Electrolyte Replacement

Potassium:
Oral: Kdur 20-40 mEq or K-lyte 25-50 mEq
Give 20 in Peripheral IV; 40 in Central IV
IV: KCl 20 mEq in 100ml NS IV over 2 hours
Magnesium:
Oral: MgGluconate 250-500 mg PO BID or qdaily
Oral: MgOxide 250-500 mg PO BID or quality
IV: MgSulfate 2 g IV in 100cc NS over 1 hour
(Give 1 gram over 30 minutes)
Phosphorus:
Oral: NeutraPhos 1-2 packets TID with meals
Phosphate 8mmol = 250mg phosphate
Sodium 6.9 mEq
Potassium 7.1 mEq
Combo:
NaPhos 30 mmol in 250mL over 6 hours
KPhos 500 mg PO TID OR 15 mmol vs 30 mmol in 250ml NS over 4-6 hours
3 mmols KPO4 = 4.4 mEq K+
10 mmol of KPhos has 12 mEq K
Calcium:
Oral: OsCal 500 mg PO TID
Calcium citrate has better absorption but non-formulary
IV: Not on the medical floor
Give IV fluids, but lasix to avoid fluid overload
Always calculate corrected calcium with albumin
Correct magnesium before correcting calcium (need for proper PTH function)
Will increase Potassium of 0.1 every 10 mEq replenished
Potassium is difficult to correct if Magnesium is low

Hyperkalemia:
For K > 5.4, ask for current heart rate and stat 12 lead EKG
If bradycardia/EKG changes: give 1 ampule Calcium Gluconate (10 mL over 2-5 min)
1 ampule of D50 (50% Dextrose)
10 units of Regular Insulin subQ
Sodium Bicarbonate 50 ml IVP
15-30 grams of Kayexlate orally or rectally

If no bradycardia/EKG changes: do not give IV Calcium, 30 grams of Kayexlate orally or

rectally, stop all Potassium supplements, inhaled albuterol via nebulizer
EKG changes: Peaked T waves, flattened P wave, prolonged PR interval, wide QRS, sine wave!

Chest Pain:
Vitals, stat 12 lead EKG, 81 mg chewable aspirin, sublingual nitroglycerin, O2 --> go see the
patient
If cardiac pain/EKG changes present- sublingual nitroglycerin (0.4 mg) q 5 minutes x 2
If pain persists, add Morphine 2-4 mg IVP
Draw blood for Cardiac Enzymes (q6 hours)
ACS Protocol:
ASA 325 mg
Plavix 300 mg loading dose, then 75 mg daily
Lipitor 80 mg
Beta Blocker- Metoprolol OR Carvedilol
ACE-I- Enalapril 2.5 mg PO daily
Therapeutic anticoagulation: Lovenox 1 mg/kg Q12 hours
(or daily vs heparin gtt if poor renal function)
Give Oxygen/Morphine
Nitroglycerin: paste (1/2 vs 1 inch) sublingual (0.4 mg q5 min x 3) patch (1 q6hours)
Nitro drip: 50 mg in 250 cc of D5W, start at 5 cc/hr & titrate
Check HbA1c, UDS, FLP; Smoking cessation
V-TACH
Get STAT electrolytes and Mg level.
If patient is unstable (hypotension) - cardioversion
If sustained: lidocaine, procainamide or amiodarone; call resident/attending
SVT:
Give Adenosine 6 mg then 12 mg, observe to see what happends- something will!
Give Cardizem bolus and then Cardizem drip 125 mg in 100 cc D5W at 5 mg/hr-- titrate to
keep HR between 80-100. NOT > 15 mg/hr
New Onset Afib:
IV push with Cardizem (0.25 mg/kg) If rate controlled, start Cardizem drip 125 mg in 100 cc
D5W at 5 mg/hr-- titrate to keep HR between 80-100. NOT > 15 mg/hr
OR Metoprolol 25 mg PO BID
Check UDS (for Cocaine) and TSH workup
Rate control with BB, CCB, Cardizem
Assess for anticoagulation need (vs TEE)
Hypertension:

Check BP yourself, chest pain/blurred vision, change in MS?

If > 180/110, give Labetalol 20 mg and ICU if CP, Pulm Edema, Encephalopahty
If nonurgent, give Lopressor 5 mg IV, Clonidine 0.1
Shortness of Breath/Hypoxia:
Oxygen- Keep SpO2 > 90%
Nasal Cannula upto 4 Liters, 100% Nonrebreather (VentiMask)
Albuterol/Atrovent breathing treatment
STAT PO-CXR & ABG
COPD Exacerbation:
Steroids, Abx (Levaquin/Azithromycin) to cover for gram negative/atypical
Nebulizer treatments with Duoneb
Hyperglycemia/Hypoglycemia:
If < 60mg/dL and if AAO x 3, feed the patient and recheck in 20 minutes
If < 60 mg/dL and if not AAO x 3, give 1 ampule of D50 IVP. If no IV access, give Glucagon 1
mg SC/IM STAT
If > 400 mg/dL, inquire about clinical scenario prior to deciding insulin dose (DKA?)
Check SMA7/Acetone (in serum or urine)
Fever > 100.5 F
Give Tylenol, check blood cultures, CBC, U/A with culture/sensitivity, CXR
Examine patient for any foley catheters/IV a lines, change them
Pain Management:
If patient with liver disease, no acetaminophen
If patient with PUD, severe anemia, low platelets- no NSAIDS
If patient with ESRD, no hydromorphone/meperidine because of impaired excretion
If patient with ESRD or Seizure disorder, avoid Demerol
Tramodol vs Morphine vs Dilaudid vs MS contin 30-60 mg PO q12-24
Demerol 25- 50 mg IM /+ Vistaril (hydroxyzine) 25 mg IM
Lortab (acetaminophen/hydrocodone) 5-7.5/500 1-2 tabs PO q 4-6 PRN
Percocet (acetaminophen/oxycodone)
Darvocet N-100 (acetaminophen/propoxyphene 650/100) 1 PO q4 PRN
Tylenol #3 (acetaminophen/codein 300/30) 1-2 PO q4 PRN
Sleep Aid:
Avoid Benadryl in elderly
Bendaryl 25-50 mg PO or Ambien 5 mg PO or Restoril 7.5-15 mg PO or Sonata 5-10 mg PO
Nausea/Vomiting:
Phenergen/Promethazine 12.5 mg-25 mg IM/IV or PRN q4-6 hours
vs Compazine 5-10 mg IV/PO

vs Inapsine/Droperidol 25 mg IM/IV
vs thorazine 25 mg PO q8 PRN
vs Zofran 4 mg IV
Constipation:
Dulcolax 5-15 mg PO q 6-8hrs or supp 10mg PRN, Colace 100 mg PO, Milk of Magnesia 15-30 cc
PO 1-2 daily, Fleet enema 120 ml PRN x 3, Glycerine supp 3gr PRN, Caster oil 15-30 cc PO,
Laculose 15-30 ml PO q daily
Diarrhea:
Peptobismol 30 cc PO q4 PRN, Lomotil 2 tab PO q4 PRN, Imodium 4 mg, then 2 mg PO q4 PRN
Seizures:
If no prior history, think DT, electrolytes, hypoxemia, CNS lesion
Get Accucheck, Chem 7, ABG, CT Head
Thiamine 100 mg, MVI, D50 stat
If status epilepticus, protect airway and give Ativan 4 mg IV until stopped
Give Dilantin 500-1000mg (15 mg/kg) IV loading dose, then Dilantin 100 mg PO q8
Hypernatremia
1) Hypovolemia- low total body Na, orthostasis,
Restore hemodynamics with isotonic fluid such as NS or LR at rate of 10-20 ml/kg over
1-2 hours (or D5W1/2 NS)
Then treat hypernatremia with hypotonic fluids such as D5W.
Check for hypocalcemia or metabolic acidosis during correction
2) Hypervolemia- excress total body Na, give loop diuretics to increase Na excretion then
replace with D5W to correct hypertonicitiy
3) Euvolemia- normal total body Na, give D5W
Free Water Deficit = Body Weight (kg) x percentage of Total Body Water (TBW)
Replenish 1/2 deficit in first 24 hours
To avoid cerebral edema, serum sodium level should be raised by no more than 1 mEq/L
every hour
Syncope Workup:
Cardio- Echo, carotid u/s vs Neuro- EEG, CT Head, seizure precaution, Thyroid, Lipids
EtOH Withdrawal:
D5 1/2 NS at 100 cc/hr with 1 mg folic acid, 100 mg thiamine, I amp of MVI with 3 gram
MgSO4
Ativan 2 mg PO/IV q6-8 hours or Librium 10-25 mg PO q 6-8 hours
Make sure to check Mg/PO4 (likely Torsades if low)
Cough:

Guaifenesin 200 mg/10 mL PO q6 PRN

Promethazine with codeine 5mL PO q6 PRN
Nystatin 6mL PO q6
Pleural effusion Tubes:
Clear tube- gram stain and culture
Lavender tube- cell count and diff (hematocrit)
Gold Tube- LDH, total protein, glucose, cholesterol, amylase, albumin
ABG syringe- fluid pH
Blood culture
Fluid bag for cytology (heparin 5000 units into specimen bag
NPO post midnight
Lidocaine 2% 50 mL vial x1
Viscous lidocaine 2% 15mL vial x 1
Lidocaine 1% with epinephrine 1/100,000 50mL vial
PT, PTT, INR in am

Important numbers
A3 5050
M3 5140 or 5120
A4 5052
CRR 2808
MICU 5043, 5045, 2817
A7 5054
A8 5055
Chief's office ext
Laboratory
Chemistry 5020
Hemetology 5018
General Lab 5010
Clinic number to give to patients 973-877-5080
Clinic direct lines for appointments 5081
Dr. Goldfarb's office 5170
Radiology after hours 732-390-0040 then dial 7777