the vein distally with the thumb of your free hand. Using the
catheter-over-needle assembly (Intracath or Angiocath), enter the
skin alongside the vein first, and then stick the vein along the side at
9. INTRAVENOUS TECHNIQUES 439
Angiocath
Vein
Vein
Needle
Catheter
Needle
Catheter
Vein
Figure III–6. To insert a catheter-over-needle assembly into a vein, stabilize the skin and vein with
gentle traction. Enter the vein and advance the catheter while holding the needle steady; then re-
move the needle. (Reproduced, with permission, from Gomella LG, ed: Clinician’s Pocket Refer-
ence. 10th ed. McGraw-Hill;2004.)
440 III: PROCEDURES
A B
Procedure
1. Before the procedure, a detailed evaluation of the patient and careful
consideration of the potential risks and benefits must be made. A neu-
roimaging procedure should precede a LP if the patient has evidence
of increased intracranial pressure (papilledema or headache) or focal
neurologic findings.
2. The most important detail in the performance of a successful LP is to
place the patient in a comfortable and accessible position. A lateral
decubitus position with the back close to the edge of the bed or table
and with the neck, back, knees, and hips maximally flexed to facilitate
an open, clear approach to the vertebral interspaces is most effective.
The hips and shoulders must be absolutely perpendicular to the bed.
Padding placed between the iliac crest and inferior costal margin
helps prevent sagging and keeps the spinal column straight and par-
allel with the bed. A pillow between the legs prevents the pelvis from
rotating forward out of the perpendicular plane with the bed. It is often
useful for an assistant to keep the patient in the optimal position. Al-
ternatively, the LP may be performed with the patient sitting, leaning
forward over the backrest of the chair or bed stand. However, in this
position, accurate interpretation of the opening and closing pressures
and comparison to standard pressures (which can only be done with
the patient in a lateral decubitus position) are impossible.
3. The spinal needle should be inserted through the L4-L5 interspace.
The tip of the spinal cord descends to L2 in 94% of adults, whereas in
another 6% it descends as low as the mid vertebral body of L3. In
442 III: PROCEDURES
neonates, the lower margin of the spinal cord descends to the lower
border of the L3 vertebral body. An imaginary line drawn across the
top of the iliac crests usually crosses the spine at about the L4 verte-
bral body. Marking the skin overlying the L4-L5 interspace with an in-
dentation of the fingernail is helpful in finding the spot later when the
patient is prepped and draped.
4. Open the LP kit and put on sterile gloves. Prep the area with povi-
done-iodine solution in a circular fashion starting in the center and
gradually working outward so that a circular area of skin measuring at
least 6 inches in diameter has been sterilized. In the same fashion, re-
peat the process of sterilizing the patch of skin two more times. Next,
drape the patient.
5. Anesthetize the overlying skin by raising a small wheal using a 25-
gauge needle and 1% lidocaine. Avoid injecting too much solution,
because too large a wheal may obscure palpable landmarks. With a
11⁄2-inch 22-gauge needle, infiltrate deeper tissues with 1% lidocaine.
Always attempt to aspirate the syringe before injecting to ensure that
the needle has not entered the subarachnoid space or vessel.
6. Inspect the spinal needle, stylet, manometer, 3-way stopcock, and
collection tubes for defects. Loosen the caps of the collection tubes
and make certain that they are properly marked and that you are fa-
miliar with the sequence in which they will be used to collect serial
specimens of CSF.
7. Using a 20-gauge spinal needle (Quinke needle) with a well-fitting
stylet, insert the needle into the subcutaneous tissues. The beveled tip
should be parallel with the long axis of the spine to minimize injury to
the longitudinal dural fibers and reduce the chances of a postspinal
headache. Guide the needle just caudal to the L4 spinous process,
keeping the needle parallel with the floor and perpendicular to the
spine but directed slightly cephalad, targeting the tip of the needle to-
ward the umbilicus. Keep pressure on the hub of the stylet to avoid
having it displaced from the needle. One useful technique to help avoid
misdirecting the needle is to hold the needle between the index fingers
of both hands with the thumbs holding the hub of the needle and stylet
while guiding the needle into the subarachnoid space (Figure III–8).
8. Continue to advance the needle slowly until a “give” or “pop” is felt, in-
dicating that the tip has passed the resistance of the longitudinal liga-
ment and has entered the subarachnoid space. Remove the stylet
and check for CSF flow. Replacing the stylet and rotating the needle
90–180 degrees may facilitate flow if it is absent or slow. If this fails,
replace the stylet and advance the needle a few millimeters, stopping
each time to remove the stylet and check for CSF flow. Never ad-
vance the needle without first replacing the stylet. The hollow barrel of
the needle may become occluded with epidermis, which can be intro-
duced into the subarachnoid space, leading to an epidermoid tumor
later. Pressing on the abdomen or having the patient undergo Val-
salva’s maneuver can improve flow when very low CSF pressure is
10. LUMBAR PUNCTURE 443
S1
L4 L5
L4
L4
Subarachnoid space
L5 Cauda equina
Figure III–8. When performing a lumbar puncture, place the patient in the lateral decubitus posi-
tion and locate the L4-L4 interspace. Control the spinal needle with two hands and enter the sub-
arachnoid space. (Reproduced, with permission, from Gomella LG, ed: Clinician’s Pocket
Reference. 10th ed. McGraw-Hill;2004.)
444 III: PROCEDURES
Opening
Pressure Protein Glucose Cells
Condition Color (mm H2O) (mg/100 mL) (mg/100 mL) (per mL)
Modified and reproduced with permission from Gomella LG, ed. Clinician’s Pocket Reference. 10th ed. McGraw-Hill; 2004.
WBC, white blood cell; RBC, red blood cell; lymphs, lymphocytes; polys, polymorphonuclear leukocytes; TB, tuberculosis.
445
446 III: PROCEDURES
REFERENCES
Evans RW: Complications of lumbar puncture. Neurol Clin 1998;16:83.
Fishman RA, ed: Cerebrospinal Fluid in Diseases of the Nervous System. 2nd ed.
Saunders;1992.
Lumbar puncture and the examination of the cerebrospinal fluid. In: Haerer AF, ed. De-
Jong’s The Neurologic Examination. 5th ed. Lippincott;1992:755.
Roos KL: Lumbar puncture. Semin Neurol 2003;23:105.
11. PARACENTESIS
Indications: Determination of the cause of new-onset ascites; ruling out
spontaneous bacterial peritonitis in patients with known ascites; therapeutic
removal of fluid in patients with tense ascites for symptomatic relief (early
satiety, abdominal discomfort, dyspnea).
Procedure
1. The patient’s bladder needs to be empty. Patients with tense ascites
can be placed supine with the head of the bed slightly elevated. Pa-
tients with less ascites can be placed in either lateral decubitus posi-
tion and tapped in the midline or can be tapped in either lower
quadrant while supine.
2. If there is any doubt about the presence of ascites, confirmation
should be made by abdominal ultrasound. If the amount of ascites is
small, ultrasound can be used to help locate the fluid during the pro-
cedure.
3. The entry site is usually the midline, 3–4 cm below the umbilicus.
However, if a midline surgical scar is present, you can locate an alter-
native entry site in the left or right lower quadrant 4–5 cm above and
medial to the anterior superior iliac spine (lateral to the rectus sheath).
Note that in obese patients the abdominal wall in the midline is signifi-
448 III: PROCEDURES
cantly thicker than in the lower quadrants and may even exceed the
length of a 3.5-inch needle.
4. Prep the patient’s skin with povidone-iodine solution and apply sterile
drapes. Raise a skin wheal with 1% lidocaine over the proposed entry
site.
5. Use the Z tract technique to avoid postprocedure leakage of fluid.
With the paracentesis needle mounted on a syringe in one hand, use
the other gloved hand to displace the skin approximately 2 cm. Do not
release the skin until the peritoneum has been penetrated. The nee-
dle should be advanced slowly in 5-mm increments aspirating inter-
mittently rather than continuously; this prevents drawing bowel or
omentum to the end of the needle.
6. Aspirate the amount of fluid needed for tests (30–50 mL). For a thera-
peutic tap, a 16- to 18-gauge steel needle can be connected to vac-
uum bottles with phlebotomy tubing. Large-volume paracentesis
(5–10 L) can be safely performed in patients with tense ascites if the
fluid is removed over 60–90 minutes.
7. Remove the needle quickly, apply a sterile 4 × 4 gauze, and apply
pressure to the site with tape.
8. Routine ascitic fluid tests include cell count, albumin, and bedside in-
oculation of blood culture bottles, which significantly increases the
sensitivity of cultures. Depending on the clinical picture, other tests
may include total protein, glucose, lactate dehydrogenase, amylase,
acid-fast bacilli smear and culture, and cytology. See Table III-2 (p
448) for differential diagnosis of the fluid obtained.
1) Albumin Gradient
ALBserum − ALBascites = X
if X > 1.1g/dL, then portal hypertension
If X < 1.1 g/dL, then not from portal hypertension
2) Total Protein < 1.0 g/dL, high risk for spontaneous bacterial peritonitis
3) Cell Count—absolute neutrophil count > 250/μL, presume infected
4) Bacterial Culture: Blood culture bottles 85% sensitivity
Routine cultures 50% sensitivity
5) Bacterial Peritonitis—Spontaneous versus secondary
Secondary: A) polymicrobial; B) total protein > 1.0 g/dL; C) LDH > normal serum
value; D) glucose < 50 mg/dL
6) Food Fibers: Found in most cases of perforated viscus.
7) Cytology: Bizarre cells with large nuclei may represent reactive mesothelial cells and not a
malignancy. Malignant cells suggest tumor.
REFERENCES
Marx JA: Peritoneal procedures. In: Roberts JR, Hedges JR, eds. Clinical Procedures
in Emergency Medicine. 3rd ed. Saunders;1998:733.
Runyon BA: Ascites and spontaneous bacterial peritonitis. In: Feldman M,
Scharschmidt B, Sleisenger M, eds. Gastrointestinal and Liver Disease. 7th ed.
Saunders;2002:1517.
Runyon BA: Care of patients with ascites. N Engl J Med 1994;330:337.
Runyon BA: Diagnosis and evaluation of patients with ascites. In: Rose BD, ed. UpTo-
Date. UpToDate, Wellesley, MA;2003.
Runyon BA, Montano AA, Akriviadis EA et al: The serum-ascites albumin gradient is
superior to the exudate-transudate concept in the differential diagnosis of ascites.
Ann Intern Med 1992;117:215.
French ICUs and that US physicians used PACs in these patients much more
often than did their French counterparts. In both of these studies, claiming
that the improved results were due to the increased rate of PAC use would be
as misleading as it would be to blame the PAC for the lack of improvement or
worse outcome associated with its use that was found in some retrospective
observational studies (Robin 1987; Connors et al 1996).
The issues of when and by whom a PAC should be used, and also
whether similar diagnostic information could be better obtained in the ICU by
other means (eg, “continuous” echocardiography or bioimpedance studies),
remain legitimate areas of research. Likewise, studying different therapeutic
approaches for a specific type of hemodynamic derangement also remains a
high priority. In any case, only experienced personnel should use PACs.
Similarly, proper PAC use requires clearly defined diagnostic and/or thera-
peutic goals that can be achieved using the data obtained from this device.
Mixed
Central Pulmonary Pulmonary Systemic Venous
Venous Artery Wedge Cardiac Vascular Oxygen
Type of Pressure Pressure Pressure Output Resistance Saturation
Shock (CVP) (PAP) (PWP) (CO) (SVR) (SvO2)
tion administration (Figure III–9). The air inflation port is used to inflate the
balloon to facilitate passage of the catheter from the right cardiac chambers
to the pulmonary artery. The thermistor can be used to measure cardiac out-
puts by thermal dilution when connected to a cardiac output computer. The
distal port is used to measure pulmonary artery pressure and pulmonary cap-
illary wedge pressure (PCWP) with the catheter in the pulmonary artery. The
right atrial port is used to administer fluids, to measure right atrial pressure, or
to inject fluid to measure cardiac output in conjunction with the thermistor and
the cardiac output computer (see Figure III–9). The catheter is often marked
so that the clinician can determine how far the distal tip lies from the entry
site. This information may help in catheter placement without fluoroscopy.
Procedure
1. The patient’s informed consent is usually required.
2. Choose the site of operation; prep and drape the area. The choice of
site is dictated by patient variables and operator experience. The eas-
Thermistor/
fiberoptic port
Distal
port
Proximal
port
Distal port
Figure III–9. An example of a pulmonary artery catheter. This one features an oximetric measur-
ing feature. (Reproduced, with permission, from Gomella LG, ed. Clinician’s Pocket Reference.
10th ed. McGraw-Hill;2004.)
12. PULMONARY ARTERY CATHETERIZATION 453
iest sites to place a PAC without fluoroscopic guidance are the right
internal jugular vein and the left subclavian vein. In a patient receiving
thrombolytic therapy, femoral and median basilic veins are preferable
routes when/if it is felt that placement of the PAC cannot be safely de-
layed for a few hours (the preferred option).
3. Always use a strict sterile approach with a properly large sterile field,
and wear gown, gloves, and mask.
4. Prepare the PAC by flushing the lumens with heparinized saline solu-
tion (1 mL of 1:100 U heparin in 10 mL of normal saline). Check the
balloon function, and tap the catheter to be sure that a waveform is
generated. You should set the pressure transducer level to the middle
of the patient’s chest.
5. Cannulate the central vein. (See Section III, Chapter 6, Central Ve-
nous Catheterization, p 426, for details.) In general, never push a
guide wire when there is resistance; always keep one hand on the
guidewire, either proximal or distal to the dilator, needle, etc.
6. When the sheath is in place, you can advance the prepared catheter
into the sheath. After it has been advanced approximately 15 cm, the
balloon will have cleared the tip of the sheath. You can then gently in-
flate the balloon with about 1.0–1.5 cm3 of air. The maximum amount
of air for use with smaller catheters (5F) is ≤ 1.0 cm3. If there is resis-
tance to full inflation, check to see that the balloon has cleared the
sheath or that it is not in an extravascular location (with an x-ray, or
with fluoroscopy if available).
7. Once the balloon is inflated, advance the catheter to the level of the
right atrium under the guidance of the pressure waveform and the
electrocardiogram. Monitor the waveform and electrocardiogram at all
times while advancing the balloon catheter. Remember to always ad-
vance the catheter with the balloon inflated and withdraw it with the
balloon deflated. PACs usually come with a preformed curve on the
tip. Insert the catheter with its tip pointing anteriorly and to the left. Po-
sitioning in the right atrium is probably best determined by watching
for the characteristic waveform. The right atrium is generally located
approximately 20 cm from the right internal jugular or subclavian vein
insertion sites and approximately 25–30 cm from the left subclavian
vein insertion site. The catheter should be advanced steadily. An
abrupt change in the pressure tracing will occur as the catheter enters
the right ventricle. There is generally little ectopy on entry into the
right ventricle; however, as you advance the catheter into the right
ventricular outflow tract, premature ventricular contractions (PVCs)
may occur. Keep advancing the catheter until the ectopy disappears
and the pulmonary artery tracing is obtained. If this does not occur,
deflate the balloon, withdraw the catheter, and try again with the bal-
loon inflated after slightly rotating the catheter. The PCWP will then be
obtained by advancing the catheter another 10–15 cm. The catheter’s
final position should be such that the PCWP is obtained with full bal-
loon inflation and the pulmonary artery pressure (PAP) tracing is pre-
454 III: PROCEDURES
sent with the balloon deflated. In the “ideal position,” transition from
PAP to PCWP (and vice versa) occurs within three or fewer heart-
beats. Caution: Never withdraw the catheter with the balloon inflated.
See Figure III–10, p 455, for normal waveforms. See Table III–4, p
456, for normal PAC measurements.
8. Suture the catheter in place and dress the site according to your insti-
tution’s practice. A chest x-ray should be obtained to document the
catheter’s present position as well as to rule out a pneumothorax or
other complication from central venous catheterization.
9. Common problems: Catheter placement is much more difficult if se-
vere pulmonary artery hypertension is present. If there is significant
cardiac enlargement, particularly dilation of the right heart structures,
the catheter may have a propensity to coil and get lost in its path to
the right ventricular outflow tract. Fluoroscopy may be required to get
the catheter into the correct position; moreover, it will hold this posi-
tion poorly. Placement of the catheter in the pulmonary artery may
also be difficult in the setting of a low cardiac output because the bal-
loon-tipped catheter is dependent on blood flow to carry it through the
right heart chambers.
10. Cardiac output can be measured by thermal dilution. First, connect
the thermistor port of the PAC to a cardiac output computer into which
the correct catheter’s constant and the proper volume and tempera-
ture of the injectate have been entered. After this is done, rapidly in-
ject fluid (usually 10 mL of normal saline at room temperature)
through the right atrial port. If feasible, it is preferred to time the injec-
tion to occur at the same point of the respiratory cycle in all trials, usu-
ally at the end of inspiration. The computer will display the cardiac
output. Repeat this procedure at least two more times. The variability
of serial thermodilution cardiac output measurements should not ex-
ceed 20%, and usually is 15% or less. For normal cardiac output and
index, consult Table III–4, p 456.
11. You can often differentiate various clinical entities by measuring the
blood pressure, PCWP, and cardiac output, and calculating the sys-
temic vascular resistance. (See Table III–3, p 451.) Abnormalities in
various pressures obtained from pulmonary artery catheterization can
often help diagnose various disease states (see Table III–5, p 457)
and may be helpful in directing fluid administration and inotropic and
vasopressor therapy in certain patients.
Complications
1. Most complications that occur in the course of pulmonary artery
catheterization are related to central vein cannulation and include arte-
rial puncture and pneumothorax, as well as inadvertent placement of
the catheter outside the vascular tree, most often in the pleural space.
2. Arrhythmias are another common complication. The most common of
these are transient PVCs that occur when the catheter is advanced
12. PULMONARY ARTERY CATHETERIZATION 455
Balloon
Distal lumen
port
Pulmonary
Proximal arteries
lumen
Superior Wedged
vena position
cava
RA
RV
A
Time
breaks
40
30
20
10
RA RV PA Wedge
B
Figure III–10. (A) Positioning and (B) pressure waveforms seen as the pulmonary artery catheter
is advanced. PA, pulmonary artery; RA, right atrium; RV, right ventricle. (Reproduced, with per-
mission, from Stillman RM, ed. Surgery Diagnosis & Therapy. Originally published by Appleton &
Lange. Copyright 1989 by The McGraw-Hill companies, Inc.)
456 III: PROCEDURES
Parameter Range
into the right ventricular outflow tract. If a patient with a PAC suddenly
develops frequent PVCs, displacement of the catheter should be sus-
pected. Sustained ventricular tachycardia and ventricular fibrillation
are both very rare occurrences.
3. Transient right bundle branch block occurs occasionally as the
catheter passes through the right ventricular outflow tract. In a patient
with preexisting left bundle branch block, this can result in complete
heart block. In this setting, some form of backup pacing should be
readily available. Complete heart block has been reported but is a
rare occurrence.
4. Significant pulmonary infarcts and pulmonary artery rupture are po-
tentially very serious but infrequent complications of PACs caused by
“permanent” wedge or peripheral placement of the catheter. Fortu-
nately, these complications can be easily avoided with careful moni-
toring of the wave tracing to make sure that the PAC is not
continuously or intermittently showing “spontaneous” PCWP position
or “wedge.”
5. Most complications and problems related to PACs tend to increase
with the length of time that the catheter is left in place. Particularly rel-
evant among them is the high risk of bacteremia and even subacute
bacterial endocarditis that is seen in severely ill patients with chronic
catheter placement. Thus, in the setting of unexplained fever, the
PAC and introducer sheath should always be removed and cultured. It
is essential to always culture the introducer sheath, but whether the
PAC itself should also be routinely cultured is not well established. A
new catheter and sheath can be placed at a different site if use of a
PAC is still indicated.
13. SKIN BIOPSY 457
REFERENCES
Connors AF, Speroff T, Dawson NV et al: The effectiveness of right heart catheteriza-
tion in the initial care of critically ill patients. JAMA 1996;276:889.
Iberti TJ, Daily EK, Leibowitz AB et al: Assessment of critical care nurses’ knowledge of
the pulmonary artery catheter. Crit Care Med 1994;22:1674.
Iberti TJ, Fisher EP, Leibowitz AB et al: A multicenter study of physician’s knowledge of
the pulmonary artery catheter. JAMA 1990;264:2928.
Knaus WA, LeGall JR, Wagner DP et al: A comparison of intensive care in the USA and
France. Lancet 1982;2:642.
Reynolds HN, Haupt MT, Thill-Baharozian MC et al: Impact of critical care physician
staffing on patients with septic shock in a university hospital medical intensive care
unit. JAMA 1988;260:3446.
Robin ED: The cult of the Swan-Ganz catheter: Overuse and abuse of pulmonary flow
catheters. Ann Intern Med 1985;103:445.
Robin ED: Death by pulmonary artery flow-directed catheter: Time for a moratorium?
Chest 1987;92:721.
when possible. Punch biopsies are not preferred in this setting as they may
not provide adequate tissue for the measurement of tumor thickness. A
platelet count < 10,000/mm3 is a relative contraindication for skin biopsy.
Procedure
1. If more than one lesion is present, it is important to choose a repre-
sentative site. For patients with vesiculobullous disease or suspected
vasculitis, an early intact lesion not older than 24–48 hours is prefer-
able. For bullous or vesicular lesions, biopsy the edge of the blister or
include the entire lesion if possible. For eruptions involving the trunk
and extremities, choose a well-developed lesion on the trunk, avoid-
ing a biopsy of the lower leg when possible.
2. Note the orientation of the resting skin tension lines. Wipe the area to
be biopsied with the alcohol pad. Mark the area with a skin-marking
pen. Apply gloves. Inject the lidocaine slowly, infiltrating an area
slightly larger than the biopsy site.
3. Immobilize the skin with one hand, pulling the skin perpendicular to
the resting skin tension lines. With the other hand, hold the skin punch
vertical to the skin surface and apply firm pressure. Rotate the punch,
alternating between clockwise and counterclockwise rotation while
continuing to apply firm pressure. As the punch enters the subcuta-
neous fat, resistance will lessen. Remove the punch. The core of tis-
sue can be elevated slightly by applying downward pressure on either
side of the biopsy site. The tissue can then be snipped at the level of
the subcutaneous fat with the scissors. If the tissue cannot be ele-
vated, the core can be speared using the 30-gauge needle and lifted
outward, allowing it to be snipped with the scissors.
4. The biopsy specimen should be immediately placed in the specimen
container. If a primary blistering process (ie, bullous pemphigoid) is
suspected, specimens should be sent for direct immunofluorescence
as well as hematoxylin & eosin staining. A 3- to 4-mm biopsy for direct
immunofluorescence should be performed from perilesional nonbul-
lous skin. This specimen should be sent in a separate container in
Michel’s solution.
5. Hemostasis is achieved by applying pressure with the gauze pads.
6. Defects from 2-mm punches generally do not require suture place-
ment. Punch defects larger than 2 mm should be closed with one or
two sutures and placed perpendicular to skin tension lines to minimize
the appearance of scarring.
14. THORACENTESIS 459
REFERENCES
Robinson J, LeBoit P: Biopsy techniques: Description and proper use. In: Arndt KA, ed.
Cutaneous Medicine and Surgery. Saunders;1996:120.
Dermatologic Surgery. In: Odom R, James W, Berger T: Andrews’ Diseases of the
Skin. Saunders;2000:1074.
Ng PC, Barzilai DA, Ismail SA et al: Evaluating invasive cutaneous melanoma: Is the
initial biopsy representative of the final depth? J Am Acad Dermatol 2003;48:420.
14. THORACENTESIS
Indications: Establish the cause of a newly discovered pleural effusion, es-
pecially in a febrile patient; therapeutic removal of pleural fluid in patients
with dyspnea.
Procedure
1. Discuss the procedure with the patient and obtain informed consent.
Teach the patient the Valsalva maneuver; or make sure the patient
can hum (to increase intrathoracic pressure at a later point in the pro-
cedure). Position the patient so that he or she is sitting on the side of
the bed with head and arms supported by pillows on a bedside table.
(The back must be vertical; leaning too far forward causes the effu-
sion to move anteriorly away from the thoracentesis needle.) For the
debilitated patient unable to assume a sitting position, thoracentesis
can be performed in the midaxillary line with the patient supine and
the upper body elevated at a slight angle.
460 III: PROCEDURES
2. The usual site for a thoracentesis is midway between the spine and
posterior axillary line. Percuss out the fluid level, or use the chest x-
ray and count ribs. The entry site should be one to two interspaces
below the level where the percussion note becomes dull or tactile
fremitus is absent. Enter just above the rib to avoid the neurovascular
bundle that traverses below the rib. Do not attempt thoracentesis
below the eighth intercostal space to avoid injury to the spleen or
liver. For high-risk patients (with mechanical ventilation, coagulopa-
thy, small effusions), ultrasound guidance can be used to locate the
optimal entry site. Be certain that during thoracentesis the patient is
positioned in the same manner as during the ultrasound localization.
3. Prep the area with chlorhexidine and drape. Make a skin wheal over
the proposed site with a 25-gauge needle and 1% lidocaine. Change
to a 22-gauge 1.5-in. needle, and infiltrate up and over the rib; anes-
thetize the periosteum of the rib and parietal pleura. During this time,
you should be aspirating (Figure III-11).
4. Attach the 20- to 22-gauge thoracentesis needle to a 50-mL syringe
with a three-way stopcock. Open the stopcock to the syringe. Pene-
trate through the anesthetized area with the thoracentesis needle en-
tering over the top of the rib to avoid the neuromuscular bundle that
runs below the rib (see Figure III–11). After entering the pleural
space, aspirate the amount of fluid needed. For a therapeutic thora-
centesis, an 8F catheter over 18-gauge needle with self-sealing valve
can be used. This prevents air from entering the pleural space when
Pleura
Lung tissue
Local 1
anesthetic
Rib
Effusion
Neurovascular bundle
(nerve, artery, vein)
Figure III–11. In a thoracentesis, the needle is passed over the top of the rib to avoid the neu-
rovascular bundle. (Reproduced, with permission, from Gomella LG, ed. Clinician’s Pocket Refer-
ence. 10th ed. McGraw-Hill;2004.)
14. THORACENTESIS 461
the needle is withdrawn. Do not use a sharp steel needle for thera-
peutic thoracentesis because as the lung expands after removal of
fluid, it can be easily lacerated. After entering the pleural space, the
catheter is advanced over the needle, which is then removed. One
end of the drainage tubing is attached to the catheter, the other to a
drainage bag system. To prevent reexpansion pulmonary edema, do
not remove more than 1000–1500 mL per tap!
5. Have the patient hum or do the Valsalva maneuver as you withdraw
the needle. These actions increase intrathoracic pressure and de-
crease the chance of a pneumothorax. Bandage the site.
6. Routine performance of a chest x-ray is not indicated after diagnostic
thoracentesis in asymptomatic patients, but should be obtained in
symptomatic patients (with new chest pain or dyspnea) and after ther-
apeutic thoracentesis.
Grossly bloody tap: Trauma, pulmonary infarction, tumor, and iatrogenic causes.
pH: The pH of pleural fluid is usually > 7.3. If between 7.2 and 7.3, suspect tuberculosis or malig-
nancy or both. If < 7.2, suspect an empyema.
Glucose: Normal pleural fluid glucose is two-thirds serum glucose. If the pleural fluid glucose is
much, much lower than the serum glucose, then consider empyema or rheumatoid arthri-
tis (0–16 mg/100 mL) as the cause of the effusion.
Triglycerides and positive Sudan stain: Chylothorax.
LDH, lactate dehydrogenase; WBC, white blood cells; polys, polymorphonuclear leukocytes; monos,
monocytes.
Modified and reproduced with permission from Gomella LG, Lefor AT, eds. Surgery On Call Reference.
3rd ed. McGraw-Hill; 2002.
462 III: PROCEDURES
REFERENCES
Aleman C, Alegre J, Armadans L et al: The value of chest roentgenography in the diag-
nosis of pneumothorax after thoracentesis. Am J Med 1999;107:340.
Light RW: Pleural Diseases. 3rd ed. Williams & Wilkins;1995.
Ruhl TS: Thoracentesis. In: Pfenninger JL, Fowler GC, eds. Procedures for Primary
Care Physicians. Mosby;1994:477.
Sahn S: Diagnostic thoracentesis. In: UpToDate, Rose BD, ed. UpToDate, Wellesley,
MA;2003.
Sahn S. Diagnostic evaluation of a pleural effusion. In: UpToDate, Rose, BD, ed. UpTo-
Date, Wellesley, MA;2003.
IV. Fluids & Electrolytes
Daily maintenance requirements for the average 70-kg male are as follows:
Fluid 2000–2500 mL
Dextrose 100–200 g
Sodium 60–100 mEq
Potassium 40–60 mEq
These requirements can be met with an infusion of D51⁄4 NS with 20–30 mEq
of potassium chloride per liter infused at 100 mL/hr. The preceding combi-
nation of fluid and electrolytes may differ depending on other clinical pa-
rameters such as congestive heart failure, cirrhosis, hyponatremia,
hypernatremia, hyperkalemia, and renal insufficiency. Maintenance fluids
should be used for only 48–72 hours, at which time more effective measures
of nutritional support (enteral tube feedings) should be instituted. For pa-
tients with severe volume depletion, normal saline can be administered as
rapidly as 500–1000 mL/hr until the patient is stabilized. For patients under-
going nasogastric suction, measured losses can be replaced every 4 hours
with an equal volume of normal saline. Additional potassium may have to be
added to the maintenance fluids to replace that lost with gastric suction.
(See Tables IV–1 and IV–2.)
Electrolytes (mEq/L)
Glucose
Fluid (g/L) Na Cl K Ca HCO3 kcal/L
463
464 IV: FLUIDS & ELECTROLYTES
Average
Electrolytes (mEq/L) Daily
Production
Fluid Na Cl K HCO3 (mL)
Sweat 50 40 5 0 Varies
Saliva 60 15 26 50 1500
Gastric juices 60–100 100 10 0 1500–2500
Duodenum 130 90 5 0–10 300–2000
Bile 145 100 5 15 100–300
Pancreatic juice 140 75 5 115 100–800
Ileum 140 100 2–8 30 100–9000
Diarrhea 120 90 25 45 —
Modified and reproduced with permission from Gomella LG, ed. Clinician’s Pocket Reference. 10th ed.:
McGraw-Hill; 2004.
V. Blood Component Therapy
Whole blood contains red blood cells (RBCs), white blood cells (WBCs),
plasma, antibodies, electrolytes, and an anticoagulate. Most patients who
require replacement therapy require only one of these components. Transfu-
sion with whole blood is rarely performed. It is used for volume expansion in
a patient with an acute massive blood loss.
■ ANEMIA
See also Section I, Chapter 5, Anemia, p 28.
When confronted with a chronic anemia, the clinician must consider
whether the Hgb and hematocrit (HCT) accurately reflect the RBC mass.
The RBC mass is more important with respect to oxygen transport than the
measured HCT or Hgb; however, low Hgb or HCT usually reflects a low
RBC mass. An increased plasma volume may result in a dilutional change in
Hgb and make an anemia appear more severe. Increased plasma volume
may occur in congestive heart failure, pregnancy, and paraproteinemia.
Acute blood loss: In the setting of acute blood loss and hypotension,
restoration of blood volume and tissue perfusion as well as improvement of
oxygen-carrying capacity must be accomplished. Use electrolyte solutions or
colloids initially. Blood losses of 500–1000 mL in an adult do not usually re-
quire blood transfusion unless there is an underlying anemia or another
medical condition requiring added oxygen-carrying capacity.
465
466 V: BLOOD COMPONENT THERAPY
■ PLATELET TRANSFUSIONS
See also Section I, Chapter 61, Thrombocytopenia, p 355.
Indications: Platelet transfusions are indicated for any patient with a major
bleeding event involving a qualitative or quantitative platelet disorder. Pro-
phylactic platelet transfusions are most commonly indicated in settings of
decreased platelet production, such as aplastic anemia, acute leukemia, or
chemotherapy- or radiation-induced bone marrow suppression. In these set-
tings, many institutions empirically give transfusions to patients with platelet
counts < 10,000. Individuals with fever, mucosal ulcerations, and planned in-
vasive procedures are frequently supported with platelets to maintain counts
> 20,000. Individuals with thrombocytopenia on the basis of platelet destruc-
PLASMA COMPONENT THERAPY 467
Complications
1. Transmission of infectious agents. The institution of polymerase
chain reaction (PCR) screening has dramatically decreased the risk of
transmission of a viral infection with transfusion. However, transfusion
of bacterially contaminated platelets continues to be a rare but poten-
tially lethal risk. Platelets are stored at 20 ° to 24 °C, and bacterial
contamination is estimated to occur in 1 in 2000 units. Coagulase-
negative Staphylococcus is the most frequently cultured bacteria.
2. Reactions to plasma components, RBCs, and WBCs. Reactions to
RBC antigens rarely cause a hemolytic transfusion reaction. They can
cause alloimmunity and a potential for problems such as the use of
Rh-positive platelets in an Rh-negative female. The patient should re-
ceive intravenous anti-D globulin (RhoGAM) if she is of childbearing
age.
3. Possible transmission of bacterial infections. A potential problem
because of the storage time and storage temperature of platelet con-
centrates.
4. Alloimmunization. This problem eventually develops in two-thirds of
patients receiving multiple transfusions of platelets. It may necessitate
the use of HLA-matched platelets to achieve adequate post-transfu-
sion counts.
sion, and back pain. These are uncommon reactions with the cur-
rently available preparations but can occur with both intravenous
and intramuscular administration. Therapy consists of discontinua-
tion of the infusion and use of diphenhydramine (Benadryl),
steroids, epinephrine, and vasopressors if necessary.
b. Inflammatory reaction. This is characteristically a delayed reac-
tion. Signs and symptoms may include headache, malaise, fever,
chills, and nausea. The reaction disappears with discontinuation of
gamma globulin therapy.
REFERENCES
Ceccherini-Nelli L, Filipponi F, Mosca F, Campa M: The risk of contracting an infectious
disease from blood. Transplant Proc 2004;36:680.
Fritsma MG: Use of blood products and factor concentrates for coagulation therapy.
Clin Lab Sci 2003;16:115.
Goodnough LT, Brecher ME, Kanter MH et al: Transfusion medicine—blood transfu-
sion. N Engl J Med 1999;340:438.
Miller R: Blood component therapy. Orthop Nurs 2001;20:57.
Wright-Kanuth MS, Smith LA: Developments in component therapy: Novel components
and new uses for familiar preparations. Clin Lab Sci 2002;15:116.
VI. Ventilator Management
1. INDICATIONS & SETUP
I. Indications
A. Ventilatory failure. A paCO2 > 50 Torr indicates ventilatory failure;
however, many patients have chronic ventilatory failure with renal
compensation (retaining HCO3−). The absolute pH is often a better
guide than paCO2 for determining the need for ventilatory assis-
tance. The patient’s mental status is actually the best indicator for
this. Some chronically ill but compensated patients may have a nor-
mal mental status despite a paCO2 of 70! A significant acidemia sug-
gests an acute respiratory acidosis or acute decompensation of a
chronic respiratory acidosis. A respiratory acidosis with a rapidly
falling pH or an absolute pH < 7.24 is an indication for ventilatory
support.
The prototype of pure ventilatory failure is the drug overdose pa-
tient who has a sudden loss of central respiratory drive with uncon-
trolled hypercarbia. Patients with sepsis, neuromuscular disease,
and chronic obstructive pulmonary disease (COPD) may have hyper-
carbic ventilatory failure.
B. Hypoxemic respiratory failure. Inability to oxygenate is an impor-
tant indication for ventilatory support. A paO2 < 60 Torr on > 50% in-
spired fraction of oxygen (FiO2) constitutes hypoxemic respiratory
failure. Newer nomenclature uses the paO2/FiO2 (P/F) ratio to char-
acterize hypoxemia. A P/F ratio < 200 is consistent with acute respi-
ratory distress syndrome (ARDS), whereas a ratio between 200 and
300 is termed acute lung injury. Although these patients can some-
times be managed with higher FiO2 delivery systems, such as partial
or nonrebreather masks, or continuous positive airway pressure
(CPAP) delivered by mask, they are at high risk for cardiopulmonary
arrest. They should be closely monitored in an intensive care unit
(ICU) if they are not intubated. Worsening of the respiratory status
necessitates prompt intubation and ventilatory support.
The prototype disease for hypoxemic respiratory failure is ARDS,
in which the high shunt fraction leads to refractory hypoxemia.
C. Mixed respiratory failure. Most patients have failure of both ventila-
tion and oxygenation. The indications for ventilatory support remain
the same as listed earlier.
An example of mixed respiratory failure is the COPD patient with
an acute exacerbation.
. . Bronchospasm alters the ventilation-perfu-
sion ratio (V/Q) relationships, leading to worsening hypoxemia. Bron-
chospasm and accumulated secretions lead to a high work of
breathing and consequent hypercarbia.
470
1. INDICATIONS & SETUP 471
I. Adjusting paO2
A. To decrease: Inspired fraction of oxygen (FiO2) should be de-
creased in increments of 10–20% every 30 minutes. The “rule of sev-
ens” states that there will be a 7-Torr fall in PaO2 for each 1%
decrease in FiO2.
B. To increase
1. Ventilation has some effect on paO2 (as shown by the alveolar
air equation); therefore, correction of the respiratory acidosis will
improve oxygenation.
2. Positive end-expiratory pressure (PEEP) can be added in in-
crements of 2–4 cm H2O. PEEP recruits previously collapsed
alveoli, holds them open, and restores functional residual capacity
(to a better physiologic level). It counteracts pulmonary shunts and
raises paO2. PEEP increases intrathoracic pressure and may thus
impede venous return and decrease cardiac output. This is partic-
ularly true in the presence of volume depletion and shock. Consult
476 VI: VENTILATOR MANAGEMENT
3. TROUBLESHOOTING
3A. AGITATION
I. Problem. The ventilator patient becomes agitated, struggles constantly,
tries to pull out all tubes, and actively fights the respirator.
II. Immediate Questions
A. Is the patient still properly connected? Hypoxemia or hypercarbia
resulting from disconnection of the respirator may result in agitation.
A patient who can speak is no longer intubated!
B. Review the ventilator flow and pressure waveforms. Look for
auto-PEEP. Failure of the expiratory flow to flatten at zero indicates
airtrapping or auto-PEEP. This may cause increased work of breath-
ing and agitation (an experienced respiratory therapist will be able to
measure it for you and then apply external positive end-expiratory
pressure [PEEP] to counterbalance it). A double dip on the inspira-
tory flow curve usually indicates the patient has air hunger and wants
a higher peak flow.
C. What were the most recent arterial blood gas (ABG) values?
Again, hypoxemia or hypercarbia can cause agitation. Adjusting the
settings can correct either problem.
D. What does the chest x-ray show? Atelectasis from mucous plug-
ging or pneumothorax can occur spontaneously in asthma or as a re-
sult of barotrauma and can result in hypoxemia or hypercarbia. The
endotracheal tube (ETT) touching the carina or the larynx almost al-
ways causes coughing and/or agitation.
E. What is the underlying diagnosis? What are the current medica-
tions and IV fluids? Agitation may be related to the underlying diag-
nosis or to a medication and may be unrelated to the patient’s
respiratory status. Cimetidine (Tagamet) and narcotics can cause
3. TROUBLESHOOTING-AGITATION 477
IV. Database
A. Physical examination key points
1. ETT. Carefully check the patency, position, and function of the
ETT.
2. Vital signs. Tachypnea may suggest hypoxemia. Tachycardia
and hypertension can result from agitation or may be associated
with respiratory failure or an underlying problem such as myocar-
dial infarction (MI). Hypotension may be due to auto-PEEP, vol-
ume depletion, sepsis, cardiogenic shock, tension pneumothorax,
or massive PE. An elevated temperature suggests sepsis, ventila-
tor-associated nosocomial pneumonia, or pulmonary emboli.
Tachycardia, tachypnea, and fever may be associated with PE or
478 VI: VENTILATOR MANAGEMENT
V. Plan
A. Emergency management
1. Examine the patient as outlined earlier. Carefully check the ETT
function, ventilator connections, and chart.
2. Suction the patient vigorously. This confirms tube patency and
clears out any mucous plugs.
3. Bag the patient manually to check for ease of ventilation.
Marked difficulty can be seen with tension pneumothorax or mu-
cous plugging. If auto-PEEP is suspected, use a slower rate and
decrease the tidal volume. This allows trapped gas time to escape
and thus allows decreased intrathoracic pressure and increased
venous return to the heart.
4. Obtain ABGs, electrolyte panel, and stat chest x-ray.
5. If the patient appears cyanotic or “air hungry,” turn the inspired
fraction of oxygen (FiO2) to 1.0 and the ventilator mode to “Assist
Control” (AC).
6. If hypotension and unilaterally absent breath sounds are
found concomitantly, consider chest tube insertion for tension
pneumothorax. Patients on ventilators can rapidly die of tension
pneumothoraces.
7. If you suspect ICU psychosis, reassure the patient. Have a
family member help reorient the patient. Often a familiar voice
works wonders! Ask the nurses to move the patient to a room with
a window; this environmental feature has been shown to reduce
ICU psychosis.
3. TROUBLESHOOTING-HYPOXEMIA 479
3B. HYPOXEMIA
I. Problem. The respirator patient requires > 60% FiO2 to maintain a paO2
> 60 Torr.
II. Immediate Questions
A. What is the sequence of ABGs? In other words, is this an acute or
a slowly developing change? A rapid deterioration implies an imme-
diate life-threatening process such as a tension pneumothorax or a
massive PE.
B. What is the underlying diagnosis? A patient with long-bone frac-
tures may develop fat embolus syndrome, a patient with sepsis may
develop acute respiratory distress syndrome (ARDS), and a patient
with head injury may develop neurogenic pulmonary edema.
C. What are the ventilator settings? Has a change been made re-
cently? An error may have been made with the ventilator settings, or
recent changes may have been made too aggressively in an attempt
to wean the patient from the ventilator. Some patients are very sensi-
tive to PEEP changes.
III. Differential Diagnosis
A. Shunts secondary to alveolar filling or by obstructed bronchi
with consequent collapse
1. Pneumonia
2. Pulmonary contusion
3. Atelectasis. The ETT may be placed too far in the right mainstem
bronchus, or there may be mucous plugs.
4. ARDS or cardiogenic pulmonary edema
B. Cardiac level shunt. An acute ventricular septal defect, especially in
the setting of an acute myocardial MI, may develop. Sudden pul-
monary hypertension may occasionally lead to a patent foramen
ovale and physiologic shunt at the atrial level. A tip-off to this is a
worsening shunt and paO2 as positive end-expiratory pressure
(PEEP) is increased.
C. Shunts secondary to pneumothorax
. .
D. Ventilation/perfusion (V/Q) mismatch
480 VI: VENTILATOR MANAGEMENT
1. Bronchospasm
2. Pulmonary embolism
3. Aspiration. Still possible, even when an ETT is in place.
E. Inadequate ventilation
1. Ventilator disconnection or malfunction
2. Incorrect settings. Has the patient recently been changed to in-
termittent mandatory ventilation, which has resulted in hypoventi-
lation?
3. Sedatives. These can result in hypoxemia secondary to hypoven-
tilation. Sedatives should be used cautiously, especially during
weaning. Patients on ventilators may develop atelectasis due to
failure to sigh or cough when sedated.
4. Neuromuscular disease. Hypophosphatemia or aminoglyco-
sides can cause neuromuscular weakness, which can cause hy-
poxemia secondary to hypoventilation and lack of sighing.
IV. Database
A. Physical examination key points
1. ETT. Confirm proper ETT position and listen for any leaks.
2. Vital signs. Tachypnea implies worsening of the respiratory sta-
tus. Tachycardia can be associated with a variety of conditions in-
cluding PE, sepsis, MI, and worsening of underlying pulmonary
pathology. Fever can be seen with PE, MI, or an infection.
3. Neck. Stridor suggests upper airway obstruction.
4. Chest. Check for bilateral breath sounds, signs of consolidation,
or new onset of wheezing. Unilateral breath sounds suggest a
pneumothorax or possibly displacement of the ETT in one of the
mainstem bronchi. Palpate the chest for new subcutaneous em-
physema, which can occur in asthmatics or as a result of high
PEEP.
5. Heart. New murmurs or a new S3 or S4 may be seen with an MI. A
new systolic murmur may suggest a ventricular septal defect (VSD)
or mitral regurgitation secondary to papillary muscle rupture.
6. Extremities. Check the patient’s nailbeds for cyanosis from wors-
ening pulmonary status. Also, check legs for unilateral edema or
other signs of phlebitis that point to PE.
7. Skin. Check for new rashes, which may suggest a drug or ana-
phylactic reaction.
B. Laboratory data
1. Repeat ABGs or check oximetry to assess accuracy of initial
ABGs and progression of deterioration.
2. Sputum appearance and Gram’s stain may direct antibiotic
therapy if pneumonia is present.
C. Radiologic and other studies
1. Stat chest x-ray. To rule out atelectasis and pneumothorax, and
to evaluate underlying pulmonary disease.
3. TROUBLESHOOTING-HYPOXEMIA 481
V. Plan
A. Suction. Vigorously suction the patient to prove patency of the ETT
and dislodge mucous plugs.
B. Treat underlying disorders
1. Insert chest tube for pneumothorax.
2. Reassess choice of antibiotic agents. A pneumonia secondary
to Legionella requires erythromycin (1 g IV Q 6 hr) or another
macrolide.
3. Consider more vigorous chest physical therapy or even bron-
choscopy for recalcitrant mucous plugging or atelectasis.
4. Maximize bronchodilators if bronchospasm is the problem. Cor-
ticosteroids such as hydrocortisone 125 mg or methylpred-
nisolone 60 mg should be added and given IV Q 6 hr. Aerosolized
albuterol should be given at least Q 4 hr.
5. Cardiogenic pulmonary edema should be vigorously treated
with afterload reduction and diuresis.
C. Optimize ventilator settings
1. Correct any hypoventilation. This may mean giving up on
weaning, and using the AC mode with the patient essentially con-
trolled on a high minute ventilation.
2. Increase FiO2 to 100%. Your first priority is to prevent anoxic
brain or cardiac damage. You may then reduce the FiO2 as other
maneuvers further improve the paO2.
3. PEEP recruits unused, collapsed, or partially collapsed alve-
oli to overcome pulmonary shunts. It should be added in 2–4
cm of H2O increments while cardiac output and blood pressure
are monitored. .
4. Oxygen consumption (VO2) can be markedly reduced by admin-
istering a neuromuscular blocking agent as a last resort. Remem-
ber to provide adequate analgesia and sedation as well. Nerve
stimulation studies should be done routinely to monitor the neuro-
482 VI: VENTILATOR MANAGEMENT
3C. HYPERCARBIA
I. Problem. The patient’s paCO2 remains > 40 Torr. paCO2 is a direct re-
flection of both CO2 production and. alveolar
. ventilation. PaCO2 in-
creases when ventilation/perfusion (V/Q) mismatch worsens or dead
space increases.
IV. Database
A. Physical examination key points
1. ETT. Check position to rule out migration down the right main-
stem bronchus; check patency of the ETT.
2. Vital signs. Tachycardia and tachypnea can occur with worsen-
ing of the underlying pulmonary disease and with agitation. Hy-
potension and tachycardia are seen with tension pneumothorax,
severe auto-PEEP, and the abdominal compartment syndrome.
3. HEENT. An increase in jugular venous distention (JVD) implies
CHF. Tracheal deviation can be seen with tension pneumothorax.
4. Chest. Absent breath sounds, especially with hypotension, and
unilateral hyperresonance to percussion point to tension pneu-
mothorax. Rales suggest CHF.
5. Heart. An S3 over the apex implies left ventricular dysfunction/
CHF.
6. Abdomen. Examine for tenderness and distention.
7. Extremities. New cyanosis is consistent with worsening of under-
lying pulmonary disease. Edema will be seen with biventricular or
right-sided heart failure.
8. Skin. Check for subcutaneous emphysema, which can be associ-
ated with barotrauma or with severe asthma.
486 VI: VENTILATOR MANAGEMENT
B. Laboratory data
1. ABGs. Repeat ABGs or check oximetry to assess accuracy of ini-
tial ABGs and progression of deterioration.
2. Complete blood count with differential. An increased white
blood count with an increase in banded neutrophils suggests an
infection or sepsis.
C. Radiologic and other studies. Use a stat portable chest x-ray to
check ETT position, rule out kinking, rule out pneumothorax, and as-
sess any change in underlying pulmonary disease.
D. Ventilator. Ask the respiratory therapist to measure auto-PEEP or
check for it via the waveforms. View the peak airway pressure pat-
tern. A rapid rise and fall suggests a kinked or obstructed ETT.
Check the patient’s mouth to be sure the patient is not biting the
tube. Suction the ETT to make sure it is not occluded and leading to
artificially high pressures.
V. Plan
A. Try to suction the patient. If the patient is biting down, insert an oral
airway or sedate the patient. If the patient is not biting down on the
ETT but the suction tube will not go down the ETT, the ETT is kinked
or blocked, possibly by a mucous plug, and must be replaced.
B. Ambu bag the patient and confirm equal breath sounds. Unequal
breath sounds may result from a tension pneumothorax or from im-
proper positioning of the ETT. Reposition the ETT if necessary. On
an average-sized person, an oral ETT should not be in farther than
24 cm at the lip; however, there is considerable variability among pa-
tients, and the chest x-ray should always be reviewed. If there is con-
siderable resistance to bagging, a tension pneumothorax,
auto-PEEP, or a mucous plug may be present.
C. Place a chest tube if a pneumothorax is present.
D. Adjust the ventilator. Try to reduce the PEEP to the minimum
needed for adequate oxygenation. Try reducing high tidal volumes to
5–6 mL/kg body weight. Increase FiO2 as needed to ensure ade-
quate oxygenation.
E. Sedation may have to be increased.
F. Consider switching to airway pressure release ventilation or
pressure control modes. These modes exquisitely control high
peak pressures while often improving oxygenation as well.
4. WEANING
I. Requirements. Once the underlying cause of respiratory failure has
been corrected, it is time for the most arduous task of all: weaning the
patient from the respirator.
4. WEANING 487
REFERENCES
Albert RK: Prone ventilation (ARDS). Clin Chest Med 2000;21:511.
Glauser FL, Polatty C, Sessler CN: Worsening oxygenation in the mechanically venti-
lated patient: Causes, mechanisms and early detection. Am Rev Respir Dis
1988;138:458.
Luce JM et al: Intermittent mandatory ventilation. Chest 1981;79:678.
MacIntyre NR: Weaning from mechanical ventilatory support: Volume-assisting inter-
mittent breaths versus pressure-assisting every breath. Respir Care 1988;33:121.
Marcy TW, Marini JJ: Respiratory distress in the ventilated patient. Clin Chest Med
1994;15:55.
Raoof S, Khan FA: Mechanical Ventilation Manual. American College of Physicians
Press;1998.
Slutsky AS: ACCP consensus conference: Mechanical ventilation. Chest 1993;104:
1833.
Tobin MJ: Mechanical ventilation. N Engl J Med 1994;330:1056.
VII. THERAPEUTICS
1. Classes of Generic Drugs, Minerals, Natural Products, & Vitamins
2. Generic Drugs: Uses, Action, Dose, Caution, Contraindications, Supplied, SE, & Notes
3. Minerals: Indications/Effects, RDA/Dosage, Signs/Symptoms of Deficiency and Toxicity,
and Other
4. Natural Products: Uses, Efficacy, Dose, Caution, Adverse Effects, and Drug Interactions
5. Unsafe Herbs: Toxicity
6. Vitamins: Indications/Effects, RDA/Dosage, Signs/Symptoms of Deficiency and Toxicity,
and Other
7. Tables
1. Insulins
2. Comparison of Glucocorticoids (also see Steroids, systemic)
3. Angiotensin-Converting Enzyme Inhibitors
4. Angiotensin Receptor Antagonists
5. Antistaphylococcal Penicillins
6. Extended-Spectrum Penicillins
7. Beta-Adrenergic Blocking Agents
8. First-Generation Cephalosporins
9. Second-Generation Cephalosporins
10. Third- and Fourth-Generation Cephalosporins
11. Nonsteroidal Anti-Inflammatory Drugs
12. Ophthalmic Agents
13. Sulfonylurea Agents
14. Proton Pump Inhibitors
15. HMG-CoA Reductase Inhibitors
16. Serotonin 5-HT1 Receptor Agonists
17. Non-Antibiotic Drug Levels
18. Therapeutic Drug Levels: Antibiotics
19. Aminoglycoside Dosing in Adults: Every 8- or 12-Hour Dosing
20. Aminoglycoside Dosing: Percentage of Loading Dose Required for Dosage Interval
Selected
21. Aminoglycoside Dosing: Once-Daily Dosing of Gentamicin and Tobramycin (Not
Amikacin)
The Therapeutics Section is designed to serve as a quick reference to commonly used
medications. You should be familiar with all of the indications, contraindications, side effects,
and drug interactions of any medications that you prescribe. Such detailed information is be-
yond the scope of this manual and can be found in the package insert, Physicians’ Desk Ref-
erence (PDR), or the American Hospital Formulary Service (AHFS) Drug Information.
MEDICATION KEY
Medications are listed by prescribing class, and the individual medications are then listed in al-
phabetical order by generic name. Some of the more commonly recognized trade names are
listed for each medication (in parentheses after the generic name).
490
BREASTFEEDING 491
Schedule (CI) I: All nonresearch use forbidden (e.g., heroin, LSD, mescaline, etc).
Schedule (CII) II: High addictive potential; medical use accepted. No telephone call-in
prescriptions; no refills. Some states require special prescription form (e.g., cocaine, mor-
phine, methadone).
Schedule (CIII) III: Low to moderate risk of physical dependence, high risk of psycho-
logic dependence; prescription must be rewritten after 6 months or five refills (e.g., aceta-
minophen plus codeine).
Schedule (CIV) IV: Limited potential for dependence; prescription rules same as for
schedule III (e.g., benzodiazepines, propoxyphene)
Schedule (CV) V: Very limited abuse potential; prescribing regulations often same as
for uncontrolled medications; some states have additional restrictions.
BREASTFEEDING
No formally recognized classification exists for drugs and breastfeeding. This shorthand was
developed for the Clinician’s Pocket Drug Reference.
+ Compatible with breastfeeding
M Monitor patient or use with caution
+/– Excreted, or likely excreted, with unknown effects or at unknown concentrations
?/– Unknown excretion, but effects likely to be of concern
– Contraindicated in breastfeeding
? No data available
492 VII: THERAPEUTICS
Antiarrhythmics
Adenosine Esmolol Propafenone
Amiodarone Flecainide Quinidine
Digoxin Ibutilide Sotalol
Diltiazem Lidocaine Tocainide
Disopyramide Mexiletine Verapamil
Dofetilide Procainamide
Antibiotics
Amikacin Ciprofloxacin Neomycin sulfate
Amoxicillin Clarithromycin Nitrofurantoin
Amoxicillin/potassium clavu- Clindamycin Norfloxacin
lanate Clofazimine Ofloxacin
Ampicillin Cloxacillin Oxacillin
Ampicillin/sulbactam Cortisporin, otic Penicillin G aqueous
Atovaquone Dalfopristin/quinupristin Penicillin G benzathine
Atovaquone/proguanil Dapsone Penicillin G procaine
Azithromycin Demeclocycline Penicillin V
Aztreonam Dicloxacillin Pentamidine
Cefaclor Dirithromycin Piperacillin
Cefadroxil Doxycycline Piperacillin/tazobactam
Cefazolin Ertapenem Pyrazinamide
Cefdinir Erythromycin Quinupristin/dalfopristin
Cefepime Ethambutol Rifabutin
Cefditoren Fosfomycin Rifampin
Cefixime Gatifloxacin Rifapentine
Cefoperazone Gentamicin Silver sulfadiazine
Cefotaxime Imipenem/cilastatin Sparfloxacin
Cefotetan Isoniazid Streptomycin
Cefoxitin Levofloxacin Tetracycline
Cefpodoxime Linezolid Ticarcillin
Cefprozil Lomefloxacin Ticarcillin/potassium clavu-
Ceftazidime Loracarbef lanate
Ceftibuten Meropenem Tobramycin
Ceftizoxime Metronidazole Trimethoprim
Ceftriaxone Mezlocillin Trimethoprim/sulfamethoxa-
Cefuroxime Moxifloxacin zole
Cephalexin Mupirocin Trimetrexate
Cephapirin Nafcillin Trovafloxacin
Cephradine Nalidixic acid Vancomycin
Anticonvulsants
Carbamazepine Diazepam Fosphenytoin
Clonazepam Ethosuximide Gabapentin
494 VII: THERAPEUTICS
Antidotes
Acetylcysteine Flumazenil Naloxone
Charcoal Fomepizole Sodium polystyrene sul-
Dexrazoxane Ipecac syrup fonate
Digoxin immune Fab Mesna Succimer
Antiemetics
Aprepitant Droperidol Prochlorperazine
Buclizine Granisetron Promethazine
Chlorpromazine Meclizine Scopolamine
Dimenhydrinate Metoclopramide Thiethylperazine
Dolasetron Ondansetron Trimethobenzamide
Dronabinol Palonosetron
Antifungal Agents
Amphotericin B Fluconazole Oxiconazole
Amphotericin B cholesteryl Flucytosine Terbinafine
Amphotericin B lipid com- Haloprogin Terconazole
plex Itraconazole Tioconazole
Amphotericin B liposomal Ketoconazole Triamcinolone and nystatin
Caspofungin Miconazole Tolnaftate
Ciclopirox Naftifine Voriconazole
Clotrimazole Nystatin
Econazole Nystatin and triamcinolone
Antigout Agents
Allopurinol Probenecid Sulfinpyrazone
Colchicine
Antihistamines
Azelastine Cyproheptadine Hydroxyzine
Cetirizine Desloratadine Loratadine
Chlorpheniramine Diphenhydramine
Clemastine fumarate Fexofenadine
CLASSES OF GENERIC DRUGS, MINERALS, NATURAL PRODUCTS 495
Antihyperlipidemics
Atorvastatin Ezetimibe/Simvastatin Niacin
Cholestyramine Fenofibrate Pravastatin
Colesevelam Fluvastatin Rosuvastatin
Colestipol Gemfibrozil Simvastatin
Ezetimibe/simvastatin Lovastatin
Antihypertensives
Acebutolol Fenoldopam Nifedipine
Amlodipine Fosinopril Nisoldipine
Atenolol Guanabenz Nitroglycerin
Benazepril Guanadrel Nitroprusside
Betaxolol Guanethidine Penbutolol
Bisoprolol Guanfacine Perindopril
Candesartan Hydralazine Pindolol
Captopril Irbesartan Prazosin
Carteolol Isradipine Propranolol
Carvedilol Labetalol Quinapril
Clonidine Lisinopril Ramipril
Diazoxide Losartan Telmisartan
Diltiazem Methyldopa Terazosin
Doxazosin Metoprolol Timolol
Enalapril Minoxidil Trandolapril
Eplerenone Moexipril Valsartan
Eprosartan Nadolol Verapamil
Felodipine Nicardipine
Antineoplastic Agents and Related Medications
Aldesleukin (IL-2) Doxorubicin Mechlorethamine
Altretamine Epirubicin Megestrol acetate
Amifostine Estramustine Melphalan
Aminoglutethimide Etoposide Mercaptopurine
Anastrozole Exemestane Methotrexate
Asparaginase Floxuridine Mitomycin
Bacillus Calmette-Guérin Fludarabine phosphate Mitotane
Bexarotene Fluorouracil Mitoxantrone
Bicalutamide Fluorouracil, topical Nilutamide
Bleomycin Fluoxymesterone Paclitaxel
Bortezomib Flutamide Procarbazine
Busulfan Fulvestrant Streptozocin
Capecitabine Gefitinib Tamoxifen citrate
Carboplatin Gemcitabine Teniposide
Carmustine Gemtuzumab ozagamicin 6-Thioguanine
Chlorambucil Goserelin Thiotepa (See Triethylene-
Cisplatin Hydroxyurea triphosphamide)
Cladribine Idarubicin Topotecan
Cyclophosphamide Ifosfamide Trastuzumab
Cytarabine Imatinib Triethylene-triphosphamide
Cytarabine liposome Irinotecan Valrubicin
Dacarbazine Letrozole Vinblastine
Dactinomycin Leuprolide Vincristine
Daunorubicin Levamisole Vinorelbine
Docetaxel Lomustine
Antiparkinsonism Agents
Amantadine Carbidopa/levodopa Pramipexole
Benztropine Entacapone Selegiline
Bromocriptine Pergolide Trihexyphenidyl
496 VII: THERAPEUTICS
Antipsychotic Agents
Aripiprazole Mesoridazine Quetiapine
Chlorpromazine Molindone Risperidone
Clozapine Olanzapine Thioridazine
Fluphenazine Perphenazine Thiothixine
Haloperidol Prochlorperazine Trifluoperazine
Lithium carbonate
Antitussive, Decongestant, Expectorant, and Mucolytic Agents
Acetylcysteine Pseudoephedrine Hydrocodone, chlorpheni-
Benzonatate Hydrocodone and guaifen- ramine, phenylephrine,
Codeine esin acetaminophen and caf-
Dextromethorphan Hydrocodone and homat- feine
Guaifenesin ropine Phenylephrine
Guaifenesin and codeine Hydrocodone and pseu-
Guaifenesin and dex- doephedrine
tromethorphan
Antiviral Agents
Abacavir Famciclovir Ribavirin
Acyclovir Foscarnet Rimantadine
Adefovir Ganciclovir Ritonavir
Amantadine Imiquimod cream Ritonavir and lopinavir
Amprenavir Indinavir Saquinavir
Atazanavir Lamivudine Stavudine
Cidofovir Lamivudine and zidovudine Trifluridine
Delavirdine Lopinavir and ritonavir Valacyclovir
Didanosine Nelfinavir Zalcitabine
Efavirenz Nevirapine Zanamivir
Emtricitabine Oseltamivir Zidovudine
Enfuvirtide Penciclovir Zidovudine and lamivudine
Bronchodilators (Also see Respiratory and Nasal Inhalants)
Albuterol Levalbuterol Salmeterol
Albuterol and ipratropium Metaproterenol Terbutaline
Aminophylline Pirbuterol Theophylline
Bitolterol
Cardiovascular Agents
Acebutolol Esmolol Nitroglycerin
Atenolol Hydralazine Nitroprusside
Atropine Inamrinone Norepinephrine
Candesartan Irbesartan Perindopril
Cilostazol Isoproterenol Pindolol
Clopidogrel Isosorbide dinitrate Propranolol
Digoxin Isosorbide mononitrate Sodium polystyrene sul-
Diltiazem Labetalol fonate
Dobutamine Losartan Telmisartan
Dopamine Metoprolol Timolol
Eplerenone Milrinone Tolazoline
Epoprostenol Nadolol Trandolapril
Eprosartan Nicardipine Treprostinil
Eptifibatide Nifedipine Valsartan
Ephedrine Nimodipine Verapamil
Epinephrine
Cathartics/Laxatives
Bisacodyl Docusate potassium Glycerin suppositories
Docusate calcium Docusate sodium Lactulose
CLASSES OF GENERIC DRUGS, MINERALS, NATURAL PRODUCTS 497
plied: Inj 2 mg/mL SE: Allergic reactions, bleeding, thrombocytopenia possible Notes:
Use with heparin
Acarbose (Precose) Uses: Type 2 DM Action: α-Glucosidase inhibitor; delays di-
gestion of carbohydrates, thus reduces glucose levels Dose: 25–100 mg PO tid (with 1st
bite of each meal) Caution: [B, ?] Avoid if CrCl < 25 mL/min Contra: IBD, cirrhosis Sup-
plied: Tabs 25, 50, 100 mg SE: Abdominal pain, diarrhea, flatulence, increased LFTs
Notes: May take with sulfonylureas; can affect digoxin levels; check LFTs q3mo for 1st year of
therapy
Acebutolol (Sectral) [See Table VII–7, p 617]
Acetaminophen [APAP, N-acetyl-p-aminophenol] (Tylenol) [OTC]
Uses: Mild to moderate pain, HA, and fever Action: Nonnarcotic analgesic; inhibits syn-
thesis of prostaglandins in the CNS; inhibits hypothalamic heat-regulating center Dose: 650
mg PO or PR q4–6h or 1000 mg PO q6h; max 4 g/24 h Caution: [B, +] Hepatotoxicity re-
ported in elderly and with alcohol use at doses > 4 g/day; alcoholic liver disease Contra:
G6PD deficiency Supplied: Tabs 160, 325, 500, 650 mg; chew tabs 80, 160 mg; liq 100
mg/mL, 120 mg/2.5 mL, 120 mg/5 mL, 160 mg/5 mL, 167 mg/5 mL, 325 mg/5 mL, 500 mg/15
mL; drops 48 mg/mL, 60 mg/0.6 mL; supp 80, 120, 125, 300, 325, 650 mg SE: Overdose
causes hepatotoxicity, which is treated with N-acetylcysteine Notes: No anti-inflammatory or
platelet-inhibiting action; avoid alcohol intake
Acetaminophen + Butalbital ± Caffeine (Fioricet, Medigesic, Repan,
Sedapap-10, Two-Dyne, Triapin, Axocet, Phrenilin Forte) [C-III] Uses:
Mild pain; HA, especially associated with stress Action: Nonnarcotic analgesic with bar-
biturate Dose: 1–2 tabs or caps PO q4/6h PRN; 4 g/24 h APAP max Caution: [D, +] Alco-
holic liver disease Contra: G6PD deficiency Supplied: Caps Medigesic, Repan,
Two-Dyne: Butalbital 50 mg, caffeine 40 mg + APAP 325 mg. Caps Axocet, Phrenilin Forte:
Butalbital 50 mg + APAP 650 mg; Triapin: Butalbital 50 mg + APAP 325 mg. Tabs Medigesic,
Fioricet, Repan: Butalbital 50 mg, caffeine 40 mg, + APAP 325 mg; Phrenilin: Butalbital 50 mg
+ APAP 325 mg; Sedapap-10: Butalbital 50 mg + APAP 650 mg SE: drowsiness, dizziness,
“hangover” effect Notes: Butalbital is habit-forming; avoid alcohol intake
Acetaminophen + Codeine (Tylenol No. 1, No. 2, No. 3, No. 4) [C-III, C-V]
Uses: No. 1, No. 2, and No. 3 for mild–moderate pain; No. 4 for moderate–severe pain
Action: Combined effects of APAP and a narcotic analgesic Dose: 1–2 tabs q3–4h PRN
(max dose APAP = 4 g/d); adjust in renal/hepatic impairment Caution: [C, +] Alcoholic liver
disease Contra: G6PD deficiency Supplied: Tabs 300 mg of APAP + codeine; caps 325
mg of APAP + codeine; helix, susp (C-V) APAP 120 mg + codeine 12 mg/5 mL SE: Drowsi-
ness, dizziness, N/V Notes: Codeine in No. 1 = 7.5 mg, No. 2 = 15 mg, No. 3 = 30 mg, No. 4
= 60 mg
Acetazolamide (Diamox) Uses: Diuresis, glaucoma, prevent and treat high-alti-
tude sickness, refractory epilepsy Action: Carbonic anhydrase inhibitor; decreases renal
excretion of hydrogen and ↑ renal excretion of sodium, potassium, bicarbonate, and water
Dose: Diuretic: 250–375 mg IV or PO q24h Glaucoma: 250–1000 mg PO q24h in ÷ doses
Epilepsy: 8–30 mg/kg/d PO in ÷ doses Altitude sickness (treatment): 250 mg PO Q 8–12 h or
SR 500 mg PO Q 12–24 h Altitude sickness (prevention): 250 mg PO Q 8–12 h or SR 500 mg
PO Q12–24h starting 24–48 h before ascent and 48 h after highest ascent. Adjust in renal im-
pairment; avoid if CrCl < 10 mL/min Caution: [C, +] Contra: Renal/hepatic failure, sulfa
hypersensitivity Supplied: Tabs 125, 250 mg; SR caps 500 mg; inj 500 mg/vial SE:
Malaise, metallic taste, drowsiness, photosensitivity, hyperglycemia Notes: Follow Na+ and
K+; watch for metabolic acidosis; SR dosage forms not recommended for use in epilepsy
Acetic Acid and Aluminum Acetate (Otic Domeboro) Uses: Otitis externa
Action: Anti-infective Dose: 4–6 drops in ear(s) q2–3h Caution: [C,?] Contra: Perfo-
rated tympanic membranes Supplied: 2% otic soln
Acetohexamide (Dymelor) [See Table VII–13, p 626]
502 VII: THERAPEUTICS
tigue Notes: Extended-release tablet—do not halve or crush; fewest reports of ejaculatory
disorders compared with other drugs in class
Allopurinol (Zyloprim, Lopurin, Aloprim) Uses: Gout, hyperuricemia of ma-
lignancy, and uric acid urolithiasis Action: Xanthine oxidase inhibitor; decreases uric
acid production Dose: PO: Initially, 100 mg/d; usual 300 mg/d; max 800 mg/d IV: 200–400
mg/m2/d (max 600 mg/24 h); adjust for renal impairment; take after meal with plenty of fluid
Caution: [C, M] Supplied: Tabs 100, 300 mg; inj 500 mg/30 mL (Aloprim) SE: Skin rash,
N/V, renal impairment, angioedema Notes: Aggravates acute gout; begin after acute attack
resolves; administer after meals; IV dose of 6 mg/mL final conc as single daily infusion or ÷ 6-,
8-, or 12-h intervals
Almotriptan (Axert) [See Table VII–16, p 629]
α1-Protease Inhibitor (Prolastin) Uses: α1-antitrypsin deficiency; panacinar em-
physema Action: Replacement of human α1-protease inhibitor Dose: 60 mg/kg IV
once/wk Caution: [C, ?] Contra: Selective IgA deficiencies with known antibodies to IgA
Supplied: Inj 500 mg/20 mL, 1000 mg/40 mL SE: Fever, dizziness, flu-like symptoms, aller-
gic reactions
Alosetron (Lotronex) WARNING: Serious GI side effects, some fatal, including is-
chemic colitis, have been reported. May be prescribed only through participation in the Pre-
scribing Program for Lotronex Uses: Treatment of severe diarrhea-predominant IBS in
women who have failed conventional therapy Action: Selective 5-HT3 receptor antago-
nist Dose: Adults: 1 mg PO qd × 4 wk; titrate to max of 1 mg bid; discontinue after 4 wk at
max dose if IBS symptoms not controlled Caution: [B, ?/–] Contra: History of chronic or
severe constipation, intestinal obstruction, strictures, toxic megacolon, GI perforation, adhe-
sions, ischemic colitis, Crohn’s disease, ulcerative colitis, diverticulitis, thrombophlebitis, or hy-
percoagulable state Supplied: Tabs 1 mg SE: Constipation, abdominal pain, nausea
Notes: Discontinue immediately if constipation or symptoms of ischemic colitis develop; must
sign a patient agreement/informed consent before use
Alprazolam (Xanax) [C-IV] Uses: Anxiety and panic disorders + anxiety with de-
pression Action: Benzodiazepine; antianxiety agent Dose: Anxiety: Initially, 0.25–0.5 mg
tid; ↑ to a max of 4 mg/d in ÷ doses Panic: Initially, 0.5 mg tid; may gradually ↑ to desired re-
sponse; ↓ dose in elderly, debilitated, and hepatic impairment Caution: [D, –] Contra:
Narrow angle glaucoma, concomitant itra-/ketoconazole Supplied: Tabs 0.25, 0.5, 1, 2 mg,
soln 1 mg/mL SE: Drowsiness, fatigue, irritability, memory impairment, sexual dysfunction
Notes: Avoid abrupt discontinuation after prolonged use
Alprostadil, Intracavernosal (Caverject, Edex) Uses: Erectile dysfunction
Action: Relaxes smooth muscles, dilates cavernosal arteries, increases lacunar spaces and
entrapment of blood by compressing venules against tunica albuginea Dose: 2.5–60 mcg
intracavernosal; adjusted to individual needs Caution: [X, –] Contra: Conditions predis-
posing to priapism; anatomic deformities of the penis; penile implants; men in whom sexual
activity is inadvisable Supplied: Caverject: 6–10 or 6–20 mcg vials ± diluent syringes
Caverject Impulse: self-contained syringe (29-gauge) 10 and 20 mcg Edex: 5-, 10-, 20-, 40-
mcg vials + syringes SE: Penile pain common; pain with injection Notes: Counsel patients
about possible priapism, penile fibrosis, and hematoma; titrate dose at physician’s office
Alprostadil, Urethral Suppository (Muse) Uses: Erectile dysfunction Action:
Alprostadil (PGE1) absorbed through urethral mucosa; vasodilator and smooth muscle relax-
ant of corpus cavernosa Dose: 125–1000 mcg system 5–10 min before sexual activity
Caution: [X, –] Contra: Conditions predisposing to priapism; anatomic deformities of the
penis; penile implants; men in whom sexual activity is inadvisable Supplied: 125, 250, 500,
1000 mcg with a transurethral delivery system SE: Hypotension, dizziness, syncope, penile
pain, testicular pain, urethral burning/bleeding, and priapism Notes: Dose titration under
physician’s supervision
Alteplase, Recombinant [tPA] (Activase) Uses: Acute MI, PE, acute ischemic
stroke and CV cath occlusion Action: Thrombolytic; initiates local fibrinolysis by binding
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 505
to fibrin in the thrombus Dose: AMI and PE: 100 mg IV over 3 h (10 mg over 2 min, then 50
mg over 1 h, then 40 mg over 2 h) Stroke: 0.9 mg/kg (max 90 mg) infused over 60 min; Cath
occlusion: 10–29 kg: 1 mg/mL; ≥ 30 kg: 2 mg/mL Caution: [C, ?] Contra: Active internal
bleeding; uncontrolled HTN (systolic BP = 185 mm Hg/diastolic = 110 mm Hg); recent (within
3 mo) CVA, GI bleed, trauma, surgery, prolonged external cardiac massage; intracranial neo-
plasm, suspected aortic dissection, AV malformation or aneurysm, bleeding diathesis, hemo-
static defects, seizure at the time of stroke, suspicion of subarachnoid hemorrhage
Supplied: Powder for inj 50, 100 mg SE: Bleeding, bruising (especially from venipuncture
sites), hypotension Notes: Give heparin to prevent reocclusion; in AMI doses of > 150 mg
associated with intracranial bleeding
Altretamine (Hexalen) Uses: Epithelial ovarian CA Action: Unknown; cytotoxic
agent, possibly alkylating agent; inhibits nucleotide incorporation into DNA and RNA Dose:
260 mg/m2/d in 4 ÷ doses for 14–21 d of a 28-d treatment cycle; dose ↑ to 150 mg/m2/d for 14
d in multiagent regimens (refer to specific protocols) Caution: [D, ?/–] Contra: Preexisting
severe bone marrow depression or neurologic toxicity Supplied: Caps 50, 100 mg SE:
Vomiting, diarrhea, and cramps; neurologic toxicity (peripheral neuropathy, CNS depression);
minimally myelosuppressive
Aluminum Hydroxide (Amphojel, AlternaGEL) [OTC] Uses: Relief of
heartburn, upset or sour stomach, or acid indigestion; supplement to Rx of hyperphos-
phatemia Action: Neutralizes gastric acid; binds phosphate Dose: 10–30 mL or 2 tabs PO
q4–6h Caution: [C, ?] Supplied: Tabs 300, 600 mg; chew tabs 500 mg; susp 320, 600
mg/5 mL SE: Constipation Notes: Can use in renal failure
Aluminum Hydroxide + Magnesium Carbonate (Gaviscon) [OTC] Uses:
Relief of heartburn, upset or sour stomach, or acid indigestion Action: Neutralizes
gastric acid Dose: 15–30 mL PO pc and hs; avoid in renal impairment Caution: [C, ?]
Supplied: Liq containing aluminum hydroxide 95 mg + magnesium carbonate 358 mg/15 mL
SE: May cause ↑ Mg2+ (with renal insufficiency), constipation, diarrhea Notes: Doses qid
are best given pc and hs; may affect absorption of some drugs
Aluminum Hydroxide + Magnesium Hydroxide (Maalox) [OTC] Uses:
Hyperacidity (peptic ulcer, hiatal hernia, etc) Action: Neutralizes gastric acid Dose:
10–60 mL or 2–4 tabs PO qid or PRN Caution: [C, ?] Supplied: Tabs, susp SE: May
cause ↑ Mg2+ in renal insufficiency, constipation, diarrhea Notes: Doses qid best given pc
and hs
Aluminum Hydroxide + Magnesium Hydroxide and Simethicone (My-
lanta, Mylanta II, Maalox Plus) [OTC] Uses: Hyperacidity with bloating Ac-
tion: Neutralizes gastric acid and defoaming Dose: 10–60 mL or 2–4 tabs PO qid or PRN;
avoid in renal impairment Caution: [C, ?] Supplied: Tabs, susp SE: Hypermagnesemia
in renal insufficiency, diarrhea, constipation Notes: Mylanta II contains twice the aluminum
and magnesium hydroxide of Mylanta; may affect absorption of some drugs
Aluminum Hydroxide + Magnesium Trisilicate (Gaviscon, Gaviscon-2)
[OTC] Uses: Relief of heartburn, upset or sour stomach, or acid indigestion Ac-
tion: Neutralizes gastric acid Dose: Chew 2–4 tabs qid; avoid in renal impairment Cau-
tion: [C, ?] Supplied: Gaviscon: Aluminum hydroxide 80 mg and magnesium trisilicate 20
mg; Gaviscon-2: Aluminum hydroxide 160 mg and magnesium trisilicate 40 mg SE: Hyper-
magnesemia in renal insufficiency, constipation, diarrhea Notes: Concomitant administra-
tion may affect absorption of some drugs
Amantadine (Symmetrel) Uses: Treatment or prophylaxis of influenza A viral in-
fections, parkinsonism, and drug-induced EPS Action: Prevents release of infectious
viral nucleic acid into the host cell; releases dopamine from intact dopaminergic terminals
Dose: Influenza A: 200 mg/d PO or 100 mg PO bid Parkinsonism: 100 mg PO qd–bid; reduce
dose in renal impairment Caution: [C, M] Supplied: Caps 100 mg; tabs 100 mg; soln 50
mg/5 mL SE: Orthostatic hypotension, edema, insomnia, depression, irritability, hallucina-
tions, dream abnormalities
506 VII: THERAPEUTICS
vaginitis Notes: Do not substitute two 250-mg tabs for one 500-mg tab or an overdose of
clavulanic acid will occur
Amphotericin B (Fungizone) Uses: Severe, systemic fungal infections; oral
and cutaneous candidiasis Action: Binds ergosterol in the fungal membrane, altering
membrane permeability Dose: Intravenous: Test dose of 1 mg in adults, then 0.25–1.5
mg/kg/24 h IV over 2–6 h (range 25–50 mg/d or qod). Total dose varies with indication Oral: 1
mL qid Topical: Apply bid–qid for 1–4 wk depending on infection; adjust dose in renal impair-
ment Caution: [B, ?] Supplied: Powder for inj 50 mg/vial, oral susp 100 mg/mL, cream,
lotion, oint 3% SE: Reduced K+ and Mg2+ from renal wasting; anaphylaxis reported, HA,
fever, chills, nephrotoxicity, hypotension, anemia Notes: Monitor renal function/LFTs; pre-
treatment with APAP and antihistamines (Benadryl) helps minimize adverse effects with IV in-
fusion (e.g., fever, chills)
Amphotericin B Cholesteryl (Amphotec) Uses: Aspergillosis in persons in-
tolerant or refractory to conventional amphotericin B, systemic candidiasis Action:
Binds to sterols in the cell membrane, alters membrane permeability Dose: Test dose
1.6–8.3 mg, over 15–20 min, followed by a dose of 3–4 mg/kg/d; infuse at rate of 1 mg/kg/h;
reduce in renal insufficiency Caution: [B, ?] Supplied: Powder for inj 50 mg, 100 mg/vial
(final conc 0.6 mg/mL) SE: Anaphylaxis reported; fever, chills, HA, ↓ K+, ↓ Mg+, nephrotoxic-
ity, hypotension, anemia Notes: Do not use in-line filter; monitor LFTs and electrolytes
Amphotericin B Lipid Complex (Abelcet) Uses: Refractory invasive fungal
infection in persons intolerant to conventional amphotericin B Action: Binds to sterols
in the cell membrane, alters membrane permeability Dose: 5 mg/kg/d IV as a single daily
dose; infuse at rate of 2.5 mg/kg/h Supplied: Inj 5 mg/mL Caution: [B, ?] SE: Anaphy-
laxis reported; fever, chills, HA, ↓ K+,↓ Mg+, nephrotoxicity, hypotension, anemia Notes: Fil-
ter soln with a 5-mm filter needle; do not mix in electrolyte-containing solns. If inf > 2 h,
manually mix bag
Amphotericin B Liposomal (Ambisome) Uses: Refractory invasive fungal in-
fection in persons intolerant to conventional amphotericin B, cryptococcal meningitis
in HIV, empiric treatment for febrile neutropenia, visceral leishmaniasis Action: Binds
to sterols in the cell membrane, resulting in changes in membrane permeability Dose: 3–5
mg/kg/d, infused over 60–120 min; reduce in renal insufficiency Caution: [B, ?] Supplied:
Powder for inj 50 mg SE: Anaphylaxis reported; fever, chills, HA, ↓ K+, ↓ Mg2+, nephrotoxic-
ity, hypotension, anemia Notes: Filter with no less than 1 μm filter
Ampicillin (Amcill, Omnipen) Uses: Respiratory tract, GU tract, GI tract infec-
tions and meningitis due to susceptible bacteria, endocarditis prophylaxis Action: β-
Lactam antibiotic; inhibits cell wall synthesis Spectrum: Gram(+) coverage, including
Streptococcus sp, Staphylococcus sp, Listeria, gram(–) coverage, including Klebsiella sp, E
coli, H influenzae, P mirabilis, Shigella sp, Salmonella sp Dose: 500 mg–2 g IM or IV q6h or
250–500 mg PO q6h; reduce in renal impairment. Take on an empty stomach Caution: [B,
M] Cross-hypersensitivity with penicillin Supplied: Caps 250, 500 mg; susp 100 mg/mL (re-
constituted as drops), 125 mg/5 mL, 250 mg/5 mL, 500 mg/5 mL; powder for inj 125 mg, 250
mg, 500 mg, 1 g, 2 g, 10 g/vial SE: Diarrhea, skin rash, allergic reaction Notes: Many hos-
pital strains of E coli now resistant
Ampicillin-Sulbactam (Unasyn) Uses: Gynecologic, intra-abdominal, skin in-
fections caused by β-lactamase-producing strains of S aureus, Enterococcus, H in-
fluenzae, P mirabilis, and Bacteroides sp Action: Combination of a β-lactam antibiotic
and a β-lactamase inhibitor Spectrum: Gram(+) coverage as amp alone, gram- coverage as
amp alone also Enterobacter, Acinetobacter, Bacteroides Dose: 1.5–3 g IM or IV q6h; reduce
in renal impairment Caution: [B, M] Supplied: Powder for inj 1.5, 3 g/vial SE: Hypersen-
sitivity reactions, rash, diarrhea, pain at injection site Notes: A 2:1 ratio of ampicillin:sulbac-
tam
Amprenavir (Agenerase) WARNING: Oral solution contraindicated in children < 4 y
due to potential toxicity from large volume of excipient polypropylene glycol in the formulation
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 509
Uses: HIV infection Action: Protease inhibitor; prevents the maturation of the virion to ma-
ture viral particle Dose: 1200 mg bid Caution: [C, ?] CDC recommends HIV-infected
mothers not breastfeed because of risk of transmission of HIV to infant; previous allergic reac-
tion to sulfonamides Contra: CYP450 3A4 substrates (ergot derivatives, midazolam, triazo-
lam, etc); soln < 4 years, pregnancy, hepatic or renal failure, disulfiram or metronidazole
Supplied: Caps 50, 150 mg; soln 15 mg/mL SE: Life-threatening rash, hyperglycemia, hy-
pertriglyceridemia, fat redistribution, N/V/D, depression Notes: Caps and soln contain vita-
min E exceeding RDA intake amounts; avoid high-fat meals with administration; many drug
interactions
Anakinra (Kineret) WARNING: Associated with an increased incidence of serious in-
fections; DC with serious infection Uses: Reduce signs and symptoms of moderately to
severely active RA, failed one or more disease-modifying antirheumatic drugs Action:
Human IL-1–receptor antagonist Dose: 100 mg SC qd Caution: [B, ?] Contra: Hyper-
sensitivity to E coli-derived proteins, active infection, < 18 y Supplied: 100 mg prefilled sy-
ringes SE: Neutropenia especially when used with TNF blocking agents, injection site
reactions, infections
Anastrozole (Arimidex) Uses: Breast CA: postmenopausal women with metasta-
tic breast CA, adjuvant treatment of postmenopausal women with early hormone recep-
tor–positive breast CA Action: Selective nonsteroidal aromatase inhibitor, ↓ circulating
estradiol Dose: 1 mg/d Caution: [C, ?] Contra: Pregnancy Supplied: Tabs 1 mg
SE: May ↑ cholesterol levels; diarrhea, hypertension, flushing, increased bone and tumor
pain, HA, somnolence Notes: No detectable effect on adrenal corticosteroids or aldosterone
Anistreplase (Eminase) Uses: Acute MI Action: Thrombolytic agent; activates
the conversion of plasminogen to plasmin, promoting thrombolysis Dose: 30 units IV over
2–5 min Caution: [C, ?] Contra: Active internal bleeding, history of CVA, recent (< 2 mo)
intracranial or intraspinal surgery or trauma, intracranial neoplasm, AV malformation,
aneurysm, bleeding diathesis, severe uncontrolled hypertension Supplied: Vials containing
30 units SE: Bleeding, hypotension, hematoma Notes: May not be effective if re-adminis-
tered > 5 d after the previous dose of anistreplase or streptokinase, or streptococcal infection,
because of the production of antistreptokinase antibody
Anthralin (Anthra-Derm) Uses: Psoriasis Action: Keratolytic Dose: Apply daily
Caution: [C, ?] Contra: Acutely inflamed psoriatic eruptions, erythroderma Supplied:
Cream, oint 0.1, 0.2, 0.25, 0.4, 0.5, 1% SE: Irritation; discoloration of hair, fingernails, skin
Antihemophilic Factor [Factor VIII] [AHF] (Monoclate) Uses: Classic he-
mophilia A, von Willebrand disease Action: Provides factor VIII needed to convert pro-
thrombin to thrombin Dose: 1 AHF unit/kg ↑ factor VIII level ~2%. Units required = (kg)
(desired factor VIII ↑ as % normal) × (0.5). Prophylaxis of spontaneous hemorrhage = 5% nor-
mal. Hemostasis after trauma/surgery = 30% normal. Head injuries, major surgery, or bleeding
= 80–100% normal. Determine patient’s % of normal factor VIII before dosing Caution: [C,
?] Supplied: Check each vial for units contained SE: Rash, fever, HA, chills, N/V
Antithymocyte Globulin (ATG) (ATGAM) Uses: Management of allograft re-
jection in transplant patients Action: Reduces the number of circulating, thymus-depen-
dent lymphocytes Dose: 10–15 mg/kg/d Caution: [C, ?/–] Contra: Do not administer to
a patient with a history of severe systemic reaction to any other equine gamma-globulin prepa-
ration Supplied: Inj 50 mg/mL SE: Thrombocytopenia, leukopenia Notes: Discontinue
treatment if severe, unremitting thrombocytopenia or leukopenia occurs
Apraclonidine (Iopidine) [See Table VII–12, p 623]
Aprepitant (Emend) Uses: Prevention of nausea and vomiting associated with
highly emetogenic cancer chemotherapy, including cisplatin (used in combination with
other antiemetic agents) Action: Substance P/neurokinin 1(NK1) receptor antagonist
Dose: 125 mg PO on day 1, 1 h before chemotherapy, then 80 mg PO q AM on days 2 and 3
Caution: [B, ?/–] Substrate and moderate inhibitor of CYP3A4; inducer of CYP2C9 Contra:
510 VII: THERAPEUTICS
Use with pimozide Supplied: Caps 80, 125 mg SE: Fatigue, asthenia, hiccups Notes:
Decreases effectiveness of oral contraceptives; decreases anticoagulant effect of warfarin
Aprotinin (Trasylol) Uses: Reduce/prevent blood loss in patients undergoing
CABG Action: Protease inhibitor, antifibrinolytic Dose: 1-mL IV test dose to assess for al-
lergic reaction High dose: 2 million KIU load, 2 million KIU to prime pump, then 500,000 KIU/h
until surgery ends Low dose: 1 million KIU load, 1 million KIU to prime pump, then 250,000
KIU/h until surgery ends. 7 million KIU max total Caution: [B, ?] Thromboembolic disease
requiring anticoagulants or blood factor administration Supplied: Inj 1.4 mg/mL (10,000
KIU/mL) SE: AF, MI, heart failure, dyspnea, postoperative renal dysfunction Notes:
1000/KIU = 0.14 mg of aprotinin
Ardeparin (Normiflo) Uses: Prevent DVT/PE after knee replacement Action:
LMW heparin Dose: 35–50 units/kg SC q12h. Begin day of surgery, continue up to 14 d;
caution in ↓ renal function Caution: [C, ?] Contra: Active hemorrhage; hypersensitivity to
pork products Supplied: Inj 5000, 10,000 units/0.5 mL SE: Bleeding, bruising, thrombocy-
topenia, pain at injection site, increased serum transaminases Notes: Laboratory monitoring
usually not necessary
Argatroban (Acova) Uses: Prophylaxis or treatment of thrombosis in HIT, PCI in
patients with risk of HIT Action: Anticoagulant, direct thrombin inhibitor Dose: 2
mcg/kg/min IV; adjust until aPTT 1.5–3 × baseline value not to exceed 100 s; 10 mcg/kg/min
max; reduce dose in hepatic impairment Caution: [B, ?] Avoid oral anticoagulants, ↑ risk of
bleeding; avoid concomitant use of thrombolytics Contra: Overt major bleeding Supplied:
Inj 100 mg/mL SE: Atrial fibrillation, cardiac arrest, cerebrovascular disorder, hypotension,
ventricular tachycardia, N/V/D, sepsis, cough, renal toxicity, decrease in Hgb Notes: Steady
state typically achieved 1–3 h after initiation of therapy
Aripiprazole (Abilify) Uses: Schizophrenia Action: Dopamine and serotonin an-
tagonist Dose: Adults: 10–15 mg PO daily; ↓ when used in combination with potent
CYP3A4 or CYP2D6 inhibitors; ↑ when used in combination with inducer of CYP3A4 Cau-
tion: [C, –] Supplied: Tabs 10, 15, 20, 30 mg SE: Neuroleptic malignant syndrome, tar-
dive dyskinesia, orthostatic hypotension, cognitive and motor impairment, hyperglycemia
Artificial Tears (Tears Naturale) [OTC] Uses: Dry eyes Action: Ocular lubri-
cant Dose: 1–2 drops tid–qid Supplied: OTC soln
L-Asparaginase (Elspar, Oncaspar) Uses: ALL (in combination with other
agents) Action: Protein synthesis inhibitor Dose: 500–20,000 IU/m2 /d for 1–14 d (refer to
specific protocols) Caution: [C, ?] Contra: Active/history of pancreatitis Supplied: Inj
10,000 IU SE: Hypersensitivity reactions in 20–35% (spectrum of urticaria to anaphylaxis),
test dose recommended; rare GI toxicity (mild nausea/anorexia, pancreatitis)
Aspirin (Bayer, Ecotrin, St. Joseph) [OTC] Uses: Angina, CABG, PTCA,
carotid endarterectomy, ischemic stroke, TIA, MI, arthritis, pain, HA, fever, inflammation,
Kawasaki disease Action: Prostaglandin inhibitor Dose: Pain, fever: 325–650 mg q4–6h
PO or PR RA: 3–6 g/d PO in ÷ doses Platelet inhibitory action: 81–325 mg PO daily Prevention
of MI: 81–325 mg PO daily; avoid use with CrCl < 10 mL/min and in severe liver disease Cau-
tion: [C, M] Use linked to Reye’s syndrome; avoid use with viral illness in children Contra: Al-
lergy to ASA, chickenpox or flu symptoms, syndrome of nasal polyps, asthma, rhinitis
Supplied: Tabs 325, 500 mg; chew tabs 81 mg; EC tabs 165, 325, 500, 650, 975 mg; SR tabs
650, 800 mg; effervescent tabs 325, 500 mg; supp 120, 200, 300, 600 mg SE: GI upset and
erosion Notes: Discontinue use 1 wk before surgery to avoid postoperative bleeding compli-
cations; avoid or limit alcohol intake. See drug levels for salicylates (Table VII–16, p 000)
Aspirin and Butalbital Compound (Fiorinal, Others) [C-III] Uses: Tension
HA, pain Action: Combination barbiturate and analgesic Dose: 1–2 PO q4h PRN, max 6
tabs/d; avoid use with CrCl < 10 mL/min and in severe liver disease Caution: [C (D if used
for prolonged periods or high doses at term), ?] Contra: Allergy to ASA, GI ulceration,
bleeding disorder, porphyria, syndrome of nasal polyps, angioedema and bronchospasm to
NSAIDs Supplied: Caps Fiorgen PF, Fiorinal. Tabs Fiorinal, Lanorinal: ASA 325 mg/butal-
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 511
cotton plug; repeat 1–2 h PRN Caution: [C, ?] Contra: Do not use with perforated
eardrum Supplied: Soln SE: Local irritation
Benzonatate (Tessalon Perles) Uses: Symptomatic relief of cough Action:
Anesthetizes the stretch receptors in the respiratory passages Dose: 100 mg PO tid Cau-
tion: [C, ?] Supplied: Caps 100 mg SE: Sedation, dizziness, GI upset Notes: Do not
chew or puncture the caps
Benztropine (Cogentin) Uses: Parkinsonism and drug-induced extrapyramidal
disorders Action: Partially blocks striatal cholinergic receptors Dose: 0.5–6 mg PO, IM,
or IV in ÷ doses/d Caution: [C, ?] Contra: < 3 y Supplied: Tabs 0.5, 1, 2 mg; inj 1
mg/mL SE: Anticholinergic side effects Notes: Physostigmine 1–2 mg SC/IV can reverse
severe symptoms
Betamethasone (Celestone) [See Table VII–2, p 613]
Betaxolol (Kerlone) [See Table VII–7, pp 617–18]
Betaxolol, Ophthalmic (Betoptic) [See Table VII–12, pp 624–25]
Bethanechol (Urecholine, Duvoid, others) Uses: Neurogenic bladder atony
with retention, acute postoperative and postpartum functional (nonobstructive) urinary
retention Action: Stimulates cholinergic smooth muscle receptors in bladder and GI tract
Dose: 10–50 mg PO tid–qid or 2.5–5 mg SC tid–qid and PRN (take on empty stomach)
Caution: [C, ?/–] Contra: Bladder outlet obstruction, PUD, epilepsy, hyperthyroidism,
bradycardia, COPD, AV conduction defects, parkinsonism, hypotension, vasomotor instability
Supplied: Tabs 5, 10, 25, 50 mg; inj 5 mg/mL SE: Abdominal cramps, diarrhea, salivation,
hypotension Notes: Do not administer IM or IV
Bicalutamide (Casodex) Uses: Advanced prostate CA (in combination with
GnRH agonists such as leuprolide or goserelin) Action: Nonsteroidal antiandrogen
Dose: 50 mg/d Caution: [X, ?] Contra: Women Supplied: Caps 50 mg SE: Hot
flashes, loss of libido, impotence, diarrhea, N/V, gynecomastia, and LFT elevation
Bisacodyl (Dulcolax) [OTC] Uses: Constipation; preoperative bowel prepara-
tion Action: Stimulates peristalsis Dose: 5–15 mg PO or 10 mg PR PRN; (Do not chew
tabs; do not give within 1 h of antacids or milk) Caution: [B, ?] Contra: Acute abdomen or
bowel obstruction, appendicitis, gastroenteritis Supplied: EC tabs 5 mg; supp 10 mg SE:
Abdominal cramps, proctitis, and inflammation with suppositories
Bismuth Subsalicylate (Pepto-Bismol) [OTC] Uses: Indigestion, nausea,
and diarrhea; combination for treatment of H pylori infection Action: Antisecretory and
antiinflammatory effects Dose: 2 tabs or 30 mL PO PRN (max 8 doses/24 h); avoid in pa-
tients with renal failure Caution: [C, D (3rd trimester), –] Contra: Influenza or chickenpox
(↑ risk of Reye’s syndrome), ASA allergy Supplied: Chew tabs 262 mg; liq 262, 524 mg/15
mL SE: May turn tongue and stools black
Bisoprolol (Zebeta) [See Table VII–7, pp 617–18]
Bitolterol (Tornalate) Uses: Prophylaxis and Rx of asthma and reversible bron-
chospasm Action: Sympathomimetic bronchodilator; stimulates β2-adrenergic receptors in
the lungs Dose: 2 inhal q8h Caution: [C, ?] Supplied: Aerosol 0.8% SE: Dizziness,
nervousness, trembling, HTN, palpitations
Bivalirudin (Angiomax) Uses: Anticoagulant used with ASA in unstable angina
undergoing PTCA Action: Anticoagulant, direct thrombin inhibitor Dose: 1 mg/kg IV
bolus, then 2.5 mg/kg/h over 4 h; if needed, use 0.2 mg/kg/h for up to 20 h. Give with aspirin
300–325 mg/day; start pre-PTCA; adjust dose in renal impairment Caution: [B, ?] Contra:
Major bleeding Supplied: Powder for inj SE: Bleeding, back pain, nausea, HA
Bleomycin Sulfate (Blenoxane) Uses: Testicular carcinomas; Hodgkin’s lym-
phoma and NHL; cutaneous lymphomas; and squamous cell carcinomas of the head
and neck, larynx, cervix, skin, penis; sclerosing agent for malignant pleural effusion
Action: Induces breakage (scission) of single- and double-stranded DNA Dose: 10–20
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 515
units/m2 1–2/wk (refer to specific protocols); adjust in renal impairment Supplied: Inj 15
units/vial Caution: [D, ?] Severe pulmonary disease SE: Hyperpigmentation (skin stain-
ing) and hypersensitivity (rash to anaphylaxis); fever in 50%; lung toxicity (idiosyncratic and
dose related); pneumonitis may progress to fibrosis; Raynaud’s phenomenon, N/V Notes:
Test dose of 1 unit recommended, especially in lymphoma patients; lung toxicity likely when
the total dose > 400 units
Bortezomib (Velcade) WARNING: May worsen pre-existing neuropathy Uses: Pro-
gression of multiple myeloma despite two previous treatments Action: Proteasome in-
hibitor Dose: 1.3 mg/m2 bolus IV twice weekly for 2 wk, with 10-day rest period (= 1 cycle);
adjust dose for hematologic toxicity, neuropathy Caution: [D, ?/–] Supplied: 3.5 mg vial
SE: Asthenia, GI upset, anorexia, dyspnea, headache, orthostatic hypotension, edema, in-
somnia, dizziness, rash, pyrexia, arthralgia, neuropathy Notes: May interact with drugs me-
tabolized via CYP450 system
Brimonidine (Alphagan) [See Table VII–12, p 623–25]
Brinzolamide (Azopt) [See Table VII–12, pp 623–25]
Bromocriptine (Parlodel) Uses: Parkinson’s syndrome, hyperprolactinemia,
acromegaly, pituitary tumors Action: Direct-acting on the striatal dopamine receptors; in-
hibits prolactin secretion Dose: Initially, 1.25 mg PO bid; titrate to effect Caution: [C, ?]
Contra: Severe ischemic heart disease or peripheral vascular disease Supplied: Tabs 2.5
mg; caps 5 mg SE: Hypotension, Raynaud’s phenomenon, dizziness, nausea, hallucina-
tions
Budesonide (Rhinocort, Pulmicort) Uses: Allergic and nonallergic rhinitis,
asthma Action: Steroid Dose: Intranasal: 2 sprays/nostril bid or 4 sprays/nostril/d Aque-
ous: 1 spray/nostril/d Oral inhaled: 1–4 inhal bid; (Rinse mouth after oral use) Caution: [C,
?/–] Supplied: Met-dose inhal, Turbuhaler, nasal inhaler, and aqueous spray SE: HA,
cough, hoarseness, Candida infection, epistaxis
Bumetanide (Bumex) Uses: Edema from CHF, hepatic cirrhosis, and renal dis-
ease Action: Loop diuretic; inhibits reabsorption of sodium and chloride in the ascending
loop of Henle and the distal renal tubule Dose: 0.5–2 mg/d PO; 0.5–1 mg IV q8–24h (max
10 mg/d) Caution: [D, ?] Contra: Anuria, hepatic coma, severe electrolye depletion
Supplied: Tabs 0.5, 1, 2 mg; inj 0.25 mg/mL SE: Hypokalemia, hyperuricemia,
hypochloremia, hyponatremia, dizziness, increased serum creatinine, ototoxicity Notes:
Monitor fluid and electrolyte status during treatment
Bupivacaine (Marcaine) Uses: Local, regional, and spinal anesthesia, local and
regional analgesia Action: Local anesthetic Dose: Dose-dependent on procedure, tis-
sue vascularity, depth of anesthesia, and degree of muscle relaxation required Caution: [C,
?] Contra: Severe bleeding, severe hypotension, shock and arrhythmias, local infections at
anesthesia site, septicemia Supplied: Inj 0.25, 0.5, 0.75% SE: Hypotension, bradycardia,
dizziness, anxiety
Buprenorphine (Buprenex) [C-V] Uses: Moderate/severe pain Action: Opiate
agonist-antagonist Dose: 0.3–0.6 mg IM or slow IV push q6h PRN Caution: [C, ?/–]
Supplied: Inj 0.324 mg/mL (= 0.3 mg of buprenorphine) SE: Sedation, hypotension, respira-
tory depression Notes: May induce withdrawal syndrome in opioid-dependent patients
Bupropion (Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban) WARNING:
Pediatric: Antidepressants may increase risk of suicidality; consider risks and benefits of use.
Patients should be closely monitored for clinical worsening, suicidality, or unusual changes in
behavior Uses: Depression, adjunct to smoking cessation Action: Weak inhibitor of
neuronal uptake of serotonin and norepinephrine; inhibits the neuronal reuptake of dopamine
Dose: Depression: 100–450 mg/d ÷ bid–tid; SR 100-200 mg bid; XL 150–300 mg daily;
Smoking cessation: 150 mg/d × 3 d, then 150 mg bid × 8–12 wk; ↓ in renal/hepatic impairment
Caution: [B, ?/–] Contra: Seizure disorder, prior diagnosis of anorexia nervosa or bulimia,
MAOI, abrupt discontinuation of alcohol or sedatives Supplied: Tabs 75, 100 mg; SR tabs
516 VII: THERAPEUTICS
100, 150, 200 mg; XL tabs 150, 300 mg SE: Associated with seizures; agitation, insomnia,
HA, tachycardia Notes: Avoid use of alcohol and other CNS depressants
Buspirone (BuSpar) Uses: Short-term relief of anxiety Action: Antianxiety agent;
selectively antagonizes CNS serotonin receptors Dose: 5–10 mg PO tid; ↑ to desired re-
sponse; usual dose 20–30 mg/d; max 60 mg/d; reduce dose in severe hepatic/renal insuffi-
ciency Caution: [B, ?/–] Supplied: Tabs 5, 10, 15, 30 mg dividose SE: Drowsiness,
dizziness; HA, nausea Notes: No abuse potential or physical or psychologic dependence
Busulfan (Myleran, Busulfex) Uses: CML, preparative regimens for allogeneic
and autologous BMT in high doses Action: Alkylating agent Dose: Refer to specific
protocols Caution: [D, ?] Supplied: Tabs 2 mg, inj 60 mg/10 mL SE: Myelosuppression,
pulmonary fibrosis, nausea (high-dose therapy), gynecomastia, adrenal insufficiency, and skin
hyperpigmentation
Butorphanol (Stadol) [C-IV] Uses: Anesthesia adjunct, pain, and migraine
headaches Action: Opiate agonist-antagonist with central analgesic actions Dose: Pain:
1–4 mg IM or IV q3–4h PRN Headaches: 1 spray in 1 nostril, may repeat × 1 if pain not re-
lieved in 60–90 min; reduce dose in renal impairment Caution: [C (D if used in high doses
or for prolonged periods at term), +] Supplied: Inj 1, 2 mg/mL; nasal spray 10 mg/ mL SE:
Drowsiness, dizziness, nasal congestion Notes: May induce withdrawal in opioid-dependent
patients
Calcipotriene (Dovonex) Uses: Plaque psoriasis Action: Keratolytic Dose:
Apply bid Caution: [C, ?] Contra: Hypercalcemia; vitamin D toxicity; do not apply to face
Supplied: Cream; oint; soln 0.005% SE: Skin irritation, dermatitis
Calcitonin (Cibacalcin, Miacalcin) Uses: Paget’s disease of bone; hypercal-
cemia; osteogenesis imperfecta, postmenopausal osteoporosis Action: Polypeptide
hormone Dose: Paget’s (salmon form): 100 units/d IM/SC initially, 50 units/d or 50–100
units q 1–3d maintenance Paget’s (human form): 0.5 mg/d initially; maintenance 0.5 mg 2–3
times/wk or 0.25 mg/d, max 0.5 mg bid Hypercalcemia (salmon calcitonin): 4 units/kg IM/SC
q12h; ↑ to 8 units/kg q12h, max q6h Osteoporosis (salmon calcitonin): 100 units/d IM/SC; in-
tranasal 200 units = 1 nasal spray/d Caution: [C, ?] Supplied: Spray, nasal 200 units/acti-
vation; inj, human (Cibacalcin) 0.5 mg/ vial, salmon 200 units/mL (2 mL) SE: Facial flushing,
nausea, edema at injection site, nasal irritation, polyuria Notes: Human (Cibacalcin) and
salmon forms; human only approved for Paget’s bone disease
Calcitriol (Rocaltrol) Uses: Reduction of elevated parathyroid hormone levels,
hypocalcemia associated with dialysis Action: 1,25-Dihydroxycholecalciferol, a vitamin
D analogue Dose: Renal failure: 0.25 mcg/d PO, ↑0.25 mcg/d q4–6wk PRN; 0.5 mcg 3× /wk
IV, ↑ PRN Hyperparathyroidism: 0.5–2 mcg/d Caution: [C, ?] Contra: Hypercalcemia; vit-
amin D toxicity Supplied: Inj 1, 2 mcg/mL (in 1-mL volume); caps 0.25, 0.5 mcg SE: Hy-
percalcemia possible Notes: Monitor dosing to keep Ca+ WNL
Calcium Acetate (Calphron, Phos-Ex, PhosLo) Uses: ESRD-associated hy-
perphosphatemia Action: Ca supplement to treat ESRD hyperphosphatemia without alu-
minum Dose: 2–4 tabs PO with meals Caution: [C, ?] Contra: Hypercalcemia
Supplied: Caps Phos-Ex 500 mg (125 mg Ca); tabs Calphron and PhosLo 667 mg (169 mg
Ca) SE: Can cause ↑ Ca2+, hypophosphatemia, constipation Notes: Monitor Ca2+ levels
Calcium Carbonate (Tums, Alka-Mints) [OTC] Uses: Hyperacidity associ-
ated with peptic ulcer disease, hiatal hernia, etc Action: Neutralizes gastric acid Dose:
500 mg–2 g PO PRN; adjust in renal impairment Caution: [C, ?] Supplied: Chew tabs
350, 420, 500, 550, 750, 850 mg; susp SE: Hypercalcemia, hypophosphatemia, constipa-
tion
Calcium Salts (Chloride, Gluconate, Gluceptate) Uses: Ca replacement,
VF, Ca blocker toxicity, Mg2+ intoxication, tetany, hyperphosphatemia in ESRD Ac-
tion: Calcium supplement/replacement, increased myocardial contractility, binding phosphate
Dose: Replacement: 1–2 g/d PO Cardiac emergencies: CaCl 0.5–1 g IV q 10 min or Ca glu-
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 517
conate 1–2 g IV q 10 min Hyperphosphatemia in end-stage renal disease: 2 tabs with each
meal Caution: [C, ?] Contra: Hypercalcemia Supplied: CaCl inj 10% = 100 mg/mL =
Ca 27.2 mg/mL = 10-mL ampule. Ca gluconate inj 10% = 100 mg/mL = Ca 9 mg/mL; tabs 500
mg = 45 mg Ca, 650 mg = 58.5 mg Ca, 975 mg = 87.75 mg Ca, 1 g = 90 mg Ca. Ca glucep-
tate inj 220 mg/mL = 18 mg/mL Ca SE: Bradycardia, cardiac arrhythmias, hypercalcemia
Notes: CaCl contains 270 mg (13.6 mEq) elemental Ca/g, and calcium gluconate contains 90
mg (4.5 mEq) Ca/g. RDA for Ca: Adults = 800 mg/d
Candesartan (Atacand) [See Table VII–4, p 615]
Capecitabine (Xeloda) WARNING: Clinically significant increases in INR have been
observed with concomitant use of Xeloda and Warfarin—frequent monitoring of INR is neces-
sary: Uses: Metastatic breast cancer and colorectal cancer Action: Enzymatically
converted to 5-fluorouracil; inhibitor of thymidylate synthetase Dose: Refer to specific proto-
cols; adjust in renal impairment Caution: [D, –] Contra: Known dihydropyrimidine dehy-
drogenase (DPD) deficiency; severe renal impairment Supplied: Tabs 150, 500 mg SE:
N/V/D, stomatitis, hand-and-foot syndrome, neutropenia, fever
Capsaicin (Capsin, Zostrix, others) [OTC] Uses: Pain due to postherpetic
neuralgia, chronic neuralgia, arthritis, diabetic neuropathy, postoperative pain, psoria-
sis, intractable pruritus Action: Topical analgesic Dose: Apply tid–qid Caution: [?, ?]
Supplied: OTC creams; gel; lotions; roll-ons SE: Local irritation, neurotoxicity, cough
Captopril (Capoten) [See Table VII–3, p 614]
Carbachol (Isopto Carbachol) [See Table VII–12, pp 623–25]
Carbamazepine (Tegretol) WARNING: Aplastic anemia and agranulosytosis have
been reported with carbamazepine Uses: Epilepsy, trigeminal neuralgia, alcohol with-
drawal Action: Anticonvulsant Dose: Initially, 200 mg PO bid; ↑ by 200 mg/d; usual
800–1200 mg/d in ÷ doses; reduce dose in renal impairment; take with food Caution: [D, +]
Contra: MAOI use, history of bone marrow depression Supplied: Tabs 200 mg; chew tabs
100 mg; XR tabs 100, 200, 400 mg; susp 100 mg/5 mL SE: Drowsiness, dizziness, blurred
vision, N/V, rash, hyponatremia, leukopenia, agranulocytosis Notes: Monitor CBC and
serum levels (see Table VII–17, p 000); generic products not interchangeable
Carbidopa/Levodopa (Sinemet) Uses: Parkinson’s disease Action: ↑ CNS
levels of dopamine Dose: 25/100 mg bid–qid; ↑ as needed (max 200/2000 mg/d) Cau-
tion: [C, ?] Contra: Narrow-angle glaucoma, suspicious skin lesion (may activate
melanoma), melanoma, MAOI use Supplied: Tabs (mg carbidopa/mg levodopa) 10/100,
25/100, 25/250; tabs SR (mg carbidopa/mg levodopa) 25/100, 50/200 SE: Psychiatric distur-
bances, orthostatic hypotension, dyskinesias, and cardiac arrhythmias
Carboplatin (Paraplatin) Uses: Ovarian, lung, head and neck, testicular, urothe-
lial and brain CAs, NHL and allogeneic and autologous BMT in high doses Action:
DNA cross-linker; forms DNA-platinum adducts Dose: Refer to specific protocols Cau-
tion: [D, ?] Contra: Severe bone marrow suppression, excessive bleeding Supplied: Inj
50, 150, 450 mg SE: Myelosuppression, N/V/D, nephrotoxicity, hematuria, neurotoxicity, ↑
LFTs Notes: Physiologic dosing based on either Culvert’s or Egorin’s formula allows for
larger doses with reduced toxicity
Carisoprodol (Soma) Uses: Adjunct to sleep and physical therapy for the relief
of painful musculoskeletal conditions Action: Centrally acting muscle relaxant Dose:
350 mg PO tid–qid Caution: [C, M] tolerance may result; caution in renal/hepatic impair-
ment Contra: Hypersensitivity to meprobamate; acute intermittent porphyria Supplied:
Tabs 350 mg SE: CNS depression; drowsiness; dizziness, tachycardia Notes: Avoid alco-
hol and other CNS depressants; available in combination with ASA or codeine
Carmustine [BCNU] (BiCNU; Gliadel) Uses: Primary brain tumors,
melanoma, Hodgkin’s and non-Hodgkin’s lymphomas, multiple myeloma, and induction
for allogeneic and autologous BMT in high doses; adjunct to surgery in patients with
recurrent glioblastoma multiforme Action: Alkylating agent; nitrosourea forms DNA
518 VII: THERAPEUTICS
cross-links; inhibitor of DNA synthesis Dose: Refer to specific protocols; dosage adjustment
may be necessary in hepatic impairment Caution: [D, ?] Administer with caution in patients
with depressed platelet, leukocyte, or erythrocyte counts, renal or hepatic impairment Con-
tra: Myelosuppression; pregnancy Supplied: Inj 100 mg/vial; wafer: 7.7 mg SE: Hypoten-
sion, N/V, myelosuppression (especially leukocytes and platelets), phlebitis, facial flushing,
hepatic and renal dysfunction, pulmonary fibrosis, and optic neuroretinitis. Hematologic toxic-
ity may persist up to 4–6 wk after dose Notes: Do not give courses more frequently than
every 6 wk because toxicity is cumulative. Baseline pulmonary function tests are recom-
mended
Carteolol (Cartrol) [See Table VII–7, pp 617–18]
Carteolol (Ocupress) [See Table VII–12, pp 623–25]
Carvedilol (Coreg) [See Table VII–7, pp 617–18]
Caspofungin (Cancidas) Uses: Invasive aspergillosis refractory/intolerant to
standard therapy, esophageal candidiasis Action: An echinocandin; inhibits fungal
cell wall synthesis; highest activity in regions of active cell growth Dose: 70 mg IV load
day 1, 50 mg/d IV; slow infusion; adjust dose in hepatic impairment Caution: [C, ?/–] Do
not use with cyclosporine; has not been studied as initial therapy Contra: Hypersensitiv-
ity to any component Supplied: IV infusion SE: Fever, HA, N/V, thrombophlebitis at in-
jection site, altered LFTs Notes: Monitor during infusion; limited experience beyond 2 wk
of therapy
Cefaclor (Ceclor) [See Table VII–9, p 619]
Cefadroxil (Duricef, Ultracef) [See Table VII–8, p 619]
Cefazolin (Ancef, Kefzol) [See Table VII–8, p 619]
Cefdinir (Omnicef) [See Table VII–10, p 620]
Cefditoren (Spectracef) [See Table VII–10, p 620]
Cefepime (Maxipime) [See Table VII–10, p 620]
Cefixime (Suprax) [See Table VII–10, p 620]
Cefoperazone (Cefobid) [See Table VII–10, p 620]
Cefotaxime (Claforan) [See Table VII–10, p 620]
Cefotetan (Cefotan) [See Table VII–9, p 619]
Cefoxitin (Mefoxin) [See Table VII–9, p 619]
Cefpodoxime (Vantin) [See Table VII–10, p 620]
Cefprozil (Cefzil) [See Table VII–9, p 619]
Ceftazidime (Fortaz, Ceptaz, Tazidime, Tazicef) [See Table VII–10,
p 620]
Ceftibuten (Cedax) [See Table VII–10, p 620]
Ceftizoxime (Cefizox) [See Table VII–10, p 620]
Ceftriaxone (Rocephin) [See Table VII–10, p 620]
Cefuroxime (Ceftin [oral], Zinacef [parenteral]) [See Table VII–9, p 619]
Celecoxib (Celebrex) [See Table VII–11, pp 621–22]
Cephalexin (Keflex, Keftab) [See Table VII–8, p 619]
Cephradine (Velosef) [See Table VII–8, p 619]
Cetirizine (Zyrtec) Uses: Allergic rhinitis and other allergic symptoms including ur-
ticaria Action: Nonsedating antihistamine Dose: 5–10 mg/d; ↓ dosage in renal/hepatic
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 519
impairment Caution: [B, ?/–] Use with caution in elderly and nursing mothers; doses > 10
mg/day may cause drowsiness Contra: Hypersensitivity to cetirizine, hydroxyzine Sup-
plied: Tabs 5, 10 mg; syrup 5 mg/5 mL SE: HA, drowsiness, dry mouth Notes: Can cause
sedation
Cevimeline HCL (Evoxac) Uses: Treatment of symptoms of dry mouth in pa-
tients with Sjögren’s syndrome Action: A cholinergic agent Dose: 30 mg tid Caution:
[C, ?/–] history of nephrolithiasis or cholelithiasis Contra: Uncontrolled asthma, narrow
angle glaucoma Supplied: Caps 30 mg SE: Excessive sweating, salivation, rhinitis, nau-
sea, visual disturbances, alteration in cardiac conduction and/or heart rate
Charcoal, Activated (Superchar, Actidose, Liqui-Char) Uses: Emergency
treatment in poisoning by most drugs and chemicals Action: Adsorbent detoxicant
Dose: Acute intoxication: 30–100 g/dose GI dialysis: 20–50 g q6h for 1–2 days; also give 70%
sorbitol solution (2 mL/kg body weight). Repeated use of sorbitol not recommended Cau-
tion: [C, ?] If ipecac used, induce vomiting with ipecac before administering charcoal; may
cause vomiting, which is hazardous in petroleum distillate and caustic ingestions; do not mix
with milk, ice cream, or sherbet Contra: Not effective for cyanide, mineral acids, caustic al-
kalis, organic solvents, iron, ethanol, methanol lithium poisoning. Do not use sorbitol in pa-
tients with fructose intolerance Supplied: Powder, liq, caps SE: Some liq dosage forms in
sorbitol base (a cathartic); vomiting, diarrhea, black stools, constipation Notes: Charcoal
with sorbitol is not recommended in children < 1yr; monitor for hypokalemia and hypomagne-
semia; protect the airway in lethargic or comatose patients
Chlorambucil (Leukeran) Uses: CLL, Hodgkin’s disease, Waldenström’s
macroglobulinemia Action: Alkylating agent Dose: Refer to specific protocol Caution:
[D, ?] Use with caution in patients with seizure disorder and bone marrow suppression; affects
human fertility Contra: Previous resistance; hypersensitivity to alkylating agents Sup-
plied: Tabs 2 mg SE: Myelosuppression, CNS stimulation, N/V, drug fever, skin rash, chro-
mosomal damage that can result in secondary leukemias, alveolar dysplasia, pulmonary
fibrosis, hepatotoxicity Notes: Monitor LFTs, CBC, leukocyte counts, platelets, serum uric
acid; reduce initial dosage if patient has received radiation therapy
Chloramphenicol, Ophthalmic (Chloromycetin Ophthalmic) [See Table
VII–12, pp 623–25]
Chlordiazepoxide (Librium) [C-IV] Uses: Anxiety, tension, alcohol withdrawal,
and preoperative apprehension Action: Benzodiazepine; antianxiety agent Dose: Mild
anxiety: 5–10 mg PO tid–qid or PRN Severe anxiety: 25–50 mg IM, IV, or PO q6–8h or PRN
Alcohol withdrawal: 50–100 mg IM or IV; repeat in 2–4 h if needed up to 300 mg in 24 h; grad-
ually taper the daily dosage; adjust dose in renal impairment Caution:[D, ?] Contra: Pre-
existing CNS depression Supplied: Caps 5, 10, 25 mg; tabs 10, 25 mg; inj 100 mg SE:
Drowsiness, CP, rash, fatigue, memory impairment, xerostomia, weight gain Notes: Erratic
IM absorption; reduce dose in the elderly; avoid in hepatic impairment
Chlorothiazide (Diuril) Uses: HTN, edema Action: Thiazide diuretic Dose: 500
mg–1 g PO or IV daily–bid Caution: [D, +] Do not administer inj IM or SQ Contra: Cross-
sensitivity to thiazides/sulfonamides, anuria Supplied: Tabs 250, 500 mg; susp 250 mg/5
mL; inj 500 mg/vial SE: Hypokalemia, hyponatremia, dizziness, hyperglycemia, hyper-
uricemia, hyperlipidemia, photosensitivity Notes: May be taken with food/milk; take early in
the day to avoid nocturia; use sunblock; monitor serum electrolytes
Chlorpheniramine (Chlor-Trimeton, Others) [OTC] Uses: Allergic reac-
tions; common cold Action: Antihistamine Dose: 4 mg PO q4–6h or 8–12 mg PO bid of
SR Caution: [C, ?/–] bladder obstruction; narrow-angle glaucoma; hepatic insufficency
Contra: Hypersensitivity Supplied: Tabs 4 mg; chew tabs 2 mg; SR tabs 8, 12 mg; syrup 2
mg/5 mL; inj 10, 100 mg/mL SE: Anticholinergic SE and sedation common, postural hy-
potension, QT changes, extrapyramidal reactions, photosensitivity
520 VII: THERAPEUTICS
2 h after breakfast and dinner Caution: [C, +/–] Dosage adjustments may be necessary
when used in conjunction with other drugs known to inhibit CYP3A4 and CYP2C19 Contra:
Use in patients with CHF of any severity Supplied: Tabs 50, 100 mg SE: HA, palpitation,
diarrhea
Cimetidine (Tagamet, Tagamet HB [OTC]) Uses: Duodenal ulcer; ulcer pro-
phylaxis in hypersecretory states, e.g., trauma, burns, surgery; and GERD Action: H2-
receptor antagonist Dose: Active ulcer: 2400 mg/d IV cont inf or 300 mg IV q6h; 400 mg PO
bid or 800 mg hs Maintenance: 400 mg PO hs GERD: 800 mg PO bid; maintenance 800 mg
PO hs; ↑ dosing interval with renal insufficiency; ↓ dose in the elderly Caution: [B, +] Many
drug interactions (p-450 system) Supplied: Tabs 200, 300, 400, 800 mg; liq 300 mg/5 mL;
inj 300 mg/2 mL SE: Dizziness, HA, agitation, thrombocytopenia, gynecomastia Notes:
Take 1 h before or 2 h after antacids; avoid excessive alcohol
Ciprofloxacin (Cipro) Uses: Treatment of lower respiratory tract, sinuses, skin
and skin structure, bone/joints, and urinary tract including prostatitis Spectrum: Effec-
tive against susceptible strains of Pseudomonas, complicated gram(–) infections due to E coli,
P mirabilis, K pneumoniae, Campylobacter jejuni or Shigella Action: Quinolone antibiotic;
inhibits DNA gyrase Dose: 250–750 mg PO q12h; XR 500-1000 mg PO q24h; or 200–400
mg IV q12h; adjust in renal impairment Caution: [C, ?/–] Children < 18 y Supplied: Tabs
100, 250, 500, 750 mg; Tabs XR 500, 1000 mg; susp 5 g/100 mL, 10 g/100 mL; inj 200, 400
mg SE: Restlessness, N/V/D, rash, ruptured tendons, ↑ LFTs Notes: Avoid antacids; re-
duce/restrict caffeine intake; little activity against streptococci; interactions with theophylline,
caffeine, sucralfate, warfarin, antacids
Ciprofloxacin, Ophthalmic (Ciloxan) [See Table VII–12, pp 623–25]
Ciprofloxacin, Otic (Cipro HC Otic) Uses: Otitis externa Action: Quinolone
antibiotic; inhibits DNA gyrase Dose: 1–2 drops in ear(s) bid for 7 d Caution: [C, ?/–]
Contra: Perforated tympanic membrane, viral infections of the external canal Supplied:
Susp ciprofloxacin 0.2% and hydrocortisone 1% SE: HA, pruritus
Cisplatin (Platinol, Platinol AQ) Uses: Testicular, small-cell and non-small-cell
lung, bladder, ovarian, breast, head and neck, and penile CAs; osteosarcoma; pediatric
brain tumors Action: DNA-binding; denatures double helix; intrastrand cross-linking; for-
mation of DNA adducts Dose: Refer to specific protocols; adjust dose in renal impairment
Caution: [D, –] Cumulative renal toxicity may be severe; serum magnesium, as well as other
electrolytes, should be monitored both before and within 48 h after cisplatin therapy Contra:
Preexisting renal insufficiency, myelosuppression, hearing impairment Supplied: Inj 1
mg/mL SE: Allergic reactions, N/V, nephrotoxicity (exacerbated by concurrent administration
of other nephrotoxic drugs and minimized by NS infusion and mannitol diuresis), high-fre-
quency hearing loss in 30%, peripheral “stocking glove”-type neuropathy, cardiotoxicity (ST-,
T-wave changes), hypomagnesemia, mild myelosuppression, hepatotoxicity; renal impairment
is dose-related and cumulative Notes: Taxane derivatives should be administered before
platinum derivatives
Citalopram (Celexa) WARNING: Pediatric: Aantidepressants may increase risk of
suicidality; consider risks and benefits of use. Patients should be closely monitored for clinical
worsening, suicidality, or unusual changes in behavior Uses: Depression Action: SSRI
Dose: Initial 20 mg/d, may be ↑ to 40 mg/d; adjust dose in elderly and hepatic insufficiency;
renal insufficiency Caution: [C, +/–] History of mania; history of seizures and patients at risk
for suicide Contra: Use with MAOI or within 14 d of MAOI administration Supplied: Tabs
10, 20, 40 mg; soln 10 mg/5mL SE: Somnolence, insomnia, anxiety, xerostomia, diaphore-
sis, sexual dysfunction Notes: May cause hyponatremia/SIADH
Cladribine (Leustatin) Uses: Hairy cell leukemia (HCL), CLL, non-Hodgkin’s lym-
phoma, progressive multiple sclerosis Action: Induces DNA strand breakage; interferes
with DNA repair/synthesis; purine nucleoside analogue Dose: Refer to specific protocols
Caution: [D, ?/–] observe for signs of neutropenia and infection Supplied: Inj 1 mg/mL
SE: Myelosuppression; T-lymphocyte suppression may be prolonged (26–34 wk); fever in
522 VII: THERAPEUTICS
46% (possibly tumor lysis); infections (especially lung and IV sites); rash (50%), HA; fatigue
Notes: Consider prophylactic allopurinol;monitor CBC
Clarithromycin (Biaxin, Biaxin XL) Uses: Upper and lower respiratory tract in-
fections, skin and skin structure infections, H pylori infections, infections caused by
non-tuberculosis (atypical) Mycobacterium, prevention of MAC infections in HIV-infected
persons Action: Macrolide antibiotic; inhibits protein synthesis Spectrum: Effective against
susceptible strains of H influenzae, M catarrhalis, S pneumoniae, Mycoplasma pneumoniae, H
pylori Dose: 250–500 mg PO bid or 1000 mg (2 × 500 mg ER tab)/d Mycobacterium:
500–1000 mg PO bid; ↓ in renal/hepatic impairment Caution: [C, ?] Antibiotic-associated col-
itis; rare QT prolongation and ventricular arrhythmias, including torsades de pointes Sup-
plied: Tabs 250, 500 mg; susp 125, 250 mg/ 5 mL; 500 mg ER tab SE: Prolongs QT interval,
multiple drug interactions; causes metallic taste, diarrhea, nausea, abdominal pain, HA, rash
Notes: Increases theophylline and carbamazepine levels; do not refrigerate oral suspension
Clemastine Fumarate (Tavist; Tavist-1) [OTC] Uses: Allergic rhinitis and
symptoms of urticaria Action: Antihistamine Dose: 1.34 mg bid–2.68 mg tid; max 8.04
mg/d Caution: [C, M] bladder neck obstruction, asthma, symptomatic prostate hypertrophy
Contra: Narrow-angle glaucoma Supplied: Tabs 1.34, 2.68 mg; syrup 0.67 mg/5 mL SE:
Drowsiness; dyscoordination; epigastric distress Notes: Avoid alcohol
Clindamycin (Cleocin, Cleocin-T) Uses: For treatment of susceptible aerobic
and anaerobic bacteria; topical for severe acne and vaginal infections Action: Bacte-
riostatic; interferes with protein synthesis Spectrum: Susceptible strains of streptococci,
pneumococci, staphylococci, and gram(+) and gram(–) anaerobes; no activity against gram(–)
aerobes and bacterial vaginosis Dose: Oral: 150–450 mg PO qid Intravenous: 300–600 mg
IV q6h or 900 mg IV q8h Vaginal: 1 applicatorful qhs for 7 d Topical: Apply 1% gel, lotion, or
soln bid; adjust dose in hepatic impairment Caution: [B, +] Can cause fatal colitis Contra:
Previous pseudomembranous colitis Supplied: Caps 75, 150, 300 mg; susp 75 mg/5 mL; inj
300 mg/2 mL; vaginal cream 2% SE: Diarrhea may be pseudomembranous colitis caused
by C difficile, rash, ↑ LFTs Notes: Discontinue drug if significant diarrhea
Clofazimine (Lamprene) Uses: Leprosy and combination therapy for MAC in
AIDS Action: Bactericidal; inhibits DNA synthesis Spectrum: Effective against multibacil-
lary dapsone-sensitive leprosy; erythema nodosum leprosum; Mycobacterium avium-intracel-
lulare Dose: 100–300 mg PO daily Caution: [C, +/–] Use with caution in patients with GI
problems; dosages > 100 mg/d should be used for as short a duration as possible Sup-
plied: Caps 50, 100 mg SE: Pink to brownish-black discoloration of the skin and conjunc-
tiva, dry skin, GI intolerance Notes: Orphan drug for the treatment of dapsone-resistant
leprosy; take with meals; monitor for GI complaints
Clonazepam (Klonopin) [C-IV] Uses: Lennox-Gastaut syndrome, akinetic and
myoclonic seizures, absence seizures, panic attacks, restless legs syndrome, neural-
gia, parkinsonian dysarthria, bipolar disorder Action: Benzodiazepine; anticonvulsant
Dose: 1.5 mg/d PO in 3 ÷ doses; ↑ by 0.5–1 mg/d q3d PRN up to 20 mg/d; avoid abrupt with-
drawal Caution: [D, M] Elderly patients, respiratory disease, CNS depression, severe he-
patic impairment, narrow-angle glaucoma Supplied: Tabs 0.5, 1, 2 mg SE: CNS side
effects, including drowsiness, dizziness, ataxia, memory impairment Notes: Can cause ret-
rograde amnesia; CYP3A4 substrate
Clonidine, Oral (Catapres) Uses: HTN; opioid, alcohol, and tobacco withdrawal
Action: Centrally acting α-adrenergic stimulant Dose: 0.1 mg PO bid, adjust daily by 0.1- to
0.2-mg increments (max 2.4 mg/d); adjust dose in renal impairment Caution: [C, +/–] Avoid
with β-blocker; withdrawl slowly Supplied: Tabs 0.1, 0.2, 0.3 mg SE: Rebound HTN with
abrupt cessation of doses > 0.2 mg bid; drowsiness, orthostatic hypotension, dry mouth, con-
stipation, bradycardia, dizziness Notes: More effective for HTN if combined with diuretics
Clonidine, Transdermal (Catapres TTS) Uses: HTN Action: Centrally acting
α-adrenergic stimulant Dose: Apply 1 patch q7d to hairless area (upper arm/torso); titrate to
effect; ↓ in severe renal impairment, do not discontinue abruptly (rebound HTN) Caution:
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 523
[C, +/–] Avoid with β-blocker; withdraw slowly Supplied: TTS-1, TTS-2, TTS-3 (delivers 0.1,
0.2, 0.3 mg, respectively, of clonidine/d for 1 wk) SE: Drowsiness, orthostatic hypotension,
dry mouth, constipation, bradycardia Notes: Doses > 2 TTS-3 usually not associated with ↑
efficacy; steady state in 2–3 days
Clopidogrel (Plavix) Uses: Reduction of atherosclerotic events Action: Inhibits
platelet aggregation Dose: 75 mg/d Caution: [B, ?] Active bleeding; TTP; liver disease
Contra: Active pathologic bleeding; intracranial bleeding Supplied: Tabs 75 mg SE: Pro-
longs bleeding time, GI intolerance, HA, dizziness, rash, thrombocytopenia, leukopenia
Notes: Use with caution in persons at risk of bleeding from trauma and other causes; platelet
aggregation returns to baseline ~ 5 d after discontinuing; platelet transfusion reverses effects
acutely; 300 mg PO × 1 dose can be used to load patients
Clorazepate (Tranxene) [C-IV] Uses: Acute anxiety disorders, acute alcohol
withdrawal symptoms, adjunctive therapy in partial seizures Action: Benzodiazepine;
antianxiety agent Dose: 15–60 mg/d PO single or ÷ doses Elderly and debilitated patients:
Start at 7.5–15 mg/d in ÷ doses Alcohol withdrawal: Day 1: Initially, 30 mg; then 30–60 mg in ÷
doses. Day 2: 45–90 mg in ÷ doses. Day 3: 22.5–45 mg in ÷ doses. Day 4: 15–30 mg in ÷
doses Caution: [D, ?/–] Contra: Narrow-angle glaucoma Supplied: Tabs 3.75, 7.5, 15
mg; Tabs-SD (once-daily) 11.25, 22.5 mg SE: CNS depressant effects (drowsiness, dizzi-
ness, ataxia, memory impairment), hypotension Notes: Monitor patients with renal/hepatic
impairment (drug may accumulate); avoid abrupt withdrawal; may cause dependence
Clotrimazole (Lotrimin, Mycelex) [OTC] Uses: Candidiasis and tinea infec-
tions Action: Antifungal agent; alters cell wall permeability Spectrum: Oropharyngeal can-
didiasis, dermatophytoses, superficial mycoses, and cutaneous vulvovaginal candidiasis
Dose: Oral: One troche dissolved in mouth 5 ×/d for 14 d Vaginal 1% Cream: 1 applicatorful
hs for 7 d; 2% Cream: 1 applicatorful hs for 3 days Tabs: 100 mg vaginally hs for 7 d or 200
mg (2 tabs) vaginally hs for 3 d or 500-mg tabs vaginally hs once Topical: Apply bid for 10–14
d Caution: [B,(C if oral)/?] Do not use for treatment of systemic fungal infection Supplied:
1% cream; soln; lotion; troche 10 mg; vaginal tabs 100, 500 mg; vaginal cream 1%, 2% SE:
Topical: Local irritation; Oral: N/V, elevated LFTs Notes: Oral prophylaxis common in im-
munosuppressed patients
Clotrimazole and Betamethasone (Lotrisone) Uses: Fungal skin infections
Action: Imidazole antifungal and anti-inflammatory Spectrum: Tinea pedis, cruris, and cor-
poris in patients ≥ 17 y Dose: Apply and massage into area bid for 2–4 wk Caution: [C, ?]
Varicella infection Contra: Do not use in children < 12 y Supplied: Cream 15, 45 g, lotion
30 mL SE: Local irritation, rash Notes: Do not use for diaper dermatitis or under occlusive
dressings
Cloxacillin (Cloxapen, Tegopen) [See Table VII–5, p 616]
Clozapine (Clozaril) WARNING: Myocarditis, agranulocytosis, seizures, and orthosta-
tic hypotension have been associated with clozapine Uses: Refractory severe schizo-
phrenia Action: Tricyclic “atypical” antipsychotic Dose: Initially, 25 mg daily–bid; ↑ to
300–450 mg/d over 2 wk. Maintain at the lowest dose possible; do not discontinue abruptly
Caution: [B, +/–] Monitor patients for psycosis and cholinergic rebound Contra: Uncon-
trolled epilepsy; comatose state; WBC count = 3500 cells/mm3 before treatment or < 3000
cells/mm3 during treatment Supplied: Tabs 25, 100 mg SE: Tachycardia, drowsiness,
weight gain, constipation, urinary incontinence, rash, seizures, CNS stimulation, hyper-
glycemia Notes: Benign, self-limiting temperature elevations may occur during the 1st 3 wk
of treatment, weekly CBC mandatory for 1st 6 mo, then every other wk
Cocaine [C-II] Uses: Topical anesthetic for mucous membranes Action: Narcotic
analgesic, local vasoconstrictor Dose: Apply lowest amount of topical soln that provides re-
lief; 1 mg/kg max Caution: [C, ?] Contra: Ophthalmologic anesthesia Supplied: Topical
soln and viscous preparations 4%, 10%; powder, soluble tabs (135 mg) for soln SE: CNS
stimulation, nervousness, loss of taste/smell, chronic rhinitis Notes: Use only on mucous
524 VII: THERAPEUTICS
membranes of the oral, laryngeal, and nasal cavities, do not use on extensive areas of broken
skin
Codeine [C-II] Uses: Mild/moderate pain; symptomatic relief of cough Action:
Narcotic analgesic; depresses cough reflex Dose: Analgesic: 15–60 mg PO or IM qid PRN
Antitussive: 10–20 mg PO q4h PRN; max 120 mg/d; ↓ in renal/hepatic impairment Caution:
[C (D if prolonged use or high doses at term), +] Supplied: Tabs 15, 30, 60 mg; soln 15
mg/5 mL; inj 30, 60 mg/mL SE: Drowsiness, constipation Notes: Usually combined with
APAP for pain or with agents (e.g., terpin hydrate) as an antitussive; 120 mg IM = 10 mg IM
morphine
Colchicine Uses: Acute gouty arthritis attacks and prevention of recurrences;
management of familial Mediterranean fever; primary biliary cirrhosis Action: Inhibits
migration of leukocytes; reduces production of lactic acid by leukocytes Dose: Initially:
0.5–1.2 mg PO, then 0.5–0.6 mg q1–2h until relief or GI side effects develop (max 8 mg/d); do
not repeat for 3 d IV: 1–3 mg, then 0.5 mg q6h until relief (max 4 mg/d); do not repeat for 7 d
Prophylaxis: PO: 0.5–0.6 mg/d or 3–4 d/wk; ↓ dose with renal impairment; caution in elderly
Caution: [D, +] Contra: Serious renal, GI, hepatic, or cardiac disorders; blood dyscrasisas
Supplied: Tabs 0.5, 0.6 mg; inj 1 mg/2 mL SE: N/V/D, abdominal pain, bone marrow sup-
pression, hepatotoxicity Notes: Colchicine 1–2 mg IV within 24–48 h of an acute attack di-
agnostic/therapeutic in monoarticular arthritis
Colesevelam (Welchol) Uses: Reduction of LDL and total cholesterol when used
alone or in combination with an HMG-CoA reductase inhibitor Action: Bile acid se-
questrant Dose: 3 tabs PO bid with meals Caution: [B, ?] Severe GI motility disorders
Contra: Bowel obstruction Supplied: Tabs 625 mg SE: Constipation, dyspepsia, myalgia,
weakness Notes: May decrease absorption of fat-soluble vitamins
Colestipol (Colestid) Uses: Adjunct to ↓ serum cholesterol in primary hypercho-
lesterolemia Action: Binds intestinal bile acids to form an insoluble complex Dose: Gran-
ules: 5–30 g/d ÷ into 2–4 doses; tabs: 2–16 g/d daily–bid Caution: [C, ?] Avoid in patients
with high triglycerides, GI dysfunction Contra: Bowel obstruction Supplied: Tabs 1 g;
granules 5 g SE: Constipation, abdominal pain, bloating, HA Notes: Do not use dry pow-
der; mix with beverages, soups, cereals, etc; may decrease absorption of other medications;
may decrease absorption of fat-soluble vitamins
Cortisone (Cortone) [See Table VII–2, p 613]
Cortisporin Ophthalmic [See Table VII–12, pp 623–25]
Cortisporin Otic Uses: Treatment of superficial bacterial infections of the external
auditory canal by organisms sensitive to neomycin and polymyxin; suspension used in
the treatment of infections of the mastoid and fenestrated cavities Actions: Topical an-
tibiotic combination Dose: 4 drops instilled into external auditory canal 3–4 times daily
Caution: [C, ?] Supplied: Otic solution and suspension Notes: Use suspension in cases
of ruptured eardrum
Cromolyn Sodium (Intal, NasalCrom, Opticrom) Uses: Adjunct to the treat-
ment of asthma; prevent exercise-induced asthma; allergic rhinitis; ophth allergic mani-
festations Action: Antiasthmatic; mast cell stabilizer Dose: Inhal: 20 mg (as powder in
caps) inhaled qid or met-dose inhaler 2 puffs qid Oral: 200 mg qid 15–20 min ac, up to 400 mg
qid Nasal instillation: Spray once in each nostril 2–6×/d Ophth: 1–2 drops in each eye 4–6×/d
Caution: [B, ?] Contra: Acute asthmatic attacks Supplied: Oral conc 100 mg/5 mL; soln
for neb 20 mg/2 mL; met-dose inhaler; nasal soln 40 mg/mL; ophth soln 4% SE: Unpleasant
taste, hoarseness, coughing Notes: No benefit in acute treatment; 2–4 wk for maximal ef-
fect in perennial allergic disorders
Cyanocobalamin [Vitamin B12] Uses: Pernicious anemia and other vitamin B12
deficiency states Action: Dietary supplement of vitamin B12 Dose: 100 mcg IM or SC qd
for 7 d, then 100 mcg IM 2×/wk for 1 mo, then 100 mcg weekly for 1 month, then 1000 mcg IM
monthly Caution: [A (C if dose exceeds RDA), +] Supplied: Tabs 50, 100, 250, 500, 1000
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 525
mcg; inj 100, 1000 mcg/mL; gel 500 mcg/0.1 mL SE: Itching, diarrhea, HA, anxiety Notes:
Oral absorption erratic, altered by many drugs and not recommended; for use with hyperali-
mentation
Cyclobenzaprine (Flexeril) Uses: Relief of muscle spasm Action: Centrally act-
ing skeletal muscle relaxant; reduces tonic somatic motor activity Dose: 10 mg PO 2–4×/d
(2–3 wk max) Caution: [B, ?] Shares the toxic potential of the TCAs; urinary hesitancy or
angle-closure glaucoma Contra: Do not use concomitantly or within 14 days of MAOIs; hy-
perthyroidism; heart failure; arrhythmias Supplied: Tabs 10 mg SE: Sedation, anticholin-
ergic side effects Notes: May inhibit mental alertness or physical coordination
posomes are similar in appearance to WBCs, care must be taken in interpreting CSF exami-
nations in patients
Cytomegalovirus Immmune Globulin [CMV-IG IV] (CytoGam) Uses: At-
tenuation of primary CMV disease associated with transplantation Action: Exogenous
IgG antibodies to CMV Dose: Administered for 16 weeks post-transplantation; see product
information for dosing schedule Caution: [C, ?] Monitor for anaphylactic reactions; use with
caution in renal dysfunction Contra: Hypersensitivity to immunoglobulins; immunoglobulin A
deficiency Supplied: Inj 50–10 mg/mL SE: Flushing, N/V, muscle cramps, wheezing, HA,
fever Notes: IV use only; administer by separate line; do not shake
Dacarbazine (DTIC) Uses: Melanoma, Hodgkin’s disease, sarcoma Action: Alky-
lating agent; antimetabolite activity as a purine precursor; inhibits synthesis of protein, RNA,
and especially DNA Dose: Refer to specific protocols; adjust in renal impairment Caution:
[C, ?] Use with caution in patients with bone marrow suppression; renal/hepatic impairment;
avoid extravasation Supplied: Inj 100, 200, 500 mg SE: Myelosuppression, severe N/V,
hepatotoxicity, flu-like syndrome, hypotension, photosensitivity, alopecia, facial flushing, facial
paresthesias, urticaria, phlebitis at injection site
Daclizumab (Zenapax) Uses: Prevent acute organ rejection Action: IL-2 recep-
tor antagonist Dose: 1 mg/kg IV/dose; 1st dose pretransplantation, then 4 doses 14 d apart
post-transplantation Caution: [C, ?] Supplied: Inj 5 mg/mL SE: Hyperglycemia, edema,
hypertension, hypotension, constipation, HA, dizziness, anxiety, nephrotoxicity, pulmonary
edema, pain Notes: Administer within 4 h of preparation
Dactinomycin (Cosmegen) Uses: Choriocarcinoma, Wilms’ tumor, Kaposi’s
sarcoma, Ewing’s sarcoma, rhabdomyosarcoma, testicular CA Action: DNA intercalat-
ing agent Dose: Refer to specific protocols; ↓ in renal impairment Caution: [C, ?] Con-
tra: Patients with concurrent or recent chickenpox or herpes zoster Supplied: Inj 0.5 mg
SE: Myelosuppression, immunosuppression, severe N/V, alopecia, acne, hyperpigmentation,
radiation recall phenomenon, tissue damage with extravasation, hepatotoxicity
Dalteparin (Fragmin) Uses: Unstable angina, non–Q-wave MI, prevention of is-
chemic complications due to clot formation in patients on concurrent ASA, prevention
and treatment of DVT after surgery Action: LMW heparin Dose: Angina/MI: 120 IU/kg
(max 10,000 IU) SC q12h with ASA DVT prophylaxis: 2500–5000 IU SC 1–2 h preop, then qd
for 5–10 d Systemic anticoagulation: 200 IU/kg/d SC or 100 IU/kg bid SC; use with caution in
renal/hepatic impairment Caution: [B, ?] Active hemorrhage, cerebrovascular disease, cere-
bral aneurysm, severe uncontrolled HTN Contra: HIT; hypersensitivity to pork products; not
for IM or IV use Supplied: Inj 2500 IU (16 mg/0.2 mL), 5000 IU (32 mg/0.2 mL), 10,000 IU
(64 mg/mL) SE: Bleeding, pain at injection site, thrombocytopenia Notes: Predictable an-
tithrombotic effects eliminate need for laboratory monitoring
Danaparoid (Orgaron) Uses: Prophylaxis of DVT which may lead to PE, in pa-
tients undergoing hip replacement surgery Action: Antithrombotic agent that acts by in-
hibition of factors Xa and IIa Dose: 750 anti-Xa units bid administered by SC injection
beginning 1–4 h preoperatively and starting no sooner than 2 h after surgery; reduce dose
with severe renal impairment Caution: [B, ?/–] Contra: Active major bleeding, hemophilia,
ITP, type II thrombocytopenia with a positive antiplatelet antibody test Supplied: Ampoules
and prefilled syringes 0.6 mL (750 anti-Xa units) SE: Bleeding, fever, injection site pain, in-
creased risk of epidural and spinal hematoma in patients receiving epidural/spinal anesthesia
Notes: aPTT monitoring is not necessary
Dantrolene (Dantrium) Uses: Clinical spasticity due to upper motor neuron dis-
orders, e.g., spinal cord injuries, strokes, CP, MS; treatment of malignant hyperthermia
Action: Skeletal muscle relaxant Dose: Spasticity: Initially, 25 mg PO qd; ↑ to effect by 25
mg to a max dose of 100 mg PO qid PRN Malignant hyperthermia: Treatment: Continuous
rapid IV push beginning at 1 mg/kg until symptoms subside or 10 mg/kg is reached Postcrisis
follow-up: 4–8 mg/kg/d in 3–4 ÷ doses for 1–3 d to prevent recurrence Caution: [C, ?] Im-
paired cardiac function or pulmonary function; potential for hepatotoxicity Contra: Active he-
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 527
patic disease; should not be used where spasticity is used to maintain posture or balance
Supplied: Caps 25, 50, 100 mg; powder for inj 20 mg/vial SE: Elevated LFTs, drowsiness,
dizziness, rash, muscle weakness, pleural effusion with pericarditis, diarrhea, blurred vision,
hepatitis Notes: Monitor transaminases
Dapsone (Avlosulfon) Uses: Treatment and prevention of PCP; toxoplasmosis
prophylaxis; leprosy Action: Unknown; bactericidal Dose: Prophylaxis of PCP 50–100
mg/d PO; treatment of PCP 100 mg/d PO with TMP 15–20 mg/kg/d for 21 d Caution: [C, +]
Caution in G6PD deficiency; severe anemia Supplied: Tabs 25, 100 mg SE: Hemolysis,
methemoglobinemia, agranulocytosis, rash, cholestatic jaundice Notes: Absorption ↑ by an
acidic environment; with leprosy, combine with rifampin and other agents
Darbepoetin Alfa (Aranesp) Uses: Anemia associated with CRF Action: Stim-
ulates erythropoiesis, recombinant variant of erythropoietin Dose: 0.45 mcg/kg single IV or
SC qwk; titrate dose, do not exceed target Hgb of 12 g/dL; see insert for converting from
Epogen Caution: [C, ?] May increase risk of cardiovascular and/or neurologic SE in renal
failure; HTN; history of seizures Contra: Uncontrolled hypertension, allergy to components
Supplied: 25, 40, 60, 100 mcg/mL, in polysorbate or albumin excipient SE: May ↑ risk of
cardiac events, chest pain, hypo-/hypertension, N/V/D, myalgia, arthralgia, dizziness, edema,
fatigue, fever, ↑ risk infection Notes: Longer half-life than Epogen; follow weekly CBC until
stable
Daunorubicin (Daunomycin, Cerubidine) WARNING: Cardiac function should
be monitored because of potential risk for cardiac toxicity and CHF Uses: Acute leukemias
Action: DNA intercalating agent; inhibits topoisomerase II; generates oxygen free radicals
Dose: Refer to specific protocols; adjust dose in renal/hepatic impairment Caution: [D, ?]
Supplied: Inj 20 mg SE: Myelosuppression, mucositis, N/V, alopecia, radiation recall phe-
nomenon, hepatotoxicity (hyperbilirubinemia), tissue necrosis on extravascular extravasation,
and cardiotoxicity (1–2% CHF risk with 550 mg/m2 cumulative dose) Notes: Prevent car-
diotoxicity with dexrazoxane
Delavirdine (Rescriptor) Uses: HIV infection Action: Nonnucleoside reverse
transcriptase inhibitor Dose: 400 mg PO tid Caution: [C, ?] CDC recommends HIV-in-
fected mothers not breastfeed because of risk of HIV transmission to infant; use caution in
renal/hepatic impairment Contra: Concomitant use with drugs highly dependent on CYP 3A
for clearance (i.e., alprazolam, ergot alkaloids, midazolam, pimozide, triazolam) Supplied:
Tabs 100 mg SE: HA, fatigue, rash, ↑ serum transaminases, N/V/D Notes: Avoid
antacids; inhibits cytochrome P-450 enzymes; numerous drug interactions; monitor LFTs
Demecarium (Humorsol) [See Table VII–12, pp 623–25]
Demeclocycline (Declomycin) Uses: SIADH Action: Antibiotic, antagonizes ac-
tion of ADH on renal tubules Dose: 300–600 mg PO q12h on an empty stomach; ↓ in renal
failure; avoid antacids Caution: [D, +] Avoid use in hepatic/renal dysfunction Contra: Hy-
persensitivity to tetracyclines Supplied: Tabs 150, 300 mg SE: Diarrhea, abdominal
cramps, photosensitivity, diabetes insipidus Notes: Avoid prolonged exposue to sunlight
Desipramine (Norpramin) WARNING: Pediatric: Antidepressants may increase risk
of suicidality; consider risks and benefits of use. Patients should be closely monitored for clini-
cal worsening, suicidality, or unusual changes in behavior Uses: Endogenous depression,
chronic pain, and peripheral neuropathy Action: TCA; increases synaptic concentration
of serotonin or norepinephrine in CNS Dose: 25–200 mg/d single or ÷ doses; usually a sin-
gle hs dose (max 300 mg/d) Caution: [C, ?/–] Caution in cardiovascular disease, seizure
disorder, hypothyroidism Contra: Use of MAO inhibitors within 14 days; pt in recovery
phase of MI Supplied: Tabs 10, 25, 50, 75, 100, 150 mg; caps 25, 50 mg SE: Anticholin-
ergic (blurred vision, urinary retention, dry mouth); orthostatic hypotension; prolongs QT inter-
val, arrythmias Notes: Numerous drug interactions
Desloratadine (Clarinex) Uses: Symptoms of seasonal and perennial allergic
rhinitis; chronic idiopathic urticaria Action: The active metabolite of loratadine, H1-antihis-
tamine, blocks inflammatory mediators Dose: 5 mg PO qd; hepatic/renal impairment: 5 mg
528 VII: THERAPEUTICS
PO qod Caution: [C, ?/–] RediTabs contain phenylalanine Supplied: Tabs and Reditabs 5
mg SE: Hypersensitivity reactions, anaphylaxis, somnolence, HA, dizziness, fatigue, pharyn-
gitis, dry mouth, nausea, dyspepsia, myalgia Notes: May be taken with or without food
Desmopressin (DDAVP, Stimate) Uses: Diabetes insipidus (intranasal and
parenteral); bleeding due to uremia, hemophilia A, and type I von Willebrand’s disease
(parenteral), nocturnal enuresis Action: Synthetic analogue of vasopressin, a naturally
occurring human ADH; ↑ factor VIII Dose: DI: Intranasal: 0.1–0.4 mL (10–40 mcg)/d in 1–4
÷ doses Parenteral: 0.5–1 mL (2–4 mcg)/d in 2 ÷ doses. If converting from nasal to parenteral,
use 1⁄10 nasal dose Oral: 0.05 mg bid; ↑ to max of 1.2 mg Hemophilia A and von Willebrand’s
disease (type I): 0.3 mcg/kg in 50 mL NS, infuse over 15–30 min Caution: [B, M] Avoid
overhydration Contra: Hemophilia B; severe classic von Willebrand’s disease; patients with
factor VIII antibodies Supplied: Tabs 0.1, 0.2 mg; inj 4 mcg/mL; nasal soln 0.1, 1.5 mg/mL
SE: Facial flushing, HA, dizziness, vulval pain, nasal congestion, pain at injection site, hy-
ponatremia, water intoxication Notes: In very young and old patients, ↓ fluid intake to avoid
water intoxication and hyponatremia
Dexamethasone (Decadron) [See Table VII–2, p 613]
Dexamethasone, Nasal (Dexacort Phosphate Turbinaire) Uses: Chronic
nasal inflammation or allergic rhinitis Action: Antiinflammatory corticosteroid Dose: 2
sprays/nostril bid–tid, max 12 sprays/d Caution: [C, ?] Supplied: Aerosol, 84 mcg/activa-
tion SE: Local irritation
Dexamethasone, Ophthalmic (AK-Dex Ophthalmic, Decadron Oph-
thalmic) [See Table VII–12, pp 623–25]
Dexpanthenol (Ilopan-Choline Oral, Ilopan) Uses: Minimize paralytic ileus,
treatment of postop distention Action: Cholinergic agent Dose: Relief of gas: 2–3 tabs
PO tid Prevent postop ileus: 250–500 mg IM stat, repeat in 2 h, then q6h PRN Ileus: 500 mg
IM stat, repeat in 2 h, followed by doses q6h, if needed Caution: [C, ?] Contra: Hemo-
philia, mechanical obstruction Supplied: Inj; tabs 50 mg; cream SE: GI cramps
Dexrazoxane (Zinecard) Uses: Prevent anthracycline-induced cardiomyopathy
Action: Chelates heavy metals; binds intracellular iron and prevents anthracycline-induced
free radicals Dose: 10:1 ratio dexrazoxane:doxorubicin 30 min prior to each dose Cau-
tion: [C, ?] Supplied: Inj 10 mg/mL SE: Myelosuppression (especially leukopenia), fever,
infection, stomatitis, alopecia, N/V/D; mild ↑ transaminase, pain at injection site
Dextran 40 (Rheomacrodex) Uses: Shock, prophylaxis of DVT and thromboem-
bolism, adjunct in peripheral vascular surgery Action: Expands plasma volume; ↓ blood
viscosity Dose: Shock: 10 mL/kg infused rapidly; 20 mL/kg max in the 1st 24 h; beyond 24 h
10 mL/kg max; discontinue after 5 d Prophylaxis of DVT and thromboembolism: 10 mL/kg IV
day of surgery, then 500 mL/d IV for 2–3 d, then 500 mL IV q2–3d based on risk for up to 2 wk
Caution: [C, ?] Infusion reactions; patients receiving corticosteroids Contra: Marked hemo-
static defects of all types; marked cardiac decompensation; renal disease with severe
oliguria/anuria Supplied: 10% dextran 40 in 0.9% NaCl or 5% dextrose SE: Hypersensi-
tivity/anaphylactoid reaction (observe patient closely during 1st minute of infusion), arthralgia,
cutaneous reactions, hypotension, fever; monitor renal function and electrolytes Notes: Ob-
serve patients for anaphylactic reactions; patients should be well hydrated
Dextromethorphan (Mediquell, Benylin DM, PediaCare 1, Others) [OTC]
Uses: Controlling nonproductive cough Action: Depresses the cough center in the
medulla Dose: 10–30 mg PO q4–8h PRN (max 120 mg/24 h) Caution: [C,?/–] Should not
be used for persistent or chronic cough Supplied: Caps 30 mg; lozenges 2.5, 5, 7.5, 15 mg;
syrup 15 mg/15 mL, 10 mg/5 mL; liq 10 mg/15 mL, 3.5, 7.5, 15 mg/5 mL; sustained-action liq
30 mg/5 mL SE: GI disturbances Notes: May be found in combination products with
guaifenesin
Dezocine (Dalgan) Uses: Moderate to severe pain Action: Narcotic agonist-an-
tagonist Dose: 5–20 mg IM or 2.5–10 mg IV q2–4h PRN; ↓ in renal impairment Caution:
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 529
[C, ?] Contra: Not recommended for patients < 18 y Supplied: Inj 5, 10, 15 mg/mL SE:
Sedation, dizziness, vertigo, N/V, injection site reaction Notes: Withdrawal possible in pa-
tients dependent on narcotics
Diazepam (Valium) [C-IV] Uses: Anxiety, alcohol withdrawal, muscle spasm,
status epilepticus, panic disorders, amnesia, preoperative sedation Action: Benzodi-
azepine Dose: Status epilepticus: 5–10 mg q10–20 min to 30 mg max in 8-h period Anxiety,
muscle spasm: 2–10 mg PO bid–qid or IM/IV q3–4h PRN Preop: 5–10 mg PO or IM 20–30
min or IV just before procedure Alcohol withdrawal: Initial 2–5 mg IV, then 5–10 mg q5–10
min, 100 mg in 1 h max. May require up to 1000 mg in 24-h period for severe withdrawal.
Titrate to agitation; avoid excessive sedation; may lead to aspiration or respiratory arrest; ↓ in
hepatic impairment; avoid abrupt withdrawal Caution: [D, ?/–] Supplied: Tabs 2, 5, 10
mg; soln 1, 5 mg/mL; inj 5 mg/mL; rectal gel 5 mg/mL SE: Sedation, amnesia, bradycardia,
hypotension, rash, decreased respiratory rate Notes: Do not exceed 5 mg/min IV in adults
because respiratory arrest possible; IM absorption erratic
Diazoxide (Hyperstat, Proglycem) Uses: Hypoglycemia due to hyperinsulin-
ism (Proglycem); hypertensive crisis (Hyperstat) Action: Inhibits pancreatic insulin re-
lease; antihypertensive Dose: Hypertensive crisis: IV: 1–3 mg/kg (maximum: 150 mg in a
single injection); repeat dose in 5–15 min until BP controlled; repeat every 4–24 h; monitor BP
closely Hypoglycemia: 3–8 mg/kg/24 h PO ÷ q8–12h Caution: [C, ?] ↓ effect w/ phenytoin;
↑ effect w/ diuretics, warfarin Contra: Hypersensitivity to thiazides or other sulfonamide-con-
taining products; HTN associated with aortic coarctation, arteriovenous shunt, or pheochromo-
cytoma Supplied: Inj 15 mg/mL; caps 50 mg; oral susp 50 mg/mL SE: Hyperglycemia,
hypotension, dizziness, sodium and water retention, N/V, weakness Notes: Can give false-
negative insulin response to glucagons; treat extravasation w/ warm compress
Dibucaine (Nupercainal) Uses: Hemorrhoids and minor skin conditions Ac-
tion: Topical anesthetic Dose: Insert PR with applicator bid and after each bowel move-
ment; apply sparingly to skin Caution: [C, ?] Supplied: 1% oint with rectal applicator;
0.5% cream SE: Local irritation, rash
Diclofenac (Cataflam, Voltaren) [See Table VII–11, pp 621–22, and Table
VII–12, pp 623–25]
Dicloxacillin (Dynapen, Dycill) [See Table VII–5, p 616]
Dicyclomine (Bentyl) Uses: Functional irritable bowel syndromes Action:
Smooth muscle relaxant Dose: 20 mg PO qid; ↑ to a max dose of 160 mg/d or 20 mg IM
q6h Caution: [B, –] Contra: Narrow-angle glaucoma, myasthenia gravis, severe ulcera-
tive colitis, obstructive uropathy, nursing mothers Supplied: Caps 10, 20 mg; tabs 20 mg;
syrup 10 mg/5 mL; inj 10 mg/mL SE: Anticholinergic side effects may limit dose Notes:
Take 30–60 min before meal; avoid alcohol
Didanosine [ddI] (Videx) WARNING: Hypersensitivity manifested as fever, rash, fa-
tigue, GI/respiratory symptoms reported; stop drug immediately and do not rechallenge; lactic
acidosis and hepatomegaly/steatosis reported Uses: HIV infection in zidovudine-intoler-
ant patients Action: Nucleoside antiretroviral agent Dose: > 60 kg: 400 mg/d PO or 200
mg PO bid < 60 kg: 250 mg/d PO or 125 mg PO bid; adults should take 2 tabs/administration;
adjust dose in renal impairment, thoroughly chew tablets, do not mix with fruit juice or other
acidic beverages; reconstitute powder with water Caution: [B, –] CDC recommends HIV-in-
fected mothers not breastfeed because of risk of transmission of HIV to the infant Supplied:
Chew tabs 25, 50, 100, 150, 200 mg; powder packets 100, 167, 250, 375 mg; powder for soln
2, 4 g SE: Pancreatitis, peripheral neuropathy, diarrhea, HA Notes: Do not take with
meals
Diflunisal (Dolobid) [See Table VII–11, pp 621–22]
Digoxin (Lanoxin, Lanoxicaps) Uses: CHF, AF and flutter, and paroxysmal
atrial tachycardia Action: Positive inotrope; ↑ AV node refractory period Dose: PO digi-
talization: 0.50–0.75 mg PO, then 0.25 mg PO q6–8h to total 1–1.5 mg or until therapeutic ef-
530 VII: THERAPEUTICS
fect at lower dose IV digitalization: 0.25–0.5 mg IV, then 0.25 mg q4–6h to total ~ 1 mg Daily
maintenance: 0.125–0.5 mg/d PO or IV (average daily dose 0.125–0.25 mg); ↓ in renal impair-
ment, follow serum levels Caution: [C, +] Contra: AV block; idiopathic hypertrophic
subaortic stenosis; constrictive pericarditis Supplied: Caps 0.05, 0.1, 0.2 mg; tabs 0.125,
0.25, 0.5 mg; elixir 0.05 mg/mL; inj 0.1, 0.25 mg/mL SE: Can cause heart block; ↓ K+ poten-
tiates toxicity; N/V, HA, fatigue, visual disturbances (yellow-green halos around lights), cardiac
arrhythmias Notes: Multiple drug interactions; IM inj painful, has erratic absorption, and
should not be used; therapeutic levels 0.5–2 ng/mL (See Table VII–17, p 630)
Digoxin Immune Fab (Digibind) Uses: Life-threatening digoxin intoxication
Action: Antigen-binding fragments bind and inactivate digoxin Dose: Based on serum level
and patient’s weight; see charts provided with the drug Caution: [C, ?] Contra: Hypersen-
sitivity to sheep products Supplied: Inj 38 mg/vial SE: Worsening of cardiac output or
CHF, hypokalemia, facial swelling, and redness Notes: Each vial binds ~ 0.6 mg of digoxin;
in renal failure may require redosing in several days because of breakdown of the immune
complex
Diltiazem (Cardizem, Cardizem CD, Cardizem SR, Cartia XT, Dilacor XR,
Diltia XT, Tiamate, Tiazac) Uses: Angina, prevention of reinfarction, HTN, AF or
flutter, and paroxysmal atrial tachycardia Action: Ca channel blocker Dose: Oral: Ini-
tially, 30 mg PO qid; ↑ to 180–360 mg/d in 3–4 ÷ doses PRN SR: 60–120 mg PO bid; ↑ to 360
mg/d max CD or XR: 120–360 mg/d (max 480 mg/d) IV: 0.25 mg/kg IV bolus over 2 min; may
repeat in 15 min at 0.35 mg/kg; may begin inf of 5–15 mg/h Caution: [C, +] Contra: Sick
sinus syndrome, AV block, hypotension, acute MI, pulmonary congestion Supplied:
Cardizem CD: Caps 120, 180, 240, 300, 360 mg; Cardizem SR: caps 60, 90, 120 mg;
Cardizem: Tabs 30, 60, 90, 120mg; Cartia XT: Caps 120, 180, 240, 300 mg; Dilacor XR: Caps
180, 240 mg; Diltia XT: Caps 120, 180, 240 mg; Tiazac: Caps 120, 180, 240, 300, 360, 420
mg; Tiamate (ext rel): Tabs 120, 180, 240 mg; inj: 5 mg/mL SE: Gingival hyperplasia, brady-
cardia, AV block, ECG abnormalities, peripheral edema, dizziness, HA Notes: Cardizem
CD, Dilacor XR, and Tiazac not interchangeable
Dimenhydrinate (Dramamine, others) Uses: Prevention and treatment of nau-
sea, vomiting, dizziness, or vertigo of motion sickness Action: Antiemetic Dose:
50–100 mg PO q4–6h, max 400 mg/d; 50 mg IM/IV PRN Caution: [B, ?] Supplied: Tabs
50 mg; chew tabs 50 mg; liq 12.5 mg/4 mL, 12.5 mg/5 mL, 15.62 mg/5 mL; inj 50 mg/mL SE:
Anticholinergic side effects
Dimethyl Sulfoxide [DMSO] (Rimso 50) Uses: Interstitial cystitis Action:
Unknown Dose: Intravesical, 50 mL, retain for 15 min; repeat q2wk until relief Caution:
[C, ?] Supplied: 50% soln in 50 mL SE: Cystitis, eosinophilia, GI, and taste disturbance
Diphenhydramine (Benadryl) Uses: Treat and prevent allergic reactions, mo-
tion sickness, potentiate narcotics, sedation, cough suppression, and treatment of ex-
trapyramidal reactions Action: Antihistamine, antiemetic Dose: 25–50 mg PO, IV, or IM
bid–tid; ↑ dosing interval in moderate/severe renal failure Caution: [B, –] Contra: Do not
use in acute asthma attack Supplied: Tabs and caps 25, 50 mg; chew tabs 12.5 mg; elixir
12.5 mg/5 mL; syrup 12.5 mg/5 mL; liq 6.25 mg/5 mL, 12.5 mg/5 mL; inj 50 mg/mL SE: Anti-
cholinergic side effects (dry mouth, urinary retention, sedation)
Diphenoxylate + Atropine (Lomotil) [C-V] Uses: Diarrhea Action: Constipat-
ing meperidine congener, reduces GI motility Dose: Initially, 5 mg PO tid–qid until under
control, then 2.5–5.0 mg PO bid Caution: [C, +] Contra: Obstructive jaundice, diarrhea
due to bacterial infection Supplied: Tabs 2.5 mg of diphenoxylate/0.025 mg of atropine; liq
2.5 mg diphenoxylate/0.025 mg atropine/5 mL SE: Drowsiness, dizziness, dry mouth,
blurred vision, urinary retention, constipation
Dipivefrin (Propine) [See Table VII–12, pp 623–25]
Dipyridamole (Persantine) Uses: Prevent postoperative thromboembolic disor-
ders, often in combination with ASA or warfarin (e.g., CABG, vascular graft; with war-
farin after artificial heart valve; chronic angina; with ASA to prevent coronary artery
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 531
thrombosis); dipyridamole IV used in place of exercise stress test for CAD Action: An-
tiplatelet activity; coronary vasodilator Dose: 75–100 mg PO tid–qid; stress test 0.14
mg/kg/min (max 60 mg over 4 min) Caution: [B, ?/–] Caution with other drugs that affect co-
agulation Supplied: Tabs 25, 50, 75 mg; inj 5 mg/mL SE: HA, hypotension, nausea, ab-
dominal distress, flushing rash, dyspnea Notes: IV can worsen angina
Dipyridamole and Aspirin (Aggrenox) Uses: ↓ risk of stroke; reduce rate of
reinfarction after MI; prevent occlusion after CABG; Action: ↓ platelet aggregation (both
agents) Dose: 1 cap PO bid Caution: [C, ?] Contra: Contra in ulcers, bleeding diathesis
Supplied: Caps Dipyridamole extended-release 200 mg/aspirin 25 mg SE: ASA compo-
nent: allergic reactions, skin reactions, ulcers/GI bleed, bronchospasm; dipyridamole compo-
nent: dizziness, HA, rash Notes: Swallow capsule whole
Dirithromycin (Dynabac) Uses: Bronchitis, community-acquired pneumonia,
and skin and skin structure infections Action: Macrolide antibiotic Spectrum: M ca-
tarrhalis, S pneumoniae, Legionella, H influenzae, S pyogenes, S aureus Dose: 500 mg/d PO;
take with food Caution: [C, M] Supplied: Tabs 250 mg SE: Abdominal discomfort, HA,
rash, hyperkalemia Notes: Swallow whole
Disopyramide (Norpace) Uses: Suppression and prevention of ventricular ar-
rhythmias Action: Class 1A antiarrhythmic Dose: 400–800 mg/d ÷ q6h for regular-re-
lease and q12h for SR; ↓ in renal/hepatic impairment Caution: [C, +] Contra: AV block,
cardiogenic shock Supplied: Caps 100, 150 mg; SR caps 100, 150 mg SE: Anticholiner-
gic side effects; negative inotropic properties may induce CHF
Disulfiram (Antabuse) Uses: Alcohol consumption deterrent Action: Blocks ox-
idation of alcohol to produce unpleasant reaction when alcohol is consumed Dose: 500 mg
PO daily for 1–2 weeks, then 250 mg PO daily Caution: [C, ?] Contra: alcohol use,
metronidazole use, severe CAD Supplied: Tabs 250, 500 mg Notes: Instruct patients to
avoid hidden forms of alcohol (cough syrup, mouthwashes, sauces, etc); CBC and LFTs
should be checked periodically
Dobutamine (Dobutrex) Uses: Short-term use in cardiac decompensation sec-
ondary to depressed contractility Action: Positive inotropic agent Dose: Cont IV inf of
2.5–15 mcg/kg/min; rarely, 40 mcg/kg/min may be required; titrate according to response
Caution: [C, ?] Supplied: Inj 250 mg/20 mL SE: Chest pain, hypertension, dyspnea
Notes: Monitor PWP and cardiac output if possible, check ECG for ↑ heart rate, ectopic activ-
ity, follow BP
Docetaxel (Taxotere) Uses: Breast (anthracycline resistant), lung, ovarian, and
prostate CAs Action: Antimitotic agent; promotes microtubular aggregation; semisynthetic
taxoid Dose: Refer to specific protocols; Start dexamethasone 8 mg bid prior to docetaxel
and continue for 3–4 d; ↓ dose with ↑ bilirubin levels Caution: [D, –] Supplied: Inj 20, 40,
80 mg/mL SE: Myelosuppression, neuropathy, N/V, alopecia, fluid retention syndrome with
cumulative doses of 300–400 mg/m2 without steroid prep and post-treatment and 600–800
mg/m2 with steroid prep; hypersensitivity reactions possible, but rare with steroid prep
Docusate Calcium (Surfak, Others) (See Docusate Sodium)
Docusate Potassium (Dialose) (See Docusate Sodium)
Docusate Sodium (DOSS, Colace, Others) Uses: Constipation; adjunct to
painful anorectal conditions (hemorrhoids) Action: Stool softener Dose: 50–500 mg
PO ÷ daily–qid Caution: [C, ?] Contra: Concomitant use of mineral oil; intestinal obstruc-
tion, acute abdominal pain, N/V Supplied: Ca: Caps 50, 240 mg. K: Caps 100, 240 mg. Na:
Caps 50, 100, 250 mg; syrup 50, 60 mg/15 mL; liq 150 mg/15 mL; soln 50 mg/mL SE: No
significant side effects, rare abdominal cramping, diarrhea; no laxative action
Dofetilide (Tikosyn) WARNING: To minimize the risk of induced arrhythmia, patients
initiated or reinitiated on tikosyn should be placed for a minimum of 3 d in a facility that can
provide calculations of creatinine clearance, continuous ECG monitoring, and cardiac resusci-
tation Uses: Maintain NSR in AF/A flutter after conversion Action: Class III antiar-
532 VII: THERAPEUTICS
rhythmic Dose: The dosage is individualized based on calculated creatinine clearance and
QTc.
• Clcr > 60 mL/min: 500 mcg PO bid
• Clcr = 40–60 mL/min: 250 mcg PO bid
• Clcr = 20–<40 mL/min: 125 mcg PO bid
Determine QTc 2–3 h after first dose. If increase in QTc is = 15%, continue current dose. If
QTc increase is > 15% or > 500 msec (550 msec in patients with ventricular conduction abnor-
malities), adjust dose as follows:
Starting Dose Adjusted Dose
500 mcg PO bid 250 mcg PO bid
250 mcg PO bid 125 mcg PO bid
125 mcg PO bid 125 mcg PO qd
Continue to check QTc 2–3 h after each subsequent dose for a minimum of 3 d. If at any time
QTc increases to > 500 msec (550 msec in patients with ventricular conduction abnormalities),
discontinue dofetilide Caution: [C, –] Contra: Baseline QTc is > 440 msec (500 msec in
patients with ventricular conduction abnormalities) or Clcr < 20 mL/min; concomitant use of
verapamil, cimetidine, trimethoprim, or ketoconazole Supplied: Caps 125, 250, 500 mcg
SE: Serious ventricular arrhythmias, HA, chest pain, dizziness Notes: Avoid use with other
drugs that prolong the QT interval. Class I or III antiarrhythmic agents should be withheld for at
least 3 half-lives before dosing with dofetilide. Amiodarone level should be < 0.3 mg/L prior to
dosing with dofetilide
Dolasetron (Anzemet) Uses: Prevent chemotherapy-associated N/V Action: 5-
HT3-receptor antagonist Dose: IV: 1.8 mg/kg IV as single dose 30 min prior to chemother-
apy. Oral: 100 mg PO as a single dose 1 h prior to chemotherapy. Caution: [B, ?]
Supplied: Tabs 50, 100 mg; inj 20 mg/mL SE: Prolongs QT interval, HTN, HA, abdominal
pain, urinary retention, transient ↑ LFTs
Dopamine (Intropin) Uses: Short-term use in cardiac decompensation secondary
to decreased contractility; increases organ perfusion (at low dose) Action: Positive in-
otropic agent with dose-related response; 2–10 mcg/kg/min β-effects (increases cardiac out-
put and renal perfusion); 10–20 mcg/kg/min β-effects (peripheral vasoconstriction, pressor); >
20 mcg/kg/min peripheral and renal vasoconstriction Dose: 5 mcg/kg/min by cont inf, ↑ in-
crements of 5 mcg/kg/min to 50 mcg/kg/min max based on effect Caution: [C, ?] Sup-
plied: Inj 40, 80, 160 mg/mL SE: Tachycardia, vasoconstriction, hypotension, HA, N/V,
dyspnea Notes: Dosage > 10 mcg/kg/min may ↓ renal perfusion; monitor urinary output;
monitor ECG for ↑ in heart rate, BP, and ectopic activity; monitor PCWP and cardiac output if
possible
Dornase Alfa (Pulmozyme) Uses: ↓ Frequency of respiratory infections in pa-
tients with CF Action: Enzyme that selectively cleaves DNA Dose: Inhal 2.5 mg/d
Caution: [B, ?] Supplied: Soln for inhalation 1 mg/mL SE: Pharyngitis, voice alteration,
chest pain, rash Notes: Use with recommended nebulizer
Dorzolamide (Trusopt) [See Table VII–12, pp 623–25]
Dorzolamide and Timolol (Cosopt) [See Table VII–12, pp 623–25]
Doxazosin (Cardura) Uses: HTN and symptomatic BPH Action: α1-Adrenergic
blocker; relaxes bladder neck smooth muscle Dose: HTN: Initially 1 mg/d PO; may increase
to 16 mg/d PO BPH: Initially 1 mg/d PO, may increase to 8 mg/d PO Caution: [B, ?] Sup-
plied: Tabs 1, 2, 4, 8 mg SE: Dizziness, HA, drowsiness, sexual dysfunction, doses > 4 mg
↑ likelihood of postural hypotension Notes: Take first dose at bedtime
Doxepin (Sinequan, Adapin) WARNING: Pediatric: Antidepressants may increase
risk of suicidality; consider risks and benefits of use. Patients should be closely monitored for
clinical worsening, suicidality, or unusual changes in behavior Uses: Depression, anxiety,
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 533
chronic pain Action: TCA; increases the synaptic CNS concentrations of serotonin or nor-
epinephrine Dose: 25–150 mg/d PO, usually hs but can be in ÷ doses; ↓ dose in hepatic im-
pairment Caution: [C, ?/–] Supplied: Caps 10, 25, 50, 75, 100, 150 mg; oral conc 10
mg/mL SE: Anticholinergic side effects, hypotension, tachycardia, drowsiness, photosensi-
tivity
Doxepin, Topical (Zonalon) Uses: Short-term treatment of pruritus (atopic der-
matitis or lichen simplex chronicus) Action: Antipruritic; H1- and H2-receptor antagonism
Dose: Apply thin coating qid for max 8 d Caution: [C, ?/–] Supplied: 5% cream SE:
Limit application area to avoid systemic toxicity (hypotension, tachycardia, drowsiness, photo-
sensitivity)
Doxorubicin (Adriamycin, Rubex) Uses: Acute leukemias; Hodgkin’s and
non-Hodgkin’s lymphomas; breast CA; soft tissue and osteosarcomas; Ewing’s sar-
coma; Wilms’ tumor; neuroblastoma; bladder, ovarian, gastric, thyroid, and lung CAs
Action: Intercalates DNA; inhibits DNA topoisomerases I and II Dose: Refer to specific pro-
tocols Caution: [D, ?] Contra: Severe CHF, cardiomyopathy, pre-existing myelosuppres-
sion, impaired cardiac function, patients who received previous treatment with complete
cumulative doses of doxorubicin, idarubicin, daunorubicin Supplied: Inj 10, 20, 50, 75, 200
mg SE: Myelosuppression, venous streaking and phlebitis, N/V, diarrhea, mucositis, radia-
tion recall phenomenon, cardiomyopathy rare but dose related; limit of 550 mg/m2 cumulative
dose (400 mg/m2 if prior mediastinal irradiation) Notes: Dexrazoxane may limit cardiac toxi-
city; extravasation leads to tissue damage; discolors urine red/orange
Doxycycline (Vibramycin) Uses: Broad-spectrum antibiotic Action: Tetracy-
cline; interferes with protein synthesis Spectrum: Activity against Rickettsia spp, Chlamydia,
and M pneumoniae Dose: 100 mg PO q12h on 1st day, then 100 mg PO daily–bid or 100
mg IV q12h Supplied: Tabs 50, 100 mg; caps 20, 50, 100 mg; syrup 50 mg/5 mL; susp 25
mg/5 mL; inj 100, 200 mg/vial Caution: [D, +] Contra: Children < 8yo, severe hepatic dys-
function SE: Diarrhea, GI disturbance, photosensitivity Notes: Useful for chronic bronchi-
tis; ↓ effect w/ antacids containing aluminum, calcium, magnesium; tetracycline of choice in
renal impairment
Dronabinol (Marinol) [C-II] Uses: N/V associated with cancer chemotherapy; ap-
petite stimulation Action: Antiemetic; inhibits the vomiting center in the medulla Dose:
Antiemetic: 5–15 mg/m2/dose q4–6h PRN Appetite stimulant: 2.5 mg PO before lunch and din-
ner Caution: [C, ?] Contra: Should not be used in patients with history of schizophrenia
Supplied: Caps 2.5, 5, 10 mg SE: Drowsiness, dizziness, anxiety, mood change, hallucina-
tions, depersonalization, orthostatic hypotension, tachycardia Notes: Principal psychoactive
substance present in marijuana
Droperidol (Inapsine) Uses: N/V; anesthetic premedication Action: Tranquiliza-
tion, sedation, and antiemetic Dose: Nausea: 2.5–5 mg IV or IM q3–4h PRN Premed:
2.5–10 mg IV, 30–60 min preop Caution: [C, ?] Supplied: Inj 2.5 mg/mL SE: Drowsi-
ness, moderate hypotension, occasional tachycardia and extrapyramidal reactions, QT inter-
val prolongation, arrhythmias Notes: Give IVP slowly over 2–5 min
Drotrecogin Alfa (Xigris) Uses: Reduce mortality in adults with severe sepsis
(associated with acute organ dysfunction) who have a high risk of death (e.g., as deter-
mined by APACHE II) Action: Recombinant form of human activated protein C; exact
mechanism unknown Dose: 24 mcg/kg/h for a total of 96 h Caution: [C, ?] Contra: Ac-
tive bleeding, recent stroke or CNS surgery, head trauma, epidural catheter, CNS lesion at
risk for herniation Supplied: 5-, 20-mg vials for reconstitution SE: Bleeding most common
SE Notes: For percutaneous procedures stop infusion 2 h before the procedure and resume
1 h after; for major surgery stop infusion 2 h before surgery and resume 12 h after surgery in
absence of bleeding
Dutasteride (Avodart) Uses: Symptomatic BPH Action: 5α-reductase inhibitor
Dose: 0.5 mg PO daily Caution: [X, –] Caution in hepatic impairment; pregnant women
should avoid handling pills Contra: Women and children Supplied: Caps 0.5 mg SE: ↓
534 VII: THERAPEUTICS
PSA levels, impotence, ↓ libido, gynecomastia Notes: Do not donate blood until 6 months
after discontinuation of this drug
Echothiophate Iodide (Phospholine Iodide) [See Table VII–12, pp 623–25]
Econazole (Spectazole) Uses: Most tinea, cutaneous Candida, and tinea versi-
color infections Action: Topical antifungal Dose: Apply to areas bid (daily for tinea versi-
color) for 2–4 wk Caution: [C, ?] Supplied: Topical cream 1% SE: Local irritation,
pruritus, erythema Notes: Symptom/clinical improvement seen early in treatment must carry
out course of therapy to avoid recurrence
Edrophonium (Tensilon) Uses: Diagnosis of myasthenia gravis (MyG); acute
myasthenic crisis; curare antagonist Action: Anticholinesterase Dose: Test for MyG: 2
mg IV in 1 min; if tolerated, give 8 mg IV; positive test is a brief increase in strength; ↓ in renal
impairment Caution: [C, ?] Contra: GI or GU obstruction; hypersensitivity to sulfite Sup-
plied: Inj 10 mg/mL SE: N/V/D, excessive salivation, stomach cramps Notes: ↑ amino-
transferases; can cause severe cholinergic effects; keep atropine available
Efavirenz (Sustiva) Uses: HIV infections Action: Antiretroviral; non-nucleoside re-
verse transcriptase inhibitor Dose: 600 mg/d PO, take qhs; avoid high-fat meals Caution:
[C, ?] CDC recommends HIV-infected mothers not breastfeed because of risk of transmission
of HIV to infant Supplied: Caps 50, 100, 200 mg SE: Somnolence, vivid dreams, dizzi-
ness, rash, N/V/D Notes: monitor transaminases, cholesterol
Eletriptan (Relpax)[See Table VII–16, p 629]
Emedastine (Emadine) Uses: Allergic conjunctivitis Action: Antihistamine; se-
lective H1-antagonist Dose: 1 drop in eye/s up to qid Caution: [B, ?] Contra: Hypersen-
sitivity to ingredients (preservatives benzalkonium, tromethamine) Supplied: 0.05% soln
SE: HA, blurred vision, burning/stinging, corneal infiltrates/staining, dry eyes, foreign body
sensation, hyperemia, keratitis, tearing, pruritus, rhinitis, sinusitis, asthenia, bad taste, der-
matitis, discomfort Notes: Do not use contact lenses if eyes are red; take care to prevent
contaminating dropper tip
Emtricitabine (Emtriva) WARNING: Class warning for lipodystrophy, lactic acidosis,
and severe hepatomegaly Uses: HIV-1 infection Action: Nucleoside reverse transcriptase
inhibitor (NRTI) Dose: 200 mg PO daily; adjust dose for renal dysfunction Caution: [B, –]
Supplied: 200 mg capsules SE: Headache, diarrhea, nausea, rash; Notes: Rarely
causes hyperpigmentation of feet and hands; post-treatment exacerbation of hepatitis; first
NRTI with once-daily dosing
Enalapril (Vasotec) [See Table VII–3, p 614]
Enfuvirtide (Fuzeon) WARNING: Rarely causes hypersensitivity, never rechallenge
patient Uses: Combination with antiretroviral agents for treatment of HIV-1 infection in
treatment-experienced patients with evidence of viral replication despite ongoing anti-
retroviral therapy Action: Fusion inhibitor Dose: 90 mg (1 mL) sq twice daily in upper
arm, anterior thigh or abdomen Caution: [B, –] Contra: Previous hypersensitivity to drug
Supplied: 90 mg/mL upon reconstitution; dispensed as patient convenience kit with monthly
supplies SE: Injection site reactions (in nearly all patients); pneumonia, diarrhea, nausea, fa-
tigue, insomnia, peripheral neuropathy Notes: Rotate injection site; available only via re-
stricted drug distribution system; must be immediately administered upon reconstitution or
refrigerated for up to 24 hours before use
Enoxaparin (Lovenox) WARNING: Recent or anticipated epidural/spinal anesthesia
increase risk of spinal/epidural hematoma with subsequent paralysis Uses: Prevention and
treatment of DVT; treatment of PE; unstable angina and non–Q-wave MI Action: LMW
heparin Dose: DVT Prevention: 30 mg SC bid or 40 mg SC q24h DVT/PE treatment: 1 mg/kg
SC q12h or 1.5 mg/kg SC q24h Angina: 1 mg/kg SC q12h; ↓ dosage adjustment necessary
with severe renal impairment (Crcl < 30 ml/min) Caution [B, ?] Not recommended for thrombo-
prophylaxis for prosthetic heart valves Contra: Active bleeding, HIT antibody positive Sup-
plied: Inj 10 mg/0.1 mL (30-, 40-, 60-, 80-, 100-, 120-, 150-mg syringes) SE: Bleeding,
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 535
3000, 4000, 10,000, 20,000, 40,000 units/mL SE: HTN, HA, tachycardia, fatigue, fever, N/V
Notes: Store in refrigerator; monitor baseline and post-treatment Hct/Hgb, BP, ferritin
Epoprostenol (Flolan) Uses: Pulmonary HTN Action: Dilates the pulmonary and
systemic arterial vascular beds; inhibits platelet aggregation Dose: Initial 2 ng/kg/min, ↑ by 2
ng/kg/min q15 min until dose-limiting SE (chest pain, dizziness, N/V, HA, hypotension, flush-
ing). IV cont infusion 4 ng/kg/min less than maximum-tolerated rate; adjustments based on
response and package insert guidelines Caution: [B, ?] ↑ Toxicity with diuretics, vasodila-
tors, acetate in dialysis fluids, anticoagulants Contra: Chronic use in CHF 2nd-degree se-
vere LVSD Supplied: Inj 0.5, 1.5 mg SE: Flushing, tachycardia, CHF, fever, chills,
nervousness, HA, N/V/D, jaw pain, flu-like symptoms Notes: Abrupt discontinuation/inter-
ruptions can cause rebound pulmonary HTN. Monitor bleeding if using other antiplatelet/anti-
coagulants; watch hypotensive effects with other vasodilators/diuretics
Eprosartan (Teveten) [See Table VII–4, p 615]
Eptifibatide (Integrilin) Uses: Acute coronary syndrome, PCI Action: Glycopro-
tein IIb/IIIa inhibitor Dose: 180-mcg/kg IV bolus, then 2-mcg/kg/min continuous inf; ↓ dose in
renal impairment (SCr > 2 mg/dL, < 4 mg/dL: 135-mcg/kg bolus and 0.5-mcg/kg/min infusion)
Caution: [B, ?] Monitor bleeding with other anticoagulants Contra: Other GPIIb/IIIa in-
hibitors, h/o abnormal bleeding or hemorrhagic stroke (within 30 d), severe HTN, major
surgery (within 6 wk), platelet count < 100,000 cells/mm3, renal dialysis Supplied: Inj 0.75, 2
mg/mL SE: Bleeding, hypotension, injection site reaction, thrombocytopenia Notes: Moni-
tor bleeding, coags, platelets, SCr, ACT with PCI (maintain ACT b/w 200–300 sec)
Ertapenem (Invanz) Uses: Complicated intra-abdominal, acute pelvic and skin in-
fections, pyelonephritis, community-acquired pneumonia Action: A carbapenem; β-lac-
tam antibiotic, inhibits cell wall synthesis Spectrum: Good gram(+)/(–) and anaerobic
coverage, but not Pseudomonas, PCN-resistant pneumococci, MRSA, Enterococcus, β-lacta-
mase(+) H influenzae, Mycoplasma, Chlamydia Dose: 1 g IM/IV once daily; 500 mg/d in CrCl
< 30 mL/min Caution: [C, ?/–] Probenecid ↓ renal clearance of ertapenem Contra: < 18
yo, caution in PCN allergy Supplied: Inj 1 g/vial SE: HA, N/V/D, injection site reactions,
thrombocytosis, ↑ LFTs Notes: Can give IM × 7 d, IV × 14 d; 137 mg sodium (~6 mEq)/g er-
tapenem
Erythromycin (E-Mycin, E.E.S., Ery-Tab, Others) Uses: Bacterial infec-
tions; bowel decontamination; GI motility; acne vulgaris Action: Bacteriostatic; inter-
feres with protein synthesis Spectrum: Group A streptococci (S pyogenes), S pneumoniae, N
meningitides, N gonorrhoeae (in penicillin-allergic patients), Legionella, M pneumoniae
Dose: 250–500 mg PO q6–12h or 500 mg–1 g IV q6h Prokinetic: 250 mg PO tid 30 min be-
fore meals Caution: [B, +] ↑ Toxicity of carbamazepine, cyclosporine, digoxin, methylpred-
nisolone, theophylline, felodipine, warfarin, simvastatin/lovastatin Contra: Hepatic
impairment, pre-existing liver disease (estolate), concomitant use with pimozide Supplied:
Powder for inj as lactobionate: 500 mg, 1 g Base: Tabs 250, 333, 500 mg; caps 250 mg Esto-
late: Caps 125, 250 mg; susp 125, 250 mg/5 mL Stearate: Tabs 250, 500 mg Ethylsuccinate:
Chew tabs 200 mg; tabs 400 mg; susp 200, 400 mg/5 mL SE: HA, abdominal pain, N/V/D,
[QT prolongation, torsades de pointes, ventricular arrhythmias/tachycardias (rare)]; cholestatic
jaundice (estolate) Notes: 400 mg ethylsuccinate = 250 mg base/state/estolate; take with
food to minimize GI upset
Erythromycin, Ophthalmic (Ilotycin) [See Table VII–12, pp 623–25]
Escitalopram (Lexapro) WARNING: Pediatric: Antidepressants may increase risk of
suicidality; consider risks and benefits of use. Patients should be closely monitored for clinical
worsening, suicidality, or unusual changes in behavior Uses: Antidepressant, anxiety
Action: SSRI Dose: 10–20 mg PO daily; 10 mg/d in elderly and hepatic impairment Cau-
tion: [C, +/–] ↑ Risk of serotonin syndrome with other SSRI, tramadol, linezolid, sumatriptan
Contra: Use with or within 14 d of discontinuing a MAOI Supplied: Tabs 5, 10, 20 mg; soln
1 mg/mL SE: N/V/D, sweating, insomnia, dizziness, dry mouth, sexual dysfunction Notes:
Full effects may take 3 wk
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 537
ing daily doses); hypophosphatemia, hypomagnesemia, bone pain, abnormal taste, fever,
convulsions, nephrotoxicity Notes: Take oral on empty stomach 2 h before any meal
Etodolac (Lodine) [See Table VII–11, pp 621–22]
Etonogestrel/Ethinyl Estradiol (NuvaRing) Uses: Contraceptive Action: Es-
trogen and progestin combination Dose: Rule out pregnancy first; insert ring vaginally for 3
wk, remove for 1 wk; insert new ring 7 d after last removed (even if still bleeding) at same time
of day ring removed. First day of menses is day 1, insert before day 5 even if still bleeding. Use
other contraception for first 7 days of starting therapy. See insert if converting from other forms
of contraception. After delivery or 2nd-trimester abortion, insert ring 4 wk postpartum (if not
breastfeeding) Caution: [X, ?/–] HTN, gallbladder disease, ↑ lipids, migraines, sudden HA
Contra: Pregnancy, heavy smokers > 35 yrs, DVT, PE, cerebro/cardiovascular disease, estro-
gen-dependent neoplasm, undiagnosed abnormal genital bleeding, hepatic tumors, cholestatic
jaundice Supplied: Intravaginal ring: ethinyl estradiol 0.015 mg/d and etonogestrel 0.12 mg/d
Notes: If ring accidentally removed, rinse with cool/lukewarm water (not hot) and reinsert
ASAP; if not reinserted within 3 h, effectiveness decreased. Do not use with diaphragm
Etoposide [VP-16] (VePesid, Toposar) Uses: Testicular CA, non–small cell
lung CA, Hodgkin’s and non-Hodgkin’s lymphomas, pediatric ALL, and allogeneic/au-
tologous BMT in high doses Action: Topoisomerase II inhibitor Dose: Refer to specific
protocols; ↓ in renal/hepatic impairment Caution: [D, –] Intrathecal administration Sup-
plied: Caps 50 mg; inj 20 mg/mL SE: Myelosuppression, N/V, alopecia, hypotension if in-
fused too rapidly, anorexia, anemia, leukopenia Notes: Emetic potential moderately low
(10–30%)
Exemestane (Aromasin) Uses: Treatment of advanced breast cancer in post-
menopausal women whose disease has progressed following tamoxifen therapy Ac-
tion: An irreversible, steroidal aromatase inhibitor, which lowers circulating estrogen
concentrations Dose: 25 mg PO daily after a meal Caution: [D, ?/–] Supplied: Tabs 25
mg SE: Hot flashes, nausea, fatigue
Ezetimibe (Zetia) Uses: Primary hypercholesterolemia alone or in combination
with an HMG-CoA reductase inhibitor Action: Inhibits intestinal absorption of cholesterol
and phytosterols Dose: 10 mg/d PO Caution: [C, +/–] Bile acid sequestrants ↓ bioavail-
ability Contra: Hepatic impairment Supplied: Tabs 10 mg SE: HA, diarrhea, abdominal
pain, ↑ transaminases when used in combination with an HMG-CoA reductase inhibitor
Ezetimibe/simvastatin (Vytorin) [See Table VII–15, p 628]
Famciclovir (Famvir) Uses: Acute herpes zoster (shingles) and genital herpes
Action: Inhibits viral DNA synthesis Dose: Zoster: 500 mg PO q8h × 7 d Simplex: 125–250
mg PO bid; ↓ in renal impairment Caution: [B, –] Supplied: Tabs 125, 250, 500 mg SE:
Fatigue, dizziness, HA, pruritus, nausea, diarrhea Notes: Most effective if given within 72 h
of initial lesion
Famotidine (Pepcid) Uses: Short-term treatment of active duodenal ulcer and be-
nign gastric ulcer; maintenance treatment for duodenal ulcer, hypersecretory condi-
tions, GERD, and heartburn Action: H1-antagonist; inhibits gastric acid secretion Dose:
Ulcer: 20–40 mg PO qhs or 20 mg IV q12h × 4–8 wk Hypersecretion: 20–160 mg PO q6h
GERD: 20 mg PO bid × 6 wk; maintenance 20 mg PO hs Heartburn: 10 mg PO prn q12h; ↓
dose in severe renal insufficiency Caution: [B, M] Supplied: Tabs 10, 20, 40 mg; chew
tabs 10 mg; susp 40 mg/5 mL; inj 10 mg/2 mL SE: Dizziness, HA, constipation, diarrhea,
thrombocytopenia Notes: Chewable tablets contain phenylalanine
Felodipine (Plendil) Uses: HTN and CHF Action: Ca channel blocker Dose:
2.5–10 mg PO daily; ↓ in hepatic impairment Caution: [C, ?] ↑ Effect with azole antifungals,
erythromycin; bioavailability ↑ with grapefruit juice Supplied: ER tabs 2.5, 5, 10 mg SE:
Peripheral edema, flushing, tachycardia, HA, gingival hyperplasia Notes: Follow BP in el-
derly and in impaired hepatic function, do not use doses > 10 mg in these patients; swallow
whole
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 541
or 6 mg/kg/d IV for 5 d/wk PO: Following induction, 1000 mg PO tid Prevention: 1000 mg PO
tid; take with food Ocular implant: One implant q5–8mo; ↓ dose in renal impairment Cau-
tion: [C, –] ↑ Effect with immunosuppressives, imipenem/cilastatin, zidovudine, didanosine,
other nephrotoxic medication Contra: Neutropenia (ANC < 500), thrombocytopenia (plt <
25,000), intravitreal implant Supplied: Caps 250, 500 mg; inj 500 mg; ocular implant 4.5 mg
SE: Granulocytopenia and thrombocytopenia are major toxicities; fever, rash, GI upset
Notes: Not a cure for CMV; injection should be handled with cytotoxic cautions; implant con-
fers no systemic benefit
Gatifloxacin (Tequin) Uses: Bronchitis, sinusitis, community-acquired pneumo-
nia, UTI, uncomplicated skin/soft tissue infection Action: Quinolone antibiotic, inhibits
DNA-gyrase Spectrum: Gram(+) (except MRSA, Listeria), gram(–) (except Pseudomonas),
atypicals, some anaerobes (Clostridium – not difficile) Dose: 400 mg/d PO or IV; ↓ dose in
renal impairment Caution: [C, M] Contra: Known prolongation of QT interval, uncorrected
hypokalemia, concurrent administration with other medications that prolong QT interval (class
Ia and III antiarrhythmics, erythromycin, antipsychotics, TCAs); do not use in children < 18 y or
in pregnant or lactating women Supplied: Tabs 200, 400 mg; inj 10 mg/mL; premixed infuse
D5W 200 mg, 400 mg SE: Prolonged QT interval, HA, N/D, tendon rupture, photosensitivity
Notes: Reliable activity against S pneumoniae; take 4 h after antacids containing Mg, Fe, Zn;
drink plenty of fluids; avoid direct sunlight
Gefitinib (Iressa) Uses: Treatment of locally advanced or metastatic non–small
cell lung cancer after failure of both platinum-based and docetaxel chemotherapies
Action: Inhibition of intracellular phosphorylation of numerous tyrosine kinases Dose: 250
mg PO daily Caution: [D, –] Supplied: Tabs 250 mg SE: Diarrhea, rash, acne, dry skin,
nausea, vomiting, interstitial lung disease, increased liver transaminases Notes: Periodically
check LFTs
Gemcitabine (Gemzar) Uses: Pancreatic CA, brain mets, NSCLC, gastric CA
Action: Antimetabolite; inhibits ribonucleotide reductase; produces false nucleotide base-in-
hibiting DNA synthesis Dose: Refer to specific protocol; dose modifications based on hema-
tologic function Caution: [D, ?/–] Supplied: Inj 200 mg, 1 g SE: Myelosuppression,
N/V/D, drug fever, and skin rash Notes: Reconstituted soln has concentration of 38 mg/mL;
monitor hepatic and renal function before treatment and periodically
Gemfibrozil (Lopid) Uses: Hypertriglyceridemia, reduction of CHD risk Action:
Fibric acid Dose: 1200 mg/d PO ÷ bid, 30 min ac AM and PM Caution: [C, ?] May en-
hance the effect of warfarin, sulfonylureas; ↑ risk of rhabdomyopathy with HMG-CoA reduc-
tase inhibitors; ↓ effects with cyclosporine Contra: Renal/hepatic impairment (SCr > 2.0
mg/dL), gallbladder disease, primary biliary cirrhosis Supplied: Tabs 600 mg SE:
Cholelithiasis may occur secondary to treatment; GI upset Notes: Avoid concurrent use with
the HMG-CoA reductase inhibitors; monitor LFTs and serum lipids
Gemtuzumab Ozagamicin (Mylotarg) WARNING: Can cause severe hypersensi-
tivity reactions and other infusion-related reactions including severe pulmonary events; Hepa-
totoxicity, including severe hepatic veno-occlusive disease has been reported Uses:
Relapsed CD33+ acute myelogenous leukemia in patients > 60 y who are poor candi-
dates for chemotherapy Action: Monoclonal antibody linked to calicheamicin; selective for
myeloid cells Dose: Refer to specific protocol Caution: [D,?/–] Should be used only as
single-agent chemo and not in combination with other chemotherapeutic agents Supplied: 5
mg/20 mL vial SE: Myelosuppression, hypersensitivity reactions (including anaphylaxis), in-
fusion reactions (chills, fever, N/V, HA), pulmonary events, hepatotoxicity Notes: Premed-
icate with diphenhydramine and acetaminophen
Gentamicin (Garamycin, G-Mycitin, Others) Uses: Serious infections
caused by Pseudomonas, Proteus, E coli, Klebsiella, Enterobacter, and Serratia and ini-
tial treatment of gram(–) sepsis Action: Bactericidal; inhibits protein synthesis Spectrum:
Synergism with penicillins; gram(–) (not Neisseria, Legionella, Acinetobacter) Dose: See
Aminoglycoside Dosing (see Tables VII–18, VII–19, VII–20, VII–21, pp 630–634); ↓ dose with
548 VII: THERAPEUTICS
renal insufficiency Caution: [C, +/–] Avoid other nephrotoxic medications; monitor CrCl and
serum concentration for dosage adjustments (see Table VII–18, p 630) Supplied: Premixed
Infusion 40, 60, 70, 80, 90, 100, 120 mg; ADD-Vantage inj vials 10 mg/mL; inj 40 mg/mL; IT
preservative-free 2 mg/mL SE: Nephrotoxic/ototoxic/neurotoxic Notes: Once daily dosing
becoming popular; follow SCr; use IBW to dose (use adjusted if obese > 30% IBW)
Gentamicin, Ophthalmic (Garamycin, Genoptic, Gentacidin, Gentak,
others) [See Table VII–12, pp 623–25]
Gentamicin, Topical (Garamycin, G-Mycitin) Uses: Skin infections caused
by susceptible organisms Action: Bactericidal; inhibits protein synthesis Dose: Apply
3–4 × d Caution: [C, ?] Contra: Pts with absent/perforated tympanic membranes Sup-
plied: Cream and oint 0.1%; SE: Irritation
Gentamicin and Prednisolone, Ophthalmic (Pred-G Ophthalmic) [See
Table VII–12, pp 623-25]
Glimepiride (Amaryl) [See Table VII–13, p 626]
Glipizide (Glucotrol, Glucotrol XL) [See Table VII–13, p 626]
Glucagon Uses: Severe hypoglycemic reactions in DM with sufficient liver glyco-
gen stores or b-blocker overdose Action: Accelerates liver gluconeogenesis Dose:
Usual: 0.5–1 mg SC, IM, or IV; repeat after 20 min PRN β-Blocker overdose: 3–10 mg IV; re-
peat in 10 min PRN; may be given as cont inf Caution: [B, M] Contra: Known pheochro-
mocytoma Supplied: Inj 1 mg SE: N/V, hypotension Notes: Administration of glucose
IV necessary; ineffective in states of starvation, adrenal insufficiency, or chronic hypoglycemia
Glyburide (DiaBeta, Micronase, Glynase) [See Table VII–13, p 626]
Glyburide/Metformin (Glucovance) Uses: Type 2 DM Action: Sulfonylurea:
stimulates pancreatic insulin release; Metformin: ↑ peripheral insulin sensitivity, ↓ hepatic glu-
cose output and production, ↓ intestinal absorption of glucose Dose: 1st line (naive pa-
tients), 1.25/250 mg PO qd–bid; 2nd line, 2.5/500 mg or 5/500 mg bid (max 20/2000 mg); take
with meals, ↑ dose gradually Caution: [C, –] Contra: SCr > 1.3 in females or > 1.4 in
males; hypoxemic conditions (CHF, sepsis, recent MI); alcoholism; metabolic acidosis; liver
disease; hold dose before and 48 h after ionic contrast media Supplied: Tabs 1.25/250 mg,
2.5/500 mg, 5/500 mg SE: HA, hypoglycemia, lactic acidosis, anorexia, N/V, rash Notes:
Avoid alcohol; hold dose if NPO; monitor folate levels for megaloblastic anemia
Glycerin Suppository Uses: Constipation Action: Hyperosmolar laxative Dose:
1 adult supp PR PRN Caution: [C, ?] Supplied: Supp (adult, infant); liq 4 mL/applicatorful
SE: Can cause diarrhea
Gonadorelin (Lutrepulse) Uses: Primary hypothalamic amenorrhea Action:
Stimulates the pituitary to release the gonadotropins LH and FSH Dose: 5 mcg IV q90min ×
21 d using Lutrepulse pump kit Caution: [B, M] ↑ Levels with androgens, estrogens, prog-
estins, glucocorticoids, spironolactone, levodopa; ↓ levels with OCP, digoxin, dopamine an-
tagonists Contra: Any condition exacerbated by pregnancy, ovarian cysts/causes of
anovulation other than hypothalamic, conditions worsened by reproductive hormones, hor-
monally-dependent tumor Supplied: Inj 100 mcg SE: Risk of multiple pregnancies; injec-
tion site pain Notes: Monitor LH, FSH
Goserelin (Zoladex) Uses: Advanced prostate CA and with radiation for localized
prostate CA; endometriosis, breast CA Action: LHRH agonist, inhibits LH, resulting in ↓
testosterone Dose: 3.6 mg SC (implant) q28d or 10.8 mg SC q3mo; usually into lower ab-
dominal wall Caution: [X, ] Contra: Pregnancy, breastfeeding, 10.8 mg implant not for
women Supplied: Subcutaneous implant 3.6 (1 month), 10.8 mg (3 month) SE: Hot
flashes, ↓ libido, gynecomastia, and transient exacerbation of CA-related bone pain (“flare re-
action” 7–10 d after 1st dose) Notes: Inject into SC fat in upper abdominal wall; do not aspi-
rate; females must use contraception
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 549
Idarubicin (Idamycin) Uses: Acute leukemias (AML, ALL, ANLL), CML in blast cri-
sis, breast CA Action: DNA intercalating agent; inhibits DNA topoisomerases I and II
Dose: Refer to specific protocol; ↓ in renal/hepatic dysfunction Caution: [D, –] Contra:
bilirubin > 5 mg/dL, pregnancy Supplied: Inj 1 mg/mL (5-, 10-, 20-mg vials) SE: Myelo-
suppression, cardiotoxicity, N/V, mucositis, alopecia, and irritation at sites of IV administration;
rare changes in renal/hepatic function Notes: Avoid extravasation—potent vesicant; only
given IV
Ifosfamide (Ifex, Holoxan) Uses: Lung, breast, pancreatic and gastric CA, HL/NHL,
soft tissue sarcoma Action: Alkylating agent Dose: Refer to specific protocol; ↓ in renal,
hepatic impairment Caution: [D, M] ↑ Effect with phenobarbital, carbamazepine, phenytoin;
St. John’s wort may ↓ levels Contra: Severely depressed bone marrow function, pregnancy
Supplied: Inj 1, 3 g SE: Hemorrhagic cystitis, nephrotoxicity, N/V, mild to moderate
leukopenia, lethargy and confusion, alopecia, and hepatic enzyme elevations Notes: Ad-
minister with mesna to prevent hemorrhagic cystitis
Imatinib (Gleevec) Uses: Treatment of CML, blast crisis, gastrointestinal stromal
tumors (GIST) Action: Inhibits BCL-ABL tyrosine kinase (signal transduction) Dose:
Chronic phase CML: 400–600 mg PO qd Accelerated/blast crisis: 600–800 mg PO qd GIST:
400–600 mg qd Caution: [D, ?/–] Metabolized by CYP3A4 (caution with warfarin, cy-
closporine, azole antifungals, erythromycin, phenytoin, rifampin, carbamazepine) Contra:
Pregnancy Supplied: Caps 100 mg SE: GI upset, fluid retention, muscle cramps, muscu-
loskeletal pain, arthralgia, rash, HA; neutropenia, thrombocytopenia Notes: Follow CBCs
and LFTs at baseline and monthly; administer with large glass of water and food to ↓ GI irrita-
tion
Imipenem-Cilastatin (Primaxin) Uses: Serious infections caused by a wide vari-
ety of susceptible bacteria Action: Bactericidal; interferes with cell wall synthesis Spectrum:
Gram(+) (inactive against S aureus, group A and B streptococci), gram(–) (not Legionella),
anaerobes Dose: 250–1000 mg (imipenem) IV q6–8h; ↓ in renal disease if calculated CrCl
is < 70 mL/min Caution: [C, +/–] Probenecid may ↑ risk for toxicity Supplied: Inj
(imipenem/cilastatin) 250/250 mg, 500/500 mg SE: Seizures may occur if drug accumulates;
GI upset, thrombocytopenia
Imipramine (Tofranil) WARNING: Pediatric: Antidepressants may increase risk of
suicidality; consider risks and benefits of use. Patients should be closely monitored for clinical
worsening, suicidality, or unusual changes in behavior Uses: Depression, enuresis, panic
attack, chronic pain Action: TCA; ↑ synaptic conc of serotonin or norepinephrine in the
CNS Dose: Hospitalized: Start at 100 mg/24 h PO in ÷ doses; can ↑ over several wk to max
300 mg/d Outpatient: Maintenance of 50–150 mg PO hs, not to exceed 200 mg/24 h Cau-
tion: [D, ?/–] ↑ Effects with amphetamines, anticholinergics, CNS depressants, warfarin
Contra: Do not use with MAOIs, narrow-angle glaucoma, acute recovery phase of MI, preg-
nancy, CHF/angina/CVD/arrhythmias Supplied: Tabs 10, 25, 50 mg; caps 75, 100, 125,
150 mg SE: Cardiovascular symptoms, dizziness, xerostomia, discolored urine Notes:
Less sedation than with amitriptyline
Imiquimod Cream, 5% (Aldara) Uses: Anogenital warts, HPV, condyloma
acuminata Action: Unknown; may induce cytokines Dose: Applied 3×/wk, leave on skin
for 6–10 h and wash off with soap and water, continue therapy for a max of 16 wk Caution:
[B, ?] Supplied: Single-dose packets 5% (250 mg of the cream) SE: Local skin reactions
common Notes: Not a cure; may weaken condoms/vaginal diaphragms, wash hands before
and after application of cream
Immune Globulin, Intravenous (Gamimmune N, Sandoglobulin, Gam-
mar IV) Uses: IgG antibody deficiency disease states (e.g., congenital agammaglob-
ulinemia, common variable hypogammaglobulinemia, and BMT), HIV, hepatitis A
prophylaxis, ITP Action: IgG supplementation Dose: Immunodeficiency: 100–200
mg/kg/mo IV at a rate of 0.01–0.04 mL/kg/min to a max of 400 mg/kg/dose ITP: 400
mg/kg/dose IV qd × 5 d BMT: 500 mg/kg/wk; ↓ renal insufficiency Caution: [C, ?] Separate
554 VII: THERAPEUTICS
cough Notes: 0.25 mL administered into each nostril; do not administer concurrently with
other vaccines. Avoid contact with immunocompromised individuals for 21 days
Insulin Uses: Type 1 or type 2 DM refractory to diet change or oral hypoglycemic
agents; management of acute life-threatening hyperkalemia Action: Insulin supplementa-
tion Dose: Based on serum glucose levels; usually SC but can be given IV (only regular)/IM;
typical starting dose for type 1 0.5–1 units/kg/d; type 2 0.3–0.4 units/kg/d; renal failure may ↓ in-
sulin needs Caution: [B, +] Supplied: See Table VII–1, p 613 SE: Highly purified insulins
↑ free insulin; monitor patients closely for several wks when changing doses/agents
Interferon Alfa (Roferon-A, Intron A) Uses: Hairy cell leukemia, Kaposi’s sar-
coma, melanoma, CML, chronic hepatitis C, follicular non-Hodgkin’s lymphoma, condy-
lomata acuminata, multiple myeloma, renal cell carcinoma, and bladder CA Action:
Direct antiproliferative action against tumor cells; modulation of the host immune response
Dose: Dictated by treatment protocol Hairy cell leukemia: Alfa-2a (Roferon-A): 3 M units/d for
16–24 wk SC or IM Alfa-2b (Intron A): 2 M units/m2 IM or SC 3×/wk for 2–6 mo Contra: Ben-
zyl alcohol sensitivity, decompensated liver disease, autoimmune disease, rapidly progressing
AIDS-related Kaposi’s sarcoma Supplied: Injectable forms SE: May cause flu-like symp-
toms; fatigue common; anorexia in 20–30% of patients; neurotoxicity may occur at high doses;
neutralizing antibodies in up to 40% of patients receiving prolonged systemic therapy
Interferon Alfa-2B and Ribavirin Combination (Rebetron) WARNING:
Contraindicated in pregnant women and their male partners Uses: Chronic hepatitis C in
patients with compensated liver disease who have relapsed following α-interferon ther-
apy Action: Combination antiviral agents Dose: 3 M units Intron A SC 3×/wk with
1000–1200 mg of Rebetron PO ÷ bid dose for 24 wk Patients < 75 kg: 1000 mg of Rebetron/d
Caution: [X, ?] Contra: Pregnancy, males with pregnant female partner, autoimmune he-
patitis, creatinine clearance < 50 mL/min Supplied: Patients < 75 kg: Combination packs: 6
vials Intron A (3 M units/0.5 mL ) with 6 syringes and alcohol swabs, 70 Rebetron caps; one
18 million-unit multidose vial of Intron A inj (22.8 M units/3.8 mL; 3 M units/0.5 mL) and 6 sy-
ringes and swabs, 70 Rebetron caps; one 18 million-unit Intron A inj multidose pen (22.5 M
units/1.5 mL; 3 M units/0.2 mL) and 6 disposable needles and swabs, 70 Rebetron caps Pa-
tients < 75 kg: Identical except 84 Rebetron caps/pack SE: Flu-like syndrome, HA, anemia
Notes: Negative pregnancy test required monthly; instruct patients in self-administration of SC
Intron A
Interferon Alfacon-1 (Infergen) Uses: Management of chronic hepatitis C Ac-
tion: Biologic response modifier Dose: 9 mcg SC 3×/wk × 24 wk Caution: [C, M] Con-
tra: Hypersensitivity to E coli-derived products Supplied: Inj 9, 15 mcg SE: Flu-like
syndrome, depression, blood dyscrasias Notes: Allow at least 48 h between inj
Interferon β-1b (Betaseron) Uses: MS, relapsing-remitting and secondary pro-
gressive Action: Biologic response modifier Dose: 0.25 mg SC every other day Cau-
tion: [C, ?] Contra: Hypersensitivity to human albumin products Supplied: Powder for inj
0.3 mg SE: Flu-like syndrome, depression, blood dyscrasias
Interferon γ-1b (Actimmune) Uses: ↓ Incidence of serious infections in chronic
granulomatous disease (CGD), osteopetrosis Action: Biologic response modifier
Dose: CGD: 50 mcg/m2 SC (1.5 M units/m2) BSA > 0.5 m2; if BSA < 0.5 m2, give 1.5
mcg/kg/dose; given 3×/wk Caution: [C, ?] Contra: Hypersensitivity to E coli-derived prod-
ucts Supplied: Inj 100 mcg (2 M units) SE: Flu-like syndrome, depression, blood
dyscrasias
Ipecac Syrup [OTC] Uses: Drug overdose and certain cases of poisoning Ac-
tion: Irritation of the GI mucosa; stimulation of the chemoreceptor trigger zone Dose: 15–30
mL PO, followed by 200–300 mL of water; if no emesis in 20 min, may repeat once Caution:
[C, ?] Contra: Ingestion of petroleum distillates or strong acid, base, or other corrosive or
caustic agents; not for use in comatose or unconscious patients Supplied: Syrup 15, 30 mL
(OTC) SE: Lethargy, diarrhea, cardiotoxicity, protracted vomiting Notes: Caution in CNS
depressant overdose; usage is falling out of favor
556 VII: THERAPEUTICS
trauma (can ↑ ICP) Supplied: Tabs 5, 10, 20, 30, 40 mg; SR tabs 40 mg; SL tabs 2.5, 5, 10
mg; chew tabs 5, 10 mg; SR caps 40 mg SE: HA, ↓ BP, flushing, tachycardia, dizziness
Notes: Higher oral dose usually needed to achieve same results as SL forms
Isosorbide Mononitrate (ISMO, Imdur) Uses: Prevention/Treatment of angina
pectoris Action: Relaxes vascular smooth muscle Dose: 20 mg PO bid, with the 2 doses
7 h apart or ER (Imdur) 30–120 mg/d PO Caution: [C, ?] Do not co-administer with sildenafil
Contra: Head trauma or cerebral hemorrhage (can ↑ ICP) Supplied: Tabs 10, 20 mg; ER
30, 60, 120 mg SE: HA, dizziness, hypotension
Isotretinoin [13-cis Retinoic Acid] (Accutane, Amnesteem, Claravis,
Sotret) WARNING: Must not be used by pregnant women; patient must be capable of
complying with mandatory contraceptive measures; must be prescribed according to product-
specific risk management system Uses: Refractory severe acne Action: Retinoic acid
derivative Dose: 0.5–2 mg/kg/d PO ÷ bid (↓ in hepatic disease, take with food) Caution:
[X, –] Avoid tetracyclines Contra: Retinoid sensitivity, pregnancy Supplied: Caps 10, 20,
40 mg SE: Isolated reports of depression, psychosis, suicidal thoughts; dermatologic sensi-
tivity, xerostomia, photosensitivity, ↑ LFTs, ↑ triglycerides Notes: Risk management pro-
gram requires 2 negative pregnancy tests before therapy and use of 2 forms of contraception
1 mo before, during, and 1 mo after therapy; informed consent recommended; monitor LFTs
and lipids
Isradipine (DynaCirc) Uses: HTN Action: Ca2+ channel blocker Dose: 2.5–10
mg PO bid (do not crush or chew) Caution: [C, ?] Heart block, CHF Supplied: Caps 2.5,
5 mg; tabs CR 5, 10 mg SE: HA, edema, flushing, fatigue, dizziness, palpitations
Itraconazole (Sporanox) WARNING: Potential for negative inotropic effects on the
heart; if signs or symptoms of CHF occur during administration, continued use should be as-
sessed Uses: Fungal infections (Aspergillosis, Blastomycosis, Histoplasmosis, Can-
didiasis) Action: Inhibits synthesis of ergosterol Dose: 200 mg PO or IV qd–bid (capsule
with meals or cola/grapefruit juice; oral solution on empty stomach; avoid antacids) Caution:
[C, ?] Numerous drug interactions Contra: CrCl < 30 mL/min, history of CHF or ventricular
dysfunction, or concurrently with H2-antagonist, omeprazole Supplied: Caps 100 mg; soln
10 mg/mL; inj 10 mg/mL SE: Nausea, rash, hepatitis, hypokalemia, CHF Notes: Oral solu-
tion and caps not interchangeable; often used in patients who cannot take amphotericin B.
Watch for signs/symptoms of CHF with IV use
Kaolin-Pectin (Kaodene, Kao-Spen, Kapectolin, Parepectolin [OTC])
Uses: Diarrhea Action: Absorbent demulcent Dose: 60–120 mL PO after each loose
stool or q3–4h PRN Caution: [C, +] Contra: Diarrhea secondary to pseuodomembranous
colitis Supplied: Multiple OTC forms; also available with opium (Parepectolin) SE: Consti-
pation, dehydration
Ketoconazole (Nizoral, Nizoral AD Shampoo [OTC]) Uses: Systemic fun-
gal infections; topical cream for localized fungal infections due to dermatophytes and
yeast; shampoo for dandruff, short term in prostate CA when rapid reduction of testos-
terone needed (i.e., cord compression) Action: Inhibits fungal cell wall synthesis Dose:
Oral: 200 mg PO qd; ↑ to 400 mg PO qd for serious infections; prostate CA 400 mg PO tid
(short term) Topical: Apply to the affected area qd (cream or shampoo) Caution: [C, +/–]
Any agent that increases gastric pH will prevent absorption of ketoconazole; may enhance
oral anticoagulants; may react with alcohol to produce a disulfiram-like reaction; numerous
other drug interactions Contra: CNS fungal infections (poor CNS penetration), concurrent
astemizole, cisapride, oral triazolam Supplied: Tabs 200 mg; topical cream 2%; shampoo
2% SE: Monitor LFTs with systemic use; can cause nausea Notes: Oral form multiple
drug interactions
Ketoprofen (Orudis, Oruvail) [See Table VII–11, pp 621-22]
Ketorolac (Toradol) [See Table VII–11, pp 621-22]
Ketorolac Ophthalmic (Acular) [See Table VII–12, pp 621-22]
558 VII: THERAPEUTICS
Supplied: Tabs 2.5 mg SE: Requires periodic CBC, thyroid function, electrolyte, LFT, and
renal monitoring; anemia, nausea, hot flashes, arthralgia
Leucovorin (Wellcovorin) Uses: Overdose of folic acid antagonist; augmenta-
tion of 5-FU, impaired MTX elimination Action: Reduced folate source; circumvents ac-
tion of folate reductase inhibitors (i.e., MTX) Dose: MTX rescue: 10 mg/m2/dose IV or PO
q6h for 72 h until MTX level < 10−8 5-FU: 200 mg/m2/d IV 1–5 d during daily 5-FU treatment or
500 mg/m2/wk with weekly 5-FU therapy Adjunct to antimicrobials: 5–15 mg/d PO Caution:
[C, ?/–] Should not be administered intrathecally/intraventrically Contra: Pernicious anemia
Supplied: Tabs 5, 15, 25 mg; inj SE: Allergic reaction, N/V/D, fatigue Notes: Many dosing
schedules for leucovorin rescue following MTX therapy
Leuprolide (Lupron, Lupron DEPOT, Lupron DEPOT-Ped, Viadur, Eli-
gard) Uses: Advanced prostate CA (CAP), endometriosis, uterine fibroids, and CPP
Action: LHRH agonist; paradoxically inhibits release of gonadotropin, resulting in decreased
pituitary gonadotropins (i.e., ↓ LH); in men ↓ testosterone Dose: CAP: 7.5 mg IM q28d or
22.5 mg IM q3mo or 30 mg IM q4mo of depot. Viadur implant (CAP only); insert in inner upper
arm using local anesthesia, replace q12mo Endometriosis (depot only): 3.75 mg IM qmo ×6
Fibroids: 3.75 mg IM qmo ×3 Caution: [X, ?] Contra: Undiagnosed vaginal bleeding, im-
plant dosage form in women; pregnancy Supplied: Inj 5 mg/mL; Lupron depot 3.75 (1 mo
for fibroids, endometriosis), Lupron depot for CAP: 7.5 mg (1 mo), 22.5 (3 mo), 30 mg (4 mo);
Eligard depot for CAP: 7.5 mg (1 mo); Viadur 12-mo SC implant; Lupron-PED 7.5, 11.25, 15
mg SE: Hot flashes, gynecomastia, N/V, alopecia, anorexia, dizziness, HA, insomnia, pares-
thesias, depression exacerbation, peripheral edema, and bone pain (transient “flare reaction”
at 7–14 d after the 1st dose due to LH and testosterone surge before suppression)
Levalbuterol (Xopenex) Uses: Asthma (Rx and prevention of bronchospasm)
Action: Sympathomimetic bronchodilator Dose: 0.63 mg neb q6–8h Caution: [C, ?]
Supplied: Soln for inhal 0.63, 1.25 mg/3 mL SE: Tachycardia, nervousness, trembling, flu
syndrome Notes: Therapeutically active R-isomer of albuterol; potential for lower incidence
of cardiovascular side effects compared with albuterol—not yet proven
Levamisole (Ergamisol) Uses: Adjuvant therapy of Dukes C colon CA (in combi-
nation with 5-FU) Action: Poorly understood immunostimulatory effects Dose: 50 mg PO
q8h for 3 d q14d during 5-FU therapy; ↓ in hepatic dysfunction Caution: [C, ?/–] Sup-
plied: Tabs 50 mg SE: N/V/D, abdominal pain, taste disturbance, anorexia, hyperbilirubine-
mia, disulfiram-like reaction on alcohol ingestion, minimal bone marrow depression, fatigue,
fever, conjunctivitis
Levetiracetam (Keppra) Uses: Partial onset seizures Action: Unknown Dose:
500 mg PO bid, may ↑ to max 3000 mg/d; ↓ in renal insufficiency Caution: [C, ?/–] Sup-
plied: Tabs 250, 500, 750 mg SE: May cause dizziness and somnolence; may impair coor-
dination
Levobetaxolol (Betaxon) [See Table VII–12, pp 623–25]
Levobunolol (A-K Beta, Betagan) [See Table VII–12, pp 623–25]
Levocabastine (Livostin) [See Table VII–12, pp 623–25]
Levofloxacin (Levaquin, Quixin Ophthalmic, Iquix Ophthalmic) Uses:
Lower respiratory tract infections, sinusitis, UTI; topical for bacterial conjunctivitis,
skin infections Spectrum: Excellent gram(+) coverage except MRSA and E faecium; excel-
lent gram(–) coverage except S maltophilia and Acinetobacter sp; poor anaerobic coverage
Action: Quinolone antibiotic, inhibits DNA gyrase Dose: 250–500 mg/d PO or IV; ↓ in renal
insufficiency, ophthal 1–2 drops in eye(s) q2h while awake for 2 d, then q4h while awake for
5 d; Oral: avoid antacids Caution: [C, –] Interactions with cation-containing products Sup-
plied: Tabs 250, 500 mg; premixed bags 250, 500 mg; ophthal 0.5%, 1.5% sol SE: N/D,
dizziness, rash, GI upset, photosensitivity
Levonorgestrel (Plan B) Uses: Emergency contraceptive (“morning-after pill”);
can prevent pregnancy if taken < 72 hours after unprotected sex (contraceptive fails or
560 VII: THERAPEUTICS
if no contraception used) Actions: progestin Dose: 1 pill Q12 hr × 2 Supplied: tab, 0.75
mg, 2 blister pack Caution: [X, M] Contra: Known/suspected pregnancy, abnormal uter-
ine bleeding SE: N/V, abdominal pain, fatigue HA, menstrual changes Notes: Will not in-
duce abortion; may increase risk of ectopic pregnancy
Levonorgestrel Implant (Norplant) Uses: Contraceptive Dose: Implant 6 caps in
the midforearm Caution: [X, +/–] Contra: Undiagnosed abnormal uterine bleeding, hepatic
disease, thromboembolism, history of intracranial HTN, breast CA, renal impairment Sup-
plied: Kits containing 6 implantable caps, each containing 36 mg SE: Uterine bleeding, HA,
acne, nausea Notes: Prevents pregnancy for up to 5 y; may be removed if pregnancy desired
Levothyroxine (Synthroid, Levoxyl, others) Uses: Hypothyroidism,
myxedema coma Action: Supplementation of L-thyroxine Dose: Initially, 25–50 mcg/d
PO or IV; ↑ by 25–50 mcg/d every month; usual dose 100–200 mcg/d. Titrate dosage based
on clinical response and thyroid function tests; dosage can ↑ more rapidly in young to middle-
aged patients Caution: [A, +] Contra: Recent MI, uncorrected adrenal insufficiency
Supplied: Tabs 25, 50, 75, 88, 100, 112, 125, 137, 150, 175, 200, 300 mcg; inj 200, 500 mcg
SE: Insomnia, weight loss, alopecia, arrhythmia; take with full glass of water to prevent gag-
ging or choking
Lidocaine (Anestacon Topical, Xylocaine, others) Uses: Local anesthetic;
treatment of cardiac arrhythmias Action: Anesthetic; class IB antiarrhythmic Dose: An-
tiarrhythmic, ET: 5 mg/kg; follow with 0.5 mg/kg in 10 min if effective IV load: 1 mg/kg/dose
bolus over 2–3 min; repeat in 5–10 min up to 200–300 mg/h; cont inf of 20–50 mcg/kg/min or
1–4 mg/min Topical: Apply max 3 mg/kg/dose Local inj anesthetic: Max 4.5 mg/kg (Table
VII–17, p 000) Caution: [C, +] Do not use lidocaine with epinephrine on the digits, ears, or
nose because vasoconstriction may cause necrosis; heart block Supplied: Inj local: 0.5, 1,
1.5, 2, 4, 10, 20% Inj IV: 1% (10 mg/mL, 2% 20 mg/mL); admixture 4, 10, 20% IV inf: 0.2%,
0.4%; cream 2%; gel 2, 2.5%; oint 2.5, 5%; liq 2.5%; soln 2, 4%; viscous 2% SE: 2nd line to
amiodarone in emergency cardiac care; dilute ET dose 1–2 mL with NS; epinephrine may be
added for local anesthesia to ↑ effect and ↓ bleeding; for IV forms, ↓ with liver disease or
CHF; dizziness, paresthesias, and convulsions associated with toxicity; see Table VII–17 (p
000) for drug levels
Lidocaine/Prilocaine (EMLA) Uses: Topical anesthetic; adjunct to phlebotomy
or dermal procedures Action: Topical anesthetic Dose: EMLA cream and anesthetic
disc (1 g/10 cm2): Apply thick layer 2–2.5 g to intact skin and cover with an occlusive dressing
(e.g., Tegaderm) for at least 1 h Anesthetic disc: 1 g/10 cm2 for at least 1 h Caution: [B, +]
Methemoglobinemia Contra: Application on mucous membranes, broken skin, ophthalmic
use; hypersensitivity to amide-type local anesthetics Supplied: Cream 2.5% lidocaine/2.5%
prilocaine; anesthetic disc (1 g) SE: Burning, stinging, methemoglobinemia Notes: Longer
contact time gives greater effect
Lindane (Kwell [OTC]) Uses: Head lice, crab lice, scabies Action: Ectoparasiti-
cide and ovicide Dose: Cream or lotion: Apply thin layer after bathing, leave on for 8–12 h,
pour on laundry Shampoo: Apply 30 mL, develop a lather with warm water for 4 min, comb out
nits Caution: [C, +/–] Contra: Open wounds, seizure disorder Supplied: Lotion 1%;
shampoo 1% SE: Arrhythmias, seizures, local irritation, GI upset Notes: Caution with
overuse; may be absorbed into blood; may repeat treatment in 7 days
Linezolid (Zyvox) Uses: Infections caused by gram(+) bacteria (including VRE),
pneumonia, skin infections Action: Unique action, binds ribosomal bacterial RNA; bacte-
ricidal for strep, bacteriostatic for enterococci and staph Spectrum: Excellent gram(+) activity
including VRE and MRSA Dose: 400–600 mg IV or PO q12h Caution: [C, ?/–] Reversible
MAOI, avoid foods containing tyramine and cough and cold products containing pseu-
doephedrine; myelosuppression Supplied: Inj 2 mg/mL; tabs 400, 600 mg; susp 100 mg/5
mL SE: HTN, N/D, HA, insomnia, GI upset Notes: Follow weekly CBC
Liothyronine (Cytomel) Uses: Hypothyroidism, goiter, myxedema coma, thyroid
suppression therapy Action: T3 replacement Dose: Initial dose of 25 mcg/24 h, then
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 561
titrate q1–2wk according to clinical response and TFT to maintenance of 25–100 mcg/d PO
Myxedema coma: 25–50 mcg IV, ↓ dose in elderly Caution: [A, +] Contra: Recent MI, un-
corrected adrenal insufficiency, uncontrolled HTN Supplied: Tabs 5, 12.5, 25, 50 mcg; inj
10 mcg/mL SE: Alopecia, arrhythmias, chest pain, HA, sweating Notes: Monitor TFT
Lisinopril (Prinivil, Zestril) [See Table VII–3, p 614]
Lithium Carbonate (Eskalith, Lithobid, others) Uses: Manic episodes of
bipolar illness Action: Effects shift toward intraneuronal metabolism of catecholamines
Dose: Acute mania: 600 mg PO tid or 900 mg SR bid Maintenance: 300 mg PO tid–qid; follow
serum levels; (↓ in renal insufficiency, elderly) Caution: [D, –] Many drug interactions
Contra: Severe renal impairment or cardiovascular disease, lactation Supplied: Caps 150,
300, 600 mg; tabs 300 mg; SR tabs 300, 450 mg; syrup 300 mg/5 mL SE: Polyuria, polydip-
sia, nephrogenic DI, tremor; sodium retention or diuretic use may potentiate toxicity; arrhyth-
mias, dizziness Notes: Table VII–17 (p 000) for drug levels.
Lodoxamide (Alomide) [See Table VII–12, pp 623–25]
Lomefloxacin (Maxaquin) Uses: UTI, acute exacerbation of chronic bronchitis;
prophylaxis in transurethral procedures Spectrum: Good gram(–) activity including H in-
fluenzae except S maltophilia, Acinetobaceter sp, and some P aeruginosa Action: Quinolone
antibiotic; inhibits DNA gyrase Dose: 400 mg/d PO; ↓ in renal insufficiency, avoid antacids
Caution: [C, –] Interactions with cation-containing products Supplied: Tabs 400 mg SE:
Photosensitivity, seizures, HA, dizziness
Lomustine (CCNU, CeeNU) Uses: Hodgkin’s lymphoma; primary brain tumors
Actions: Nitrosourea alkylating agent Dose: Refer to specific protocol Caution: [D, ?]
Supplied: 10, 40, 100 mg caps SE: Toxicity includes myelosuppression, renal injury,
anorexia, nausea and vomiting, stomatitis, pulmonary fibrosis, and hepatotoxicity Notes:
High lipid solubility translates into excellent penetration into the CNS
Loperamide (Imodium) [OTC] Uses: Diarrhea Action: Slows intestinal motility
Dose: Initially 4 mg PO, then 2 mg after each loose stool, up to 16 mg/d Caution: [B, +] Do
not use in acute diarrhea caused by Salmonella, Shigella, or C difficile Supplied: Caps 2
mg; tabs 2 mg; liq 1 mg/5 mL (OTC) SE: Constipation, sedation, dizziness
Lopinavir/Ritonavir (Kaletra) Uses: HIV infection Action: Protease inhibitor
Dose: 3 caps or 5 mL PO bid (with food) Caution: [C, ?/–] Numerous drug interactions
Contra: Concomitant drugs dependent on CYP3A or CYP2D6 Supplied: Caps 133.3
mg/33.3 mg (lopinavir/ritonavir), solution 400 mg/100 mg/5 mL SE: Solution contains alco-
hol, avoid disulfiram and metronidazole; GI upset, asthenia, ↑ cholesterol and triglycerides,
pancreatitis; protease metabolic syndrome
Loracarbef (Lorabid) [See Table VII–9, p 619]
Loratadine (Claritin, Alavert) [OTC] Uses: Allergic rhinitis, chronic idiopathic
urticaria Action: Nonsedating antihistamine Dose: 10 mg/d PO (take on an empty
stomach; ↓ in hepatic insufficiency) Caution: [B, +/–] Supplied: Tabs 10 mg (OTC);
rapidly disintegrating Reditabs 10 mg; syrup 1 mg/mL SE: HA, somnolence, xerostomia
Lorazepam (Ativan, others) [C-IV] Uses: Anxiety and anxiety with depression;
preop sedation; control of status epilepticus; alcohol withdrawal; antiemetic Action:
Benzodiazepine; antianxiety agent Dose: Anxiety: 1–10 mg/d PO in 2–3 ÷ doses Preop se-
dation: 0.05 mg/kg to 4 mg max IM 2 h before surgery Insomnia: 2–4 mg PO hs Status epilep-
ticus: 4 mg/dose IV PRN q10–15 min; usual total dose 8 mg Antiemetic: 0.5–2 mg IV or PO
q4–6h PRN. Alcohol withdrawal: 2–5 mg IV or 1–2 mg PO initially depending on severity. Sub-
sequent dosing depends on patient (see Section 1, Chapter 16, Delirium Tremens: Major Al-
cohol Withdrawal) ↓ in elderly; do not administer IV > 2 mg/min or 0.05 mg/kg/min Caution:
[D, ?/–] Contra: Severe pain, severe hypotension, sleep apnea, narrow-angle glaucoma, hy-
persensitivity to propylene glycol or benzyl alcohol Supplied: Tabs 0.5, 1, 2 mg; soln, oral
conc 2 mg/mL; inj 2, 4 mg/mL SE: Sedation, ataxia, tachycardia, constipation, respiratory
562 VII: THERAPEUTICS
depression Notes: May take up to 10 min to see effect when given IV; do not administer IV
faster than 2 mg/min or 0.05 mg/kg/min
Losartan (Cozaar) [See Table VII–4, p 615]
Lovastatin (Mevacor, Altocor) [See Table VII–15, p 628]
Lymphocyte Immune Globulin [Antithymocyte Globulin, ATG] (Atgam)
Uses: Allograft rejection in transplant patients; aplastic anemia if not candidates for
BMT Action: ↓ number of circulating, thymus-dependent lymphocytes Dose: Prevent re-
jection: 15 mg/kg/day IV × 14 d, then qod × 7; initial within 24 h before/after transplant. Treat
rejection: Same except use 10–15 mg/kg/day Caution: [C, ?] Contra: H/O reaction to
other equine γ-globulin preparation, leukopenia, thrombocytopenia Supplied: Inj 50 mg/mL
SE: Test dose 0.1 mL of a 1:1000 dilution in NS; discontinue with severe thrombocytopenia or
leukopenia; rash, fever, chills, hypotension, HA, ↑ K+
Magaldrate (Riopan, Lowsium) [OTC] Uses: Hyperacidity associated with
peptic ulcer, gastritis, and hiatal hernia Action: Low-Na antacid Dose: 5–10 mL PO
between meals and hs Caution: [B, ?] Do not use in renal insufficiency due to Mg content
Contra: Ulcerative colitis, diverticulitis, ileostomy/coleostomy Supplied: Susp SE: GI upset
Notes: < 0.3 mg Na/tab or tsp
Magnesium Citrate [OTC] Uses: Vigorous bowel preparation; constipation
Action: Cathartic laxative Dose: 120–240 mL PO PRN (take with a beverage) Caution:
[B, +] Contra: Severe renal disease, heart block, N/V, rectal bleeding Supplied: Efferves-
cent soln (OTC) SE: Abdominal cramps, gas
Magnesium Hydroxide (Milk of Magnesia) [OTC] Uses: Constipation Ac-
tion: NS laxative Dose: 15–30 mL PO PRN (follow dose with 8 ounces of water) Caution:
[B, +] Contra: Renal insufficiency or intestinal obstruction, ileostomy/colostomy Supplied:
Tabs 311 mg, liq 400, 800 mg/5 mL SE: Diarrhea, abdominal cramps
Magnesium Oxide (Mag-Ox 400, others) [OTC] Uses: Replacement for low
plasma levels Action: Mg supplementation Dose: 400–800 mg/d ÷ qd–qid with full glass
of water Caution: [B, +] Contra: Ulcerative colitis, diverticulitis, ileostomy/colostomy, heart
block, renal insufficiency Supplied: Caps 140 mg; tabs 400 mg (OTC) SE: Diarrhea, nau-
sea
Magnesium Sulfate Uses: Replacement for low Mg levels; preeclampsia and pre-
mature labor; refractory hypokalemia and hypocalcemia Action: Mg supplement
Dose: Supplement: 1–2 g IM or IV; repeat PRN Preeclampsia/premature labor: 4 g load then
1–4 g/h IV infusion; ↓ dose with low urine output or renal insufficiency Caution: [B, +]
Contra: Heart block, renal failure Supplied: Inj 100, 125, 250, 500 mg/mL; oral soln 500
mg/mL; granules 40 mEq/5 g SE: CNS depression, diarrhea, flushing, heart block
Mannitol Uses: Cerebral edema, intraocular pressure, renal impairment, poison-
ings Action: Osmotic diuretic Dose: Diuresis: 0.2 g/kg/dose IV over 3–5 min; if no diure-
sis within 2 h, discontinue Cerebral edema: 0.25 g/kg/dose IV push, repeated at 5-min
intervals PRN; ↑ incrementally to 1 g/kg/dose PRN for increased ICP; caution with CHF or vol-
ume overload Caution: [C, ?] Contra: Anuria, dehydration, heart failure, PE Supplied:
Inj 5, 10, 15, 20, 25% SE: Initial volume increase may exacerbate CHF; monitor for volume
depletion, N/V/D
Mechlorethamine (Mustargen) WARNING: Highly toxic agent, handle with care
Uses: Hodgkin’s and NHL, cutaneous T-cell lymphoma (mycosis fungoides), lung CA,
CML, malignant pleural effusions, and CLL Action: Alkylating agent (bifunctional)
Dose: 0.4 mg/kg single dose or 0.1 mg/kg/d for 4 d; 6 mg/m2 1–2 ×/mo; highly volatile; must
be administered within 30–60 min of preparation Caution: [D, ?] Contra: Presence of
known infectious disease Supplied: Inj 10 mg SE: Toxicity symptoms: Myelosuppression,
thrombosis, or thrombophlebitis at inj site; tissue damage with extravasation (Na thiosulfate
may be used topically to treat); N/V, skin rash, amenorrhea, and sterility. High rates of sterility
(especially in men) and secondary leukemia in patients treated for Hodgkin’s disease
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 563
before and 48 h after ionic contrast Supplied: Tabs 500, 850, 1000 mg; XR Tabs 500 mg
SE: Anorexia, N/V, rash, lactic acidosis (rare, but serious)
Methadone (Dolophine) [C-II] Uses: Severe pain; detoxification and mainte-
nance of narcotic addiction Action: Narcotic analgesic Dose: 2.5–10 mg IM q3–8h or
5–15 mg PO q8h; titrate as needed; ↑ slowly to avoid respiratory depression; (↓ in renal dis-
ease) Caution: [B/D (prolonged use or high doses at term) + (with doses = 20 mg/24 h)] Se-
vere liver disease Supplied: Tabs 5, 10, 40 mg; oral soln 5, 10 mg/5 mL; oral conc 10
mg/mL; inj 10 mg/mL SE: Respiratory depression, sedation, constipation, urinary retention,
ventricular arrhythmias Notes: Equianalgesic with parenteral morphine; longer half-life; pro-
longs QT interval
Methenamine (Hiprex, Urex, others) Uses: Suppression or elimination of bac-
teriuria associated with chronic/ recurrent UTI Dose: Hippurate: 1 g bid Mandelate: 1 g
qid pc and hs; take with food and ascorbic acid; adequate hydration Caution: [C, +] Con-
tra: Renal insufficiency, severe hepatic disease, and severe dehydration; allergy to sulfon-
amides Supplied: Methenamine hippurate (Hiprex, Urex): 1 g tabs Methenamine
mandelate: 500 mg, 1 g EC tabs SE: Rash, GI upset, dysuria, increased LFTs
Methimazole (Tapazole) Uses: Hyperthyroidism, thyrotoxicosis, and prep for
thyroid surgery or radiation Action: Blocks the formation of T3 and T4 Dose: Initial:
15–60 mg/d PO ÷ tid Maintenance: 5–15 mg PO qd (take with food) Caution: [D, +/–]
Contra: Breastfeeding Supplied: Tabs 5, 10 mg SE: GI upset, dizziness, blood
dyscrasias Notes: Follow clinically and with TFT
Methocarbamol (Robaxin) Uses: Relief of discomfort associated with painful
musculoskeletal conditions Action: Centrally acting skeletal muscle relaxant Dose:
1.5 g PO qid for 2–3 d, then 1-g PO qid maintenance therapy; IV form rarely indicated Cau-
tion: [C, +] Contra: Myasthenia gravis, renal impairment; caution in seizure disorders
Supplied: Tabs 325, 500, 750 mg; inj 100 mg/mL SE: Can discolor urine; drowsiness, GI
upset
Methotrexate (Folex, Rheumatrex) Uses: ALL and AML (including leukemic
meningitis), trophoblastic tumors (chorioepithelioma, choriocarcinoma, chorioade-
noma destruens, hydatidiform mole), breast CA, Burkitt’s lymphoma, mycosis fun-
goides, osteosarcoma, head and neck CA, Hodgkin’s and NHL, lung CA; psoriasis; and
RA Action: Inhibits dihydrofolate reductase-mediated generation of tetrahydrofolate
Dose: CA; Varies per protocol RA: 7.5 mg/wk PO as a single dose or 2.5 mg q12h PO for 3
doses/wk; “high dose” RX requires leucovorin rescue to limit hematologic and mucosal toxic-
ity; ↓ in renal/hepatic impairment Caution: [D, –] Contra: Severe renal/hepatic impair-
ment, pregnancy/lactation Supplied: Tabs 2.5, 5, 7.5, 10, 15 mg; inj 2.5, 25 mg/mL;
preservative-free inj 25 mg/mL SE: Myelosuppression, N/V/D, anorexia, mucositis, hepato-
toxicity (transient and reversible; may progress to atrophy, necrosis, fibrosis, cirrhosis),
rashes, dizziness, malaise, blurred vision, alopecia, photosensitivity, renal failure, pneumoni-
tis, and, rarely, pulmonary fibrosis. Chemical arachnoiditis and HA with IT delivery Notes:
Monitor blood counts, LFTs, renal function tests, chest x-ray, and MTX levels
Methyldopa (Aldomet) Uses: HTN Action: Centrally acting antihypertensive
Dose: 250–500 mg PO bid–tid (max 2–3 g/d) or 250 mg–1 g IV q6–8h; ↓ dose in renal insuffi-
ciency and in elderly Caution: [B (oral), C (IV), +] Contra: Liver disease; MAOIs Sup-
plied: Tabs 125, 250, 500 mg; oral susp 50 mg/mL; inj 50 mg/mL SE: Can discolor urine;
initial transient sedation or drowsiness frequent; edema, hemolytic anemia; hepatic disorders
Methylergonovine (Methergine) Uses: Postpartum bleeding (uterine subinvo-
lution) Action: Ergotamine derivative Dose: 0.2 mg IM after delivery of placenta, may re-
peat at 2–4 h intervals or 0.2–0.4 mg PO q6–12h for 2–7 d Caution: [C, ?] Contra: HTN,
pregnancy Supplied: Injectable forms; tabs 0.2 mg SE: IV doses should be given over a
period of > 1 min with frequent BP monitoring; HTN, N/V
Methylprednisolone (Solu-Medrol) [See Steroids, Table VII–2, p 613]
566 VII: THERAPEUTICS
ritonavir Supplied: Inj 1, 5 mg/mL; syrup 2 mg/mL SE: Monitor for respiratory depression;
hypotension in conscious sedation, nausea Notes: Reversal with flumazenil
Mifepristone [RU 486] (Mifeprex) WARNING: Patient counseling and information
required, may be associated with fatal infections and bleeding Uses: Termination of in-
trauterine pregnancies of < 49 d Action: Antiprogestin; ↑ prostaglandins, resulting in uter-
ine contraction Dose: Administered with 3 office visits: day 1, three 200-mg tablets PO; day
3 if no abortion, two 200-mg misoprostol PO; on or about day 14, verify termination of preg-
nancy Caution: [X, –] Contra: Anticoagulation therapy, bleeding disorders Supplied:
Tabs 200 mg SE: Abdominal pain and 1–2 wk of uterine bleeding Notes: Must be admin-
istered under physician’s supervision
Miglitol (Glyset) Uses: Type 2 DM Action: α-Glucosidase inhibitor; delays digestion
of ingested carbohydrates Dose: Initial 25 mg PO tid; maintenance 50–100 mg tid (with 1st
bite of each meal) Caution: [B, –] Contra: Obstructive or inflammatory GI disorders; avoid
if SCr > 2 Supplied: Tabs 25, 50, 100 mg SE: Used alone or in combination with sulfony-
lureas; flatulence, diarrhea, abdominal pain
Milrinone (Primacor) Uses: CHF Action: Positive inotrope and vasodilator; little
chronotropic activity Dose: 50 mcg/kg, then 0.375–0.75 mcg/kg/min inf; ↓ dose in renal im-
pairment Caution: [C, ?] Supplied: Inj 1 mcg/mL SE: Arrhythmias, hypotension, HA
Notes: Carefully monitor fluid/electrolyte status and BP/HR
Mineral Oil Uses: Constipation Action: Emollient laxative Dose: 5–45 mL PO PRN
Caution: [C, ?] N/V, difficulty swallowing, bedridden patients Contra: Appendicitis, divertic-
ulitis, ulcerative colitis Supplied: Liq [OTC] SE: Lipid pneumonia, anal incontinence, im-
paired vitamin absorption
Minoxidil (Loniten, Rogaine) Uses: Severe HTN; male and female pattern bald-
ness Action: Peripheral vasodilator; stimulates vertex hair growth Dose: Oral: 2.5–10 mg
PO bid–qid; ↓ oral dose in elderly Topical: Apply bid to affected area Caution: [C, +] Sup-
plied: Tabs 2.5, 5, 10 mg; topical soln (Rogaine) 2% SE: Pericardial effusion and volume
overload may occur with oral use; hypertrichosis after chronic use; edema, ECG changes,
weight gain
Mirtazapine (Remeron) WARNING: Pediatric: Antidepressants may increase risk of
suicidality; consider risks and benefits of use. patients should be closely monitored for clinical
worsening, suicidality, or unusual changes in behavior Uses: Depression Action: Tetra-
cyclic antidepressant Dose: 15 mg PO hs, up to 45 mg/d hs Caution: [C, ?] Contra:
MAOIs within 14 d Supplied: Tabs 15, 30, 45 mg SE: Somnolence, increased cholesterol,
constipation, xerostomia, weight gain, agranulocytosis Notes: Do not ↑ dose at intervals of
less than 1–2 wk
Misoprostol (Cytotec) Uses: Prevention of NSAID-induced gastric ulcers; induc-
tion of labor, incomplete and therapeutic abortion Action: Prostaglandin with both antise-
cretory and mucosal protective properties Dose: Ulcer prevention: 200 mcg PO qid with
meals; in females, start on 2nd or 3rd of next normal menstrual period; 25–50 mcg for induction
of labor (term): 400 mcg on day 3 of mifepristone for pregnancy termination (take with food
Caution: [X, –] Supplied: Tabs 100, 200 mcg SE: Can cause miscarriage with potentially
dangerous bleeding; HA, GI symptoms common (diarrhea, abdominal pain, constipation)
Mitomycin (Mutamycin) Uses: Stomach, pancreas, breast, colon cancers; squa-
mous cell carcinoma of the anus; non–small cell lung, head, and neck, cervical, and
breast cancers; bladder cancer (intravesically) Action: Alkylating agent; may also gener-
ate oxygen free radicals, induces DNA strand breaks Dose: 20 mg/m2 q6–8wk or 10 mg/m2
in combination with other myelosuppressive drugs; bladder CA 20–40 mg in 40 mL NS via a
urethral catheter once/wk for 8 wk, followed by monthly treatments for 1 y; ↓ dose in renal/he-
patic impairment Caution: [D, –] Contra: Thrombocytopenia, leukopenia, coagulation dis-
orders, serum creatinine > 1.7 mg/dL Supplied: Inj SE: Myelosuppression (may persist
up to 3–8 wk after dose and may be cumulative minimized by a lifetime dose < 50–60 mg/m2),
N/V, anorexia, stomatitis, and renal toxicity; microangiopathic hemolytic anemia (similar to he-
568 VII: THERAPEUTICS
molytic-uremic syndrome) with progressive renal failure; venoocclusive disease of the liver, in-
terstitial pneumonia, alopecia (rare); extravasation reactions can be severe
Mitotane (Lysodren) Uses: Palliative treatment of inoperable adrenocortical car-
cinoma Action: Unclear; induces mitochondrial injury in adrenocortical cells Dose: 8–10
g/d in 3–4 ÷ doses (begin at 2 g/d with glucocorticoid replacement); ↓ in hepatic insufficiency;
adequate hydration necessary Caution: [C, ?] Supplied: Tabs 500 mg SE: Anorexia,
N/V/D; acute adrenal insufficiency may be precipitated by physical stresses (shock, trauma,
infection), Rx with steroids; allergic reactions (rare), visual disturbances, hemorrhagic cystitis,
albuminuria, hematuria, HTN or hypotension, minor aches, fever
Mitoxantrone (Novantrone) Uses: AML (with cytarabine), ALL, CML, prostate
CA, MS, breast CA and NHL Action: DNA-intercalating agent; inhibitor of DNA topoiso-
merase II Dose: Per specific protocols. ↓ dose in hepatic failure, leukopenia, thrombocy-
topenia; maintain hydration Caution: [D, –] Contra: Pregnancy Supplied: Inj 2 mg/mL
SE: Myelosuppression, N/V, stomatitis, alopecia (infrequent), cardiotoxicity, urine discol-
oration
Modafinil (Provigil) Uses: Improve wakefulness in patients with excessive day-
time sleepiness associated with narcolepsy Action: Possible mechanisms include al-
tered dopamine and norepinephrine release, decreased GABA-mediated neurotransmission
Dose: 200 mg PO Q morning Caution: [C, ?/–] Increases effects of warfarin, diazepam,
phenytoin; decreases effects of oral contraceptives, cyclosporine, theophylline Supplied:
Tablets 100 mg, 200 mg SE: HA, N, D, paresthesias, rhinitis, agitation Notes: Consider
lower doses in elderly patients, reduce dose by 50% in patients with hepatic impairment; use
with caution in patients with cardiovascular disease
Moexipril (Univasc) [See Table VII–3, p 614]
Molindone (Moban) Uses: Psychotic disorders Action: Piperazine phenothiazine
Dose: 50–75 mg/d, ↑ to 225 mg/d if necessary Caution: [C, ?] Narrow-angle glaucoma
Contra: Drug or alcohol-induced CNS depression Supplied: Tabs 5, 10, 25, 50, 100 mg;
conc 20 mg/mL SE: Hypotension, tachycardia, arrhythmias, extrapyramidal symptoms,
seizures, constipation, xerostomia, blurred vision
Montelukast (Singulair) Uses: Prophylaxis and Rx of chronic asthma, seasonal
allergic rhinitis Action: Leukotriene receptor antagonist Dose: Asthma: 10 mg/d PO
taken in PM Rhinitis: 10 mg qd Caution: [B, M] Supplied: Tabs 10 mg; chew tabs 4, 5 mg
SE: HA, dizziness, fatigue, rash, GI upset, Churg-Strauss syndrome Notes: Not for acute
asthma attacks
Morphine (Avinza ER, Duramorph, MS Contin, Kadian SR, Oramorph
SR, Roxanol) [C-II] Uses: Relief of severe pain Action: Narcotic analgesic
Dose: Oral: 5–30 mg q4h PRN; SR tabs 30–60 mg q8–12h (do not chew/crush) IV/IM: 2.5–15
mg q2–6h; supp 10–30 mg q4h Caution: [B (D if prolonged use or high doses at term) +/–]
Contra: Severe asthma, respiratory depression, GI obstruction Supplied: Immediate re-
lease tabs 10, 14, 20 mg; MS Contin CR tabs 15, 30, 60, 100, 200 mg; Oramorph SR CR tabs
15, 30, 60, 100 mg; Kadian SR caps 20, 30, 50, 60, 100 mg; Avinza ER caps 30, 60, 90, 120
mg; soln 10, 20, 100 mg; supp 5, 10, 20 mg; inj 2, 4, 5, 8, 10, 15 mg/mL; Duramorph preserva-
tive-free inj 0.5, 1 mg/mL; 5, 10, 20, 30 mg suppository SE: Narcotic SE (respiratory depres-
sion, sedation, constipation, N/V, pruritus) Notes: May require scheduled dosing to relieve
severe chronic pain; MS Contin commonly used SR form (do not crush)
Moxifloxacin (Avelox, Vigamox ophth) Uses: Acute sinusitis, acute bronchitis,
skin/soft tissue infections, conjunctivitis, and community-acquired pneumonia Action:
Quinolone; inhibits DNA gyrase. Spectrum: Excellent gram(+) coverage except MRSA and E
faecium. Good gram(–) coverage except P aeruginosa, S maltophilia and Acinetobacter sp. Good
anaerobic coverage Dose: 400 mg/d PO (avoid cation products, antacids)/IV qd; ophthal: 1
drop tid × 7d Caution: [C, ?/–] Quinolone sensitivity; interactions with Mg2+, Ca2+, Al2+, and Fe2+-
containing products and class IA and III antiarrhythmic agents Supplied: Tabs 400 mg, inj,
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 569
opthal 0.5% SE: Dizziness, nausea, QT prolongation, seizures, photosensitivity, tendon rup-
ture Notes: Take 4 h before or 8 h after antacids
Mupirocin (Bactroban) Uses: Impetigo; eradication of MRSA in nasal carriers
Action: Inhibits bacterial protein synthesis Dose: Topical: Apply small amount to affected
area Nasal: Apply bid in nostrils Caution: [B, ?] Do not use concurrently with other nasal
products Supplied: Oint 2%; cream 2% SE: Local irritation, rash
Muromonab-CD3 (Orthoclone OKT3) WARNING: Can cause anaphylaxis; moni-
tor fluid status Uses: Acute rejection following organ transplantation Action: Blocks
T-cell function Dose: 5 mg/d IV for 10–14 d Caution: [C, ?/–] Murine sensitivity, fluid over-
load Contra: Heart failure/fluid overload, history of seizures, pregnancy, uncontrolled HTN
Supplied: Inj 5 mg/5 mL SE: Murine antibody; fever and chills after the 1st dose (premed-
icate with steroid/APAP/antihistamine); monitor closely for anaphylaxis or pulmonary edema
Notes: Use 0.22 micron filter for administration
Mycophenolate Mofetil (CellCept) WARNING: Increased risk of infections, possi-
ble development of lymphoma Uses: Prevent organ rejection after transplant Action:
Inhibits immunologically-mediated inflammatory responses Dose: 1 g PO bid; used with
steroids and cyclosporine; ↓ in renal insufficiency or neutropenia; IV: infuse over at least 2 h;
PO: take on empty stomach, do not open capsules Caution: [C, ?/–] Supplied: Caps 250,
500 mg; inj 500 mg SE: N/V/D, pain, fever, HA, infection, HTN, anemia, leukopenia, edema
Nabumetone (Relafen) [See Table VII–1, p 613]
Nadolol (Corgard) [See Table VII–7, pp 617–18]
Nafcillin (Nallpen) [See Table VII–5, p 616]
Naftifine (Naftin) Uses: Tinea pedis, cruris, and tinea corporis Action: Antifungal
antibiotic Dose: Apply bid Caution: [B, ?] Supplied: 1% cream; gel SE: Local irritation
Nalbuphine (Nubain) Uses: Moderate/severe pain; preop and obstetrical analge-
sia Action: Narcotic agonist-antagonist; inhibits ascending pain pathways Dose: 10–20
mg IM or IV q4–6h PRN; max of 160 mg/d; single max dose, 20 mg; ↓ in hepatic insufficiency
Caution: [B (D if prolonged or high doses at term), ?] Contra: Sulfite sensitivity Supplied:
Inj 10, 20 mg/mL SE: Causes CNS depression and drowsiness; caution in patients receiving
opiates
Naloxone (Narcan) Uses: Opioid addiction (diagnosis) and overdose Action:
Competitive narcotic antagonist Dose: 0.4–2.0 mg IV, IM, or SC q5min; max total dose, 10
mg Caution: [B, ?] May precipitate acute withdrawal in addicts Supplied: Inj 0.4, 1.0
mg/mL; neonatal inj 0.02 mg/mL SE: Hypotension, tachycardia, irritability, GI upset, pul-
monary edema Notes: If no response after 10 mg, suspect nonnarcotic cause
Naltrexone (ReVia) Uses: Alcohol and narcotic addiction Action: Competitively
binds to opioid receptors Dose: 50 mg/d PO; do not give until opioid free for 7–10 d Cau-
tion: [C, M] Contra: Acute hepatitis, liver failure; opioid use Supplied: Tabs 50 mg SE:
May cause hepatotoxicity; insomnia, GI upset, joint pain, HA, fatigue
Naphazoline and Antazoline (Albalon-A Ophthalmic, others) Napha-
zoline and Pheniramine Acetate (Naphcon A) [See Table VII—12, pp
623–25]
Naproxen (Aleve, Naprosyn, Anaprox, Naprelan) [See Table VII–11, pp
621–22]
Naratriptan (Amerge) [See Table VII–16, p 629]
Nateglinide (Starlix) Uses: Type 2 DM Action: ↑ pancreatic release of insulin
Dose: 120 mg PO tid 1–30 min pc; ↓ to 60 mg tid if near target HbA1c (take 1 – 30 min before
meals) Caution: [C, –] Caution with drugs metabolized by CYP2C9/3A4 Contra: Diabetic
ketoacidosis, type I diabetes Supplied: Tabs 60, 120 mg SE: Hypoglycemia, URI; salicy-
lates, nonselective β-blockers may enhance hypoglycemia
570 VII: THERAPEUTICS
Tabs 500 mg; oral soln 125 mg/5 mL SE: Hearing loss with long-term use; rash, N/V
Notes: Do not use parenterally due to ↑ toxicity. Part of the Condon bowel prep
Nesiritide (Natrecor) Uses: Acutely decompensated CHF Action: Human B-type
natriuretic peptide Dose: 2 mcg/kg IV bolus, then 0.01 mcg/kg/min IV Caution: [C, ?/–]
Patients in whom vasodilators are not appropriate Contra: SBP < 90, cardiogenic shock
Supplied: Vials 1.5 mg SE: Hypotension, HA, GI upset, arrhythmias, ↑ Cr Notes: Re-
quires continuous BP monitoring
Nevirapine (Viramune) WARNING: Reports of fatal hepatotoxicity even after short-
term use; severe life-threatening skin reactions (Stevens-Johnson, toxic epidermal necrolysis,
and hypersensitivity reactions); monitor closely during 1st 8 wk of treatment Uses: HIV in-
fection Action: Nonnucleoside reverse transcriptase inhibitor Dose: Initially 200 mg/d for
14 d, then 200 mg bid Caution: [C, +/–] Oral contraceptive use Supplied: Tabs 200 mg;
susp 50 mg/5 mL SE: May cause life-threatening rash; HA, fever, diarrhea, neutropenia, he-
patitis Notes: Give without regard to food; not recommended to initiate in women if CD4
> 250 or men > 400 unless benefit outweighs risk of potential hepatotoxicity
Niacin (Niaspan) Uses: Adjunctive therapy in patients with significant hyperlipi-
demia Action: Inhibits lipolysis; decreases esterification of triglycerides; increases lipopro-
tein lipase activity Dose: 1–6 g PO in divided doses tid; max of 9 g/d Caution: [A (C if
doses > RDA), +] Contra: Liver disease, peptic ulcer, arterial hemorrhage Supplied: SR
caps 125, 250, 300, 400, 500 mg; tabs 25, 50, 100, 250, 500 mg; SR tabs 150, 250, 500, 750
mg; elixir 50 mg/5 mL SE: Upper body and facial flushing and warmth following dose; may
cause GI upset; HA, flatulence, paresthesias, liver damage, may exacerbate peptic ulcer,
gout; may worsen glucose control in DM Notes: Administer with food; flushing may be ↓ by
taking an aspirin or NSAID 30–60 min before dose
Nicardipine (Cardene) Uses: Chronic stable angina and HTN; prophylaxis of mi-
graine Action: Ca channel blocker Dose: Oral: 20–40 mg PO tid SR: 30–60 mg PO bid
IV: 5 mg/h IV cont inf; ↑ by 2.5 mg/h q15min to max 15 mg/h; ↓ dose in renal/hepatic impair-
ment Caution: [C, ?/–] Heart block, CAD Contra: Cardiogenic shock Supplied: Caps
20, 30 mg; SR caps 30, 45, 60 mg; inj 2.5 mg/mL SE: Flushing, tachycardia, hypotension,
edema, HA Notes: Oral-to-IV conversion: 20 mg tid = 0.5 mg/h, 30 mg tid = 1.2 mg/h, 40 mg
tid = 2.2 mg/h; take with food (not high fat)
Nicotine Gum (Nicorette [OTC]) Uses: Aid to smoking cessation for the relief
of nicotine withdrawal Action: Provides systemic delivery of nicotine Dose: Chew 9–12
pieces/d PRN; max 30 pieces/d Caution: [C, ?] Contra: Life-threatening arrhythmias, un-
stable angina Supplied: 2 mg, 4 mg/piece; mint, orange, original flavors SE: Tachycardia,
HA, GI upset, hiccups Notes: Patients must stop smoking and perform behavior modifica-
tion for max effect
Nicotine Nasal Spray (Nicotrol NS) Uses: Aid to smoking cessation for the re-
lief of nicotine withdrawal Action: Provides systemic delivery of nicotine Dose: 0.5
mg/actuation; 1–2 sprays/h, not to exceed 10 sprays/h Caution: [D, M] Contra: Life-
threatening arrhythmias, unstable angina Supplied: Nasal inhaler 10 mg/mL SE: Local ir-
ritation, tachycardia, HA, taste perversion Notes: Patients must stop smoking and perform
behavior modification for max effect
Nicotine Transdermal (Habitrol, Nicoderm CQ [OTC], Nicotrol [OTC])
Uses: Aid to smoking cessation for the relief of nicotine withdrawal Action: Provides
systemic delivery of nicotine Dose: Individualized to the patient’s needs; apply 1 patch
(14–22 mg/d), and taper over 6 wk Caution: [D, M] Contra: Life-threatening arrhythmias,
unstable angina Supplied: Habitrol and Nicoderm CQ 7, 14, 21 mg of nicotine/24 h; Nicotrol
5, 10, 15 mg/24 h; SE: Insomnia, pruritus, erythema, local site reaction, tachycardia
Notes: Nicotrol to be worn for 16 h to mimic smoking patterns; others worn for 24 h; patients
must stop smoking and perform behavior modification for max effect
Nifedipine (Procardia, Procardia XL, Adalat, Adalat CC) Uses: Vasospas-
tic or chronic stable angina and HTN; tocolytic Action: Ca channel blocker Dose: SR
572 VII: THERAPEUTICS
tabs 30–90 mg/d Tocolysis: 10–20 mg PO q4–6h Caution: [C, +] Heart block, aortic steno-
sis Contra: Immediate-release preparation for urgent or emergent HTN; acute MI Sup-
plied: Caps 10, 20 mg; SR tabs 30, 60, 90 mg SE: HA common on initial treatment; reflex
tachycardia may occur with regular release dosage forms; peripheral edema, hypotension,
flushing, dizziness Notes: Adalat CC and Procardia XL not interchangeable; sublingual ad-
ministration is neither safe nor effective and should be abandoned
Nilutamide (Nilandron) WARNING: Interstitial pneumonitis possible; most cases in
1st 3 mo; follow chest x-ray before treatment Uses: Combination with surgical castration
for metastatic prostate CA Action: Nonsteroidal antiandrogen Dose: 300 mg/d PO in ÷
doses for 30 d, then 150 mg/d Caution: [C, ?] Contra: Severe hepatic impairment or res-
piratory insufficiency Supplied: Tabs 150 mg SE: Hot flashes, loss of libido, impotence,
N/V/D, gynecomastia, hepatic dysfunction (follow LFTs), interstitial pneumonitis Notes: May
cause a severe reaction when taken with alcohol
Nimodipine (Nimotop) Uses: Prevent vasospasm after subarachnoid hemor-
rhage Action: Ca channel blocker Dose: 60 mg PO q4h for 21 d; ↓ dose in hepatic failure
Caution: [C, ?] Supplied: Caps 30 mg SE: Hypotension, HA, constipation Notes: Con-
tents of caps may be administered via NG tube if caps cannot be swallowed whole
Nisoldipine (Sular) Uses: HTN Action: Ca channel blocker Dose: 10–60 mg/d
PO; do not take with grapefruit juice or high-fat meal; ↓ starting doses in elderly or hepatic im-
pairment Caution: [C, ?] Contra: N/A Supplied: ER tabs 10, 20, 30, 40 mg SE:
Edema, HA, flushing
Nitrofurantoin (Macrodantin, Furadantin, Macrobid) WARNING: Pulmonary
reactions possible Uses: Prevention and treatment of UTI Action: Bacteriostatic; inter-
feres with carbohydrate metabolism Spectrum: Susceptible gram(–) and some gram(+) bacte-
ria; Pseudomonas, Serratia, and most Proteus sp. generally resistant Dose: Suppression:
50–100 mg/d PO Treatment: 50–100 mg PO qid. Take with food, milk, or antacid Caution:
[B, +] Avoid if CrCl < 50 mL/min, pregnant at term Supplied: Caps and tabs 50, 100 mg; SR
caps 100 mg; susp 25 mg/5 mL SE: GI side effects common; dyspnea and a variety of acute
and chronic pulmonary reactions, peripheral neuropathy Notes: Macrocrystals (Macrodan-
tin) cause less nausea than other forms of the drug
Nitroglycerin (Nitrostat, Nitrolingual, Nitro-Bid Ointment, Nitro-Bid IV,
Nitrodisc, Transderm-Nitro, Others) Uses: Angina pectoris, acute and pro-
phylactic therapy, CHF, BP control Action: Relaxation of vascular smooth muscle, dilates
coronary arteries Dose Sublingual: 1 tab q5min SL PRN for 3 doses Translingual: 1–2 met-
doses sprayed onto oral mucosa q3–5min, max 3 doses Oral: 2.5–9 mg tid IV: 5–20 mcg/min,
titrated to effect Topical: Apply 1⁄2 in. of oint to the chest wall tid, wipe off at night TD: 0.2–0.4
mg/h/patch qd Caution: [B, ?] Restrictive cardiomyopathy Contra: IV: Pericardial tampon-
ade, constrictive pericarditis PO: Concurrent use with sildenafil, tadalafil, vardenafil, head
trauma, closed-angle glaucoma Supplied: SL tabs 0.3, 0.4, 0.6 mg; translingual spray 0.4
mg/dose; SR caps 2.5, 6.5, 9, 13 mg; SR tabs 2.6, 6.5, 9.0 mg; inj 0.5, 5, 10 mg/mL; oint 2%;
TD patches 0.1, 0.2, 0.4, 0.6 mg/hr; buccal CR 2, 3 mg SE: HA, hypotension, lightheaded-
ness, GI upset Notes: Tolerance to nitrates develops with chronic use after 1–2 wk; can be
avoided by providing a nitrate-free period each day, using shorter-acting nitrates tid, and re-
moving long-acting patches and oint before hs to prevent tolerance
Nitroprusside (Nipride, Nitropress) Uses: Hypertensive crisis, CHF, con-
trolled hypotension periop (↓ bleeding), aortic dissection, pulmonary edema Action: ↓
SVR Dose: 0.5–10 mcg/kg/min IV inf, titrated to effect; usual dose 3 mcg/kg/min Caution:
[C, ?] Decreased cerebral perfusion Contra: High output failure, compensatory HTN Sup-
plied: Inj 25 mg/mL SE: Excessive hypotensive effects, palpitations, HA Notes: Thio-
cyanate, the metabolite, excreted by the kidney; thiocyanate toxicity at levels of 5–10 mg/dL,
more likely when used for > 2–3 d; if used to treat aortic dissection, use β-blocker concomi-
tantly
Nizatidine (Axid) Uses: Duodenal ulcers, GERD, heartburn Action: H2-receptor
antagonist Dose: Active ulcer: 150 mg PO bid or 300 mg PO hs; maint 150 mg PO hs
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 573
GERD: 300 mg PO bid; maint PO bid Heartburn: 75 mg PO bid. ↓ dose in renal impairment
Caution: [B, +] Supplied: Caps 75, 150, 300 mg SE: Dizziness, HA, constipation, diar-
rhea; 75 mg tabs available OTC
Norepinephrine (Levophed) Uses: Acute hypotension, cardiac arrest (adjunct)
Action: Peripheral vasoconstrictor acting on both the arterial and venous beds Dose: 8–12
mcg/min IV, titrate to effect Caution: [C, ?] Contra: Hypotension due to hypovolemia
Supplied: Inj 1 mg/mL SE: Bradycardia, arrhythmia Notes: Correct blood volume deple-
tion as much as possible prior to vasopressor therapy; interaction with TCAs leads to severe
HTN; infuse into large vein to avoid extravasation; phentolamine 5–10 mg/10 mL NS injected
locally for extravasation
Norethindrone Acetate/Ethinyl Estradiol (FemHRT) Uses: Treatment of
moderate to severe vasomotor symptoms associated with menopause; prevention of
osteoporosis Action: Hormone replacement Dose: 1 tab qd Caution [X, –] Supplied:
1 mg norethindrone/5 mcg ethinyl estradiol tabs SE: Thrombosis, dizziness, HA, libido
changes Notes: Use in women with intact uterus.
Norfloxacin (Noroxin, Chibroxin Ophth) Uses: Complicated and uncompli-
cated UTI due to gram(–) bacteria, prostatitis, gonorrhea and infectious diarrhea Ac-
tion: Quinolone, inhibits DNA gyrase Spectrum: Susceptible infections due to E faecalis, E
coli, K pneumoniae, P mirabilis, P aeruginosa, S epidermidis, S saprophyticus Dose: 400 mg
PO bid Gonorrhea: 800 mg single dose Prostatitis: 400 mg PO bid Caution: [C, –] Tendini-
tis/tendon rupture, quinolone sensitivity, dose ↓ in renal impairment Contra: History of hy-
persensitivity or tendinitis with fluoroquinolones Supplied: Tabs 400 mg SE:
Photosensitivity, HA, GI Notes: Drug interactions with antacids, theophylline, and caffeine;
good concentrations in the kidney and urine, poor blood levels; do not use for urosepsis
Norgestrel (Ovrette) Uses: Contraceptive Action: Prevent follicular maturation
and ovulation Dose: 1 tab/d PO; begin day 1 of menses Caution: [X, ?] Contra: Throm-
boembolic disorders, breast CA, pregnancy, severe hepatic disease Supplied: Tabs 0.075
mg SE: Edema, breakthrough bleeding, thromboembolism Notes: Progestin-only products
have higher risk of failure in prevention of pregnancy
Nortriptyline (Aventyl, Pamelor) WARNING: Pediatric: Antidepressants increase
risk of suicidality; consider risks and benefits of use. Patients should be closely monitored for
clinical worsening, suicidality, or unusual changes in behavior Uses: Endogenous depres-
sion Action: TCA; increases the synaptic CNS concentrations of serotonin and/or norepi-
nephrine Dose: 25 mg PO tid–qid; doses > 150 mg/d not recommended Elderly: 10–25 mg
hs; ↓ dose with hepatic insufficiency Caution: [D, +/–] Narrow-angle glaucoma, CV disease
Contra: TCA hypersensitivity, concomitant use of MAOI Supplied: Caps 10, 25, 50, 75 mg;
soln 10 mg/5 mL SE: Many anticholinergic side effects (blurred vision, urinary retention, dry
mouth) Notes: Max effect seen after 2 wk of therapy
Nystatin (Mycostatin) Uses: Mucocutaneous Candida infections (oral, skin, vagi-
nal) Action: Alters membrane permeability Spectrum: Susceptible Candida sp. Dose: Oral:
400,000–600,000 units PO “swish and swallow” qid Vaginal: 1 tab vaginally hs for 2 wk Topi-
cal: Apply bid–tid to affected area Caution: [B (C oral), +] Contra: N/A Supplied: Oral
susp 100,000 units/mL; oral tabs 500,000 units; troches 200,000 units; vaginal tabs 100,000
units; topical cream and oint 100,000 units/g SE: GI upset, Stevens-Johnson syndrome
Notes: Not absorbed orally; not effective for systemic infections
Octreotide (Sandostatin, Sandostatin LAR) Uses: Suppresses/inhibits se-
vere diarrhea associated with carcinoid and neuroendocrine GI tumors (i.e., VIPoma,
ZE syndrome); bleeding esophageal varices Action: Long-acting peptide; mimics
natural hormone somatostatin Dose: 100–600 mcg/d SC/IV in 2–4 ÷ doses; initiate at
50 mcg qd–bid Sandostatin LAR (depot): 10–30 mg IM q4wk Caution: [B, +] Hepatic/
renal impairment Supplied: Inj 0.05, 0.1, 0.2, 0.5, 1 mg/mL; 10, 20, 30 mg/5 mL depot SE:
N/V, abdominal discomfort, flushing, edema, fatigue, cholelithiasis, hyper-/hypoglycemia,
hepatitis
574 VII: THERAPEUTICS
bleeding q28d; may also reduce uterine bleeding and dysmenorrhea Dose: 28-d cycle pills
taken qd; 21-d cycle pills taken qd, no pills taken during the last 7 d of the cycle (during
menses); some products now available as transdermal patch Caution: [X, +] Migraine,
HTN, diabetes, sickle cell disease, gallbladder disease Contra: Undiagnosed abnormal vagi-
nal bleeding, pregnancy, estrogen-dependent malignancy, hypercoagulation disorders, liver
disease, hemiplegic migraine, and smokers > 35 y Supplied: 28-d cycle pills (21 hormonally
active pills + 7 placebo/Fe supplementation); 21-d cycle pills (21 hormonally active pills).
SE: Intramenstrual bleeding, oligomenorrhea, amenorrhea, increased appetite/weight gain,
loss of libido, fatigue, depression, mood swings, mastalgia, HAs, melasma, ↑ vaginal dis-
charge, acne/greasy skin, corneal edema, nausea Notes: Taken correctly, 99.9% effective
for preventing pregnancy; not protective against STDs; encourage additional barrier contra-
ceptive. Long term, can ↓ risk of ectopic pregnancy, benign breast disease, ovarian and uter-
ine CA Treatment for menstrual cycle control: Start with a monophasic pill. Pill must be taken
for 3 mo before switching to another brand. If abnormal bleeding continues, change to pill with
higher estrogen dose Treatment for birth control: Choose pill with most beneficial side effect
profile for particular patient. Side effects numerous and due to symptoms of estrogen excess
or progesterone deficiency. Each pill’s side effect profile is unique (found in package insert);
tailor treatment to specific patient
Orlistat (Xenical) Uses: Management of obesity in patients with BMI ≥ 30 kg/m2 or
≥ 27 kg/m2 in presence of other risk factors; type 2 DM, dyslipidemia Action: Re-
versible inhibitor of gastric and pancreatic lipases Dose: 120 mg PO tid with a fat-containing
meal Caution: [B, ?] May lower cyclosporine levels and lessen daily dose requirements for
warfarin Contra: Cholestasis, chronic malabsorption Supplied: Capsules 120 mg SE:
abdominal pain/discomfort, fatty/oily stools, fecal urgency Notes: Do not administer if meal
contains no fat. GI effects increase with higher-fat meals. Supplement with fat-soluble vitamins
Orphenadrine (Norflex) Uses: Muscle spasms Action: Central atropine-like ef-
fects cause indirect skeletal muscle relaxation, euphoria, and analgesia Dose: 100 mg PO
bid, 60 mg IM/IV q12h Caution: [C, +] Contra: Glaucoma, GI obstruction, cardiospasm,
myasthenia gravis Supplied: Tabs 100 mg; SR tabs 100 mg; inj 30 mg/mL SE: Drowsi-
ness, dizziness, blurred vision, flushing, tachycardia, constipation
Oseltamivir (Tamiflu) Uses: Prevention and treatment of influenza A and B Ac-
tion: Inhibits viral neuraminidase Dose: 75 mg PO bid for 5 d; ↓ dose in renal impairment
Caution: [C, ?/–] Supplied: Caps 75 mg, powder 12 mg/mL SE: N/V, insomnia Notes:
Initiate within 48 h of symptom onset or exposure
Oxacillin (Bactocill, Prostaphlin) [See Table VII–5, p 616]
Oxaprozin (Daypro) [See Table VII–11, pp 621–22]
Oxazepam (Serax) [C-IV] Uses: Anxiety, acute alcohol withdrawal, anxiety with
depressive symptoms Action: Benzodiazepine Dose: 10–15 mg PO tid–qid; severe
anxiety and alcohol withdrawal may require up to 30 mg qid; avoid abrupt discontinuation
Caution: [D, ?] Contra: N/A Supplied: Caps 10, 15, 30 mg; tabs 15 mg SE: Sedation,
ataxia, dizziness, rash, blood dyscrasias, dependence Notes: Metabolite of diazepam (Val-
ium)
Oxcarbazepine (Trileptal) Uses: Partial seizures Action: Blocks voltage-sensi-
tive Na+ channels, resulting in stabilization of hyperexcited neural membranes Dose: 300
mg PO bid, ↑ dose weekly to target maintenance dose of 1200–2400 mg/d. ↓ dose in renal in-
sufficiency Caution: [C, –] Possible cross-sensitivity to carbamazepine Supplied: Tabs
150, 300, 600 mg SE: Hyponatremia, HA, dizziness, fatigue, somnolence, GI upset,
diplopia, mental concentration difficulties Notes: Do not abruptly discontinue
Oxiconazole (Oxistat) Uses: Tinea pedis, tinea cruris, and tinea corporis Ac-
tion: Antifungal antibiotic Dose: Apply bid Spectrum: Effective against most strains of Epi-
dermophyton floccosum, Trichophyton mentagrophytes, Trichophyton rubrum, Malassezia
furfur Caution: [B, M] Supplied: Cream 1%; lotion SE: Local irritation
576 VII: THERAPEUTICS
tumors Supplied: Inj 6 mg/mL, Abraxane - 5 mg/mL albumin-bound drug SE: Myelosup-
pression, peripheral neuropathy, transient ileus, myalgia, bradycardia, hypotension, mucositis,
N/V/D, fever, rash, HA, and phlebitis; hematologic toxicity schedule-dependent; leukopenia
dose-limiting by 24-h inf; neurotoxicity dose-limiting by short (1–3 h) inf Notes: Hypersensi-
tivity reactions (dyspnea, hypotension, urticaria, rash) usually within 10 min of starting inf; min-
imize with corticosteroid, antihistamine (H1- and H2-antagonist) pretreatment
Palonosetron (Aloxi) WARNING: May prolong QTc interval Uses: Prevention of
acute and delayed nausea and vomiting with moderately and highly emetogenic cancer
chemotherapy Action: 5HT3 serotonin receptor antagonist Dose: 0.25 mg IV 30 min be-
fore chemotherapy; do not repeat within 7 d Caution: [B, ?] Supplied: 0.25 mg/5 mL vial
SE: Headache, constipation, dizziness, abdominal pain, and anxiety
Pamidronate (Aredia) Uses: Hypercalcemia of malignancy and Paget’s disease;
palliation of symptomatic bone metastases Action: Inhibition of normal and abnormal
bone resorption Dose: Hypercalcemia: 60 mg IV over 4 h or 90 mg IV over 24 h Paget’s dis-
ease: 30 mg/d IV for 3 d; slow inf rate necessary Caution: [D, ?/–] Contra: Pregnancy
Supplied: Powder for inj 30, 60, 90 mg SE: Fever, tissue irritation at inj site, uveitis, fluid
overload, HTN, abdominal pain, N/V, constipation, UTI, bone pain, hypokalemia, hypocal-
cemia, hypomagnesemia, and hypophosphatemia Notes: Slow infusion rate necessary
Pancrelipase (Pancrease, Cotazym, Creon, Ultrase) Uses: Exocrine pan-
creatic secretion deficiency (CF, chronic pancreatitis, other pancreatic insufficiency)
and for steatorrhea of malabsorption syndrome Action: Pancreatic enzyme supplemen-
tation Dose: 1–3 caps (tabs) with meals and snacks; dosage ↑ to 8 caps (tabs); do not
crush or chew enteric-coated products; dosage is dependent on digestive requirements of pa-
tient; avoid antacids Caution: [C, ?/–] Contra: Hypersensitivity to pork products Sup-
plied: Caps, tabs SE: N/V, abdominal cramps Notes: Each patient requiring pancreatic
supplementation should receive individualized enzymatic therapy
Pancuronium (Pavulon) Uses: Treatment of patients on mechanical ventilation
Action: Nondepolarizing neuromuscular blocker Dose: 2–4 mg IV q2–4h PRN; ↓ dose for
renal/hepatic impairment; intubate patient and keep on controlled ventilation; use an adequate
amount of sedation or analgesia Caution: [C, ?/–] Supplied: Inj; 1, 2 mg/mL SE: Tachy-
cardia, HTN, pruritus, other histamine reactions
Pantoprazole (Protonix) [See Table VII–14, p 627]
Paregoric (Camphorated Tincture of Opium) [C-III] Uses: Diarrhea, pain,
and neonatal opiate withdrawal syndrome Action: Narcotic Dose: 5–10 mL PO qd–qid
PRN Caution: [B (D if prolonged use or high dose near term, +] Contra: Convulsive disor-
der Supplied: Liq 2 mg morphine = 20 mg opium/5 mL SE: Hypotension, sedation, consti-
pation Notes: Contains anhydrous morphine from opium; short-term use only
Paroxetine (Paxil, Paxil CR) WARNING: Pediatric: Antidepressants may increase
risk of suicidality; consider risks and benefits of use. Patients should be closely monitored for
clinical worsening, suicidality, or unusual changes in behavior Uses: Depression, OCD,
panic disorder, social anxiety disorder, PMDD Action: Serotonin reuptake inhibitor
Dose: 10–60 mg PO single daily dose in AM; CR 25 mg/d PO; ↑ 12.5 mg/wk (max range
26–62.5 mg/d) Caution: [B ?/– ] Contra: MAOI Supplied: Tabs 10, 20, 30, 40 mg; susp
10 mg/5 mL; CR 12.5, 25 mg SE: Sexual dysfunction, HA, somnolence, dizziness, GI upset,
diarrhea, xerostomia, tachycardia
Pegfilgrastim (Neulasta) Uses: ↓ The frequency of infection in patients with
nonmyeloid malignancies receiving myelosuppressive anticancer drugs that cause
febrile neutropenia Actions: Colony-stimulating factor Dose: 6 mg SC × 1 per chemo
cycle; never give between 14 d before and 24 h after dose of cytotoxic chemotherapy Cau-
tion: [C, M] Caution in sickle cell Contra: Hypersensitivity to drugs used to treat E coli or to
filgrastim Supplied: Syringes: 6 mg/0.6 mL SE: HA, fever, weakness, fatigue, dizziness,
insomnia, edema, N/V/D, stomatitis, anorexia, constipation, taste perversion, dyspepsia, ab-
dominal pain, granulocytopenia, neutropenic fever, ↑ LFT, uric acid, arthralgia, myalgia, bone
pain, ARDS, alopecia, splenic rupture, aggravation of sickle cell disease
578 VII: THERAPEUTICS
phases of protein synthesis at the ribosomes Spectrum: Susceptible infections due to van-
comycin-resistant Enterococcus faecium, methicillin-susceptible S aureus, and S pyogenes;
NOT active against E faecalis Dose: 7.5 mg/kg IV q8–12h (use central line if possible); not
compatible with NS or heparin; therefore, flush IV lines with dextrose; ↓ in hepatic failure
Caution: [B, M] Contra: Hypersensitivity Supplied: Inj 500 mg (150 mg quinupristin/350
mg dalfopristin) SE: Hyperbilirubinemia, inf site reactions and pain, arthralgia, myalgia
Notes: Multiple drug interactions (e.g., cyclosporine)
Rabeprazole (Aciphex) [See Table VII–14, p 627]
Raloxifene (Evista) Uses: Prevention of osteoporosis Action: Partial antagonist
of estrogen that behaves like estrogen Dose: 60 mg/d Caution: [X, –] Contra: Throm-
boembolism, pregnancy Supplied: Tabs 60 mg SE: Chest pain, insomnia, rash, hot
flashes, GI upset, hepatic dysfunction
Ramipril (Altace) [See Table VII–3, p 614]
Ranitidine (Zantac) Uses: Duodenal ulcer, active benign ulcers, hypersecretory
conditions, and GERD Action: H2-receptor antagonist Dose: Ulcer: 150 mg PO bid, 300
mg PO hs, or 50 mg IV q6–8h; or 400 mg IV/d cont inf, then maintenance of 150 mg PO hs
Hypersecretion: 150 mg PO bid, up to 600 mg/d GERD: 300 mg PO bid; maintenance 300 mg
PO hs; ↓ dose in renal failure Caution: [B, +] Supplied: Tabs 75, 150, 300 mg; syrup 15
mg/mL; inj 25 mg/mL SE: Dizziness, sedation, rash, GI upset Notes: Oral and parenteral
doses differ; available OTC in 75 mg and 150 mg tabs
Repaglinide (Prandin) Uses: Type 2 DM Action: Stimulates insulin release from
pancreas Dose: 0.5–4 mg PO ac, start 1–2 mg, ↑ to 16 mg/d max; take pc Caution: [C,
?/–] Contra: DKA, type 1 DM Supplied: Tabs 0.5, 1, 2 mg SE: HA, hyper-/hypo-
glycemia, GI upset
Reteplase (Retavase) Uses: Post-AMI Action: Thrombolytic agent Dose: 10
units IV over 2 min, 2nd dose in 30 min 10 units IV over 2 min Caution: [C, ?/–] Contra:
Internal bleeding, spinal surgery or trauma, history of CVA vascular malformations, uncon-
trolled hypotension, sensitivity to thrombolytics Supplied: Inj 10.8 units/2 mL SE: Bleed-
ing, allergic reactions
Ribavirin (Virazole) Uses: RSV infection in infants and hepatitis C (in combina-
tion with interferon alfa-2b) Action: Unknown Dose: RSV: 6 g in 300 mL sterile water
inhaled over 12–18 h Hep C: 600 mg PO bid in combination with interferon alfa-2b (see Rebe-
tron, p 000) Caution: [X, ?] Contra: Pregnancy, autoimmune hepatitis, CrCl < 50 mL/min
Supplied: Powder for aerosol 6 g; caps 200 mg SE: May accumulate on soft contact lenses;
fatigue, HA, GI upset, anemia, myalgia, alopecia, bronchospasm Notes: Aerosolized by a
SPAG; monitor Hgb/Hct frequently; PRG test monthly
Rifabutin (Mycobutin) Uses: Prevention of M avium complex infection in AIDS
patients with a CD4 count < 100 Action: Inhibits DNA-dependent RNA polymerase activity
Dose: 150–300 mg/d PO Caution: [B; ?/–] WBC < 1000/mm3 or platelets < 50,000/mm3; ri-
tonavir Contra: Hypersensitivity Supplied: Caps 150 mg SE: Discolored urine, rash,
neutropenia, leukopenia, myalgia, ↑ LFTs Notes: Adverse effects/drug interactions similar
to rifampin
Rifampin (Rifadin) Uses: TB and treatment and prophylaxis of N meningitidis, H
influenzae, and S aureus carriers; adjunct for severe S aureus Action: Inhibits DNA-de-
pendent RNA polymerase activity Dose: N meningitidis and H influenzae: Carrier 600 mg/d
PO for 4 d TB: 600 mg PO or IV qd or 2×/wk with combination therapy regimen; ↓ dose in he-
patic failure Caution: [C, +] Amprenavir, multiple drug interactions Contra: Hypersensitiv-
ity, presence of active N meningitidis infection Supplied: Caps 150, 300 mg; inj 600 mg
SE: Orange-red discoloration of bodily fluids, increased LFTs, flushing, HA Notes: Never
use as single agent for active TB; multiple drug interactions; concomitant use with
saquinavir/ritonavir may cause hepatitis
Rifapentine (Priftin) Uses: Pulmonary TB Action: Inhibits DNA-dependent RNA
polymerase activity Spectrum: Mycobacterium tuberculosis Dose: Intensive phase: 600 mg
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 587
PO 2×/wk for 2 mo; separate doses by 3 or more days Continuation phase: 600 mg/wk PO for
4 mo; should be part of 3–4 drug regimen Caution: [C, red/orange breast milk] Drug Inter-
actions: ↓ Efficacy of protease inhibitors, antiepileptics, β-blockers, calcium channel blockers
Contra: Hypersensitivity to rifamycins Supplied: 150 mg tablets SE: Neutropenia, hyper-
uricemia, HTN, HA, dizziness, rash, GI upset, blood dyscrasias, increased LFTs, hematuria,
discolored secretions Notes: Monitor LFTs if history of liver dysfunction
Rimantadine (Flumadine) Uses: Prophylaxis and treatment of influenza A viral
infections Action: Antiviral agent Dose: 100 mg PO bid; change to qd in severe renal/he-
patic impairment and elderly; initiate within 48 h of symptom onset Caution: [C, breastfeed-
ing unsafe] Drug Interactions: Cimetidine Supplied: Tabs 100 mg; syrup 50 mg/5 mL
(raspberry) SE: Orthostatic hypotension, edema, dizziness, GI upset, lowered seizure
threshold Notes: Avoid in pregnancy or breastfeeding
Rimexolone (Vexol Ophthalmic) [See Table VII–12, pp 623–25]
Risedronate (Actonel) Uses: Paget’s disease; treat/prevent glucocorticoid-in-
duced osteoporosis or postmenopausal osteoporosis Action: Bisphosphonate; inhibits
osteoclast-mediated bone resorption Dose: Paget’s: 30 mg/d PO for 2 mo Osteoporosis
treatment/prevention: 5 mg PO qd or 35 mg PO qwk; take 30 min before 1st food/drink of the
day, and maintain upright position for at least 30 min after administration. Not recommended
in CrCl < 30 mL/min Caution: [C, ?/–] Calcium supplements and antacids decrease absorp-
tion Contra: Hypersensitivity, hypocalcemia, esophageal abnormalities, unable to stand/sit
for 30 min Supplied: Tabs 5, 30 mg, and 35 mg SE: HA, diarrhea, abdominal pain,
arthralgia; flu-like symptoms, rash, esophagitis, bone pain Notes: Monitor alkaline phos-
phatase, Ca2+, Phos, K+ periodically
Risperidone (Risperdal) WARNING: May increase risk of hyperglycemia and dia-
betes Uses: Psychotic disorders (schizophrenia), dementia of the elderly, bipolar disor-
der, mania, Tourette’s disorder, autism Action: Benzisoxazole antipsychotic agent
Dose: 0.5–6 mg PO bid; ↓ starting doses in elderly, renal/hepatic impairment Caution: [C,
–] ↑ hypotension with antihypertensives, clozapine Supplied: Tabs 0.25, 0.5, 1, 2, 3, 4 mg;
soln 1 mg/mL SE: Orthostatic hypotension, extrapyramidal reactions with higher doses,
tachycardia, arrhythmias, sedation, dystonias, neuroleptic malignant syndrome, sexual dys-
function, constipation, xerostomia, blood dyscrasias, cholestatic jaundice, weight gain
Notes: May take several weeks to see effect
Ritonavir (Norvir) Uses: HIV infection Actions: Protease inhibitor; inhibits maturation
of immature noninfectious virions to mature infectious virus Dose: Start at 300 mg PO bid
and titrate over 1 week to 600 mg PO bid (titration ↓ GI SE); dose adjustments required with
amprenavir, indinavir, nelfinavir and saquinavir; take with food Caution: [B, +] Drug Interac-
tions: ergotamine, amiodarone, bepridil, flecainide, propafenone, quinidine, pimozide, midazo-
lam, triazolam Supplied: Caps 100 mg; soln 80 mg/mL SE: ↑ triglycerides, ↑ LFTs,
N/V/D/C, abdominal pain, taste perversion, anemia, weakness, HA, fever, malaise, rash,
paresthesias Notes: Store in refrigerator
Rivastigmine (Exelon) Uses: Mild/moderate dementia associated with
Alzheimer’s disease Action: Enhances cholinergic activity Dose: 1.5 mg PO bid; ↑ to 6
mg bid, with increases at 2-wk intervals (take with food) Caution: [B, ?] β-Blockers, CA+
channel blockers, smoking, neuromuscular blockade, digoxin Contra: Hypersensitivity to ri-
vastigmine or carbamates Supplied: Caps 1.5, 3, 4.5, 6 mg; soln 2 mg/mL SE: Dose-re-
lated GI adverse effects (A/N/V/D); dizziness, insomnia, fatigue, tremor, diaphoresis, HA
Notes: Swallow capsules whole, do not break, chew, or crush; avoid concurrent ethanol use
Rizatriptan (Maxalt, Maxalt MLT) [See Table VII–16, p. 629]
Rocuronium (Zemuron) Uses: Skeletal muscle relaxation during rapid-sequence
intubation, surgery, or mechanical ventilation. Action: Nondepolarizing neuromuscular
blockade Dose: Rapid sequence intubation: 0.6–1.2 mg/kg IV. Continuous infusion 4–16
mcg/kg/min IV; reduce dose in patients with hepatic impairment Caution: [C, ?] Aminogly-
cosides, vancomycin, tetracycline, polymyxins enhance blockade Supplied: 10 mg/mL 5-,
10-mL vials SE: BP changes, tachycardia
588 VII: THERAPEUTICS
sage 5–10 mL into wet scalp, leave on 2–3 min, rinse, and repeat; use 2×/wk, then once
q1–4wk PRN Tinea versicolor: Apply 2.5% qd for 7 d on area and lather with small amounts of
water; leave on skin for 10 min, then rinse Caution: [C, ?] Contra: Open wounds Sup-
plied: Shampoo 1% [OTC], 2.5% SE: Dry or oily scalp, lethargy, hair discoloration, local irri-
tation Notes: Do not use more than 2×/wk
Sertraline (Zoloft) WARNING: Pediatric: Antidepressants may increase risk of suici-
dality; consider risks and benefits of use. Patients should be closely monitored for clinical
worsening, suicidality, or unusual changes in behavior Uses: Depression, panic disor-
ders, obsessive–compulsive disorder (OCD), post-traumatic stress disorders (PTSD),
social anxiety disorder, eating disorders, premenstrual disorders Action: Inhibits neu-
ronal uptake of serotonin Dose: Depression: 50–200 mg/d PO PTSD: 25 mg PO qd×1 wk,
then 50 mg PO qd, max 200 mg/d Caution: [C, ?/–] Haloperidol (serotonin syndrome),
sumatriptan, linezolid Contra: MAOI use within 14 d; caution in hepatic impairment, con-
comitant pimozide Supplied: Tabs 25, 50, 100 mg SE: Can activate manic/hypomanic
state; weight loss; insomnia, somnolence, fatigue, tremor, xerostomia, nausea, dyspepsia, di-
arrhea, ejaculatory dysfunction, ↓ libido, hepatotoxicity
Sevelamer (Renagel) Uses: Reduction of serum phosphorus in end-stage renal
disease Action: Binds phosphate within intestinal lumen Dose: 2–4 capsules PO tid with
meals, with subsequent adjustment based on serum phosphorus Caution: [C, ?] Contra:
Bowel obstruction Supplied: Capsules 403 mg SE: BP changes, N/V/D, dyspepsia,
thrombosis Notes: Instruct patient not to open or chew capsules; may reduce fat-soluble vit-
amin absorption; 800 mg sevelamer = 667 mg calcium acetate
Sibutramine (Meridia) [C-IV] Uses: Obesity Action: Blocks uptake of norepi-
nephrine, serotonin, and dopamine Dose: 10 mg/d PO, may ↓ to 5 mg after 4 wk Caution:
[C, –] SSRIs, lithium, dextromethorphan, opioids Contra: MAOI use within 14 d, uncon-
trolled HTN, arrhythmias Supplied: Caps 5, 10, 15 mg SE: HA, insomnia, xerostomia,
constipation, rhinitis, tachycardia, HTN Notes: Use with low-calorie diet, monitor BP and
heart rate
Sildenafil (Viagra) Uses: Erectile dysfunction Action: Smooth muscle relaxation
and increased inflow of blood to the corpus cavernosum; inhibits phosphodiesterase type 5 re-
sponsible for cGMP breakdown; ↑ cGMP activity Dose: 25–100 mg PO 1 h before sexual
activity, max dosing is once daily; ↓ dose if > 65 y (avoid fatty foods with dose) Caution: [B,
?] Potent CYP3A4 inhibitors (e.g., protease inhibitors) Contra: Nitrates; retinitis pigmentosa;
hepatic/severe renal impairment Supplied: Tabs 25, 50, 100 mg SE: HA; flushing; dizzi-
ness; blue haze visual disturbance, usually reversible; cardiac events in absence of nitrates
debatable Notes: Caution in patients with CAD
Silver Nitrate (Dey-Drop, others) Uses: Removal of granulation tissue and
warts; prophylaxis in burns Action: Caustic antiseptic and astringent Dose: Apply to
moist surface 2–3×/wk for several wk or until effect Caution: [C, ?] Contra: Do not use on
broken skin Supplied: Topical impregnated applicator sticks, oint 10%, soln 10, 25, 50%;
ophth 1% ampule SE: May stain tissue black, usually resolves; local irritation, methemoglo-
binemia Notes: Discontinue if redness or irritation develops
Silver Sulfadiazine (Silvadene) Uses: Prevention and treatment of infection in
2nd- and 3rd-degree burns Action: Bactericidal Dose: Aseptically cover the affected
area with 1⁄16-in. coating bid Caution: [B, ?/–] Supplied: Cream 1% SE: Itching, rash,
skin discoloration, blood dyscrasias, hepatitis, allergy Notes: Can have systemic absorption
with extensive application
Simethicone (Mylicon) [OTC] Uses: Flatulence Action: Defoaming action
Dose: 40–125 mg PO pc and hs PRN Caution: [C, ?] Contra: Intestinal perforation or ob-
struction Supplied: Tabs 80, 125 mg; caps 125 mg; drops 40 mg/0.6 mL SE: Diarrhea,
nausea
Simvastatin (Zocor) [See Table VII–15, p 628]
590 VII: THERAPEUTICS
Caution: [C, ?/–] Contra: Active varicella infection, serious infection except TB, fungal in-
fections Supplied: Table VII–2, p 613 Notes/SE: Hydrocortisone succinate administered
systemically, acetate form intra-articular; all can cause increased appetite, hyperglycemia, hy-
pokalemia, osteoporosis, nervousness, insomnia, “steroid psychosis,” adrenal suppression;
never abruptly stop steroids, especially in chronic treatment; taper dose
ids; avoid salicylates) Caution: [C (D if near term), ?/–] Contra: Avoid in renal impairment,
avoid salicylates; peptic ulcer; blood dyscrasias, near term pregnancy, hypersensitivity Sup-
plied: Tabs 100 mg; caps 200 mg SE: N/V, stomach pain, urolithiasis, leukopenia Notes:
Take with plenty of water
Sulindac (Clinoril) [See Table VII–11, pp 621–22]
Sumatriptan (Imitrex) [See Table VII–16, p 629])
Tacrine (Cognex) Uses: Mild/moderate Alzheimer’s dementia Action:
Cholinesterase inhibitor Dose: 10–40 mg PO qid to 160 mg/d; separate doses from food
Caution: [C, ?] Contra: Previous tacrine-induced jaundice Supplied: Caps 10, 20, 30, 40
mg SE: ↑ LFT, HA, dizziness, GI upset, flushing, confusion, ataxia, myalgia, bradycardia
Notes: Serum conc > 20ng/mL assoc with more SE, monitor LFTs
Tacrolimus [FK 506] (Prograf, Protopic) Uses: Prophylaxis of organ rejec-
tion, eczema Action: Macrolide immunosuppressant Dose: IV: 0.05–0.1 mg/kg/d as cont
inf PO: 0.15–0.3 mg/kg/d ÷ into 2 doses Eczema: Apply bid, continue 1 wk after clearing; de-
crease dose in hepatic/renal impairment Caution: [C, –] Do not use with cyclosporine
Supplied: Caps 1, 5 mg; inj 5 mg/mL; ointment 0.03, 0.1% SE: Neurotoxicity and nephro-
toxicity, HTN, edema, HA, insomnia, fever, pruritus, hypo-/hyperkalemia, hyperglycemia, GI
upset, anemia, leukocytosis, tremors, paresthesias, pleural effusion, seizures, lymphoma
Notes: Monitor serum drug levels; Serum conc > 20 see Table VII–17, p 630
Tamoxifen (Nolvadex) Uses: Breast CA (postmenopausal, estrogen receptor
positive), reduction of breast CA in high-risk women, metastatic male breast CA,
mastalgia, pancreatic CA, gynecomastia, ovulation induction Action: Nonsteroidal antiestro-
gen; mixed agonist-antagonist effect Dose: 20–40 mg/d PO (typically 10 mg bid or 20 mg/d)
Caution: [D, –] Contra: Caution in leukopenia, thrombocytopenia, hyperlipidemia Sup-
plied: Tabs 10, 20 mg SE: Uterine malignancy and thrombotic events in breast CA preven-
tion trials; menopausal symptoms (hot flashes, N/V) in premenopausal patients; vaginal
bleeding and menstrual irregularities; skin rash, pruritus vulvae, dizziness, HA, peripheral
edema; acute flare of bone metastasis pain and hypercalcemia; retinopathy reported (high
dose) Notes: ↑ Risk of pregnancy in premenopausal women by inducing ovulation
Tamsulosin (Flomax) Uses: BPH Action: Antagonist of prostatic α-receptors
Dose: 0.4 mg/d PO; do not crush, chew, or open caps Caution: [B, ?] Contra: Female
gender Supplied: Caps 0.4, 0.8 mg SE: HA, dizziness, syncope, somnolence, decreased
libido, GI upset, retrograde ejaculation, rhinitis, rash, angioedema Notes: Not for use as an-
tihypertensive
Tazarotene (Tazorac) Uses: Facial acne vulgaris; stable plaque psoriasis up to
20% body surface area Action: Keratolytic Dose: Acne: Cleanse face, dry, and apply
thin film q hs on acne lesions Psoriasis: Apply hs Caution: [X, ?/–] Contra: Retinoid sen-
sitivity Supplied: Gel 0.05, 0.1% SE: Burning, erythema, irritation, rash, photosensitivity,
desquamation, bleeding, skin discoloration Notes: Discontinue if excessive pruritus, burn-
ing, skin redness or peeling until symptoms resolve
Tegaserod maleate (Zelnorm) WARNING: Rare reports of ischemic colitis Uses:
Short-term treatment of constipation-predominant IBS in women, chronic idiopathic
constipation in pts < 65 y Action: 5HT4 serotonin agonist Dose: 6 mg PO bid pc for 4–6
wk; may continue for 2nd course Caution: [B, ?/–] Contra: Severe renal, moderate-se-
vere hepatic impairment, history of bowel obstruction, gallbladder disease, sphincter of Oddi
dysfunction, abdominal adhesions Supplied: Tabs 2, 6 mg SE: Do not administer if diar-
rhea is present because drug increases GI motility; discontinue if abdominal pain worsens
Notes: Maintain adequate hydration
Telmisartan (Micardis) [See Table VII–4, p 615]
Temazepam (Restoril) [C-IV] Uses: Insomnia, anxiety, depression, panic at-
tacks Action: Benzodiazepine Dose: 15–30 mg PO hs PRN; ↓ dose in elderly Caution:
[X; ?/–] potentiates CNS depressive effects of opioids, barbiturates, alcohol, antihistamines,
MAOIs, TCAs Contra: Narrow-angle glaucoma Supplied: Caps 7.5, 15, 30 mg SE:
GENERIC DRUGS: INDICATIONS, ACTIONS, DOSAGE, SUPPLIED, & NOTES 595
Confusion, dizziness, drowsiness, hangover Notes: Abrupt discontinuation after > 10 days
of use may cause withdrawal
Tenecteplase (TNKase) Uses: Restore perfusion and reduce mortality with
acute MI Action: Thrombolytic; TPA Dose: 30–50 mg; see following table:
Weight (kg) TNKase (mg) Volume TNKase*(mL)
< 60 30 6
≥ 60 to < 70 35 7
≥ 70 to < 80 40 8
≥ 80 to < 90 45 9
≥ 90 50 10
*From one vial of reconstituted TNKase.
Caution: [C, ?] ↑ bleeding with concurrent NSAIDs, ticlodipine, clopidogrel, GPIIb/IIIa antago-
nists Contra: Bleeding, CVA, major surgery (intracranial, intraspinal) or trauma within 2 mo
Supplied: Inj 50 mg, reconstitute with 10 mL sterile water SE: Bleeding, hypersensitivity
Notes: Do not shake when reconstituting; do NOT use D5W either in the IV line or to reconsti-
tute
Teniposide (VM-26, Vumon) Uses: Small cell lung cancer, Kaposi’s sarcoma,
non-Hodgkin’s lymphoma Action: Topoisomerase II inhibitor, interfering with strand pas-
sage and DNA ligase activities of topoisomerase II. Cell cycle-specific activity at S, early G2
phase Dose: Refer to specific protocol.↓ dose in Down’s syndrome, leukemia, renal failure;
consider adjustment in hepatic impairment Caution: [D, ?] Supplied: 10 mg/mL 5 mL am-
pule SE: Toxicity includes myelosuppression (especially leukopenia and thrombocytopenia),
hypotension, chemical phlebitis, skin rashes, hypertension, hypersensitivity reactions (ur-
ticaria, flushing, rashes, or hypotension), and secondary leukemia
Tenofovir (Viread) Uses: HIV infection Action: Nucleotide reverse transcriptase in-
hibitor Dose: 300 mg po qd with a meal Caution: [B, ?/–] Didanosine (separate admin
times), lopinavir, ritonavir Contra: CrCl < 60 mL/min; caution with known risk factors for liver
disease Supplied: Tabs 300 mg SE: GI upset, metabolic syndrome, hepatotoxicity; sepa-
rate didanosine doses by 2 h Notes: Take with fatty meal; available in combination with
emtricitabine, known as Truvada
Terazosin (Hytrin) Uses: BPH and HTN Action: α1-Blocker (blood vessel and blad-
der neck/prostate) Dose: Initially, 1 mg PO hs; ↑ 20 mg/d max Caution: [C, ?] ↑ Hypoten-
sion with β-blocker, calcium channel blocker, ACEI Contra: α-Antagonist sensitivity
Supplied: Tabs 1, 2, 5, 10 mg; caps 1, 2, 5, 10 mg SE: Hypotension and syncope after 1st
dose; dizziness, weakness, nasal congestion, peripheral edema common; palpitations, GI
upset Notes: Caution with 1st dose syncope. If for HTN, combine with thiazide diuretic
Terbinafine (Lamisil) Uses: Onychomycosis, athlete’s foot, jock itch, ringworm,
cutaneous candidiasis, pityriasis versicolor Action: Inhibits squalene epoxidase result-
ing in fungal death Dose: Oral: 250 mg/d PO for 6–12 wk Topical: Apply to affected area; ↓
dose in renal/hepatic impairment Caution: [B, –] May ↑ effects of drugs metab by CYP2D6
Contra: Liver disease or kidney impairment Supplied: Tabs 250 mg; cream 1% SE: HA,
dizziness, rash, pruritus, alopecia, GI upset, taste perversion, neutropenia, retinal damage,
Stevens-Johnson syndrome Notes: Effect may take months due to need for new nail
growth; do not use occlusive dressings
Terbutaline (Brethine, Bricanyl) Uses: Reversible bronchospasm (asthma,
COPD); inhibition of labor (tocolytic) Action: Sympathomimetic Dose: Bronchodilator:
2.5–5 mg PO qid or 0.25 mg SC; may repeat in 15 min (max 0.5 mg in 4 h) Met-dose inhaler:
2 inhal q4–6h Premature labor: Acutely 2.5–10 mg/min/IV, gradually ↑ as tolerated
q10–20min; maintenance 2.5–5 mg PO q4–6h until term; ↓ dose in renal failure Caution: [B,
+] ↑ Toxicity with MAOIs, TCAs; diabetes, HTN, hyperthyroidism; tachycardia Supplied:
Tabs 2.5, 5 mg; inj 1 mg/mL; met-dose inhaler SE: HTN, hyperthyroidism; high doses may
precipitate β1-adrenergic effects; nervousness, trembling, tachycardia, HTN, dizziness
Notes: Caution with diabetes
596 VII: THERAPEUTICS
Tabs 5, 10, 25, 50, 100, 500 mg; inj 100, 200 mg/mL SE: Angioedema, paresthesias, rash,
anaphylaxis with rapid IV administration Notes: IV thiamine use associated with anaphylac-
tic reaction; must give IV slowly
Thiethylperazine (Torecan) Uses: N/V Action: Antidopaminergic antiemetic
Dose: 10 mg PO, PR, or IM qd–tid; ↓ dose in hepatic failure Caution: [X, ?] Contra: Phe-
nothiazine and sulfite sensitivity, pregnancy Supplied: Tabs 10 mg; supp 10 mg; inj 5
mg/mL SE: Extrapyramidal reactions may occur; xerostomia, drowsiness, orthostatic hy-
potension, tachycardia, confusion
6-Thioguanine [6-TG] (Tabloid) Uses: AML, ALL, CML Action: Purine-based
antimetabolite (substitutes for natural purines interfering with nucleotide synthesis) Dose:
2–3 mg/kg/d PO; ↓ dose in severe renal/hepatic impairment Caution: [D, –] Contra: Re-
sistance to mercaptopurine Supplied: Tabs 40 mg SE: Myelosuppression (especially
leukopenia and thrombocytopenia), N/V/D, anorexia, stomatitis, rash, hyperuricemia; hepato-
toxicity occurs rarely
Thioridazine (Mellaril) WARNING: Dose-related QT prolongation Uses: Schizo-
phrenia, psychosis Action: Phenothiazine antipsychotic Dose: Initially, 50–100 mg PO
tid; maintenance 200–800 mg/24 h PO in 2–4 ÷ doses. Caution: [C, ?] ↑ Phenothiazines,
QTc prolonging agents, aluminum (↓) Contra: Phenothiazine sensitivity Supplied: Tabs
10, 15, 25, 50, 100, 150, 200 mg; oral conc 30, 100 mg/mL; oral susp 25, 100 mg/5 mL SE:
Low incidence of extrapyramidal effects; ventricular arrhythmias; hypotension, dizziness,
drowsiness, neuroleptic malignant syndrome, seizures, skin discoloration, photosensitivity,
constipation, sexual dysfunction, blood dyscrasias, pigmentary retinopathy, hepatic impair-
ment Notes: Avoid alcohol, must dilute oral conc in 2–4 oz liquid
Thiotepa (see Triethylene-Triphosphamide)
Thiothixene (Navane) Uses: Psychotic disorders Action: Antipsychotic Dose:
Mild to moderate psychosis: 2 mg PO tid, up to 20–30 mg/d Severe psychosis: 5 mg PO bid; ↑
to a max of 60 mg/24 h PRN IM use: 16–20 mg/24 h ÷ bid–qid; max 30 mg/d Caution: [C, ?]
Contra: Phenothiazine sensitivity Supplied: Caps 1, 2, 5, 10, 20 mg; oral conc 5 mg/mL; inj
2, 5 mg/mL SE: Drowsiness and extrapyramidal side effects most common; hypotension,
dizziness, drowsiness, neuroleptic malignant syndrome, seizures, skin discoloration, photo-
sensitivity, constipation, sexual dysfunction, blood dyscrasias, pigmentary retinopathy, hepatic
impairment Notes: Dilute oral conc immediately before administration
Tiagabine (Gabitril) Uses: Adjunctive therapy in treatment of partial seizures,
bipolar disorder Action: Inhibition of GABA Dose: Initially 4 mg/d PO, ↑ by 4 mg during
2nd wk; ↑ PRN by 4–8 mg/d based on response, 56 mg/d/max Caution: [C, M] Supplied:
Tabs 4, 12, 16, 20 mg SE: Dizziness, HA, somnolence, memory impairment, tremors
Notes: Use gradual withdrawal; used in combination with other anticonvulsants
Ticarcillin (Ticar) [See Table VII–6, p 616]
Ticarcillin/Potassium Clavulanate (Timentin) [See Table VII–6, p 616]
Ticlopidine (Ticlid) WARNING: Neutropenia/agranulocytosis, TTP, and aplastic ane-
mia reported Uses: ↓ Risk of thrombotic stroke, protect grafts post-CABG, diabetic mi-
croangiopathy, ischemic heart disease, DVT prophylaxis, graft prophylaxis after renal
transplantation Action: Platelet aggregation inhibitor Dose: 250 mg PO bid with food
Caution: [B, ?/–] ↑ Toxicity of ASA, anticoagulants, NSAIDs, theophylline Contra: Bleeding,
hepatic impairment, neutropenia, thrombocytopenia Supplied: Tabs 250 mg SE: Bleed-
ing, GI upset, rash, ↑ on LFTs Notes: monitor hematologic status 1st 3 mo
Timolol (Blocadren) [See Table VII–7, pp 617–18]
Timolol, Ophthalmic (Timoptic) [See Table VII–12, pp 623–25]
Tinzaparin (Innohep) Uses: Treatment of DVT with or without PE Action: Low-
molecular-weight heparin Dose: 175 units/kg SC qd at least 6 d until warfarin dose stabi-
lized Caution: [B, ?] Pork hypersensitivity, active bleeding; caution in mild to moderate renal
598 VII: THERAPEUTICS
Total dose 100 mg/d PO. See product information for 8-wk titration schedule; ↓ dose in renal
failure Caution: [C, ?/–] May cause metabolic acidosis, thus requiring monitoring Sup-
plied: Tabs 25, 100, 200 mg; caps sprinkles 15, 25, 50 mg SE: May precipitate kidney
stones; fatigue, dizziness, psychomotor slowing, memory impairment, GI upset, tremor, nys-
tagmus; acute secondary angle closure glaucoma requiring drug discontinuation Notes:
May be associated with weight loss; metabolic acidosis generally responsive to dose reduc-
tion or discontinue; discontinuation requires taper
Topotecan (Hycamtin) WARNING: Chemotherapy precautions, bone marrow sup-
pression possible Uses: Ovarian CA (cisplatin-refractory), small cell lung CA, sarcoma
Action: Topoisomerase I inhibitor; interferes with DNA synthesis Dose: 1.5 mg/m2/d as a
1-h IV inf for 5 consecutive d, repeated q3wk; ↓ dose in renal failure Caution: [D, –] Sup-
plied: 4 mg vials SE: Myelosuppression, N/V/D, drug fever, skin rash
Torsemide (Demadex) Uses: Edema, HTN, CHF, and hepatic cirrhosis Action:
Loop diuretic; inhibits reabsorption of sodium and chloride in ascending loop of Henle and dis-
tal tubule Dose: 5–20 mg/d PO or IV Caution: [B, ?] Contra: Sulfonylurea sensitivity
Supplied: Tabs 5, 10, 20, 100 mg; inj 10 mg/mL SE: Orthostatic hypotension, HA, dizzi-
ness, photosensitivity, electrolyte imbalance, blurred vision, renal impairment Notes: 20 mg
torsemide equivalent to 40 mg furosemide
Tramadol (Ultram) Uses: Moderate/severe pain Action: Centrally acting analgesic
Dose: 50–100 mg PO q4–6h PRN, not to exceed 400 mg/d Caution: [C, ?/–] Contra:
Opioid dependency; MAOIs Supplied: Tabs 50 mg SE: Dizziness, HA, somnolence, GI
upset, respiratory depression, anaphylaxis (sensitivity to codeine) Notes: Lowers seizure
threshold, tolerance or dependence may develop
Tramadol/Acetaminophen (Ultracet) Uses: Short-term management of acute
pain (< 5 d) Action: Centrally acting analgesic; nonnarcotic analgesic Dose: 2 tab PO
q4–6h PRN; 8 tab/d max; Elderly/renal impairment: Use lowest possible dose; 2 tab q12h max
if CrCl < 30 Caution: [C, –] Seizures, hepatic/renal impairment, or history of addictive ten-
dencies Contra: Acute intoxication Supplied: Tabs 37.5 mg tramadol/325 mg APAP
SE: SSRIs, TCAs, opioids, MAOIs increase risk of seizures; dizziness, somnolence, tremor,
headache, N/V/D, constipation, dry mouth, liver toxicity, rash, pruritus, increased sweating,
physical dependence Notes: Avoid alcohol use
Trandolapril (Mavik) [See Table VII–3, p 614]
Trastuzumab (Herceptin) Uses: Treatment of metastatic breast cancer tumors
that overexpress the HER2/neu protein Actions: Monoclonal antibody binds to the human
epidermal growth factor receptor 2 protein (HER2); mediates cellular cytotoxicity Dose:
Refer to specific protocol Caution: [B, ?] CV dysfunction, hypersensitivity/infusion reactions
Supplied 440-mg vial SE: Anemia, cardiomyopathy, nephrotic syndrome, pneumonitis
Notes:Infusion-related reactions should be minimized with acetaminophen, diphenhydramine,
and meperidine
Trazodone (Desyrel) WARNING: Pediatric: Antidepressants may increase risk of sui-
cidality; consider risks and benefits of use. Patients should be closely monitored for clinical
worsening, suicidality, or unusual changes in behavior Uses: Depression, hypnotic, aug-
ment other antidepressants Action: Antidepressant; inhibits reuptake of serotonin and
norepinephrine Dose: 50–150 mg PO qd–qid; max 600 mg/d Sleep: 50 mg PO, qhs, PRN
Caution: [C, ?/–] Supplied: Tabs 50, 100, 150, 300 mg SE: Dizziness, HA, sedation, nau-
sea, xerostomia, syncope, confusion, tremor, hepatitis, extrapyramidal reactions Notes:
May take 1–2 wk for symptomatic improvement; may interact with CYP3A4 inhibitors to in-
crease conc, carbamazepine to decrease trazodone conc
Treprostinil Sodium (Remodulin) Uses: NYHA Class II-IV pulmonary arterial
hypertension Action: Vasodilation, inhibition of platelet aggregation Dose: 0.625-1.25
ng/kg/min continuous infusion Caution: [B, ?/–] Supplied: 1, 2.5, 5, 10 mg/mL injection
SE: Additive effects with anticoagulants, antihypertensives; infusion site reactions Notes:
Initiate in monitored setting; do not discontinue or reduce dose abruptly
600 VII: THERAPEUTICS
greater than 20 mg Caution: [B, –] Contra: Nitrates Supplied: 2.5-mg, 5-mg, 10-mg,
20-mg tabs SE: Hypotension, headache, dyspepsia, priapism Notes: Concomitant α-
blockers may cause hypotension; caution in patients with cardiovascular, hepatic or renal dis-
ease
Varicella Virus Vaccine (Varivax) Uses: Prevention of varicella (chickenpox)
infection Action: Active immunization Dose: 0.5 mL SC, repeated in 4–8 wk Caution:
[C, M] Contra: Immunocompromise; neomycin-anaphylactoid reaction, blood dyscrasias;
immunosuppressive drugs; avoid pregnancy for 3 mo after injection Supplied: Powder for
inj SE: Live attenuated virus; may cause mild varicella infection; fever, local reactions, irri-
tability, GI upset Notes: Recommended for all patients who have not had chickenpox
Vasopressin [Antidiuretic Hormone, ADH] (Pitressin) Uses: Diabetes in-
sipidus; postop treatment of abdominal distention; adjunct treatment of GI bleeding
and esophageal varices; pulseless VT and VF, adjunct systemic vasopressor (IV drip)
Action: Posterior pituitary hormone, potent GI vasoconstrictor, potent peripheral vasoconstric-
tor Dose: Diabetes insipidus: 2.5–10 units SC or IM tid–qid GI hemorrhage: 0.2–0.4
units/min; ↓ dose in cirrhosis; caution in vascular disease VT/VF: 40 units IVP× 1 Vasopres-
sor: 0.01–0.1 units/kg/min Caution: [B, +] Contra: hypersensitivity Supplied: Inj 20
units/mL SE: HTN, arrhythmias, fever, vertigo, GI upset, tremor Notes: Addition of vaso-
pressor to concurrent norepinephrine or epinephrine infusions
Vecuronium (Norcuron) Uses: Skeletal muscle relaxation during surgery or me-
chanical ventilation Action: Nondepolarizing neuromuscular blocker Dose: 0.08–0.1
mg/kg IV bolus; maint 0.010–0.015 mg/kg after 25–40 min; additional doses q12–15min PRN;
↓ dose in severe renal/hepatic impairment Caution: [C, ?] Drug interactions causing ↑ effect
of vecuronium (e.g., aminoglycosides, tetracycline, succinylcholine) Supplied: Powder for
inj 10 mg SE: Bradycardia, hypotension, itching, rash, tachycardia, CV collapse Notes:
Fewer cardiac effects than with pancuronium
Venlafaxine (Effexor) WARNING: Pediatric: Antidepressants may increase risk of
suicidality; consider risks and benefits of use. Patients should be closely monitored for clinical
worsening, suicidality, or unusual changes in behavior Uses: Depression, generalized
anxiety, social anxiety disorder; OCD, chronic fatigue syndrome, ADHD, autism Ac-
tion: Potentiation of CNS neurotransmitter activity Dose: 75–375 mg/d PO ÷ into 2–3 equal
doses; ↓ dose in renal/hepatic impairment Caution: [C, ?/–] Contra: MAOIs Supplied:
Tabs 25, 37.5, 50, 75, 100 mg; ER caps 37.5, 75, 150 mg SE: HTN, HA, somnolence, GI
upset, sexual dysfunction; actuates mania or seizures Notes: Avoid alcohol, can ↑ mean
heart rate
Verapamil (Calan, Isoptin) Uses: Angina, HTN, PSVT, AF, atrial flutter, migraine
prophylaxis, hypertrophic cardiomyopathy, bipolar disorder Action: Ca2+ channel
blocker Dose: Arrhythmias: 2nd line for PSVT with narrow QRS complex and adequate BP
2.5–5 mg IV over 1–2 min; repeat 5–10 mg in 15–30 min PRN (30 mg max) Angina: 80–120
mg PO tid, ↑ 480 mg/24 h max HTN: 80–180 mg PO tid or SR tabs 120–240 mg PO qd to 240
mg bid; ↓ dose in renal/hepatic impairment Caution: [C, +] Amiodarone/β-blockers/fle-
cainide can cause bradycardia; statins, midazolam, tacrolimus, theophylline levels may be in-
creased Contra: Conduction disorders, cardiogenic shock; caution with elderly patients
Supplied: Tabs 40, 80, 120 mg; SR tabs 120, 180, 240 mg; SR caps 120, 180, 240, 360 mg;
inj 5 mg/2 mL SE: Gingival hyperplasia, constipation, hypotension, bronchospasm, heart
rate or conduction disturbances
Vinblastine (Velban, Velbe) WARNING: Chemotherapeutic agent; handle with cau-
tion Uses: Hodgkin’s and NHLs, mycosis fungoides, CAs (testis, renal cell, breast,
non–small cell lung, AIDS-related Kaposi’s sarcoma, choriocarcinoma), histiocytosis
Action: Inhibits microtubule assembly through binding to tubulin Dose: 0.1–0.5 mg/kg/wk
(4–20 mg/m2); ↓ dose in hepatic failure Caution: [D, ?] Contra: Intrathecal use Sup-
plied: Inj 1 mg/mL SE: Myelosuppression (especially leukopenia), N/V (rare), constipation,
neurotoxicity (like vincristine but less frequent), alopecia, rash; myalgia, tumor pain
604 VII: THERAPEUTICS
Zalcitabine (Hivid) WARNING: Use with caution in patients with neuropathy, pancre-
atitis, lactic acidosis, hepatitis Uses: HIV Action: Antiretroviral agent Dose: 0.75 mg PO
tid; ↓ dose in renal failure Caution: [C, +] Supplied: Tabs 0.375, 0.75 mg SE: Periph-
eral neuropathy, pancreatitis, fever, malaise, anemia, hypo-/hyperglycemia, hepatic impair-
ment Notes: May be used in combination with zidovudine
Zaleplon (Sonata) Uses: Insomnia Action: A nonbenzodiazepine sedative hyp-
notic, a pyrazolopyrimidine Dose: 5–20 mg hs PO PRN; ↓ dose in renal/hepatic insuffi-
ciency, elderly Caution: [C, ?/–] Caution in mental/psychological conditions Supplied:
Caps 5, 10 mg SE: HA, edema, amnesia, somnolence, photosensitivity Notes: Take im-
mediately before desired onset
Zanamivir (Relenza) Uses: Influenza A and B Action: Inhibits viral neuraminidase
Dose: 2 inhal (10 mg) bid for 5 d; initiate within 48 h of symptoms Caution: [C, M] Contra:
Pulmonary disease Supplied: Powder for inhal 5 mg SE: Bronchospasm, HA, GI upset
Notes: Uses a Diskhaler for administration
Zidovudine (Retrovir) WARNING: Neutropenia, anemia, lactic acidosis, and he-
patomegaly with steatosis Uses: HIV infection, prevention of maternal transmission of
HIV Action: Inhibits reverse transcriptase Dose: 200 mg PO tid or 300 mg PO bid or 1–2
mg/kg/dose IV q4h Pregnancy: 100 mg PO 5×/d until the start of labor, then during labor 2
mg/kg over 1 h followed by 1 mg/kg/h until clamping of the umbilical cord; ↓ dose in renal fail-
ure Caution: [C, ?/–] Contra: Life-threatening hypersensitivity Supplied: Caps 100 mg;
tabs 300 mg; syrup 50 mg/5 mL; inj 10 mg/mL SE: Hematologic toxicity, HA, fever, rash, GI
upset, malaise
Zidovudine and Lamivudine (Combivir) WARNING: Neutropenia, anemia, lac-
tic acidosis, and hepatomegaly with steatosis Uses: HIV infection Action: Combination
of reverse transcriptase inhibitors Dose: 1 tab bid; ↓ dose in renal failure Caution: [C, ?/–]
Supplied: Caps zidovudine 300 mg/lamivudine 150 mg SE: Hematologic toxicity, HA, fever,
rash, GI upset, malaise, pancreatitis Notes: Combination product decreases daily pill bur-
den
Zileuton (Zyflo) Uses: Chronic treatment of asthma Action: Inhibitor of 5-lipoxyge-
nase Dose: 600 mg PO qid Caution: [C, ?/–] Contra: Hepatic impairment Supplied:
Tabs 600 mg SE: Hepatic damage, HA, GI upset, leukopenia Notes: Monitor LFTs every
month × 3, then q2–3 mo; must take on a regular basis; not for acute asthma
Ziprasidone (Geodon) WARNING: A typical antipsychotics may increase risk of hy-
perglycemia and diabetes Uses: Schizophrenia, acute agitation Action: Atypical antipsy-
chotic Dose: 20 mg PO bid with food, may increase in 2-d intervals up to 80 mg bid; agitation
10–20 mg IM PRN up to 40 mg/d. Separate 10-mg doses by 2h and 20-mg doses by 4 h
Caution: [C, –] Contra: QT prolongation, recent MI, uncompensated heart failure, meds that
prolong QT interval Supplied: Caps 20, 40, 60, 80 mg; Inj 20 mg/mL SE: Bradycardia;
monitor electrolytes; rash, somnolence, respiratory disorder, Epstein-Barr syndrome, weight
gain, orthostatic hypotension Notes: Caution in hypokalemia/hypomagnesemia
Zoledronic Acid (Zometa) Uses: Hypercalcemia of malignancy (HCM), ↓ skeletal-
related events in prostate CA, multiple myeloma, and metastatic bone lesions Action: Bis-
phosphonate; inhibits osteoclastic bone resorption Dose: HCM: 4 mg IV over at least 15
min; may retreat in 7 d if adequate renal function Bone lesions/myeloma: 4 mg IV over at least
15 min repeat q3–4wk PRN; prolonged with Cr ↑ Caution: [C, ?/–] Loop diuretics, aminogly-
cosides; ASA-sensitive asthmatics Contra: Bisphosphonate hypersensitivity Supplied:
Vial 4 mg SE: Adverse effects ↑ with renal dysfunction; fever, flu-like syndrome, GI upset,
insomnia, anemia; electrolyte abnormalities; osteonecrosis of jaw Notes: Requires vigorous
prehydration; do not exceed recommended doses/infusion duration to minimize dose-related
renal dysfunction; follow Cr; conduct dental exam prior to initiation
Zolmitriptan (Zomig, Zomig ZMT) [see Table VII–16, p 629]
Zolpidem (Ambien) [C-IV] Uses: Short-term treatment of insomnia Action:
Hypnotic agent Dose: 5–10 mg PO hs PRN; ↓ dose in elderly, hepatic insufficiency Cau-
606 VII: THERAPEUTICS
tion: [B, +] Supplied: Tabs 5, 10 mg SE: HA, dizziness, drowsiness, nausea, myalgia
Notes: May be habit forming
Zonisamide (Zonegran) Uses: Adjunct treatment complex-partial seizures Ac-
tion: Anticonvulsant Dose: Initial 100 mg/d PO; may ↑ to 400 mg/d Caution: [C, –] ↑ Tox-
icity with CYP3A4 inhib; ↓ levels with concurrent carbamazepine, phenytoin, phenobarbital,
VPA Contra: Hypersensitivity to sulfonamides Supplied: Caps 100 mg SE: Dizziness,
drowsiness, confusion, ataxia, memory impairment, paresthesias, psychosis, nystagmus,
diplopia, tremor; anemia, leukopenia; GI upset, nephrolithiasis, Stevens-Johnson syndrome;
monitor for ↓ sweating and ↑ body temperature Notes: Swallow capsules whole
Magnesium [See also p 562] Indications/Effects: Strengthens bones and teeth, re-
duces neurologic irritability in patients at risk for seizures (e.g., eclampsia), may reduce pre-
menstrual symptoms (headache, fluid retention, mood changes), maintains normal sinus
rhythm RDA/Dosage: 200–400 mg (1 g = 82.3 mEq) Signs/Symptoms of Deficiency:
Weakness, confusion, tingling, muscle contractions, cramps Signs/Symptoms of Toxicity
(> 350 mg/d): Diarrhea, nausea, drowsiness, lethargy, sweating, slurred speech
Selenium Indications/Effects: Decreases risk of heart disease (antioxidant), essential
for normal function of immune system and thyroid gland RDA/Dosage: Women: 55 mcg
Men: 70 mcg Signs/Symptoms of Deficiency: Rare, due to TPN or GI malabsorptive dis-
eases; can cause cardiomyopathy (“Keshan disease”) Signs/Symptoms of Toxicity (> 400
mg/d): Selenosis: GI upset, hair loss, white-blotchy nails, mild nerve damage Other: Bal-
anced diet meets RDA requirements (dietary source: plant foods)
Zinc Indications/Effects: Supplementation strengthens immune system if patient is zinc
deficient; may prevent macular degeneration; may improve cognition. Zinc supports normal
growth and development during pregnancy, childhood, and adolescence RDA/Dosage: Fe-
males: 12 mg Males: 10 mg Signs/Symptoms of Deficiency: Impaired night vision, im-
mune function, taste; also poor appetite, poor growth, delayed wound healing, anemia,
hyperpigmentation, hepatosplenomegaly. Signs/Symptoms of Toxicity (> 100–450 mg/d):
Altered iron function, reduced immune function, lowered HDL levels, GI intolerance, anemia,
copper deficiency Other: High calcium intake (> 1400 mg/d) reduces zinc absorption, requir-
ing increased zinc intake of 18 mg/d
ports of possible increased risk of seizures Adverse Effects: GI upset, headaches, dizzi-
ness, heart palpitations, rash Drug Interactions: Aspirin, other salicylates, warfarin
Ginseng Uses: “Energy booster,” stress reduction, enhancement of brain activity and
physical endurance (adaptogenic), antioxidant, aid in glucose control Efficacy: Not well es-
tablished Dose: 1–2 g of root or 100–300 mg of extract (standardized to contain 7% gin-
senosides) tid Caution: Use with caution in patients with cardiac disorders, diabetes,
hypotension, hypertension, mania, and schizophrenia, and in patients receiving corticos-
teroids. Avoid during pregnancy. Discontinue at least 7 d before surgery (bleeding risk) Ad-
verse Effects: Controversial “ginseng abuse syndrome” (nervousness, excitation, headache,
insomnia) reported in high doses; palpitations, vaginal bleeding, breast nodules, hypoglycemia
Drug Interactions: Warfarin, antidepressants (augmented stimulant effect), caffeine (aug-
mented stimulant effect), antidiabetic agents (additive hypoglycemic effect)
Kava Kava (Kava Kava Root Extract, Piper methysticum) Uses: Anxiety,
stress, restlessness, and insomnia Efficacy: May have mild anxiolytic benefit Dose: Stan-
dardized extract (70% kavalactones) 100 mg 2–3 × daily Caution: Growing evidence of he-
patotoxicity risk has resulted in bans in Europe and Canada. Not recommended during
pregnancy and lactation. Discontinue at least 24 h before surgery (may increase sedative ef-
fect of anesthetics) Adverse Effects: Mild gastrointestinal disturbances; in rare cases, aller-
gic skin reactions can occur; may increase cholesterol; elevation of liver enzymes/jaundice;
may cause rash and/or vision changes, red eyes, puffy face, muscle weakness Drug Inter-
actions: Avoid using with other sedatives, alcohol, or stimulants. Potentiation of effectiveness
is possible for substances acting on the CNS, such as alcohol, barbiturates, and other psy-
chopharmacologic agents
Melatonin Uses: Insomnia, jet lag; use as antioxidant, use as immunostimulant Effi-
cacy: Sedative effects most pronounced in elderly patients with decreased endogenous mela-
tonin levels; some evidence of benefit for jet lag Dose: 1–3 mg 20 minutes before bedtime
(controlled-release: administer 2 h before bedtime) Caution: Use synthetic rather than prod-
uct derived from animal pineal gland; avoid if patient has autoimmune disease, AIDS/HIV, or is
trying to get pregnant Adverse Effects: “Heavy head,” headache, depression, daytime se-
dation, dizziness Drug Interactions: β-Blockers, corticosteroids, NSAIDs, benzodiazepines
Milk Thistle (Silybum marianum) Uses: Prophylaxis and treatment of liver dam-
age from alcohol, toxins, cirrhosis, chronic hepatitis, fatty liver, cholestasis, and cholangitis; in-
cludes preventive use in individuals with chronic exposure to toxins (painters, farmers,
chemical workers, etc) Efficacy: Administration before exposure has been reported to be
more effective than use after damage has occurred Dose: 70–200 mg tid Adverse Ef-
fects: Possible GI intolerance Drug Interactions: None known
Agent Toxicities
Aconite Salivation, nausea/vomiting, blurred vision, cardiac arrhythmias
Calamus Possible carcinogenicity
Chaparral Hepatotoxicity, possible carcinogenicity
Chinese herbal mixtures May contain Ma huang or other dangerous herbs
Coltsfoot Hepatotoxicity, possible carcinogenicity
Comfrey Hepatotoxicity, carcinogenicity
Juniper High allergy potential, diarrhea, seizures, nephrotoxicity
Licorice Large daily amounts (> 30 g) over months can result in hy-
pokalemia, sodium/fluid retention with resultant hypertension,
myoglobinuria, and hyporeflexia
Life root Hepatotoxicity, liver cancer
Ma-huang/ephedra Elevated BP, MI, stroke, psychosis
Pokeweed Severe GI cramping, nausea, diarrhea, vomiting, labored
breathing, hypotension, seizures
Sassafras Vomiting, stupor, hallucinations, dermatitis, abortion, hypother-
mia, liver cancer
Yohimbine Hypotension, abdominal distress, CNS stimulation (including
mania and psychosis in predisposed individuals)
VITAMINS 611
tion: Alcoholics. Strict vegans (no egg/milk intake) need B12 supplement if not eating fortified
cereals
Vitamin C (Ascorbic Acid) Indications/Effects: Antioxidant, healthy gums, assists
in collagen formation, improves iron absorption, may improve wound healing, may shorten du-
ration of a viral upper respiratory infection RDA/Dosage*: Males: 90 mg Females: 75 mg
Smokers: Add 35 mg. *Food and Nutrition Board, Institute of Medicine, the National Acade-
mies, 2000. www.iom.edu Signs/Symptoms of Deficiency: Anemia, hemorrhage, muscle
weakness, gum disease (scurvy), delayed wound healing, skin changes including perifollicular
hyperkeratotic papules and hemorrhage and purpura Signs/Symptoms of Toxicity (> 2000
mg/d): Abdominal cramps, nausea, diarrhea, nosebleeds. May increase risk of renal calculi
and exacerbate hemochromatosis; interferes with absorption of vitamin B12
Vitamin D Indications/Effects: Assists in calcium and phosphorus absorption; may re-
duce risks of colon and breast cancer RDA/Dosage: Under age 50, 200 units. Age 50–70,
400 units. Over age 70, 600 units (may have difficulty with absorption) Signs/Symptoms of
Deficiency: Osteomalacia, increased risk of fractures (especially in postmenopausal women),
muscle spasms Signs/Symptoms of Toxicity (> 1000 units/d): Nausea, headache, fa-
tigue, heart irregularities, anorexia, metallic taste, increased calcium levels with subsequent
renal disease Other: Requires UV light to convert to active forms (sufficient amount of sun
exposure: 5–15 minutes, 2–3 ×/wk)
Vitamin E Indications/Effects: Cardioprotective (decreases LDL oxidation, anticoagu-
lant, 40% reduction in CHD on 100 units qd × 2 y), immunostimulant, protects against
cataracts, slows progression of Alzheimer’s disease, reduces premenstrual symptoms
RDA/Dosage: 15 mg/33 units (although many studies use 100–400 units qd–qid for preven-
tion of CV/CNS disease) Signs/Symptoms of Deficiency: Deficiency more likely on low-fat
diet; may need to supplement; erythrocyte hemolysis, peripheral neuropathy Signs/Symp-
toms of Toxicity (> 1000 units/d): Can result in bleeding (inhibits platelet aggregation); this
effect may occur at lower doses on warfarin. Also fatigue, headache, nausea, diarrhea, flatu-
lence, blurred vision, dermatitis Other: Discontinue use before surgery because of its effects
on platelet aggregation and tendon healing
Vitamin K [See also p 581] Indications/Effects: Enhances production of clotting
factors, healthy bone formation RDA/Dosage: 65—80 mcg (1 mcg/kg) Signs/Symptoms
of Deficiency: Rare, but more likely to occur in hospitalized patients, newborn infants, those
on tube feedings, and/or those on antibiotics, especially sulfas; bruising, bleeding
Signs/Symptoms of Toxicity: Usually not toxic in older children/adults Other: Blocks phar-
macologic effects of warfarin (as a supplement and in dietary intake)
REFERENCES
Anonymous: Dietary Reference Intakes: Applications in Dietary Assessment. National
Academy Press;2000.
Anonymous: Review of Natural Products, Facts & Comparisons, Inc.;2001.
Dasgupta A. Review of abnormal laboratory test results and toxic effects due to use of
herbal medicines. Am J Clin Pathol 2003;120(1):127.
Fowler JB, German TC: The essence of herbal products for the hospital pharmacist.
Pharmacy Practice News 2001;1:28.
Jellin J, Gregory P, Batz F (eds). Natural Medicines Comprehensive Database. Thera-
peutic Research Faculty; Stockton, CA (www.naturaldatabase.com). Accessed Janu-
ary 30, 2004.
Internet Sites: Food and Drug Administration: www.fda.gov
Medical Sites: www.drkoop.com, www.webmd.com, www.medscape.com
TABLES 613
TABLES
Duration Compatible to
Type of Insulin Onset (hr) Peak (hr) (hr) Mix With
■ Rapid-acting
Aspart (Novolog) 0.25 0.5–1.5 3–5 All
Glulisine (Apidra) 0.25 0.5–1.5 3–4 All
Lispro (Humalog) 0.25 0.5–1.5 3–4 All
Regular Iletin II 0.5–1 5–10 6–8 All
Humulin R 0.5–1 5–10 6–8 All
Novolin R 0.5–1 5–10 6–8 All
■ Intermediate-acting
NPH Iletin II 1–1.5 4–6 24 Regular
Humulin N 1–1.5 4–6 24 Regular
Novolin N 1–1.5 4–6 24 Regular
Lente Iletin II 1–2.5 7.5 24 Regular, Semilente
■ Long-acting
Humulin U 4–8 10–30 36 Regular
Ultralente 4–8 10–30 36 Regular
Insulin Glargine (Lantus) 1–1.5 Peakless 24 Do not mix with
other insulins
■ Combinations
Humulin 70/30 0.5 4–8 24
Novolin 70/30 0.5 4–8 24
■ Short-acting
Cortisone (Cortone) 25 0.8 2
Hydrocortisone (Cortef) 20 1 2
■ Intermediate-acting
Methylprednisolone (Medrol) 4 5 0
Prednisone (Deltasone) 5 4 1
Prednisolone (Delta-Cortef) 5 4 1
Triamcinolone 4 5 0
■ Long-acting
Betamethasone (Celestone) 0.6–0.75 20–30 0
Dexamethasone (Decadron) 0.75 20–30 0
614 VII: THERAPEUTICS
Left Ventricular
Drug (Trade) Hypertension Heart Failure Dysfunction
Daily Dosage
Drug (Trade) Range Renal Dysfunction Product Availability (mg)
Dosing
Drug (Brand) Dosage Interval Suplied Notes
Drug (Trade) Receptor Angina Hypertension Myocardial Infarction Congestive Heart Failure
Drug (Trade) Receptor Angina Hypertension Myocardial Infarction Congestive Heart Failure
Precautions:
1
Use with caution in diabetic patients. May blunt symptoms/signs of acute hypoglycemia; nonselective agents may potentiate insulin-induced hypoglycemia. Beta-
blockade also reduces the release of insulin in response to hyperglycemia.
2
May increase serum lipid concentrations. May not be as pronounced with agents having intrinsic sympathomimetic activity.
3
Use with caution in patients with congestive heart failure (decreased myocardial contractility) and chronic obstructive pulmonary diseases (potential blockade of B2 receptors).
4
When discontinuing chronically administered beta-blockers, particularly in patients with ischemic heart disease, reduce dose gradually, especially with agents with a
short half-life (propranolol, metoprolol).
TABLES 619
Dosing
Drug (Brand) Dose Interval Supplied Notes
Dosing
Drug (Brand) Dose Interval Supplied Notes
■ Salicylates 2
■ Propionic acids 2
Notes:
1
Can cause renal insufficiency/failure, especially in the elderly. Do not take in the third trimester of pregnancy. Information regarding CV risks of long term
use is emerging.
2
Chronic use can cause gastrointestinal bleeding from gastroduodenal ulceration. Inhibits platelet aggregation except for meloxicam.
3
First dose 1000 mg, then 500 mg bid–tid.
4
Inhibits COX-2 more than COX-1.
5
Dosage for familial adenomatous polyposis is 400 mg bid. Doses greater than 200 mg/day may not be associated with CV risks.
6
Does not inhibit platelet aggregation.
7
Avoid with sulfa allergy
8
Associated with Stevens-Johnsons syndrome and toxic epidermal necrolysis. Use contraindicated in patients immediately following CABG.
TABLE VII–12. OPHTHALMIC AGENTS.
Notes:
1
Systemic absorption may cause bradycardia.
2
May darken light irides.
3
Wait at least 10 minutes before putting in contact lens.
625
626 VII: THERAPEUTICS
■ First-generation
Acetohexamide (Dymelor) 24 500 250–1500 mg q day
Chlorpropamide (Diabinese) ≥ 60 250 100–500 mg q day
Tolazamide (Tolinase) 12–24 250 100–500 mg q day
Tolbutamide (Orinase) 6–12 1000 500–1000 mg bid
■ Second-generation
Glipizide3 10–16 10 5–15 mg q day–bid
(Glucotrol, Glucotrol-XL)
Glyburide non-micronized4 24 5 1.25–10 mg q day–bid
(DiaBeta, Micronase)
Glyburide micronized4 24 3 1.5–6 mg q day–bid
(Glynase)
Glimepiride 24 2 1–4 mg q day
(Amaryl) 8 mg q day5
1
Indications: Management of non-insulin-dependent diabetes mellitus (NIDDM).
2
Actions: Stimulates the release of insulin from the pancreas; increases insulin sensitivity at peripheral
sites; reduces glucose output from the liver.
3
Glipizide: Give approximately 30 minutes before a meal. Divide total daily doses when doses exceed 15
mg. Maximum daily recommended daily dose is 40 mg.
4
Glyburide: Administer with first main meal. Maximum recommended daily dose non-micronized, 20 mg;
micronized, 12 mg.
5
Given with the first main meal in patients receiving low-dose insulin.
TABLE VII–14. PROTON PUMP INHIBITORS.1–3
GERD
Duodenal Gastric Hypersecretory
Ulcer Ulcer Conditions Healing Maintenance H pylori Eradication
Notes:
1
All products are delayed-release formulations. Swallow whole—do not crush or chew.
2
If patient has dificulty swallowing the capsule, open delayed-release capsule and mix the pellets inside the capsule in 1 tablespoon of applesauce. Swallow immediately—
627
Comparative Hydrophilic/
Dose Dosages Lipophilic Metabolism LFT Monitoring
Notes:
1. Pregnancy category X.
2. Maximum response occurs in 4–6 weeks.
3. Counsel patients to report unexplained muscle pain, tenderness or weakness due to risk of myopathy, or jaundice and abdominal pain
due to risk of hepatic injury.
4. Do not exceed 5 mg q day with cyclosporin or 10 mg q day with gemfibrozil or CrCl < 30 mL/min.
5. Available in combination with cholesterol absorption inhibitor ezetimibe. Vytorin tablets available as 10 mg ezetimibe with 10, 20, 40 or
80 mg simvastatin.
TABLE VII–16. 5-HT3 RECEPTOR AGONISTS
Precautions/contraindications: (C, M) ischemic heart disease, coronary artery vasospasm, Prinzmetal’s angina, uncontrolled HTN, hemi-
plegic or basilar migraine, ergots, use of another serotonin agonist within 24 hr use with MAOI. Side effects: dizziness, somnolence,
paresthesias, nausea, flushing, dry mouth, coronary vasospasm, chest tightness, HTN, GI upset.
a
Do not use within 72 hours of drugs that are potent CYP3A4 inhibitors.
b
Reduce dose in mild renal and hepatic insufficiency (2.5 mg/d MAX); contraindicated with severe renal (CrCl < 15 mL/min) or hepatic
impairment.
c
Initiate therapy at 5 mg PO (15 mg/d max) in patients receiving propranolol.
629
630 VII: THERAPEUTICS
Note: Each lab may have its own set of values that vary slightly from those given.
Modified and reproduced with permission from Gomella LG, ed. Clinician’s Pocket Reference. 10th ed.
McGraw-Hill; 2004.
Trough (mcg/mL)
Antibiotic Maintain Below Upper Limit) Peak (mcg/mL)
Note: See Table VII–18, p 000, for the trough and peak levels of the aminoglycosides gentamicin, to-
bramycin, and amikacin. Peak levels should be drawn 30 minutes after the dose is completely infused;
trough levels should be drawn 30 minutes prior to dose. As a general rule, draw the peak and trough
around the fourth maintenance dose. Therapy can be initiated with the recommended guidelines. These
calculations are not valid for netilmicin.
1
Modified and reproduced with permission from Gomella LG, ed. Clinician’s Pocket Reference. 10th ed.
McGraw-Hill; 2004.
632 VII: THERAPEUTICS
90 90% — —
80 88 — —
70 84 — —
60 79 91% —
50 74 87 —
40 66 80 —
30 57 72 92%
25 51 66 88
20 45 59 83
15 37 50 75
10 29 40 64
7 24 33 55
5 20 28 48
2 14 20 35
0 9 13 25
Several studies suggest that larger doses of aminoglycosides given once daily are just as effec-
tive, and less toxic, than conventional dosing given three times a day. Once-daily dosing of gen-
tamicin and tobramycin regimens takes advantage of concentration-dependent killing through the
optimization of peak concentration/MIC ratio. In addition, there are potential cost savings for
nursing, pharmacy, and laboratory personnel.
Inclusion Criteria: All patients ordered aminoglycosides for prophylaxis, empiric therapy, or doc-
umented infection. (Aminoglycosides are usually indicated as synergistic or adjunctive therapy
with other antibiotics as double coverage for gram-negative infections.)
Exclusion Criteria: 1. Patients with ascites
2. Patients with burns on > 20% of body surface
3. Pregnant patients
4. Patients receiving dialysis
5. Patients with gram-positive bacterial endocarditis
6. Pediatric patients
Initial Dose: Doses will be based on DOSING BODY WEIGHT, ideal body weight plus 40% of esti-
mated adipose tissue mass (see Dosing Guidelines). Patients with estimated Clcr ≥ 40 mL/min/1.73
m2 will receive initial gentamicin dose of 7 mg/kg-DBW, infused over 30 minutes. Patients with
estimated creatinine clearances < 40 mL/min/1.73 m2 will receive an initial gentamicin dose of 3
mg/kg, infused over 30 minutes.
Monitoring: Two random concentrations will be obtained to monitor. Once-daily dosing of gen-
tamicin and tobramycin:
The 1st random concentration will be drawn 4 hours* after completion of the 1st dose. The average
4-hour random sample, with a 7 mg/kg dose will be ∼ 13–15 mg/L 4 hours after a 30-minute infusion.
Note: The Therapeutic Drug Monitoring Lab should be notified that the expected gentamicin/to-
bramycin level will be greater than 10 mg/L.
The 2nd random concentration will be drawn 12 hours after completion of the 1st dose.
*The rationale for the 4-hour sample versus a “peak” is to determine the serum concen-
tration after the distribution phase. A study (Jennings HJ, Davis GA, June 2000) was con-
ducted at the University of Kentucky Medical Center that demonstrated a prolonged
distribution phase following a 7 mg/kg dose in trauma surgery patients.
Subsequent Doses: Scr/BUN should be measured at baseline and 2 times per week thereafter.
Subsequent doses will be the same as the initial dose, but the dosing intervals will be adjusted to
achieve troughs less than or equal to 1 mg/L. Appropriate dosing intervals include every 24, 36,
or 48 hours.
If the serum concentration following a 7 mg/kg dose requires > 48 hours to decline to 1
mg/L, then 3 mg/kg or conventional dosing may be warranted. Some patients may have a
prolonged “drug-free” period that may warrant conventional dosing to maintain concen-
trations. Patients should not receive a single dose of 7 mg/kg more frequently than every
24 hours until more studies are available.
(continued )
634 VII: THERAPEUTICS
Males Cl cr =
(140 − Age) ⴛ ABW
Females Cl cr = Cl cr ⴛ 0.85
72 ⴛ Scr
2. Estimate Body Surface Area (BSA) using the Mosteller equation:
2 Ht(cm) × Wt (kg)
BSA (m ) = (Mosteller; N Engl J Med 1987; 317: 1098)
60
3. Calculate Standardized Creatinine Clearance:
2
1.73m
Cl cr(Std) = Cl cr ×
BSA
4. Determine Ideal Body Weight (IBW).
IBW (kg) = 50 (kg) + (2.3 (kg) × ea. inch over 5 ft) male
= 45 (kg) + (2.3 (kg) × ea. inch over 5 ft) female
5. Calculate Dosing Body Weight (DBW):
DBW = IBW + 0.4 (ABW − IBW)
(If ABW < IBW, then DBW = ABW )
6. Calculate the patient’s dose based on Dosing Body Weight:
a) If Clcr(std) ≥ 40 mL/min/1.73 m2, then give 7 mg/kg ⴚ DBW.
b) If Clcr(std) < 40 mL/min/1.73 m2, then give 3 mg/kg ⴚ DBW.
Dilute dose in 100 mL of either 5% Dextrose or Normal Saline and infuse over 30 minutes.
Order two random concentrations at 4 and 12 hours after the end of 1st dose. Notify lab of the
patient’s name to allow for proper dilution of sample.
Modified and reproduced with permission from Davis GA: Clinical Pharmacokinetics Service Policy and
Procedural Manual. 23rd ed. University of Kentucky Medical Center; 2000.
Appendix
CONTENTS
Item Description Page
Table A–1 Fahrenheit/centigrade temperature conversion 635
Table A–2 Pounds/kilograms weight conversion 636
Table A–3 Glasgow Coma Scale 636
Figure A–1 Calculating body surface area 637
Table A–4 Endocarditis prophylaxis 638
Table A–5 Specimen tubes for venipuncture 639
ⴗF ⴗC ⴗC ⴗF
Modified and Reproduced with permission from Gomella LG, ed. Clinician’s Pocket Reference. 10th ed.
McGraw-Hill; 2004.
635
636 APPENDIX
lb kg kg lb
1 0.5 1 2.2
2 0.9 2 4.4
4 1.8 3 6.6
6 2.7 4 8.8
8 3.6 5 11.0
10 4.5 6 13.2
20 9.1 8 17.6
30 13.6 10 22.0
40 18.2 20 44.0
50 22.7 30 66.0
60 27.3 40 88.0
70 31.8 50 110.0
80 36.4 60 132.0
90 40.9 70 154.0
100 45.4 80 176.0
150 68.2 90 198.0
200 90.8 100 220.0
kg = lb × 0.454 lb = kg × 2.2
1
Reproduced with permission from Gomella LG, ed. Clinician’s Pocket Reference. 10th ed. McGraw-Hill; 2004.
Note: The Glasgow Coma Scale (EMV Scale) is a fairly reliable and objective way to monitor changes in levels
of consciousness. It is based on eye opening, motor responses, and verbal responses (EMV). A person’s EMV
score is based on the total of the three different responses. The score ranges from 3 (lowest) to 15 (highest).
Modifided and reproduced with permission from Gomella LG, ed. Clinician’s Pocket Reference. 10th ed.
McGraw-Hill; 2004.
APPENDIX 637
Figure A–1. Calculating body surface area. To determine the body surface of an adult, use a
straightedge to connect height and mass. The point of intersection in the body surface line gives
the body surface area in meters squared (m2). (Reproduced with permission from Lentner C, ed.
Geigy Scientific Tables. Vol 1. 8th ed. Basel: CIBA-Geigy;1981:227.
638 APPENDIX
NOTE: Page numbers in boldface type indicate a major discussion. A t following a page number indi-
cates tabular material, and an f following a page number indicates a figure. Drugs are listed
under their generic names. When a drug trade name is listed, the reader is referred to the
generic name.
641
642 INDEX
AIN. See Acute interstitial in diarrhea, 106 Aldara. See Imiquimod cream,
nephritis electrophoresis values for, 5%
Air trapping, agitation in venti- 401t Aldesleukin, 503
lator patient and, 476 in hypercalcemia, 187 Aldomet. See Methyldopa
Airway obstruction in hypocalcemia, 211 Aldosterone levels, 370
anaphylaxis and, 26 in hypophosphatemia, 235 in hyperkalemia, 200
aspiration and, 39 serum levels of, 369 Aldosteronism
cardiopulmonary arrest and, therapeutic, 468, 503 hypernatremia and, 203
46 urine levels of, 370 hypertension and, 206
respiratory acidosis and, 12 Albumin gradient, ascitic fluid, hypokalemia and, 219
Airway pressure release venti- 448t hypomagnesemia and, 223
lation (APRV), 474 Albuminar. See Albumin, thera- metabolic alkalosis and, 23
for high peak pressures in peutic Alendronate, 503
ventilator patient, 486 Albutein. See Albumin, thera- Aleve. See Naproxen sodium
Airway status/management peutic Alfacept, 503
in alcohol withdrawal/delirium Albuterol, 503 Alfuzosin, 503–504
tremens, 95 for dyspnea in asthma, 121 Alka-Mints. See Calcium car-
cardiopulmonary arrest and, hypokalemia and, 218 bonate
46 with ipratropium, 503 Alkalemia, 20. See also Alkalo-
hemoptysis and, 184 nebulized, for bronchospasm, sis
AIVR. See Accelerated id- 367 coma/acute mental status
ioventricular rhythm Alcohol use/abuse changes and, 78
AK-Chlor. See Chlorampheni- coma/acute mental status differential diagnosis/causes
col, ophthalmic changes and, 76, 77, 82 of, 21–23
AK-Dex Ophthalmic. See Dex- gastrointestinal bleeding and Alkaline phosphatase, 6, 370
amethasone, ophthalmic hematemesis/melena, 166 in hypercalcemia, 187
AK-Mycin. See Erythromycin, hematochezia and, 171 in jaundice, 257–258
ophthalmic hypertension and, 206 leukocyte. See Leukocyte al-
AK-Neo-Dex Ophthalmic. See hypoglycemia and, 214 kaline phosphatase (LAP)
Neomycin, with dexam- hypomagnesemia and, 223 score
ethasone, ophthalmic hypophosphatemia and, 234 in nausea and vomiting, 281
AK-Poly Bac Ophthalmic. See insomnia and, 248, 249 pain management and, 308
Bacitracin, with polymyxin jaundice and, 256, 259 Alkalinization of urine, in over-
B, ophthalmic leukopenia and, 271 dose management, 301
AK-Pred. See Prednisolone, metabolic acidosis and, 14, Alkalosis, 19–25
ophthalmic 16, 17, 18 cardiopulmonary arrest and,
AK-Spore HC Ophthalmic. See nausea and vomiting and, 48
Bacitracin, with polymyxin 278 characteristics of, 19–21
B and neomycin and hy- seizures and, 98, 330, 335 coma/acute mental status
drocortisone, ophthalmic toxic levels and, 630t changes and, 78
AK-Spore Ophthalmic. See withdrawal and, 94–101. See compensation in, 20–21,
Bacitracin, with polymyxin also Alcohol withdrawal 375t
B and neomycin, oph- Alcohol withdrawal, 94–101. differential diagnosis/causes
thalmic See also Alcohol of, 21–23
AK-Tob. See Tobramycin, oph- use/abuse hypokalemia and, 218
thalmic differential diagnosis of delir- hypomagnesemia and, 224
AK-Tracin Ophthalmic. See ium and, 95–96 hypophosphatemia and, 234,
Bacitracin, ophthalmic hypertension and, 206 235
Alamast. See Pemirolast seizures and, 98, 330, 335 imaging/clinical studies in, 24
Alanine aminotransferase Alcoholic hepatitis, jaundice initial evaluation of, 19–21
(ALT/SGPT), 371 and, 256 laboratory findings/data in,
in jaundice, 257–258 Alcoholic ketoacidosis, 14, 18 23–24, 375t
in nausea and vomiting, 281 Alcoholic liver disease, jaun- management of, 24–25
pain management and, 308 dice and, 256, 259 physical examination/findings
Alavert. See Loratadine Alcoholism. See Alcohol in, 23
Albalon-A. See Naphazoline, use/abuse pseudorespiratory, 13, 22
with antazoline Aldactazide. See Hy- Alkeran. See Melphalan
Albumin drochlorothiazide, with Alkylating agents, for poly-
calcium levels and, 187, 211, spironolactone cythemia vera, 316
377 Aldactone. See Spironolactone Allegra. See Fexofenadine
644 INDEX
Bacterial overgrowth, diarrhea Belladonna and opium suppos- Bextra. See Valdecoxib
and, 104 itories, 513 Biaxin. See Clarithromycin
Bacterial vaginosis, dysuria Benadryl. See Diphenhy- Bicalutamide, 514
and, 123, 127 dramine Bicarbonate. See also Bicar-
Bacteriuria, 125 Benazepril, 614t bonate therapy
Bactocill. See Oxacillin Bence–Jones protein, urine, in body fluids, 464t
Bactrim. See Trimethoprim 374, 400f in crystalloid solutions, 463t
(TMP)-sulfamethoxazole Benemid. See Probenecid gastrointestinal loss of, acido-
(SMX) Benicar. See Olmesartan sis and, 13
Bactroban. See Mupirocin Benign positional vertigo, 110, in hypophosphatemia, 235
Balsalazide, 513 111 renal loss of, acidosis and, 14
Banded (stab) neutrophils, Bentyl. See Dicyclomine serum levels of, 374–375,
413 Benylin DM. See Dex- 374t, 375t
laboratory reference/normal tromethorphan in acidosis, 10, 10–11, 375t
values for, 380t Benzocaine and antipyrine, in alkalosis, 20, 375t
Barbiturate withdrawal, 96 513–514 in hyperglycemia, 192
Barium Benzodiazepines. See also laboratory reference/normal
hypokalemia caused by, 218 specific agent values for, 374, 374t
retained, constipation caused for alcohol withdrawal/delirium Bicarbonate therapy (sodium
by, 86 tremens, 99, 100 bicarbonate), 590
Barium studies for dizziness/vertigo, 115 for diabetic ketoacidosis,
in constipation, 88 for insomnia, 250–251 196
in diarrhea, 107 overdose/toxicity of, antidote for hyperkalemia, 201
in nausea and vomiting, 281 for, 300 hypernatremia and, 203
Bartonella (Rochalimaea) Benzonatate, 514 for hypotension/shock, 241
henselae, bacillary an- Benztropine, 514 for metabolic acidosis, 17, 18
giomatosis caused by, in for extrapyramidal side effects for overdose, 299–300
HIV-positive patient, 144 of antiemetics, 282 Bicillin. See Penicillin G, ben-
Bartter’s syndrome Bernard-Soulier syndrome, zathine
hypokalemia and, 220 71 BICNU. See Carmustine
hypomagnesemia and, 223 Beta-adrenergic blocking Bidirectional positive airway
metabolic alkalosis and, 23 agents, 617–618t pressure (BiPAP), 471
Base deficit, 374, 374t for alcohol withdrawal/delirium extubation to, 488
Base excess, 374, 374t tremens, 100 for pulmonary edema, 367
in acidosis, 10 cessation of, rebound hyper- for stridor, 367
in alkalosis, 20 tension and, 206 Bile
Basilar artery insufficiency, for glaucoma, 623t composition/daily production
syncope and, 340 hyperkalemia and, 198 of, 464t
Basilic vein, median, for central hypokalemia and, 218 in vomitus, 278
venous catheterization, for myocardial infarction, 67 Bile salt deficiency, hypocal-
433 overdose/toxicity of, antidote cemia and, 210
Basiliximab, 513 for, 300 Biliary cirrhosis
Basophilic stippling, 403 for tachycardia, 353 primary, jaundice and, 257
Basophils, 414 Beta-globulin, electrophoresis pruritus in, 320
laboratory reference/normal values for, 401t Biliary colic
values for, 380t Beta-thalassemia. See Thal- chest pain in, 63
Bayer Aspirin. See Aspirin assemia jaundice and, 256
BCNU. See Carmustine Betagan Liquifilm. See Levo- nausea and vomiting and, 278
BE. See Base excess bunolol Biliary disorders
Becaplermin, 513 Betamethasone, 613t abdominal pain and, 3t
Beclomethasone with clotrimazole, 523 jaundice and, 256, 260
nasal inhaler, 513 Betapace/Betapace AF. See Biliary obstruction
oral metered-dose inhaler, Sotalol jaundice and, 256, 260
513 Betaseron. See Interferon β-1b pruritus and, 320
Beconase. See Beclometha- Betaxolol, 617t Biliary surgery, jaundice and,
sone, nasal inhaler ophthalmic, 623t 256
Bed rest, prolonged, hypercal- Betaxon. See Levobetaxolol Bilirubin, 375
cemia and, 186 Bethanechol, 514 in abdominal pain, 6
Beer potomania, hyponatremia Betoptic/Betoptic-S, . See Be- in hypophosphatemia, 235
and, 230 taxolol, ophthalmic in jaundice, 257–258
650 INDEX
Blood urea nitrogen/creatinine Bowel resection, diarrhea and, hypercarbia and, 483
ratio, 376 104 hypoxemia and, 480
in hematemesis/melena, 168 Bowel sounds, in fever, 136 Breathlessness. See also
in hematochezia, 173 BPV. See Benign positional Dyspnea
in oliguria/anuria, 283, 287 vertigo psychogenic, 118
Blue top specimen tubes, 639t Bradycardia/bradyarrhythmias, Brethine. See Terbutaline
Blue/yellow label specimen 42–46 Brevibloc. See Esmolol
tubes, 639t in chest pain, 64 Bricanyl. See Terbutaline
Body fluids, composition/daily in coma/acute mental status Brimonidine, 623t
production of, 464t changes, 81 Brinzolamide, 623t
Body surface area, calculating, dyspnea and, 118 Broad casts, in urine, micro-
637f falls and, 130, 131 scopic appearance of, 411
Body temperature. See also in hypotension, 237 Bromocriptine, 515
Fever; Hyperthermia; Hy- in hypothermia, 246 Bronchi, obstructed, hypox-
pothermia in nausea and vomiting, 277 emia in ventilator patient
in coma/acute mental status pacemaker complications caused by, 479
changes, 79, 81–82 and, 301–302 Bronchial adenoma, hemopty-
in heart murmur, 161 in shock, 237 sis and, 181
in hypophosphatemia, 234 syncope and, 338, 339, 340 Bronchial breath sounds, in
in hypothermia, 244 Bradypnea cough, 92
in oliguria/anuria, 286 in acidosis, 10 Bronchial provocation testing,
in overdose, 295 in coma/acute mental status in cough, 93
reducing, 138 changes, 81 Bronchial tear, hemoptysis
Bone, metastatic/tumor inva- Brain imaging and, 181
sion of in dizziness/vertigo, 114 Bronchiectasis, hemoptysis
hypercalcemia and, 186 in polycythemia, 315 and, 181
pain caused by, 307 in seizures, 334 Bronchitis
Bone films Brain stem, tumors of, dizzi- cough and, 91, 93
in hypercalcemia, 188 ness/vertigo and, 111 dyspnea and, 121
in hypocalcemia, 212 Brain stem–evoked audiome- hemoptysis and, 180
in hypophosphatemia, 235 try, in dizziness/vertigo, management of, 93, 121
Bone marrow aspiration/biopsy, 114 Bronchodilators, 496t. See also
423–425 Brain tumor specific agent and Nasal
in anemia, 33 coma/acute mental status inhalants; Respiratory in-
in coagulopathy, 73 changes and, 76, 80, 85 halants
in leukocytosis, 270 headache and, 153 for anaphylaxis, 27
in leukopenia, 274 in HIV-positive patient, 144 for aspiration, 41
in pruritus, 323 nausea and vomiting and, 279 for asthma, 93
in thrombocytopenia, 359 seizures and, 331 for hypoxemic ventilator pa-
Bone marrow disorders/failure BRCA-1/BRCA-2, 378 tient, 481
leukopenia and, 272, 276 Breast, male, examination of, Bronchogenic carcinoma. See
in polycythemia vera, 313 in jaundice, 257 Lung cancer
Bone marrow infiltration Breast cancer genes 1 and 2, Bronchoprovocation testing, in
leukopenia and, 272 378 cough, 93
thrombocytopenia and, 356 Breastfeeding, medication use Bronchoscopy
Bone resorption, decreased, and, 491 for aspiration, 41
hypocalcemia and, 211 Breath odor, in diabetic ke- in cough, 93
Bone scan toacidosis, 191 fever and, 134
in fever, 137 Breath sounds in hemoptysis, 183–184, 184
in hypercalcemia, 188 bronchial, in cough, 92 in HIV-positive patient, 147
Bortezomib, 515 in chest pain, 64 Bronchospasm. See also
Bowel bypass/resection, hypo- in dyspnea, 119 Wheezing
magnesemia and, 223 in fever, 136 acute, 365
Bowel ischemia/strangulation in nausea and vomiting, 280 cough and, 91
abdominal pain and, 1, 5t in syncope, 341 management of, 367
diarrhea and, 103 in tachycardia, 350 in ventilator patient
hematochezia and, 172 in ventilator patient hypercarbia and, 483
Bowel obstruction agitation and, 478 hypoxemia and, 480, 481
abdominal pain and, 2, 5t high peak pressures and, Brontex. See Guaifenesin, with
constipation and, 86, 87, 87–88 485 codeine
652 INDEX
Candida vaginitis Cardiac failure. See Heart fail- management of, 49–56
dysuria and, 123, 127 ure amiodarone in, 352
pruritus and, 318, 319 Cardiac index, pulmonary in asystole, 52–53f, 53–55
Cannon A waves artery catheter measure- in pulseless electrical activity
in bradycardia, 44 ment of, 456t (PEA), 54–55f, 55–56
in cardiopulmonary arrest, 48 Cardiac level shunt, hypoxemia in sustained ventricular tachy-
in tachycardia, 350 in ventilator patient caused cardia with no palpable
Capecitabine, 517 by, 479 pulse, 50–51f, 51
Capoten. See Captopril Cardiac medications. See also in ventricular fibrillation,
Capsaicin, 517 specific agent 49–51, 50–51f
Capsin. See Capsaicin cardiopulmonary arrest and, in ventricular tachycardia with
Capsule endoscopy, in he- 47 palpable pulse, 51–53
matemesis/melena, 169 diarrhea caused by, 104 physical examination/findings
Captopril, 614t Cardiac monitoring, in car- in, 48
for pulmonary edema, 367 diopulmonary arrest, 48 Cardiopulmonary bypass,
Capture (pacemaker), failure Cardiac murmurs. See Heart leukopenia and, 273
of, 302–303, 302f, 305 sounds/murmurs Cardiopulmonary examination.
Carafate. See Sucralfate Cardiac output (CO) See Cardiovascular exam-
Carbachol, 623t low ination; Heart, examination
Carbamate toxicity, antidote coma/acute mental status of; Lungs, examination of
for, 300 changes and, 85 Cardiopulmonary exercise test-
Carbamazepine, 517 delirium and, 97 ing, in dyspnea, 121
for alcohol withdrawal/delirium in hypoxemic ventilator pa- Cardiopulmonary resuscitation
tremens, 100 tient, correction of, 482 (CPR), 46, 49, 50f. See
therapeutic/toxic levels of, 630t pulmonary artery catheter also Cardiopulmonary ar-
Carbidopa/levodopa, 517 measurement of, 454, rest, management of
Carbohydrates, dietary, hyper- 456t Cardiovascular agents, 496t.
carbia in ventilator patient inaccurate/poorly repro- See also specific agent
and, 483 ducible, 328 cardiopulmonary arrest and,
Carbon dioxide in shock, 451t 47
alveolar. See PaCO2 Cardiac shock. See Cardio- diarrhea caused by, 104
arterial. See pCO2 genic shock; Shock Cardiovascular disorders. See
increased production of, in hy- Cardiac syncope, 337, 338, also Heart disease
percarbic ventilator pa- 340, 344 falls and, 130
tient, 483 coma/acute mental status polycythemia and, 313
Carbon monoxide poisoning, changes and, 81, 85 Cardiovascular examination.
294 Cardiac tamponade. See Tam- See also Heart, examina-
Carbonic anhydrase inhibitors, ponade tion of
for glaucoma, 623t Cardiac troponins. See Tro- in heart murmur, 162–163
Carboplatin, 517 ponin I; Troponin T in hyperkalemia, 200
Carboxyhemoglobin, 377 Cardiogenic pulmonary edema in hypokalemia, 220
polycythemia and, 313, 315 hemoptysis and, 181 in insomnia, 250
Carcinoembryonic antigen in ventilator patient in overdose, 296
(CEA), 378 high peak pressures and, 485 pacemaker complications
Carcinoid hypoxemia and, 479, 481 and, 304
hemoptysis in, 181 wheezing and, 365 Cardioversion, electrical (defib-
pruritus in, 319 Cardiogenic shock, 238 rillation), for tachyarrhyth-
Carcinoid syndrome, diarrhea management of, 242–243 mias, 351–352
and, 103 pulmonary artery catheter ventricular fibrillation, 49
Carcinoma markers, 377–378 monitoring in, 451t ventricular tachycardia, 51, 53
in leukocytosis, 270 syncope and, 340 Cardizem. See Diltiazem
Cardene. See Nicardipine Cardiomyopathy, hypertrophic, Cardura. See Doxazosin
Cardiac disease. See Heart heart murmur in, 161, 163 Carisoprodol, 517
disease Cardiopulmonary arrest, 46–56 Carmustine, 517–518
Cardiac enzymes differential diagnosis/causes Carotene, serum, in leukope-
in chest pain, 65 of, 47–48 nia, 274
in dyspnea, 120 imaging/clinical studies in, Carotid artery dissection,
in heart murmur, 164 48–49 headache and, 154
Cardiac examination. See initial evaluation in, 46–47 Carotid sinus hypersensitivity/
Heart, examination of laboratory findings/data in, 48 carotid sinus syndrome
654 INDEX
Clotting factors. See Coagula- with guaifenesin, 549 exogenous causes of, 77, 85
tion factors Coffee-ground emesis. See fluid/electrolyte status and,
Cloxacillin, 616t Hematemesis 77–78
Cloxapen. See Cloxacillin Cogentin. See Benztropine hypernatremia and, 77, 201
Clozapine, 523 Cognex. See Tacrine imaging/clinical studies in,
Clozaril. See Clozapine Cohosh, black, 607 84–85
Clubbing Colace (docusate sodium). infection causing, 76, 79, 85
in cough, 92 See Docusate initial evaluation of, 76–77
in dyspnea, 119 calcium/potassium/sodium laboratory findings/data in,
in heart murmur, 163 Colazal. See Balsalazide 83–84
in hemoptysis, 182 Colchicine, 524 management of, 85
in hyponatremia, 231 diarrhea caused by, 104 metabolic causes of, 77, 85
in polycythemia, 314 Cold agglutinins, 381 organ failure and, 78
in wheezing, 366 Colesevelam, 524 physical examination/findings
Cluster headaches, 152, 158 Colestid. See Colestipol in, 81–83
CMV. See under Cy- Colestipol, 524 psychogenic, 80
tomegalovirus Colic tumors causing, 80, 85
CO. See Cardiac output biliary in vitamin deficiency states, 79
CO2. See Carbon dioxide chest pain in, 63 Coma scale (Glasgow), 83,
Coagulation/clotting jaundice and, 256 636t
central venous line malfunc- nausea and vomiting and, Combivent. See Albuterol, with
tion and, 56, 58 278 ipratropium
disorders of, 70–75. See also intestinal. See Abdominal pain Combivir. See Zidovudine, with
Bleeding/blood loss Colistin, with neomycin and hy- lamivudine
Coagulation factors. See also drocortisone and thonzo- Comfrey, toxicity of, 610
under Factor nium, otic, 570 Community-acquired pneumo-
deficiency of, 71 Colitis nia, management of, 93
prothrombin time in evaluation ischemic, hematochezia and, Compazine. See Prochlorper-
of, 402 172 azine
replacement of. See Factor microscopic, 107 Compensation
replacement pseudomembranous, 104 in metabolic acidosis, 12
Coagulation studies. See also Collagen-vascular/connective in metabolic alkalosis, 21
Partial thromboplastin tissue diseases in respiratory acidosis, 11–12
time; Prothrombin time antinuclear antibody tests in, in respiratory alkalosis, 20–21
in coma/acute mental status 372–373 Complement activation, leuko-
changes, 84 arthritis and, 262, 263 cytosis and, 267
Foley catheter problems and, fever and, 134 Complement C3, 381
150 Colon, obstruction of. See also Complement C4, 381
in hematuria, 178 Intestinal obstruction Complement CH50 (total),
international normalized ratio nausea and vomiting and, 278 381–382
and, 392 Colon carcinoma, diarrhea and, Complete blood count (CBC),
in thrombocytopenia, 359 103 379, 380t. See also He-
Coagulopathy, 70–75, 72t. See Colonoscopy mogram
also specific disorder and in constipation, 88 in alcohol withdrawal/delirium
Bleeding/blood loss in hematemesis/melena, 169 tremens, 98
Coarctation of aorta, hyperten- in hematochezia, 173 in arthritis, 264
sion and, 206 hyponatremia after, 227, 230 in cardiopulmonary arrest, 48
Cobalamin (vitamin B12). See Colony-stimulating factors. See in central venous line prob-
Vitamin B12 also specific type lems, 57
Cobalt ingestion, polycythemia leukocytosis and, 267 in coagulopathy, 72
and, 313 for leukopenia, 276 in coma/acute mental status
Cocaine, 523–524 Coltsfoot, toxicity of, 610 changes, 83
delirium and, 97 CoLYTE. See Polyethylene in constipation, 88
hypertension and, 207 glycol in diarrhea, 106
Codeine, 311t, 524 Coma, 76–86. See also Mental in dizziness/vertigo, 114
with acetaminophen, 309, 501 status in dysuria, 125
with aspirin, 511 body temperature changes in falls, 132
with aspirin and butalbital and causing, 79 in fever, 136
caffeine, 511 differential diagnosis/causes in HIV-positive patient, 145
for cough suppression, 94 of, 77–81 in headache, 155
658 INDEX
Complete blood count (CBC), Congenital heart disease, mur- heart murmur and, 160
(cont) murs in, 159, 161 Coronary care unit. See also
in heart murmur, 164 Congestive heart failure. See Intensive care unit
in hematemesis/melena, 168 Heart failure admission to
in hematochezia, 173 Connective tissue/collagen- for aortic dissection, 68
in hemoptysis, 182 vascular disorders myocardial infarction and, 68
in hyperglycemia, 192 antinuclear antibodies in, Cortef. See Hydrocortisone
in hypertension, 208 372–373 Corticosteroids. See also Glu-
in hypoglycemia, 216 arthritis and, 262, 263 cocorticoids; Steroids
in hypophosphatemia, 235 fever and, 134 comparison of, 613t
in hypotension, 239–240 Consciousness. See also for hypercalcemia, 189
in hypothermia, 245 Coma ophthalmic, 625t
laboratory reference/normal assessment of, in overdose, in pain management, 311
values for, 380t 292 Cortifoam rectal. See Hydro-
in leukopenia, 273 impairment of, aspiration and, cortisone, rectal
in nausea and vomiting, 281 39, 41 Cortisol, 382
pain management and, 308 Constipation, 86–90, 89t ACTH stimulation test in eval-
in seizures, 334 narcotic analgesics and, 308 uation of, 369
in shock, 239–240 Contact dermatitis, pruritus in, dexamethasone suppression
in ventilator patient 318, 319, 323 test in evaluation of, 385
high peak pressures and, 486 Continuous positive airway in hyponatremia, 231
hypercarbia and, 483 pressure (CPAP), 471, Cortisone, 613t
in wheezing, 366 473 Cortisporin
Complete (third-degree) atrio- for pulmonary edema, 367 ophthalmic, 513, 570, 624t,
ventricular block, 44 for stridor, 367 625t
cardiopulmonary arrest and, 47 for ventilator weaning, 488 otic, 524, 570
ECG/rhythm strip in, 45 Contraception/sexual protec- topical, 512
syncope and, 340 tion, dysuria and, 123 Cortone. See Cortisone
Computed tomography (CT) Contraceptives, oral, 574–575 Cortrosyn stimulation test. See
in abdominal pain, 7 Contrast bowel studies, in ab- ACTH
in chest pain, 66 dominal pain, 8 (cosyntropin/Cortrosyn)
in coagulopathy, 73 Contrast media, renal failure stimulation test
in constipation, 88 prevention and, 291–292 Corvert. See Ibutilide
in fever, 137 Controlled substance classifi- Corynebacterium minutissi-
in headache, 155 cation, 490–491 mum, erythrasma caused
in hemoptysis, 183 Contusion, brain, coma/acute by, pruritus and, 319
in hypertension, 208 mental status changes Cosmegen. See Dactinomycin
in hypotension, 240–241 and, 77 Cosopt. See Dorzolamide, with
in jaundice, 258 Conversion disorder, syncope timolol
in leukocytosis, 270 and, 339 Costochondritis, chest pain in,
in nausea and vomiting, 282 Convulsive syncope, 338 63, 69
in oliguria/anuria, 288 Coombs’ test Cosyntropin (Cortrosyn) stimu-
in overdose, 297 direct, 382 lation test. See ACTH
in polycythemia, 315 in anemia, 33 (cosyntropin/Cortrosyn)
in respiratory acidosis, 17 indirect, 382 stimulation test
in seizures, 334 in anemia, 33 Cotazyme. See Pancrelipase
in shock, 240–241 COPD. See Chronic obstruc- Co-trimoxazole. See Trimetho-
in thrombocytopenia, 359 tive pulmonary disease prim (TMP)-sulfamethoxa-
Comtan. See Entacapone Copper, 606 zole (SMX)
Concussion, coma/acute men- Cordarone. See Amiodarone Cough, 90–94
tal status changes and, 77 Core rewarming, 247 abdominal pain and, 2
Conduction abnormalities, in Core temperature. See also hemoptysis and, 180
hypothermia, 246 Body temperature hyponatremia and, 227
Condylox/Condylox Gel 0.5%. in hypothermia, 244 syncope and, 339, 345
See Podophyllin Coreg. See Carvedilol Cough suppression, 94
Confusion. See also Delirium; Corgard. See Nadolol in hemoptysis, 184
Mental status Corlopam. See Fenoldopam Cough syncope, 339, 345
in alcohol withdrawal/delirium Coronary artery disease. See Coumadin. See Warfarin
tremens, 97 also Heart disease Counterimmunoelectrophoresis
after seizures, 80 chest pain and, 60 (CIE), 382
INDEX 659
Flutter, atrial, 253, 347 Free hemoglobin, in transfu- leukocytosis and, 267
syncope and, 340 sion reaction, 363 for leukopenia, 276
“Flutter waves,” 347 Fremitus, tactile G-Mycitin. See Gentamicin
Fluvastatin, 628t in cough, 92 Gabapentin, 546
Fluvirin. See Influenza vaccine in fever, 136 Gabitril. See Tiagabine
Fluvoxamine, 545 Fresh-frozen plasma, transfu- Galantamine, 546
Fluzone. See Influenza vac- sion of, 468 Gallium nitrate, 546
cine for disseminated intravascular Gallstones, jaundice caused
FML. See Fluorometholone coagulation (DIC), 75 by, 260
Folate/folic acid, 611 for vitamin K deficiency/liver Gamimmune N. See Immune
deficiency of, 31, 33, 34 disease, 75 globulin, intravenous
in leukopenia, 271, 274 for von Willebrand’s disease, Gamma-globulins
red blood cell, 386 74 electrophoresis values for,
serum (folic acid), 386 Friction rub, in chest pain, 64 401t
supplementary/therapeutic, Frova. See Frovatriptan transfusion of, 468–469
34, 545 Frovatriptan, 629t Gamma-
Folex. See Methotrexate Frozen stored red blood cells glutamyltransferase/trans-
Foley balloon, inability to de- (RBCs), transfusion of, peptidase (GGT), 387
flate, 149, 150 466 alkaline phosphatase eleva-
Foley catheter FTA-ABS (fluorescent trepone- tion and, 370
hematuria and, 175 mal antibody absorbed) in jaundice, 257–258
in hypotension/shock, 241 test, 387 pain management and, 308
improperly positioned, 149 5-FU. See Fluorouracil Gamma hydroxybutyrate
insertion of, 422–423 FUDR (floxuridine), 542 (GHB), overdose/toxicity
dysuria after removal and, Fulvestrant, 546 of, 294
123 Functional (paralytic) ileus Gammar IV. See Immune glob-
irrigating, 150 abdominal pain and, 5t ulin, intravenous
obstructed, 149 nausea and vomiting and, 278 Gammopathy, polyclonal, pro-
in oliguria/anuria/acute renal Fundus, ocular tein electrophoresis in,
failure, 288–289, 290–291 in coma/acute mental status 400f
problems with, 148–150 changes, 82 Ganciclovir, 546–547
Folic acid. See Folate in dizziness/vertigo, 113 Ganite. See Gallium nitrate
Fomepizole, 545 in hyperglycemia, 191 Gap acidosis, 14–16
for methanol and ethylene gly- Fungal infection Garamycin. See Gentamicin
col toxicity, 19, 300 in HIV-positive patient, 143 Garlic (Allium sativum), 608
Fondaparinux, 545 leukocytosis and, 268 Gastrectomy, hypocalcemia
Food, reactive hypoglycemia pruritus in, 319 after, 210
and, 214 serologic testing for, 387 Gastric acid hypersecretion,
Foradil Aerolizer. See For- Fungal meningitis, cere- management of, 627t
moterol brospinal fluid findings in, Gastric contents, aspiration
Foreign body 445t of, 38–42. See also Aspir-
aspirated, 39 Fungizone. See Amphotericin ation
stridor and, 365 B Gastric decompression, for ab-
wheezing and, 365, 366 Fungus ball (mycetoma), he- dominal pain, 8
retained, hemoptysis and, 181 moptysis and, 181 Gastric emptying scan, in nau-
Formoterol, 545 FUO. See Fever, of unknown sea and vomiting, 282
Fortaz. See Ceftazidime origin Gastric juices,
Forteo. See Teriparatide Furadantin. See Nitrofurantoin composition/daily produc-
Fortovase. See Saquinavir Furosemide, 546 tion of, 464t
Fosamax. See Alendronate for congestive heart failure, Gastric lavage
Foscarnet, 545 121 in hematemesis/melena, 168
Foscavir. See Foscarnet for hypercalcemia, 188–189 in hematochezia, 173
Fosfomycin, 545–546 for hyponatremia, 232 Gastric outlet obstruction, nau-
Fosinopril, 614t for oliguria/anuria/acute renal sea and vomiting and, 278
Fosphenytoin, 546 failure, 289–290 Gastric surgery, diarrhea and,
for seizures, 336 for pulmonary edema, 367 104
Fractional excreted sodium, in Fuzeon. See Enfuvirtide Gastric tubes, 437
oliguria/anuria/acute renal Gastrin, 387
failure, 288, 412t G Gastrinomas, diarrhea and,
Fragmin. See Dalteparin G-CSF (filgrastim), 542 103
670 INDEX
Glucose, 387. See also Hyper- Glycyrrhizic acid, in licorice, hy- Growth factors
glycemia; Hypoglycemia pokalemia and, 219 leukocytosis and, 267
in alcohol withdrawal/delirium Glynase. See Glyburide for leukopenia, 276
tremens, 99–100 Glyset. See Miglitol Guaifenesin, 549
cerebrospinal fluid, 445t GM-CSF (sargramostim), 588 with codeine, 549
in crystalloid solutions, 463t leukocytosis and, 267 with dextromethorphan, 549
in dizziness/vertigo, 114 for leukopenia, 276 with hydrocodone, 551
exogenous, hyperglycemia G-Mycitin. See Gentamicin Guillain-Barré syndrome
and, 191 GoLYTELY. See Polyethylene mechanical ventilation for,
for hyperkalemia, 201 glycol 471
for hypoglycemia, 216–217 Gonadorelin, 548 respiratory acidosis and, 13
in hypophosphatemia, 235 Gonococcal arthritis, 262, 266 Gynecologic disorders
in hypothermia, 245 Gonococcal urethritis abdominal pain and, 2, 3t
in metabolic gap acidosis, 17 dysuria in men and, 124 in HIV-positive patient, fever
pleural fluid, 461t dysuria in women and, 123 and, 145
in pruritus, 322 management of, 127 Gynecologic examination. See
in seizures, 333, 335 Gonorrhea also Genitalia, examina-
serum, 387 pruritus and, 318 tion of
delirium and, 98 urine test for (ligase chain re- abdominal pain and, 6
in hyperglycemia, 191 action), 394 in hypotension, 239
in hyperosmolar, hyper- Goodpasture’s syndrome, he- in leukocytosis, 269
glycemic nonketotic syn- moptysis and, 182, 183 in nausea and vomiting, 280
drome, 195 Goserelin, 548 in shock, 239
in hypertension, 208 Gout, arthritis and, 260, 261, Gynecomastia, jaundice and,
in hypoglycemia, 215–216, 264 257
217 Gram’s stain, 387–388
in hypomagnesemia, 224 joint fluid, 264 H
in overdose, 297 sputum H-BIG. See Hepatitis B im-
urine, 409 in dyspnea, 119 mune globulin
Glucose intolerance. See also in fever, 137, 146 H1 blockers. See also Antihista-
Diabetes mellitus in hypoxemic ventilator pa- mines
pregnancy and, 190 tient, 480 for pruritus, 323
Glucotrol/Glucotrol-XL. See of untransfused blood, in H2 antagonists, for
Glipizide transfusion reaction, 364 gastritis/esophagitis, 69
Glucovance. See Glyburide, Granisetron, 549 Habitrol. See Nicotine transder-
with metformin Granular casts, in urine, micro- mal
Glutamic-oxaloacetic trans- scopic appearance of, Haemophilus B conjugate vac-
ferase, serum (SGOT). 411 cine, 549
See AST Granulocyte colony-stimulating Halcion. See Triazolam
Glutamic-pyruvic transferase, factor (G-CSF/filgrastim), Haldol. See Haloperidol
serum (SGPT). See ALT 542 Hallpike-Dix (Nylen-Barany)
γ-Glutamyltransferase/ leukocytosis and, 267 maneuver, in
transpeptidase (GGT), for leukopenia, 276 dizziness/vertigo, 114
387 Granulocyte-macrophage Hallucinations, in alcohol with-
alkaline phosphatase eleva- colony-stimulating factor drawal/delirium tremens,
tion and, 370 (GM-CSF/sargramostim), 94, 97
in jaundice, 257–258 588 Hallucinogens, overdose/toxic-
pain management and, 308 leukocytosis and, 267 ity of, 294
Glyburide, 626t for leukopenia, 276 Haloperidol, 549
with metformin, 548 Granulomatous disease for alcohol withdrawal/delirium
micronized/non-micronized, hypercalcemia and, 186 tremens, 100–101
626t leukopenia and, 272 for nausea and vomiting,
Glycerin suppositories, 89t, meningitis, cerebrospinal fluid 282
548 findings in, 445t Haloprogin, 549
Glycohemoglobin (hemoglobin Gray top specimen tubes, 639t Halotestin. See Fluoxymes-
A1C), 387 Green/glass bead specimen terone
Glycoprotein IIb/IIIa inhibitors tubes, 639t Halotex. See Haloprogin
for myocardial infarction, 68 Green top specimen tubes, Ham test, in leukopenia, 274
platelet function affected by, 639t Hands. See also Extremities
71 Groin, pruritus affecting, 318 pruritus affecting, 318
672 INDEX
Hungry bone syndrome, hypo- for polycythemia vera, 316 in hyponatremia, 231
magnesemia and, 223 Hydroxyzine, 552 pacemaker failure to capture
Hyaline casts, in urine, micro- for insomnia, 251 and, 303
scopic appearance of, 410 for pruritus, 323 Hyperkalemic periodic paraly-
Hycamtin. See Topotecan Hygroton. See Chlorthalidone sis, 199
Hycodan. See Hydrocodone, Hyoscyamine, 552 Hyperlipidemia
with homatropine with hyponatremia and, 227
Hycomine Compound. See Hy- atropine/scopolamine/phe- in nephrotic syndrome, protein
drocodone, with chlor- nobarbital, 552 electrophoresis in, 400f
pheniramine/phenylephrin Hyperaldosteronism Hypermagnesemia,
e/acetaminophen/caffeine hypernatremia and, 203 coma/acute mental status
Hycotuss Expectorant. See Hy- hypertension and, 206 changes and, 78
drocodone, with guaifen- hypokalemia and, 219 Hypermetabolism, hypercarbia
esin hypomagnesemia and, 223 in ventilator patient caused
Hydralazine, 550 metabolic alkalosis and, 23 by, 483
Hydrea. See Hydroxyurea Hyperalimentation. See Total Hypernatremia, 201–205
Hydrochlorothiazide, 550 parenteral nutrition coma/acute mental status
with irbesartan, 615t Hyperammonemia, in changes and, 77, 201
with losartan, 615t coma/acute mental status Hyperosmolality, hyperkalemia
with spironolactone, 550–551 changes, 84 and, 199
with triamterene, 551 Hyperamylasemia. See Amy- Hyperosmolar/hyperglycemic
with valsartan, 615t lase nonketotic syndrome,
Hydrocodone, 311t Hypercalcemia, 185–189 management of, 194–195
with acetaminophen, 309, 551 cancer and, 79, 185–186 Hyperparathyroidism
with aspirin, 551 coma/acute mental status coma/acute mental status
with changes and, 78 changes and, 78
chlorpheniramine/phenyle- metastatic disease and, 79 hypercalcemia and, 185
phrine/acetaminophen/caf- falls and, 130 hypertension and, 207
feine, 551 familial hypocalciuric, 185, hypophosphatemia and, 234
with guaifenesin, 551 186 multiple endocrine neoplasia
with homatropine, 551 hypomagnesemia and, 223 and, 185
with ibuprofen, 551 oliguria/anuria/acute renal fail- primary, 185
with pseudoephedrine, 551 ure and, 186, 285 pruritus in, 318
Hydrocortisone, 613t Hypercalciuria, hypomagne- Hyperphosphatemia, hypocal-
with bacitracin and neomycin semia and, 223 cemia and, 211
and polymyxin B Hypercapnia, correction of, al- Hyperpnea, in coma/acute
ophthalmic, 513 kalosis and, 22 mental status changes, 81
topical, 512 Hypercarbia Hyperproteinemia, hypona-
with neomycin and colistin mechanical ventilation for, tremia and, 227
and thonzonium, otic, 570 470 Hyperreflexia
with neomycin and polymyxin agitated patient and, 476 in alcohol withdrawal/delirium
ophthalmic, 570, 624t, 625t in neuromuscular disease, tremens, 97
otic, 570 471 in coma/acute mental status
with polymyxin B, 582 in ventilator patient, 482–483 changes, 83
with pramoxine, 582–583 Hyperglycemia, 190–197. See Hyperreninemia, hypokalemia
rectal, 551–552 also Diabetes mellitus and, 219–220
HydroDIURIL. See Hy- coma/acute mental status Hyperresonance, in chest pain,
drochlorothiazide changes and, 78 64
Hydromet. See Hydrocodone, delirium and, 96, 98 Hypersegmentation, white
with homatropine falls and, 129 blood cell, 414
Hydromorphone, 311t, 552 hypernatremia and, 202 Hypersplenism, 273, 276
Hydroxyapatite crystals, in spurious, 191 platelet sequestration and,
arthritis, 262, 264–265 HyperHep. See Hepatitis B im- 358
5-Hydroxyindoleacetic acid mune globulin Hyperstat. See Diazoxide
(5-HIAA), 391 Hypericum perforatum (St. Hypertension, 205–209
11-Hydroxylase deficiency, hy- John’s wort), 610 accelerated, 207, 209
pokalemia and, 219 Hyperkalemia, 197–201 acute renal failure and, 286
17-Hydroxylase deficiency, hy- coma/acute mental status in alcohol withdrawal/delirium
pokalemia and, 219 changes and, 78 tremens, 94, 97
Hydroxyurea, 552 factitious, 198 in chest pain, 64
676 INDEX
IMV (intermittent mandatory arthritis and, 262, 262–263 Insulinoma, hypoglycemia and,
ventilation), 473 diarrhea and, 103 215
synchronized (SIMV), 473 gamma-globulin transfusion Intake/output values, in hyper-
for ventilator weaning, and, 468–469 natremia, 202
487–488 gastrointestinal, constipation Intal. See Cromolyn sodium
Inamrinone, 554 and, 87 Integrilin. See Eptifibatide
Inapsine. See Droperidol leukocytosis and, 268 Intensive care unit, admission
Incisions, examination of, in co- Inflammatory bowel disease to
agulopathy, 72 arthritis and, 261 for aortic dissection, 68
Indapamide, 554 constipation and, 87 hematemesis/melena and,
Inderal. See Propranolol diarrhea and, 103 169
Indinavir, 554 hematochezia and, 172 hematochezia and, 174
Indirect Fick method, for car- Infliximab, 554 hemoptysis and, 184
diac output, 328 Influenza vaccine, 554 for hyperosmolar, hyper-
Indocin. See Indomethacin live, intranasal, 554 glycemia nonketotic syn-
Indomethacin, 621t Ingestion overdose, decontami- drome, 194
for pericarditis, 69 nation for, 299 hypertensive emergency and,
Infection. See also Sepsis INH. See Isoniazid 208
arthritis and, 261, 262 Inhalants, respiratory and for hypothermia, 246
atrioventricular (AV) node nasal, 499t. See also spe- myocardial infarction and, 68
blocks and, 43 cific agent for overdose, 298
central nervous system Inhaled irritants, cough and, 91 Intensive care unit (ICU) psy-
coma/acute mental status Innohep. See Tinzaparin chosis, 80
changes and, 76, 79, 85 Inocor. See Inamrinone agitation in ventilator patient
delirium and, 96 Inotropin. See Dopamine caused by, 477, 478
central venous line, 56, 57, INR. See International normal- Interferon, for polycythemia
58, 59, 137 ized ratio vera, 316
coma/acute mental status Insomnia, 247–251 Interferon alfa, 555
changes and, 76, 79, 85 rebound, 248 Interferon alfa-2B and ribavirin
cough and, 93 Inspiratory force, negative, combination, 555
delirium and, 97 ventilator weaning guide- Interferon alfacon-1, 555
diarrhea and, 102–103 lines and, 487 Interferon β-1b, 555
falls and, 131 Inspired fraction of oxygen Interferon gamma-1b, 555
fever and, 134, 138 (FiO2) Interleukin-2 (IL-2/aldesleukin),
hematuria and, 176, 177, 179 adjusting, for ventilator pa- 503
hemoptysis and, 180–181, tient, 475 Intermediate-acting insulins,
184 high peak pressures and, 486 613t. See also Insulin
hypothermia and, 243, 244 hypoxemia and, 481 Intermittent mandatory ventila-
leukocytosis and, 267, 268 ratio of to PaO2 (P/F ratio), in tion (IMV), 473
leukopenia and, 271, 272, respiratory failure, mechan- synchronized (SIMV), 473
273, 274–276 ical ventilation and, 470 for ventilatory weaning,
oliguria/anuria/acute renal fail- ventilatory setup/initial set- 487–488
ure and, 285, 286 tings and, 473, 474 Internal jugular vein
respiratory alkalosis and, 21, Inspra. See Eplerenone left, for central venous
22 Insulin, 193, 193t, 555, 613t catheterization, 429
seizures and, 331 critical illness and, 196–197 right, for central venous
thrombocytopenia and, 355, deficiency of, hyperkalemia catheterization, 427–429
356, 357 and, 198 International normalized ratio
Infectious mononucleosis, neu- for diabetic ketoacidosis, 195 (INR), 392. See also Pro-
tropenia and, 272 for hyperkalemia, 201 thrombin time
INFeD. See Iron dextran for hyperosmolar/hyper- Interstitial lung disease
Infergen. See Interferon alfa- glycemia nonketotic syn- cough and, 91
con-1 drome, 194–195 dyspnea and, 117
Infestation, pruritus caused by, overdose/toxicity of, 294 high peak pressures and, 485
319 hypoglycemia and, 213–214, respiratory alkalosis and, 22
Infiltrative processes, thrombo- 214, 217, 294 Interstitial renal disease/inter-
cytopenia and, 356 serum, in hypoglycemia, 216 stitial nephritis
Inflammation/inflammatory dis- for type 2 diabetes, 193, 193t hematuria and, 176
orders Insulin Glargine, 613t. See also oliguria/anuria/acute renal fail-
anemia and, 29 Insulin ure and, 285–286
INDEX 679
Large bowel obstruction. See fecal, testing for, 405 Ligase chain reaction, for Neis-
also Intestinal obstruction in diarrhea, 106 seria gonorrhoeae and
nausea and vomiting and, 278 in HIV-positive patient, 146 Chlamydia trachomatis, for
Laryngeal tumor, stridor and, in urine urine, 394
365 hematuria and, 178 Lightheadedness, 112, 116
Laryngospasm, stridor and, microscopic appearance of, Lindane, 560
365 410 Line sepsis, pacemaker com-
Larynx, disorders of, cough Leukocytosis, 266–270 plications and, 304
and, 91 in polycythemia vera, 312, Linezolid, 560
Lasix. See Furosemide 314 Lioresal. See Baclofen
Latanoprost, 624t Leukopenia, 270–277. See Liothyronine, 560–561
Laxatives, 496–497t. See also also Neutropenia Lipase, 394
specific agent Leuprolide, 559 in abdominal pain, 6–7
for constipation, 89–90, 89t Leustatin. See Cladribine in hypercalcemia, 187
diarrhea caused by, 102, 103 Levalbuterol, 559 in hyperglycemia, 192
overuse/abuse of, hypocal- Levamisole, 559 in nausea and vomiting, 281
cemia and, 210 Levaquin. See Levofloxacin Lipitor. See Atorvastatin
LDH. See Lactate dehydroge- Levatol. See Penbutolol Liqui-Char. See Charcoal, acti-
nase Level of consciousness. See vated
LDL cholesterol. See Low- Coma; Consciousness Lisinopril, 614t
density lipoprotein (LDL) Levetiracetam, 559 Lispro, 613t
cholesterol Levine tube, 437 Lithium, 561
Lead, overdose/toxicity of, anti- Levitra. See Vardenafil overdose/toxicity of, 294, 630t
dote for, 301 Levobetaxolol, 623t therapeutic levels of, 630t
Leads, pacemaker, failure to Levobunolol, 623t Lithobid. See Lithium
capture and, 302 Levocabastine, 625t Liver biopsy, in jaundice, 259
Leflunomide, 558 Levodopa/carbidopa, 517 Liver disease/disorders. See
Left internal jugular vein, for Levofloxacin, 559 also Cirrhosis
central venous catheteri- Levonorgestrel, 559–560 abdominal pain and, 3t
zation, 429 with ethinyl estradiol, 539 alcoholic, jaundice and, 256,
Legs. See also Extremities Levonorgestrel implant, 560 259
pruritus affecting, 318 Levophed. See Norepineph- bleeding and, 71, 75
Leiomyomas, uterine, poly- rine hematemesis/melena and,
cythemia and, 313 Levothyroxine, 560 166
Lepirudin, 558 Levoxyl. See Levothyroxine hemoptysis and, 181
Lescol. See Fluvastatin Levsin. See Hyoscyamine hypocalcemia and, 211
Lethargy, hypernatremia and, Lexapro. See Escitalopram hypoglycemia and, 214
201 Librium. See Chlordiaze- hypophosphatemia and, 234
Letrozole, 558–559 poxide pruritus in, 318, 320
Leucovorin, 559 Lice (pediculosis), pruritus and, respiratory alkalosis and, 22
Leukemia 318, 319 Liver enzymes, in hypophos-
hypokalemia and, 218 Lichen planus, pruritus in, 318, phatemia, 235
leukopenia and, 272 319 Liver failure, nausea and vomit-
pruritus and, 320 Lichen simplex, pruritus in, ing and, 279
Leukeran. See Chlorambucil 318, 319 Liver function tests
Leukine. See Sargramostim Licorice, toxicity of, 610 in abdominal pain, 6
Leukocyte alkaline phos- hypokalemia and, 219, 610 in alcohol withdrawal/delirium
phatase (LAP) score, 394 Liddle’s syndrome, hy- tremens, 98
in leukocytosis, 270 pokalemia and, 220 in falls, 132
in leukopenia, 274 Lidocaine, 560 in fever, in HIV-positive pa-
in polycythemia vera, 312, with bacitracin and neomycin tient, 146
314 and polymyxin B, topical, in hematemesis/melena, 167
Leukocyte count. See White 512 in hypoglycemia, 216
blood cell (WBC) count with prilocaine, 560 in hyponatremia, 231
Leukocyte esterase, urine, 410 therapeutic/toxic levels of, in jaundice, 257–258
Leukocyte-poor red blood cells 630t in leukocytosis, 269
(RBCs), transfusion of, for ventricular fibrillation, 49 in leukopenia, 274
466 for ventricular tachycardia, 51, in nausea and vomiting, 281
Leukocytes. See also under 53, 353–354 in overdose, 297
White blood cell Life root, toxicity of, 610 in pruritus, 322
682 INDEX
Magnesium, 395, 607 Malarone. See Atovaquone, Mean cellular hemoglobin con-
disorders of balance of. See with proguanil centration (MCHC), 403
also Hypermagnesemia; Male breast, examination of, in laboratory reference/normal
Hypomagnesemia jaundice, 257 values for, 380t
in alcohol withdrawal/delirium Malignancy. See Cancer Mean cellular hemoglobin
tremens, 98 Malignant carcinoid syndrome, (MCH), 403
coma/acute mental status diarrhea and, 103 laboratory reference/normal
changes and, 78 Malignant hypertension, 207 values for, 380t
hypokalemia and, 220 oliguria/anuria/acute renal fail- Mechanical ventilation,
metabolic alkalosis and, 23 ure and, 286 470–489
in hyperglycemia, 192 Malignant neuroleptic syndrome agitated patient and, 476–479
in hypophosphatemia, 235 fever and, 134–135, 141 for aspiration, 41
serum, 395 management of, 141 disconnection/malfunction
in hypomagnesemia, 222 Mallory-Weiss tear, hemateme- and, hypoxemia caused
supplementary, 607 sis/melena and, 167, 170 by, 480
for hypocalcemia, 212–213 Malnutrition high peak pressures and,
for hypomagnesemia, hypocalcemia and, 210 484–486
212–213, 225–226 hypoglycemia and, 215 hypercarbia in patient with,
for tachycardia, 354 hypophosphatemia and, 234 482–484
urine, 395 thrombocytopenia and, 356 hypoxemia in patient with,
in hypomagnesemia, 224 Mandol. See Cefamandole 479–482
Magnesium carbonate, with Mannitol, 562 indications for, 470–471
aluminum hydroxide, 505 for coma/acute mental status intubation for, 434–435, 435f,
Magnesium chloride, for hypo- changes in CNS tumor, 85 472
magnesemia, 225 hypernatremia and, 202 modes of, 473–474
Magnesium citrate, 89t, 562 hyponatremia and, 226–227 partial ventilatory assistance
Magnesium hydroxide, 89, 89t, for oliguria/anuria/acute renal and, 471–472
562 failure, 290 pneumothorax and
with aluminum hydroxide, 505 Marcaine. See Bupivacaine agitation and, 477
with aluminum hydroxide and Margination (neutrophil), en- high peak pressures and, 485
simethicone, 505 hanced, 273 hypoxemia and, 479, 481
Magnesium lactate, for hypo- Marinol. See Dronabinol respiratory acidosis and, 19
magnesemia, 225 Mast cell stabilizers, oph- respiratory alkalosis and, 24
Magnesium oxide, 562 thalmic, 625t settings for
for hypomagnesemia, 225 MAST suit, for initial, 474
Magnesium retention test, 224 hypotension/shock, 241 reviewing/adjusting
Magnesium sulfate, 562 Mastocytosis, pruritus and, in agitated patient, 477, 479
for hypomagnesemia, 318, 320 in hypoxemic patient, 479,
212–213, 224–225 Matulane. See Procarbazine 480, 481–482
Magnesium trisilicate, with alu- Mavik. See Trandolapril routine, 475–476
minum hydroxide, 505 Maxair. See Pirbuterol ventilator setup for, 472–475
Magnetic resonance cholan- Maxalt. See Rizatriptan weaning from, 486–488
giopancreatography Maxipime. See Cefepime Mechlorethamine, 562–563
(MRCP), in jaundice, 259 Maxitrol. See Neomycin, with Meclizine, 563
Magnetic resonance imaging polymyxin B and dexa- for dizziness/vertigo, 115
(MRI) methasone, ophthalmic Median basilic vein, for central
in fever, 137 Maxzide. See Hydrochlorothi- venous catheterization, 433
in headache, 155 azide, with triamterene Medic Alert bracelet, for ana-
in oliguria/anuria, 288 Mazaquin. See Lomefloxacin phylaxis patients, 28
in polycythemia, 315 MCH. See Mean cellular hemo- Medications. See Drugs/toxins
in seizures, 334 globin Medigesic. See Aceta-
MagTab. See Magnesium lac- MCV. See Mean cell volume minophen, with butalbital
tate MDMA (3,4-methylene- and caffeine
Malabsorption dioxymethamphetamine/ Mediquell. See Dextromethor-
diarrhea and, 104 ecstasy), overdose/toxicity phan
hypocalcemia and, 210 of, 294 Medrol. See Methylpred-
hypomagnesemia and, 223 Mean cell volume (MCV), 403 nisolone
hypophosphatemia and, 234 in anemia, 30–31 Medroxyprogesterone, 563
Malaise, in HIV-positive pa- laboratory reference/normal with conjugated estrogens,
tient, fever and, 141 values for, 380t 538
684 INDEX
Methylprednisolone, 613t Milk, phosphate content of, Mixed venous oxygen satura-
for anaphylaxis, 28 236, 236t tion (SvO2), pulmonary
for bronchospasm, 367 Milk-alkali syndrome artery catheter measure-
for dyspnea in asthma, 121 hypercalcemia and, 186 ment of, 456t
for stridor, 367 metabolic alkalosis and, 23 in shock, 451t
Methylprogesterone, with con- Milk of Magnesia. See Magne- Moban. See Molindone
jugated estrogens, sium hydroxide Mobic. See Meloxicam
538–539 Milk thistle (Silybum mari- Mobitz type I second-degree
4-Methylpyrazole. See Fomepi- anum), 609 atrioventricular block
zole Milrinone, 567 (Wenckebach), 43, 253
Methyltestosterone Miltown. See Meprobamate ECG/rhythm strip in, 44
with conjugated estrogens, 539 Mineral oil, 89, 89t, 567 Mobitz type II second-degree
with esterified estrogens, 537 Mineralocorticoids atrioventricular block, 43,
Metipranolol, 623t excess, hypokalemia and, 253, 255
Metoclopramide, 566 219–220 ECG/rhythm strip in, 44–45
for nausea and vomiting, 282 hypernatremia and, 203 Modafinil, 568
Metolazone, 566 Minerals, 500t, 606–607. See Moexipril, 614t
for oliguria/anuria/acute renal also specific type Molindone, 568
failure, 290 Minipress. See Prazosin Monistat. See Miconazole
Metoprolol, 617t Minoxidil, 567 Monitoring
for myocardial infarction, 67 Minute ventilation (V̇e) arterial line, 416–417
for tachycardia, 353 high, high peak pressures problems with, 36–38
MetroGel. See Metronidazole and, 485 central venous, 426–434
Metronidazole, 566 inadequate, in hypercarbic problems with, 56–60
for Clostridium difficile diar- ventilator patient, 482–483 pulmonary artery (Swan-
rhea, 108–109 ventilator setup and, 472–473 Ganz), 449–457, 451t,
Mevacor. See Lovastatin ventilator weaning guidelines 452f, 455f, 456t, 457t
Mexiletine, 566 for, 487 problems with, 324–329,
Mexitil. See Mexiletine Miotics, for glaucoma, 623t 454
Mezlin. See Mezlocillin MiraLax. See Polyethylene gly- Monitors, for pulmonary artery
Mezlocillin, 616t col catheter, problems related
Miacalcin. See Calcitonin, ther- Mirapex. See Pramipexole to, 326
apeutic Mirtazapine, 567 Monocid. See Cefonicid
Micardis. See Telmisartan Misoprostol, 567 Monoclate. See Antihemophilic
Miconazole, 566 Mithracin. See Plicamycin factor
Micro-K. See Potassium, sup- Mithramycin. See Plicamycin Monocytes, 414
plementary Mitomycin, 567–568 laboratory reference/normal
Microalbuminuria, 370 Mitotane, 568 values for, 380t
Microcytic anemia, 30, 30t Mitoxantrone, 568 Mononucleosis, infectious,
Micronase. See Glyburide Mitral regurgitation neutropenia and, 272
Microscopic colitis, 107 congestive failure and, 160 Monopril. See Fosinopril
Microsporidia, diarrhea caused heart murmur in, 161, 162 Monosodium urate crystals, in
by, 104–105 Mitral stenosis gout, 264
Micturition syncope, 339, 345 heart murmur in, 160, 161, Monospot test, 395
Midamor. See Amiloride 163 Montelukast, 568
Midazolam, 566–567 hemoptysis and, 181, 182 Monurol. See Fosfomycin
for seizures, 336 Mitral valve prolapse, heart Morphine, 309–310, 311t, 568
Midrin. See murmur in, 160, 162–163 for aortic dissection, 68
Isometheptene/dichlo- Mixed connective tissue dis- for myocardial infarction, 67
ralphenazone/aceta- ease. See also Connective in pain management,
minophen tissue/collagen-vascular 309–310, 311t
Mifeprex. See Mifepristone disorders for pulmonary edema, 121,
Mifepristone, 567 antinuclear antibodies in, 367
Miglitol, 194, 567 372–373 Moschowitz’s syndrome
Migraine headache, 151–152 arthritis and, 263 (thrombotic thrombocy-
abdominal pain and, 4 Mixed respiratory failure, me- topenia purpura/TTP), 70,
management of, 157–158 chanical ventilation for, 357, 360
nausea and vomiting and, 279 470 Motor examination, in seizures,
prophylactic therapy for, 158 Mixed venous blood gases, 333
syncope and, 340 374t Motrin. See Ibuprofen
686 INDEX
Nitrostat. See Nitroglycerin Novafed. See Pseudoephedrine Obturator sign, abdominal pain
Nix. See Permethrin Novantrone. See Mitoxantrone and, 6
Nizatidine, 572–573 Novolin, 613t Occult blood, in stool, testing
for gastritis/esophagitis, 69 Novolog. See Aspart for, 405
Nizoral. See Ketoconazole NSAIDs. See Nonsteroidal in anemia, 32
Noise, insomnia and, 249 anti-inflammatory drugs in constipation, 88
Nolvadex. See Tamoxifen Nubain. See Nalbuphine in diarrhea, 107
Non–tonic-clonic seizures, Nuclear scans Occupational exposures
coma/acute mental status in hypotension/shock, 241 coma/acute mental status
changes and, 80 in jaundice, 259 changes and, 77
Nonepileptic psychogenic in oliguria/anuria, 288 jaundice and, 256
seizures, 331–332 Nuclear venogram, in central leukopenia and, 271
Nongap acidosis, 13–14 venous line problems, 58 Octamide. See Metoclo-
Nongonococcal urethritis, dys- Nucleated red blood cells, 403 pramide
uria in men and, 124 Nucleic acid amplification test Octreotide, 573
Nonsteroidal anti-inflammatory (NAAT), for Neisseria gon- for esophageal varices, 170
drugs (NSAIDs), 309, orrhoeae and Chlamydia Ocufen. See Flurbiprofen
621–622t trachomatis, in dysuria, 125 Ocuflox ophthalmic. See
anemia and, 29 Nucleolar RNA, antibodies to, Ofloxacin
for arthritis, 265 373 Ocular decontamination, 299
for chronic tension-type 5′-Nucleotidase, 395 Ocular fundus. See Fundus
headache, 156 Numorphan. See Oxymor- Ocular movements. See Eye
for episodic tension-type phone movements
headache, 156 Nupercainal. See Dibucaine Oculocephalic reflex, in
for migraine headache, 157 Nutrition coma/acute mental status
nausea and vomiting and, 278 for oliguria/anuria/acute renal changes, 83
ophthalmic, 624t failure, 291 Ocupress. See Carteolol, oph-
in pain management, 309 reviewing/adjusting, in hyper- thalmic
platelet function affected by, carbic ventilator patient, Ofloxacin, 574
71 484 Oil retention enema, 89t
Norcuron. See Vecuronium thrombocytopenia and, 356 Olanzapine, 574
Norelgestromin, with ethinyl NuvaRing. See Ethinyl estra- Oligemic shock, pulmonary
estradiol, 539 diol, with etonogestrel artery catheter monitoring
Norepinephrine Nylen-Barany (Hallpike-Dix) in, 451t
serum/urine levels of, labora- maneuver, in Oliguria, 283–292
tory reference/normal val- dizziness/vertigo, 114 definition of, 283
ues for, 379t Nystagmus differential diagnosis/causes
therapeutic, 573 in alcohol withdrawal/delirium of, 285–286
Norethindrone acetate/ethinyl tremens, 97 diuretic use and, 289,
estradiol, 573 in coma/acute mental status 289–290
Norflex. See Orphenadrine changes, 82 imaging/clinical studies in,
Norfloxacin, 573 in dizziness/vertigo, 113–114 288–289
Norgestrel, 573 Nystatin, 573 initial evaluation of, 283–285
Normiflo. See Ardeparin with triamcinolone, 600 laboratory findings/data in,
Normodyne. See Labetalol 287–288
Noroxin. See Norfloxacin O management of, 291
Norpace. See Disopyramide O2. See Oxygen management of specific
Norplant. See Levonorgestrel Obesity causes of, 290–291
implant respiratory acidosis and, 13 physical examination/findings
Norpramin. See Desipramine type 2 diabetes and, 190 in, 286–287
Nortriptyline, 573 Obstipation urinary indices in, 412, 412t
Norvasc. See Amlodipine abdominal pain and, 2, 5t Olmesartan, 615t
Norvir. See Ritonavir constipation and, 86, 87, Olopatadine, 625t
Norwalk virus, diarrhea caused 87–88 Olsalazine, 574
by, 102 Obstructive cardiomyopathy, Omalizumab, 574
Nose, examination of, in alco- hypertrophic, heart mur- Omeprazole, 627t
hol withdrawal/delirium mur in, 161, 163 for gastritis/esophagitis, 69
tremens, 97 Obstructive extracardiac shock, Omnicef. See Cefdinir
Nosocomial infection, fever pulmonary artery catheter Omnipen. See Ampicillin
and, 133 monitoring in, 451t Oncaspar. See L-Asparaginase
690 INDEX
Oxygen therapy PaCO2. See also pCO2 PAP. See Pulmonary artery
for anaphylaxis, 27 adjusting, for ventilator pa- pressure
for aspiration, 41 tient, 476 Papillary muscle
for chest pain, 66 in ventilatory failure, mechani- dysfunction/rupture, heart
for cluster headache, 158 cal ventilation and, 470 murmur and, 160
for dyspnea, 121 PACs. See Premature atrial Papulosquamous diseases,
for hypotension/shock, 241 contractions pruritus in, 319
for pneumothorax, 69 Paget’s disease, hypercal- Paracentesis, 447–449
for pulmonary edema, 367 cemia and, 186 in abdominal pain, 8
for pulmonary embolism, 68 Pain urgent surgery and, 9t
OxyIR. See Oxycodone insomnia and, 247, 248 in hypotension/shock, 241
Oxymorphone, 576 respiratory alkalosis and, 22 Paraflex. See Chlorzoxazone
Oxytocin, 576 Pain management, 306–311 Parafon Forte DSC. See Chlor-
Oxytrol. See Oxybutynin, trans- for abdominal pain, 8–9 zoxazone
dermal system analgesics in, 308–311 Paraldehyde, metabolic acido-
for myocardial infarction, 165 sis caused by, 17
P Painful rib syndrome, abdomi- Paralytic ileus
32 nal pain and, 4 abdominal pain and, 5t
P, for polycythemia vera, 316
p50. See Oxygen affinity of he- Palonosetron, 577 nausea and vomiting and, 278
moglobin Pamelor. See Nortriptyline Paraneoplastic syndromes
P-ANCA. See Perinuclear- Pamidronate, 577 arthritis and, 263
staining ANCA for hypercalcemia, 189 cancer pain and, 307
P/F (PaO2/FiO2) ratio, in respi- Pancreas, disorders of coma/acute mental status
ratory failure, mechanical abdominal pain and, 3t, 6–7 changes and, 80
ventilation and, 470 coma/acute mental status Paraplatin. See Carboplatin
P wave–QRS complex relation- changes and, 78 Parasites
ship, in supraventricular in HIV-positive patient, fever diarrhea caused by infection
tachyarrhythmias, 346 and, 144 with, 103, 107
P waves hyperglycemia and, 191 in HIV infection/AIDS, 104–105
in bradycardia, 44–45 Pancrease. See Pancrelipase pruritus caused by, 318, 319,
in irregular pulse, 254 Pancreatic islet cell tumor, hy- 320
pacemaker oversensing of, poglycemia and, 215 in stool, testing for
304 Pancreatic juice, in diarrhea, 107
in supraventricular tach- composition/daily produc- in HIV-positive patient, 146
yarrhythmias, 346 tion of, 464t in pruritus, 322
PAC. See Premature atrial Pancreatitis in urine, microscopic appear-
contractions; Pulmonary abdominal pain and, 3t, 6–7 ance of, 410
artery (Swan-Ganz) chest pain in, 63 Parasympathetic nervous sys-
catheter diarrhea in, 104 tem, bradycardia caused
Pacemaker in HIV-positive patient, 144 by changes in, 42
adjusting settings of, 305 hyperglycemia and, 191 Parathyroid glands, disorders
for bradycardia, 45–46 hypocalcemia and, 210, 211 of
failure to capture and, hypomagnesemia and, 223 coma/acute mental status
302–303, 302f nausea and vomiting and, changes and, 78
failure to sense and, 303, 277, 278 hypocalcemia and, 210
303f, 305 Pancrelipase, 577 Parathyroid hormone (PTH),
troubleshooting, 301–306 Pancuronium, 577 396–397
Pacemaker spikes Pancytopenia, 30 in hypocalcemia, 210, 211
in bradycardia, 45 Panorex, in leukopenia, 274 Parathyroid hormone–related
without capture, 302, 302f Pantoprazole, 627t peptide, coma/acute men-
failure to sense and, 303, 303f PaO2. See also pO2 tal status changes and, 80
Pacemaker syncope, 340 adjusting, for ventilator pa- Parathyroidectomy, hypomag-
Pacerone. See Amiodarone tient, 475–476 nesemia and, 223
Pacing wire, pacemaker com- in respiratory failure, mechani- Paregoric, 577
plications and, 305 cal ventilation and, 470 Parepectolin. See Kaolin-pectin
Pacis. See Bacillus Calmette- ventilator weaning guidelines Parkinson’s disease
Guerin for, 487 disequilibrium and, 112
Packed red blood cells (RBCs), PaO2/FiO2 (P/F) ratio, in respi- falls and, 129
transfusion of, 466 ratory failure, mechanical Parlodel. See Bromocriptine
Paclitaxel, 576–577 ventilation and, 470 Paroxetine, 577
692 INDEX
Paroxysmal atrial tachycardia Pediculosis, pruritus in, 318, 319 for seizures, 336
with block, 347 Pediculus capitis, pruritus Pentosan polysulfate sodium,
syncope and, 340 caused by, 318, 319 579
Paroxysmal nocturnal hemo- Pediculus corporis, pruritus Pentoxifylline, 579
globinuria (PNH) caused by, 318, 319 Pepcid. See Famotidine
leukopenia and, 271, 272 PedvaxHIB. See Haemophilus Peptic ulcer disease
thrombocytopenia and, 356 B conjugate vaccine chest pain in, 63
Partial thromboplastin time PEEP (positive end-expiratory hematemesis/melena and,
(PTT), 72–73, 72t, 397 pressure) 166, 167, 170
in central venous line prob- adjusting PaO2 for ventilator management of, 170, 627t
lems, 57, 59 patient and, 475 nausea and vomiting and,
in coagulopathy, 72–73, 72t hypoxemia and, 481 277, 278
in diarrhea, 106 high peak pressures and, 484, Pepto-Bismol. See Bismuth
in headache, 155 486 subsalicylate
in hematemesis/melena, 168 PEG (polyethylene glycol), 89, Percocet. See Oxycodone, with
in hematochezia, 173 89t, 582 acetaminophen
in hemoptysis, 182–183 Peg interferon alfa 2a, 578 Percodan/Percodan-Demi. See
in hypotension, 240 Peg interferon alfa 2b, 578 Oxycodone, with aspirin
in hypothermia, 245 Pegasys. See Peg interferon Percutaneous transhepatic
in shock, 240 alfa 2a cholangiogram (PTC), in
in thrombocytopenia, 359 Pegfilgrastim, 577 jaundice, 258–259
in transfusion reaction, 363 PEG-Intron. See Peg interferon Perforated viscus
Particulate aspiration, 39 alfa 2b abdominal pain and, 3–4, 5t
Parvovirus B19 infection, arthri- Pellagra, coma/acute mental nausea and vomiting and, 279
tis and, 263 status changes and, 79 Pergolide, 579
PASG. See Pneumatic anti- Pelvic computed tomography Periactin. See Cyproheptadine
shock garment in nausea and vomiting, 282 Pericardial friction rub, in chest
Patanol. See Olopatadine in polycythemia, 315 pain, 64
Pathologic fracture, in cancer, Pelvic exam. See Gynecologic Pericardial tamponade. See
pain caused by, 307 examination Tamponade
Patient positioning Pelvic inflammatory disease, Pericardiocentesis
aspiration and, 38, 41 nausea and vomiting and, in hypotension/shock, 241, 243
for CPR, 46 279 for pulseless electrical activity
gastritis/esophagitis and, 69 Pelvic trauma, constipation caused by tamponade, 55
for hypoxemic ventilator pa- and, 87 Pericarditis
tient, 482 Pelvis, examination of, in chest pain in, 61, 64, 69
for lumbar puncture, 441, hematuria, 178 dyspnea and, 118
443f Pemirolast, 625t management of, 69
syncope and, 337 Pemphigoid, bullous, pruritus Perindopril, 614t
Pausinystalia yohimbe (yohim- in, 319 Perinuclear-staining ANCA
bine), 610 Pemphigus, pruritus in, 319 (P-ANCA), 372
toxicity of, 610 Pen-Vee K. See Penicillin V Periodic breathing (Cheyne-
Pavulon. See Pancuronium Penbutolol, 617t Stokes respiration), in
Paxil/Paxil CR. See Paroxetine Penciclovir, 578 coma/acute mental status
pCO2, 377. See also PaCO2 Penicillin changes, 81
in acidosis, 10, 10–11, 375t antistaphylococcal, 616t Periodic limb movements, in-
in alkalosis, 19–20, 375t extended-spectrum, 616t somnia and, 249
laboratory reference/normal Penicillin G Periodic paralysis
values for, 374t aqueous (potassium or familial, hypokalemia and, 218
PCP. See Pneumocystis carinii sodium), 578 hyperkalemic, 199
pneumonia benzathine, 578 Perioperative delirium, 77
PCWP. See Pulmonary capil- procaine, 578 Peripheral blood smear
lary wedge pressure Penicillin V, 578 in anemia, 30–31, 32
PE. See Pulmonary embolism Pentam 300. See Pentamidine in coagulopathy, 73
PEA. See Pulseless electrical Pentamidine, 579 in hypertension, 208
activity Pentasa. See Mesalamine in hypophosphatemia, 235
Peak pressures, ventilator, Pentazocine, 579 in leukocytosis, 269
high, 484–486 Pentids. See Penicillin G, in leukopenia, 274
PediaCare 1. See Dex- aqueous in thrombocytopenia, 359
tromethorphan Pentobarbital, 579 in transfusion reaction, 363
INDEX 693
Platelet count, (cont) Pneumococcal vaccine polyva- Polycitra-K. See Potassium cit-
in headache, 155 lent, 581 rate, with citric acid
in hematemesis/melena, 168 Pneumocystis carinii pneumo- Polyclonal gammopathy, pro-
in hematochezia, 173 nia (PCP), in HIV-positive tein electrophoresis in,
in hemoptysis, 182–183 patient, 143, 147 400f
in hyperkalemia, 200 Pneumonia Polycythemia, 312–317
in hypophosphatemia, 235 aspiration and, 39 management of, 315–317
in hypotension/shock, 240 chest pain in, 62 relative (apparent), 312, 315
in hypothermia, 245 community-acquired, 93 secondary, 313, 315–316
laboratory reference/normal cough and, 91, 93 vera, 312–313, 316–317
values for, 380t dyspnea and, 117, 122 pruritus and, 318, 320
in polycythemia vera, 312, 314 hemoptysis and, 180, 184 Polydipsia
Platelet transfusions, 466–467 in HIV-positive patient hypernatremia and, 202
for disseminated intravascular acid-fast organisms causing, hyponatremia and, 229, 230
coagulation (DIC), 75 143 Polyethylene glycol (PEG), 89,
for thrombocytopenia, 74, 360 bacterial, 143 89t, 582
prophylactic, 360–361 Pneumocystis carinii, 143, Polymox. See Amoxicillin
Platelets, 397–398 147 Polymyalgia rheumatica, 263
disorders of function/number hypoxemia in ventilator pa- Polymyositis, antinuclear anti-
of, 70–71. See also tient caused by, 479 bodies in, 372–373
Thrombocytopenia management of, 93, 122, 139 Polymyxin B
decreased production and, 70 respiratory acidosis and, 12 with bacitracin
peripheral destruction and, 70 respiratory alkalosis and, 22 ophthalmic, 512–513
sequestration in spleen and, Pneumothorax, 62 topical, 512
70, 358 in cardiogenic shock, 243 with bacitracin and neomycin
Platinol AQ. See Cisplatin cardiopulmonary arrest and, ophthalmic, 513
Platypnea, 116 48 topical, 512
Plavix. See Clopidogrel chest pain and, 62, 69 with bacitracin and neomycin
Plendil. See Felodipine dyspnea and, 117 and hydrocortisone
Pletal. See Cilostazol management of, 69, 243 ophthalmic, 513
Plethora, in polycythemia, 314 pulseless electrical activity topical, 512
Plethysmography, impedance, and, 55 with bacitracin and neomycin
in central venous line respiratory acidosis and, 13 and lidocaine, topical,
problems, 58 respiratory alkalosis and, 22 512
Pleural effusion spontaneous, 62 with hydrocortisone, 582
diagnosis/evaluation of, thoracentesis and, 462 with neomycin
459–462, 460f, 461t. See in ventilator patient for bladder irrigation, 570
also Thoracentesis agitation and, 477 topical, 570
dyspnea and, 117, 122 high peak pressures and, with neomycin and dexa-
management of, 122 485 methasone, ophthalmic,
respiratory acidosis and, 13 hypoxemia and, 479, 481 625t
Pleural fluid, removal/differen- Pneumovax-23. See Pneumo- with neomycin and hydrocorti-
tial diagnosis of, 459–462, coccal vaccine polyvalent sone
460f, 461t. See also Tho- PNH. See Paroxysmal noctur- ophthalmic, 570, 624t, 625t
racentesis nal hemoglobinuria otic, 570
Pleural friction rub, in chest pO2, 396. See also PaO2 with neomycin and pred-
pain, 64 laboratory reference/normal nisolone, ophthalmic,
Pleuritic pain, hemoptysis and, values for, 374t 625t
180 Podocon-25. See Podophyllin Poly-Pred. See Neomycin, with
Pleuritis, chest pain in, 62 Podophyllin, 581 polymyxin B and pred-
Pleurodynia, 62 Poikilocytosis, 403 nisolone, ophthalmic
Plicamycin, for hypercalcemia, Point of maximal impulse, as- Polyps, gastrointestinal, hema-
189 sessment of tochezia and, 172
PM-1 antibodies, 372 in chest pain, 64 Polysporin. See Bacitracin,
PMI. See Point of maximal im- in cough, 92 with polymyxin B
pulse in dyspnea, 119 Polyuria, hypernatremia and,
Pneumatic antishock garment, Pokeweed, toxicity of, 610 202
241 Polychondritis, arthritis and, Porphyria, coma/acute mental
Pneumococcal 7-valent conju- 263 status changes and, 79
gate vaccine, 581 Polychromasia, 404 Positional vertigo, 110, 111
INDEX 695
Positive end-expiratory pres- Potassium-binding resins, for nausea and vomiting and,
sure (PEEP) hyperkalemia, 201 277, 280
adjusting PaO2 for ventilator Potassium citrate, 582 pseudoanemia and, 29
patient and, 475 with citric acid, 582 respiratory alkalosis and, 22
hypoxemia and, 481 Potassium hydroxide (KOH) syncope and, 340
high peak pressures and, 484, prep, 393 thrombocytopenia and, 358
486 in pruritus, 322 Pregnancy test
Positive pressure breathing. Potassium iodide (Lugol’s solu- in abdominal pain, 7
See also Mechanical venti- tion/SSKI), 582 HCG beta subunit, 392
lation Potassium phosphate, 236 in hypotension/shock, 240
for aspiration, 41 Potassium-sparing diuretics, in nausea and vomiting, 281
Posterior iliac crest, bone mar- hyperkalemia and, 199 Preleukemic syndrome
row aspiration and biopsy Potomania, beer, hyponatremia (myelodysplasia)
from, 423–425 and, 230 leukopenia and, 272
Postextubation care, 488 Pounds/kilograms weight con- thrombocytopenia and, 356
Postictal confusion, 80 version chart, 636t Premarin. See Estrogens, con-
Post-lumbar puncture PPD (purified protein deriva- jugated
headache, 446 tive) skin test Premarin with methylproges-
Postobstructive diuresis in cough, 93 terone. See Estrogens,
hypernatremia and, 202 in hemoptysis, 183 conjugated, with methyl-
management of, 290 PR interval, in bradycardia, 44 progesterone
Postprandial orthostasis, syn- Pralidoxime, for organophos- Premarin with methyltestos-
cope and, 339 phate and carbamate tox- terone. See Estrogens,
Postural hypotension. See Or- icity, 300 conjugated, with methyl-
thostatic hypotension Pramipexole, 582 testosterone
Potassium Pramoxine, 582 Premature atrial contractions
in body fluids, 464t with hydrocortisone, (PACs), 252
in crystalloid solutions, 463t 582–583 Premature ventricular contrac-
daily maintenance require- Prandin. See Repaglinide tions (PVCs), 252–253,
ments for, 463 Pravachol. See Pravastatin 255
for diabetic ketoacidosis, Pravastatin, 628t pulmonary artery catheteriza-
196 Prazosin, 583 tion and, 454–456
dietary, inadequate, hy- Precose. See Acarbose Premphase. See Estrogens,
pokalemia and, 218 Pred Forte. See Prednisolone, conjugated, with medroxy-
disorders of balance of. See ophthalmic progesterone
also Hyperkalemia; Hy- Pred-G Ophthalmic. See Gen- Prempro. See Estrogens, con-
pokalemia tamicin, ophthalmic, with jugated, with medroxy-
in alcohol withdrawal/delirium prednisolone progesterone
tremens, 98 Prednisolone, 613t Prerenal azotemia, 285, 290
coma/acute mental status ophthalmic, 625t Pressure control ventilation,
changes and, 78 with gentamicin, 625t 473–474
metabolic alkalosis and, 23 with neomycin and polymyxin for high peak pressures in
exogenous, hyperkalemia B, 625t ventilator patient, 486
and, 197, 198 with sulfacetamide, 625t Pressure support (PS) ventila-
in hyperglycemia, 192 Prednisone, 613t tion, 473
for hyperosmolar/hyper- for idiopathic thrombocy- for weaning, 488
glycemia nonketotic syn- topenic purpura (ITP), 74, Pre-syncope, 112. See also
drome, 194 360 Syncope
in hypophosphatemia, 235 for pruritus, 323 Prevacid. See Lansoprazole
serum, 398 for thrombotic thrombocytope- Preven. See Ethinyl estradiol,
in acidosis, 16 nia purpura (TTP), 360 with levonorgestrel
in hyperglycemia, 192 Pregnancy Prevnar. See Pneumococcal
in hyperkalemia, 200 cholestasis of, pruritus in, 320 7-valent conjugate vaccine
supplementary, 582 diabetes and, 190 Priftin. See Rifapentine
for alcohol withdrawal/delirium ectopic, abdominal pain and, Prilocaine, with lidocaine,
tremens, 100 2, 7 560
hyperkalemia and, 197, 198 hepatitis B screening tests in, Prilosec. See Omeprazole
for hypokalemia, 221–222 390t Primacor. See Milrinone
urine, 398, 411–412 hypertension and, 207 Primaxin. See Imipenem-
in hypokalemia, 220 jaundice and, 257 cilastin
696 INDEX
Tobrex. See Tobramycin, oph- Toxins. See Drugs/toxins for anemia, 33, 465–466
thalmic Toxoids, 499t. See also spe- for coagulopathy, 74–75
Tofranil. See Imipramine cific type contaminated, 362, 364
Tolazamide, 626t Toxoplasma gondii, infection in fever and, 134, 361, 362
Tolazoline, 598 HIV-positive patient for hematemesis/melena, 170
Tolbutamide, 626t caused by, 144, 147 for hematochezia, 174
Tolcapone, 598 TPN. See Total parenteral nu- hypokalemia and, 218
Tolectin. See Tolmetin trition plasma, 467–469
Tolinase. See Tolazamide Tracheal deviation platelet, 466–467
Tolmetin, 621t in cardiopulmonary arrest, 48 red blood cell, 465
Tolnaftate, 598 in chest pain, 64 Transient ischemic attack
Tolterodine, 598 in dyspnea, 119 (TIA), syncope and,
Toluene, metabolic acidosis in hypotension/shock, 239 339–340
caused by, 14 Tracheal intubation, 434–436, Transudate, pleural, 461t, 462
Tonic-clonic seizures, 330, 335 435f, 472. See also Endo- Transvenous pacemaker. See
management of, 335 tracheal tube; Mechanical also Pacemaker
syncope and, 338 ventilation complications of, 304
Tonic-clonic status epilepticus, Tracheal tumor, stridor and, failure to capture and,
335, 336 365 302–303, 302f, 305
Topamax. See Topiramate Tracheobronchial tree, disor- failure to sense and, 303,
Topical decontamination, 299 ders of, cough and, 91 303f, 305
Topiramate, 598–599 Tracheostomy, 472 Tranxene. See Clorazepate
Toposar. See Etoposide for stridor, 367 Trastuzumab, 599
Topotecan, 599 Tracrium. See Atracurium Trasylol. See Aprotinin
Toprol XL. See Metoprolol Tramadol, 599 Trauma
Toradol. See Ketorolac with acetaminophen, 599 arthritis and, 261
Torecan. See Thiethylperazine Trandate. See Labetalol coma/acute mental status
Tornalate. See Bitolterol Trandolapril, 599, 614t changes and, 76, 77
Torsades de pointes, 47, 53, Transaminases. See also ALT; head. See Head trauma
350 AST hematuria and, 177
syncope and, 340 in abdominal pain, 6 rectal examination and, 178
Torsemide, 599 in nausea and vomiting, 281 hemoptysis and, 181
for oliguria/anuria/acute renal pain management and, 308 joint swelling and, 261
failure, 289–290 Transcutaneous cardiac pac- leukocytosis and, 267
Total body water, excess, ing, for bradycardia, 45 neurologic, respiratory alkalo-
pseudoanemia and, 29 Transderm-Nitro. See Nitro- sis and, 22
Total iron binding capacity glycerin pneumothorax and, 62
(TIBC), 393 Transderm-Scop. See Scopol- spinal/pelvic, constipation
in anemia, 30t, 32 amine, transdermal and, 87
Total parenteral nutrition (TPN) Transducer error Travel history
abrupt discontinuation of, hy- arterial line problems related fever and, 134
poglycemia and, 215 to, 36, 37 pruritus and, 318
hypomagnesemia and, 223 pulmonary artery catheter Trazodone, 599
hypophosphatemia and, 234 problems related to, 325 for insomnia, 251
jaundice and, 257 Transferrin, 407 Trelstar Depot/Trelstar LA. See
Total protein, in hypercalcemia, in anemia, 32 Triptorelin
187 Transfusion reaction, 361–364 Tremulousness
Total protein-to-albumin ratio, contaminated blood and, 362, in alcohol withdrawal/delirium
in hypercalcemia, 187 364 tremens, 97
Toxic granulation, white blood hemolytic, 362, 364 in hypomagnesemia, 222
cell, 414 delayed, 363 Trendelenburg position, for hy-
Toxicology screening oliguria/anuria/acute renal fail- potension/shock, 241
in coma/acute mental status ure and, 285 Trental. See Pentoxifylline
changes, 84 platelet transfusion and, 467 Trepopnea, 116
in dizziness/vertigo, 114 self-limiting febrile, 362, 364 Treprostinil sodium, 599
in hypoglycemia, 216 Transfusions, blood/blood com- Tretinoin (retinoic acid), topical,
in hypothermia, 245 ponents, 465–469. See 600
in insomnia, 250 also specific type and Triamcinolone, 613t
in overdose, 296 Transfusion reaction inhalation, 600
in seizures, 333 alkalosis and, 22 with nystatin, 600
INDEX 709
Vitamin B3 (niacin), 571 VMA. See Vanillylmandelic Waxy casts, in urine, micro-
deficiency of, coma/acute acid scopic appearance of, 411
mental status changes VO2. See Mixed venous oxy- WBC. See under White blood
and, 79 gen saturation cell and Differential count
Vitamin B6 (pyridoxine), 585, V̇O2. See Oxygen consumption Weaning, ventilator, 486–488
611 Vocal cord dysfunction, stridor Weber test, in dizziness/ver-
for ethylene glycol toxicity, and, 365 tigo, 113
300 Voltaren. See Diclofenac Wedge pressure, pulmonary
Vitamin B12, 373, 524–525, Volume challenge, in (PWP), 456t
611–612 oliguria/anuria, 289 high/low, abnormalities asso-
deficiency of, 30, 31, 33, 34 Volume expanders, 499t. See ciated with, 457t
coma/acute mental status also specific agent permanent wedge and,
changes and, 79 Volume resuscitation. See also 324–325, 327, 456
pernicious anemia and, 30, Fluid management in shock, 451t, 457t
31, 34 in hematemesis/melena, Wegener’s granulomatosis, he-
in leukocytosis, 270 169–170 moptysis and, 182, 183
in leukopenia, 274 in hematochezia, 174 Weight conversion chart
in polycythemia vera, 312, 314 Volume status. See Fluid (vol- (pounds/kilograms), 636t
supplementary, 34, 524–525, ume) status Weight loss
611–612 Vomiting. See also Nausea in HIV-positive patient, fever
hypokalemia and, 218 and vomiting and, 141
Vitamin C (ascorbic acid), 612 blood. See Hematemesis hyponatremia and, 227
Vitamin D, 612 Vomitus, appearance/volume Welchol. See Colesevelam
in hypocalcemia, 210–211, of, 277–278 Wellbutrin. See Bupropion
211 von Willebrand’s disease, 71 Wellcovorin. See Leucovorin
management of deficiency bleeding time in, 73 Wenckebach second-degree
and, 212 management of, 74 AV block (Mobitz type I),
hypophosphatemia and, 234 Voriconazole, 604 43, 253
supplementary, hypomagne- VP-16. See Etoposide ECG/rhythm strip in, 44
semia and, 223 V̇/Q̇ scan. See Ventilation-per- Wernicke’s encephalopathy,
Vitamin D intoxication, hyper- fusion (V̇/Q̇) scan 96, 97
calcemia and, 186 VSD. See Ventricular septal coma/acute mental status
Vitamin D2 (ergocalciferol), for defect changes and, 79
hypocalcemia, 212 VT. See Ventricular tachycar- glucose administration and,
Vitamin D2 analogue (dihydro- dia 100
tachysterol), for hypocal- Vumon. See Teniposide hypothermia and, 244
cemia, 212 vWD. See von Willebrand’s dis- Westergren scale, for sedimen-
Vitamin D3 (cholecalciferol), ease tation test, 404
520 in arthritis, 265
Vitamin E, 612 W Western blot assay, for HIV an-
Vitamin K, 581, 612 Wandering spleen syndrome, tibody, 392
deficiency of abdominal pain and, 4 Wheezing, 364–368. See also
bleeding and, 71 Warfarin, 604 Bronchospasm; Stridor
management of, 75 abdominal pain in patient tak- anaphylaxis and, 27
supplementary, 581, 612 ing, 4 aspiration and, 39, 40, 365
for vitamin K deficiency/liver Warning headache, before in cough, 92
disease, 75 subarachnoid bleed, 153 localized, 366
Vitamins, 500t, 611–612. See Washed red blood cells pruritus and, 318, 321
also specific type (RBCs), transfusion of, Whipple’s disease, diarrhea
deficiency of, coma/acute 466 and, 104
mental status changes Water deprivation/vasopressin Whipworms (Trichuris
and, 79 test, in hypernatremia, 204 trichiura), pruritus caused
supplementary, for alcohol Water intoxication, hypona- by, 318, 320
withdrawal/delirium tremia and (hypotonic hy- White blood cell (WBC) count,
tremens, 100 ponatremia), 229 413. See also Differential
Vitrasert. See Ganciclovir Water loss, in hypernatremia count; Leukocytosis;
Vivelle. See Estradiol, trans- with sodium loss, 202–203 Leukopenia
dermal management of, 205 high peak pressures in venti-
Vivonex tube, 437 without sodium loss, 203 lator patient and, 486
VM-26. See Teniposide management of, 205 in hyperkalemia, 200
714 INDEX
White blood cell (WBC) count, Xanax. See Alprazolam ZETA scale, for sedimentation
(cont) Xeloda. See Capecitabine test, 404
laboratory reference/normal Xenical. See Orlistat Zetia. See Ezitimibe
values for, 380t Xerosis (dry skin), pruritus and, Ziagen. See Abacavir
pleural fluid, 461t 319, 323 Zidovudine, 605
in polycythemia, 314 Xigris. See Drotrecogin alfa fever caused by, 142
White blood cell (WBC) differ- Xolair. See Omalizumab with lamivudine, 605
ential. See Differential Xopenex. See Levalbuterol Zileuton, 605
count Xylocaine. See Lidocaine Zinacef. See Cefuroxime
White blood cells (WBCs) D-Xylose test, in diarrhea, 107 Zinc, 414, 607
morphology of, 414 Xyrem. See Sodium oxybate Zinecard. See Dexrazoxane
in stool, testing for, 405 Zingiber officinale (ginger),
in diarrhea, 106 Y 608
in HIV-positive patient, 146 Yeasts, in urine, microscopic Ziprasidone, 605
in urine appearance of, 410 Zithromax. See Azithromycin
hematuria and, 178 Yellow top specimen tubes, Zocor. See Simvastatin
microscopic appearance of, 639t Zofran. See Ondansetron
410 Yersinia, diarrhea caused by, Zoladex. See Goserelin
Whole blood, transfusion of, 102, 105 Zoledronic acid, 605
465–466 Yohimbine (Pausinystalia Zolmitriptan, 629t
Wintrobe scale, for sedimenta- yohimbe), 610 for cluster headache, 158
tion test, 404 toxicity of, 610 for migraine headache, 157
Withdrawal syndromes. See Zoloft. See Sertraline
also specific type Z Zolpidem, 605–606
alcohol, 94–101 Zaditor. See Ketotifen for insomnia, 250
opioid/barbiturate, 96 Zafirlukast, 60 Zometa. See Zoledronic acid
seizures and, 98, 330, 335 Zagam. See Sparfloxacin Zomig. See Zolmitriptan
Wolff-Parkinson-White syn- Zalcitabine, 605 Zonalon. See Doxepin, topical
drome (atrioventricular re- fever caused by, 142 Zonegran. See Zonisamide
ciprocating tachycardia), Zaleplon, 605 Zonisamide, 606
348 for insomnia, 250 Zostrix. See Capsaicin
management of, 354 Zanamivir, 605 Zosyn. See Piperacillin-
syncope and, 340 Zanosar. See Streptozocin tazobactam
Wood’s ultraviolet light, in pruri- Zantac. See Ranitidine Zovirax. See Acyclovir
tus, 322 Zarontin. See Ethosuximide Zyban. See Bupropion
WPW syndrome. See Wolff- Zaroxolyn. See Metolazone Zyflo. See Zileuton
Parkinson-White syndrome Zebeta. See Bisoprolol Zyloprim. See Allopurinol
Wrist, arthrocentesis of, 420, Zefazone. See Cefmetazole Zyprexa/Zyprexa Zydis. See
421f Zelnorm. See Tegaserod Olanzapine
Wycillin. See Penicillin G, pro- Zemuron. See Rocuronium Zyrtec. See Cetirizine
caine Zenapax. See Daclizumab Zyvox. See Linezolid
Isoproterenol 2–10 mcg/min IV titration Significant bradycardia, refractory Add 1 mg to 500 mL D5W to get 2 mcg/mL
torsades de pointes Use with caution.
Lidocaine 1–1.5 mg/kg IV bolus, then 0.5–0.75 mg/kg Q 5–10 PVCs, ventricular fibrillation, ventricular Give drip after bolus to maintain effect (adult 2–4
min to maximum total dose of 3 mg/kg tachycardia, wide complex tachycardia mg/kg). Use more aggressive dosing in cardiac
arrest. Stop/decrease immediately with signs of
toxicity.
Magnesium 1–2 g IV over 1–2 min (hypomagnesemia) Polymorphic ventricular tachycardia Dilute in 50–100 mL D5W.
sulfate 1–2 g IV over 5–60 min, followed by 0.5–1 g/hr (torsades de pointes) and suspected
(torsades de pointes) hypomagnesemia
Milrinone 50 mcg/kg IV over 10 min; maintenance infusion Optimize cardiac output Dosage reduced in renal failure.
0.375–0.75 mcg/kg/min
Procainamide 20–30 mg/min IV, up to 17 mg/kg; maintenance Refractory ventricular fibrillation, Dosage reduced in renal failure; avoid if QT
infusion 1–4 mg/min ventricular tachycardia, paroxysmal prolongation or torsades de pointes.
supraventricular tachycardia, atrial
fibrillation/flutter
Sodium 1 mEq/kg IV initially, then 0.5 mEq/kg Q 10 min Hyperkalemia; metabolic acidosis (pH Flush line before giving calcium or epinephrine. Do
bicarbonate thereafter < 7.20), tricyclic antidepressant or not correct the acidosis completely. Do not use to
barbiturate overdose; no longer correct respiratory acidosis.
recommended for routine ACLS use
Sotalol 1–1.5 mg/kg IV at rate of 10 mg/min Monomorphic ventricular tachycardia, Infusion rate must be carefully observed.
polymorphic ventricular tachycardia
following pacing, paroxysmal
supraventricular tachycardia, atrial
tachycardia, atrial fibrillation/flutter
Vasopressin 40 units IV; maintenance infusion 1–4 mg/min Ventricular fibrillation, ventricular Repeat doses not recommended.
tachycardia.
Verapamil 2.5–5 mg IV over 2 min, repeat 5–10 mg Q 15–30 min Atrial fibrillation/flutter, MAT, narrow Give slowly over 1 min (3 min in elderly); use carotid
to max 20 mg SVT, junctional tachycardia. massage before administering verapamil. Not for
use in impaired ventricular function or heart failure.
See Section I, Chapter 9, Cardiopulmonary Arrest, p 00. ACLS = advanced cardiac life support; ET = endotracheal; IVF = intravenous fluids; MAT = multifocal atrial tachycardia; NS = normal
saline; PVC = premature ventricular contractions; SVT = supraventricular tachycardia.