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: Departmental Manual- ICCU
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CDMO cum Civil Surgeon
CDMO cum Civil Surgeon
CDMO cum Civil Surgeon
CDMO cum Civil Surgeon
Guidelines for Admission in I.C.C.U.
The decision to admit a patient will be made by the ICCU physician on duty; in case of physician disagreement, the decision will be made at the senior physician level. It is advisable for the following patient to be routinely admitted to the ICCU. 1. Any patient with suspected acute ST-elevation myocardial Infarction ,up to 24 hrs from the onset of symptoms, especially if suitable for thrombolytic treatment. 2. Patient with AMI presenting more than 24 hrs after the onset of symptoms with complications, or unstable high –risk patients (heart failure that requires intravenous therapy or hemodynamic monitoring or an intra-aortic balloon, serious cardiac dysrrhythmias, conduction disturbances, temporary pacemaker); 5. Patient with high-risk unstable coronary syndromes (e.g. on going or repeated anginal pain, heart failure, significant ST-depression, diffuse ST- dynamic ST-shift, elevated troponins). 6. Unstable patients after a complicated percutaneous coronary intervention(PCI), who need special attention( at the discretion of the PCI operator). 7. Patients with life threatening cardiac arrythmias, as a result of ischemic heart disease cardiomyopathy rheumatic heart disease electrolyte disturbances, drugs effects, or 8. Patients with acute pulmonary oedema unresolved by initial therapy and depending on the underlying conditions. 9. Patient in need of hemodynamic monitoring for evaluation of therapy. 10. Patient after a heart transplant with acute problem, i.e. infection hemodynamic deterioration, electrolyte imbalance, suspected acute rejection ,and so on ; This list is conclusive and should be adapted accordingly to each individual case. Discharge Criteria for patients Admitted in ICCU and RR
 The decision to discharge a patient will be made by the physician on duty during the routine rounds. The patient will be informed of the follow up visit’s importance and also of the regular follow up. CDMO cum Civil Surgeon
 Patient will also be advised also be advised for further investigations and management at a  On discharge from the hospital patient and one of the nearest relative is also informed of the thereon high risk factors, need for life style modifications, dietary and follow up.  Also we are giving IEC material consisting if healthy eating habits and some tips for Following are the criteria for discharging a patient from ICCU
1. Patient who is relieved if chest pain and chief complains at the time of admission for at least 2. ECG picture when returns to nearly normal or when the ST-elevation returns to baseline. 3. When the patient is heamodynamically stable i.e. the vital parameters are normal. TRANSFER – PROTOCOL
The decision to transfer a patient to a higher centre will be made by the ICCU physician / medical officer on duty. This will be carried out on the basis of the following criteria. 1. Patients with life threatening persistent cardiac arrhythmias not responding woth conventional therapy for further management. 2. Patient of AMI with failed thrombolysis for surgical intervention i.e. Rescue Angioplasty. 3. Patient who come to the hospital within the golden hour for Primary Angioplasty against 4. Further intervention in high risk chest pain patients not responding to the conventional 5. Patients in cardiogenic shock for sustained IABP (Intra aortic balloon counter pulsation ) 6. Any patient requiring critical care support in the form of ventilatory support are transferred 7. Patients with complete heart block for temporary / permanent pacing, homodynamic deterioration, electrolyte imbalance, suspected acute rejection, and so on. 8. Patient needing expert cardiologist opinion. 9. Patient after a heart transplant with acute problem, i.e. infection, homodynamic deterioration, electrolyte imbalance, suspected acute rejection, and so on. CDMO cum Civil Surgeon
Such patients are transferred with ambulance on wheels with life support appliance to the higher centre. Relocation Policy
1. Once stabilized, patients are transferred from ICCU to the Cardiac Intermediate Care Unit also known as the Recovery Room with all the necessarily required equipments and trained staff and then after he/she gets stable then and then only then the Wards. 2. We as the staff discuss the following with the patient in the presence of one of their dominant family members: medications, return to activities, risk factors, life style modifications, a healthy diet, and recommendations for future tests (invasive and noninvasive) including follow up appointment shortly before their discharge from the ICCU RR (Recovery Room)
Decision to admit a patient to intermediate ward is at the discretion of the treating physician, or a well trained ICCU Medical Officer at this particular institutions. Recommendations are to consider the following conditions. 1. Intermediate risk unstable coronary syndrome pts; 2. Patients in 1st stages of recovery from myocardial infection. 3. Patients with uncontrollable cardiac insufficiency not responsive to regular oral therapy 4. Patients with heart disease in need of medical therapy adjustment, special cardiac investigations (e.g. electrophysiological study, cardiac catheterization, etc.) or some of the patients after special cardiac procedure (e.g. implantation of permanent pacemaker or internet The number of beds in ICCU suits the size of the reference population and the relative specific workload of the hospital. The hospital’s specific workload can be evaluated in a number of ways: the simplest measure of the relative workload is the number of admissions to the hospital’s ICCU in the past years. BED OCCUPANCY for last past years at any given point of time is not more than 5/DAY CDMO cum Civil Surgeon
Keeping the last past 5 years ICCU admissions records and the length of stay and other constraints in mind we have come to the conclusion that -- 5 beds seem to be enough for CICU. or RR TOTAL bed strength 4+5=09
The number of beds in the ICCU and the RR can be increased accordingly as per the needs of the rising population i.e. the size of the reference population and the up gradation of the All the ICCU rooms are centrally as well as individually air conditioned. Recovery Room is also having and air conditioning system. SALIENT FEATURES OF ICCU / RR
1. The cardiac intensive care unit / recovery unit is an independent ward in this hospital. 2. The desired intensive care unit is a separate room for each patient and 4-6 patients in the 3. The separate intensive care room is spacious enough to contain all specialists in need, as well as to accommodate multitude of bulky equipments. 4. The electrical equipment has an emergency support of generator facility with continuity apparatus. 5. There is a central nursing station with central monitoring system having the imp. chest lead and other vital parameters in display all the time. 6. There is a centralized air conditioning system to provide comfort zone to the ICCU patients. 7. In addition there is a doctors / meeting room, pantry, waiting area with sitting arrangements, a
storeroom, sanitary rooms, a ECG room, and I/C room with pipe line stock. ICCU Equipment
1. Patient Monitoring Unit :- the basic monitoring unit i.e. the multi para monitor includes non-invasive blood pressure monitor, and SpO2 probe and a 5 lead ECG channels and thermometer. CDMO cum Civil Surgeon
2. Nurse station: - to be used for central monitoring and analyzing. At least one ECG lead from each patient as well as relevant haemodynamic and respiratory data O2 saturation ST-segment changes should continuously be present on the central screen. Patients beds for ICCU
 Beds in the ICCU allow vertical movement, with the possibility of up and down head and leg positioning. Every bed is equipped with Oxygen Vaccum Suction.  Requisition for portable X-ray on bed is also available. Additional Equipments
1. Defibrillator machine is present in each ICCU room. Well-trained CPR team to handle CODE-BLUE response is available round the clock to take care of any eventually of pts going in cardiac arrest. 2. Biochemical markers kits, for myocardial infarction i.e. TROP-I and CK-MB can also be carried out 3. Glucometers to check emergency blood glucose level is available. 4. 2-D echo is also carried out on Wednesday at 4 pm onwards. 5. Ambu-Bag and a complete intubations kit is also available. 6. A well-equipped crash-cart trolley with all Life Saving Drugs and the apparatus (ambu-bag, defib , ICCU and RR staff
 Three physicians are available for ICCU and RR  Four medical officers are available in shift duties, one available round the clock.  Five nursing staff are available in shift duties, one available round the clock.  Four class – 4 employees are present. one round the clock.  One Sister in charge is present to look after the requisites of ICCU and RR  A Biomedical engineer is also available took after and maintenance of the ECG machines and other  Routine Rounds are taken by the CDMO cum Civil Surgeon, RMO, AHA, Matron and the support staff, and necessary instructions are passed by them accordingly. CDMO cum Civil Surgeon
 In case of M.I. after Reperfusion therapy is completed pt. is kept for at least 48 hours in ICCU and there after for at least another 48 hours in RR and then if found out to be stable can be discharged  After all the available Investigations are carried out and found to be normal patient can be discharged  So in all 1 Medical officer, 1 staff nurse and 1 class 4 servant will remain available round the clock Quality Assurance Programme :
 Number of patient complaints per month CDMO cum Civil Surgeon
Master List of Documents
12. D.C. Shock and / or Streptokinase injection Consent form  Registers
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Current Clinical Strategies
Medical Documentation: -
On admission to I.C.C.U. the patient is taken to the ward in a stretcher accompanied by the stretcher-bearer where a detail history is taken by the concerned medical officer on duty and filled in the initial assessment form and accordingly the treatment is initiated by the trained staff History and Physical Examination
Identifying Data: Patient's name; age, race, sex. List the patient’s significant medical problems.
Chief Compliant: Reason given by patient for seeking medical care and the duration of the
symptom. List the chest pain whether associated with profuse perspiration radiating to the jaw or to the left arm along with heaviness like sensation in the chest. History of Present Illness (HPI):
Describe the course of the patient's illness, including when it began, character of the symptoms, location where the symptoms began; aggravating or alleviating factors; pertinent positives and negatives. Describe past illnesses or surgeries, and past diagnostic testing. Past Medical History (PMH): Past diseases, surgeries, hospitalizations; medical problems;
history of diabetes, hypertension, peptic ulcer disease, asthma, myocardial infarction, cancer. In children include birth history, prenatal history, immunizations, and type of feedings. Medications:Allergies: Penicillin, codeine?
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Family History: Medical problems in family, including the patient's disorder. Asthma, coronary
artery disease, heart failure, cancer, tuberculosis. and Diabetes Mellitus. Personal History: Alcohol, smoking, drug usage. Marital status, employment situation. Level of
Bleeding tendency :- Patient is asked for history of any bleeding gums or h / o piles or any
active functional bleeding or any recent operative procedure in last fortnight for the need of Review of Systems (ROS): General: Weight gain or loss, loss of appetite, fever, chills, fatigue,
night sweats. Skin: Rashes, skin discolorations. Head: Headaches, dizziness, masses,
seizures. Eyes: Visual changes, eye pain. Ears: Tinnitus, vertigo, hearing loss. Nose: Nose
bleeds, discharge, sinus diseases. Mouth and Throat: Dental disease, hoarseness, throat pain.
Respiratory: Cough, shortness of breath, sputum (color). Cardiovascular: Chest pain,
orthopnea, paroxysmal nocturnal dyspnea; dyspnea on exertion, claudication, edema, valvular Gastrointestinal: Dysphagia, abdominal pain, nausea, vomiting, hematemesis, diarrhea,
constipation, melena (black tarry stools), hematochezia (bright red blood per rectum). Genitourinary: Dysuria, frequency, hesitancy, hematuria, discharge.
Endocrine: Polyuria, polydipsia, skin or hair changes, heat intolerance. Musculoskeletal: Joint
pain or swelling, arthritis, myalgias. Skin and Lymphatics: Easy bruising, lymphadenopathy.
Neuropsychiatric: Weakness, seizures, memory changes, depression.
General appearance: Note whether the patient appears ill, well, or malnourished.
Vital Signs: Temperature, heart rate, respirations, blood pressure.

Skin: Rashes, scars, moles, capillary refill (in seconds).
Eyes: Pupils equal round and react to light and accommodation
Ears: Acuity, tympanic membranes (dull, shiny, intact, injected, bulging).
Mouth and Throat: Mucus membrane color and moisture; oral lesions, dentition,
CDMO cum Civil Surgeon
Neck: Jugulovenous distention (JVD) at a 45 degree incline, thyromegaly,
lymphadenopathy, masses, bruits, abdominojugular reflux.  Chest: Equal expansion, tactile fremitus, percussion, auscultation, rhonchi, crackles,
rubs, breath sounds, egophony, whispered pectoriloquy.  Heart: Point of maximal impulse (PMI), thrills (palpable turbulence); regular rate and
rhythm (RRR), first and second heart sounds (S1, S2); gallops (S3, S4), murmurs (grade 1-6), pulses (graded 0-2+).  Abdomen: Contour (flat, scaphoid, obese, distended); scars, bowel sounds, bruits,
tenderness, masses, liver span by percussion; hepatomegaly, splenomegaly; guarding, rebound, percussion note (tympanic), costovertebral angle tenderness (CVAT), suprapubic tenderness.  Extremities: Joint swelling, range of motion, edema (grade 1-4+); cyanosis, clubbing,
edema (CCE); pulses (radial, ulnar, femoral, popliteal, posterior tibial, dorsalis pedis; simultaneous palpation of radial and femoral pulses).  Neurological: Mental status and affect; gait, strength (graded 0-5); touch sensation,
pressure, pain, position and vibration; deep tendon reflexes (biceps, triceps, patellar, ankle; graded 0-4+); Romberg test (ability to stand erect with arms outstretched and eyes closed).
Cranial Nerve Examination:

I: Smell
II: Vision and visual fieldsIII, IV, VI: Pupil responses to light,extraocular eye movements, ptosis
V: Facial sensation, ability to open jawagainst resistance, corneal reflex.
VII: Close eyes tightly, smile, showteeth
VIII: Hears watch tic; Weber test (lateralization of sound when tuning fork is placed on top of
head); Rinne test (air conduction last longer than bone conduction when tuning fork is placed on  IX, X: Palette moves in midline when patient says “ah,” speech
XI: Shoulder shrug and turns head against resistance
XII: Stick out tongue in midline
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Labs: Electrolytes (sodium, potassium, bicarbonate, chloride, BUN, creatinine), CBC
(hemoglobin, hematocrit, WBC count, platelets, differential); X-rays, ECG, urine analysis (UA),  Admission Check List and Documentation
1. Call and request old chart, ECG, and X-rays.
2. Stat labs: CBC, B.T. and C.T. Chem 7, cardiac enzymes ( troponin I, CPK), INR, PTT, C&S,
3. Labs: Lipid profile and S. electrolyte levels.
4. Cultures: if required.
5. CXR, ECG on admission and as and when required,
6. Discuss case with resident, attending, and family.
7. 2-D ECHO on Wednesdays in the evening
8 . Day to day documentation in the form of nursing reg, nursing chart, progress sheet
9. Post Cardiac Arrest Code Blue Response Documentation .
10. Discharge / Transfer / or case of deaths documentation is done
Progress Notes
Daily progress notes should summarize developments in a patient's hospital course, problems that remain active, plans to treat those problems, and arrangements for discharge. Progress notes should address every element of the problem list and dated and signed by the visiting doctor at the time of the visit . Progress Note
Subjective: Any problems and symptoms of the patient should be charted. Appetite,
pain, headaches or insomnia may be included. Objective: General appearance. Vitals, including highest temperature over past 24 hours.
Fluid I/O (inputs and outputs), including oral, parenteral, urine, and stool volumes. Physical examination including chest and abdomen with particular attention to active problems Labs: Include new test results and circle abnormal values and note down new one if needed.
CDMO cum Civil Surgeon

Current medications: List all medications and dosages
Consent Note is taken prior to giving Streptokinase Inj in case of an fresh Myocardial Infarction
Information also regarding the element of High Risk invoved in M.I. cases in giving S.K . ( Bleeding anywhere) and need of giving D.C. shock is also shared with the patient's relatives in case of patient is going into cardiac arrest . Over and above this need to transfer the patient in case of failed thrombolysis or patient not responding to the line of treatment or in case of aggravation of symptoms or in case of worsening condition is also informed in writing to the patients relatives . Procedure Note
A procedure note should be written in the chart when a procedure is performed. Procedure notes Briefly describe the procedure, method of procedure people involved whether D.C. shock given , if yes what joules, and outcome and then document in the Code-Blue register. Complications if any need to Document that the indications and risks were explained to the patient and that the patient consented: “The
patient understands the risks of the procedure and consents in writing.
Lab tests: Relevant labs, such as the INR and CBC and positive lab reports to be documented as and
Discharge Note
The discharge note should be written in the patient’s chart prior to discharge. It includes  Date/time
Treatment: Briefly describe treatment provided during hospitalization, including
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surgical procedures and antibiotic therapy.  Studies Performed: Electrocardiograms, CT scans.
Discharge Medications: Follow-up Arrangements:
Discharge Summary
 Patient's Name and Medical Record Number  Attending or Ward Team Responsible for Patient:  Diagnostic Tests, Lab Tests and reports  Brief History, Pertinent Physical Examination, and Laboratory Data: Describe the
course of the patient's disease up until the time that the patient came to the hospital, including physical exam and laboratory data.  Thrombolyzation if carried out: with date and time of thrombolysis.
Hospital Course: Describe the course of the patient's illness while in the hospital,
including evaluation, treatment, medications, and outcome of treatment.  Discharged Condition: Describe improvement or deterioration in the patient's condition,
and describe present status of the patient.  Disposition: Describe the situation to which the patient will be discharged (home,
nursing home), and indicate who will take care of patient.  Discharged Medications: List medications and instructions for patient on taking the
Discharged Instructions and Follow-up Care: Date of return for follow-up care at
Problem List: List all active and past problems.
Copies: Send copies to attending, clinic, and medical records department.
Adv . on Discharge :- for further intervention if needed , for further follow up .
IEC material :-7 steps for leading heart- attack free life .
Prescription Writing
CDMO cum Civil Surgeon
• Drug name, dosage form, dose, route, frequency (include concentration for oral liquids or mg strength for oral solids): Amoxicillin 125mg/5mL 5 mL PO tid Quantity to dispense: mL for oral Cardiovascular Disorders
ST-Segment Elevation Myocardial Infarction
1. Admit to: Coronary care unit and start oxygen at 4-6litres /min and take I / V acess
2. Diagnosis: Rule out myocardial infarction through 12 lead E.C.G.
3 Attach multi para monitor with chest leads to monitor centrally
4. Vital Signs: q1h. Call physician if pulse >90,<60; BP >150/90, <90/60; R>25, <12; T
5. Activity: Bed rest with bedside commode.
7. Nursing: If patient has consistent chest pain, obtain 12-lead serial ECG and call physician.
8. Diet: Cardiac diet, 1-2 gm sodium, low fat, low cholesterol diet. No caffeine or temperature
9. IV Fluids: flushed in case of hypotension if need be inj.Dopamine in N.S. pint is given @ 6-8
drops / min to maintain the Blood Pressure. 10. Special Medications: -Oxygen 2-4 L/min by NC. -Aspirin 325 mg stat, chew and swallow,
then aspirin EC 162 mg PO qd OR Clopidogrel (Plavix) 300 mg PO stat (if allergic to aspirin). -
Nitroglycerine 10 mcg/min infusion (50 mg in 250-500 mL D5W, 100200 mcg/mL). Titrate to control symptoms in 5-10 mcg/min steps, up to 200-300 mcg/min; maintain systolic BP >90 OR -
Nitroglycerine SL, 0.4 mg (0.15-0.6 mg) SL q5min until pain free (up to 3 tabs) OR -Nitroglycerin
spray (0.4 mg/aerosol spray)1-2 sprays under the tongue q 5min; may repeat x 2. -Heparin 60 U/kg IV push, then 12 U/kg/hr by continuous IV infusion for 48 hours. CDMO cum Civil Surgeon
BT/ CT is done regularly 6 hourly when pt is on Inj. Heparin.
Thrombolytic Therapy
Absolute Contraindications to Thrombolytics: Active internal bleeding, suspected aortic
dissection, known intracranial neoplasm, previous intracranial hemorrhagic stroke at any time, other strokes or cerebrovascular events within 1 year, head trauma, pregnancy, recent non- compressible vascular puncture, uncontrolled hypertension (>180/110 mmHg). Relative Contraindications to Thrombolytics: Absence of ST segment elevation,
severe hypertension, cerebrovascular disease, recent surgery (within 2 weeks), A. Alteplase (tPA, tissue plasminogen activator, Activase): if affordable and indicated
1. 15 mg IV push over 2 min, followed by 0.75 mg/kg (max 50 mg) IV infusion over 30 min,
followed by 0.5 mg/kg (max 35 mg) IV infusion over 60 min (max total dose 100 mg). 2. Labs: INR / BTCT, CBC, fibrinogen.
B. Reteplase (Retavase):
1. 10 U IV push over 2 min; repeat second 10 U IV push after 30 min. 2. Labs: INR, aPTT, CBC, fibrinogen, BT/Ct CKMB, Trop- 1 & routine treatment RFT, LFT,RBS
C. Streptokinase (Streptase):
1. 1.5 million IU in 100 mL NS IV over 60 min. Pretreat with inj avil 2 cc IV push AND inj.
2. Check BT CT level now and q6h for 24h until normal limits
3. No IM or arterial punctures, watch IV for bleeding.
4. Inj. Low molecular Heparin 0.4ml s/c 12 hourly from next day for 5 days preferably if
thrombolysis is successful and there is no need of urgent rescue thrombolysis. Angiotensin Converting Enzyme Inhibitor: -
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 Ramipril , (Cardace, Zorem) 2.5-5 mg od ; titrate to 10-20 mg a day .  Enalapril 2.5 - 5 mg od; can be titrated to 5 - 10 mg a day . Long-acting Nitrates: -
Isosorbide dinitrate (Isordil) 10-60 mg PO tid [5,10,20, 30,40 mg] OR -Isosorbide mononitrate
 Contraindicated in cardiogenic shock and L.V.F with E.F.<25 %. but very M.I.  -Metoprolol (Lopressor,) 25 mg once a day or twice a day as indicated. Watch for bradycardia and hypotension .Stop if pulse<60 and if systolic B.P.<100 mm of hg.  -Esmolol hydrochloride (Brevibloc) 500 mcg/kg IV over 1 min, then 50 mcg/kg/min IV infusion, titrated to heart rate >60 bpm (max 300 mcg/kg/min). as and when indicated .  Tab - Bisoprolol 5 mg can also be given twice a day as and when indicated  Tab - Carvedilol ( Carca )can also be given to a max dose of 25 mg a day as and when Statins:
 -Atorvastatin (Lipitor) 40 mg hs at bedtime for atleast a week ,if the pt has been thrombolysed and then tapered to 10 mg at bedtime till it is indicated 11. Symptomatic Medications:
 Morphine sulfate 2-4 mg IV push prn chest pain.  Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn headache.  Lorazepam (Ativan, Zapiz) 1-2 mg PO tid-qid prn anxiety  Zolpidem (Ambien) 5-10 mg qhs prn insomnia.  Dimenhydrinate (Dramamine) 25-50 mg IV over 2-5 min q4-6h or 50 mg PO q4-6h prn nausea. -Famotidine (Pepcid) 20 mg IV/PO bid. 12. Extras: ECG stat and in 12h and in AM, portable CXR, echocardiogram.
13. Labs: Cardiac enzymes: CPK-MB, troponin I , and q6h for 24h. CBC, BTCT ,LFT ,RFT and
Non-ST Segment Elevation Myocardial Infarction (NSTEMI)
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1. Admit to: Coronary care unit
2. Diagnosis: Unstable Angina
3 Condition:
4. Vital Signs: q1h. Call physician if pulse >90,<60; BP >150/90, <90/60; R>25,
5. Activity: Bed rest with bedside commode.
7. Nursing: If patient has chest pain, obtain 12-lead ECG and call physician.
8. Diet: Milk diet, 1-2 gm sodium, low fat, low cholesterol diet , salt restricted diet . as and what
9. IV Fluids: In hypotension give N.S pint with flush therapy
10. Special Medications: -Oxygen 2-4 L/min by NC. -Aspirin 325 mg PO, chew and swallow,
then aspirin EC 162 mg PO qd OR –Clopidogrel (Plavix) 75 mg PO qd (if allergic to aspirin). -
Nitroglycerine infusion 10 mcg/min infusion (50 mg in 250-500 mL D5W, 100-200 mcg/mL). Titrate to control symptoms in 5-10 mcg/min steps, up to 200-300 mcg/min; maintain systolic BP -Heparin 25000 iu in a pint to be completed by continuous iv infusion over 24 hours. Repeat BTCT before giving next dose of inj heparin after 6 hours of thrombolization or giving Inj .heparin hours to maintain aPTT of 50-70 seconds. Check aPTTq6h x 4, then qd. Repeat aPTT 6 hours after each heparin dosage change. Angiotensin Converting Enzyme Inhibitor:
Ramipril (Zorem, Cardace) 2.5-5 mg PO qd; titrate to 10-20 mg qd. Long-acting Nitrates:
 Isosorbide dinitrate (Isordil) 10-60 mg PO tid [5,10,20, 30,40 mg]  Isosorbide mononitrate (Imdur) 30-60 mg PO qd. CDMO cum Civil Surgeon
Beta-Blockers: Contraindicated in cardiogenic shock.
 Metoprolol (Betaloc ) 25 mg od or bd can be given Statins:
11. Symptomatic Medications: -Morphine sulfate 2-4 mg IV push prn chest pain. -
Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn mg PO tid-qid prn anxiety. - Zolpidem (Ambien) 5-10 mg qhs prn insomnia. -Docusate (Colace) 100 mg PO bid. -Dimenhydrinate (Dramamine) 25-50 mg IV over 2-5 q4-6h or 50 mg PO q4-6h prn nausea. -Famotidine (Pepcid) 20 mg IV/PO bid. 12. Extras: ECG stat and in 12h and in AM, portable CXR, impedance
13. Labs: Cardiac enzymes: CPK-MB, troponin I, and q6h for 24h. CBC, B.T.C.T. LFT, RFT.
Congestive Heart Failure
1. Admit to:
2. Diagnosis: Congestive Heart Failure
3. Condition:
4. Vital Signs: q1h. Call physician if P >120; BP >150/100 <80/60; T >38.5°C; R >25, <10.
5. Activity: Bed rest with bedside commode.
6. Nursing: Daily weights, measure inputs and outputs. Head-of-bed at 45 degrees, legs
7. Diet: 1-2 gm salt, cardiac diet.
8. IV Fluids: Heparin lock with flush q shift.
9. Special Medications: -Oxygen 2-4 L/min by NC.
Diuretics: -Furosemide (Lasix) 10-160 mg IV qdbid or 20-80 mg PO qAM-bid [20,40,80 mg] or
10-40 mg/hr IV infusion OR -Torsemide (Demadex) 10-40 mg IV or PO qd; max 200 mg/day [5,
10, 20, 100 mg] OR -Bumetanide (Bumex) 0.5-1 mg IV q23h until response; then 0.5-1.0 mg IV
q8-24h (max 10 mg/d); or 0.5-2.0 mg PO qAM. -Metolazone (Zaroxolyn) 2.5-10 mg PO qd, max
20 mg/d; 30 min before loop diuretic [2.5,5,10 mg].
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ACE Inhibitors: -Quinapril (Accupril) 5-10 mg PO qd x 1 dose, then 20-80 mg PO qd in
1 to 2 divided doses [5,10,20,40 mg] OR -Lisinopril (Zestril, Prinivil) 5-40 mg POqd
[5,10,20,40 mg] OR -Benazepril (Lotensin) 10-20 mg PO qd-bid, max 80 mg/d
[5,10,20,40 mg] OR Fosinopril (Monopril) 10-40 mg PO qd, max 80 mg/d [10,20 mg] OR
Ramipril (Cardace , Zorem) 2.5-10 mg PO qd, max 20 mg/d [1.25,2.5,5,10 mg]. -C
Enalapril 1.25-5 mg slow IV push q6h or 2.5-20 mg PO Angiotensin-II Receptor Blockers:
 Losartan (Cozaar) 25-50 mg bid [25, 50 mg].  Valsartan (Diovan) 80 mg qd; max 320 mg qd [80, 160 mg].  Telmisartan (Micardis) 40-80 mg qd [40, 80 mg]. Beta-blockers:
-Carvedilol (Coreg) 1.625-3.125 mg PO bid, then slowly increase the dose every 2 weeks to target dose of 25-50 mg bid [tab 3.125, 6.25, 12.5, 25 mg] OR
-Metoprolol (Lopressor) start at 12.5 mg bid, then slowly increase to target dose of 100 mg bid -Bisoprolol (Zebeta) start at 1.25 mg qd, then slowly increase to target of 10 mg qd. [5,10 mg]. Digoxin: (Lanoxin) 0.125-0.5 mg PO or IV qd [0.125,0.25, 0.5 mg].
Inotropic Agents :
 Dobutamine (Dobutrex) 2.5-10 mcg/kg/min IV, max of 14 mcg/kg/min (500 mg in 250 mL D5W, 2 mcg/mL) OR
 Dopamine (Intropin) 3-15 mcg/kg/min IV (400 mg in 250 cc D5W, 1600 mcg/mL), titrate to CO >4, CI >2; systolic >90 OR
 Milrinone (Primacor) 0.375 mcg/kg/min IV infusion (40 mg in 200 mL NS, 0.2 mg/mL); titrate to 0.75 mgc/kg/min; arrhythmogenic; may cause hypotension. Vasodilators:
-Nitroglycerin 5 mcg/min IV infusion (50 mg in 250 mL D5W). Titrate in increments of 5 mcg/min to control symptoms and maintain systolic BP >90 mmHg. -Nesiritide (Natrecor) 2 mcg/kg IV loadover 1 min, then 0.010 mcg/kg/min IV infusion. Titrate in increments of 0.005 mcg/kg/min Potassium:
CDMO cum Civil Surgeon
-KCL (Micro-K) 20-60 mEq PO qd if the patient is taking loop diuretics. -Synchronized biventricular pacing if ejection fraction <40% and QRS duration >150 msec. 10. Symptomatic Medications: -Morphine sulfate 2-4 mg IV push prn dyspnea or anxiety. -
Heparin 5000 U SQ q12h or enoxaparin (Lovenox) 1 mg/kg SC q12h. -Docusate sodium (Colace) 100-200 mg PO qhs. -Famotidine (Pepcid) 20 mg IV/PO q12h. 11. Extras: CXR PA and LAT, ECG now and repeat if chest pain or palpitations, impedance
12. Labs: CBC; B-type natriuretic peptide (BNP), cardiac enzymes: CPK-MB, troponin i, STAT
Supraventricular Tachycardia
1. Admit to:
2. Diagnosis: PSVT
3. Condition:
4. Vital Signs: q1h. Call physician if BP >160/90, <90/60; apical pulse >130, <50; R >25, <10; T
5. Activity: Bed rest with bedside commode.
6. Nursing:
7. Diet: Low fat, low cholesterol, no caffeine.
8. IV Fluids: D5W at TKO.
9. Special Medications: Attempt vagal maneuvers (Valsalva maneuver) before drug therapy.
Cardioversion (if unstable or refractory to drug therapy):
1. NPO for 6h, digoxin level must be less than 2.4 and potassium and magnesium must be CDMO cum Civil Surgeon
Pharmacologic Therapy of Supraventricular Tachycardia:
-Adenosine (Adenocard) 6 mg rapid IV over 1-2 sec, followed by saline flush, may repeat 12 mg IV after 23 min, up to max of 30 mg total OR
-Verapamil (Isoptin) 2.5-5 mg IV over 2-3min (may give calcium gluconate 1 gm IV over 3-6 min prior to verapamil); then 40-120 mg PO q8h [40, 80, 120 mg] or verapamil SR 120-240 mg PO qd [120, 180, 240 mg] OR
-Esmolol hydrochloride (Brevibloc) 500 mcg/kg IV over 1 min, then 50 mcg/kg/min IV infusion titrated to HR of <80 (max of 300 mcg/kg/min) OR -Diltiazem (Cardizem) 0.25 mg/kg IV over 2-5
minutes, followed by 5 mg/h IV infusion. Titrate to max 15 mg/h; then diltiazem-CD (Cardizem- CD)120-240 mg PO qd OR
-Metoprolol (Lopressor) 5 mg IVP q46h; then 50-100 mg PO bid, or metoprolol XL (Toprol-XL) 50- 100 mg PO qd OR
-Digoxin (Lanoxin) 0.25 mg q4h as needed; up to 1.0-1.5 mg; then 0.125-0.25 mg PO qd. 10.Symptomatic Medications: -Lorazepam (Ativan) 1-2 mg PO tid prn anxiety.
11.Extras: Portable CXR, ECG; repeat if chest pain. Cardiology consult.
12.Labs: CBC, SMA 7&12, Mg, thyroid panel. UA.
Ventricular Arrhythmias
1. Ventricular Fibrillation and Tachycardia: -If unstable (see ACLS protocol): Defibrillate with
unsynchronized 200 J, then 300 J. -Oxygen 100% by mask. -Lidocaine (Xylocaine) loading dose 75-100 mg IV, then 2-4 mg/min IV OR -Amiodarone (Cordarone) 300 mg in 100 mL of D5W, IV
infusion over 10 min, then 900 mg in 500 mL of D5W, at 1 mg/min for 6 hrs, then at 0.5 mg/min thereafter; or 400 mg PO q8h x 14 days, then 200-400 mg qd. -Also see "other
antiarrhythmics" below.
2. Torsades De Pointes Ventricular Tachycardia: -Correct underlying cause andconsider
discontinuing quinidine, procainamide, disopyramide, moricizine, amiodarone, sotalol, Ibutilide, phenothiazine, haloperidol, tricyclic and tetracyclic antidepressants, ketoconazole, itraconazole, bepridil, hypokalemia, and hypomagnesemia. CDMO cum Civil Surgeon
-Magnesium sulfate 1-4 gm in IV bolus over 5-15 min or infuse 3-20 mg/min for 7-48h until QTc -Isoproterenol (Isuprel), 2-20 mcg/min (2 mg in 500 mL D5W, 4 mcg/mL). -Consider ventricular 3. Other Antiarrhythmics: Class I:
-Moricizine (Ethmozine) 200-300 mg PO q8h, max 900 mg/d [200, 250, 300 mg]. Class Ia: -Quinidine gluconate (Quinaglute) 324648 mg PO q8-12h [324 mg]. -Procainamide
IV: 15 mg/kg IV loading dose at 20mg/min, followed by 2-4 mg/mincontinuous IV infusion.PO:
500 mg (nonsustained release)PO q2h x 2 doses, then Procanbid1-2 gm PO q12h [500, 1000 -Disopyramide (Nor-pace, Norpace CR) 100-300 mg PO q6-8h [100, 150, mg] or disopyramide CR Class Ib: -Lidocaine (Xylocaine) 75-100 mg IV, then 2-4 mg/min IV -Mexiletine (Mexitil) 100-200
mg PO q8h, max 1200 mg/d [150, 200, 250 mg]. -Tocainide (Tonocard) loading 400-600 mg PO, then 400-600 mg PO q812h (1200-1800 mg/d) PO in divided doses q8-12h [400, 600 mg]. -Phenytoin (Dilantin), loading dose 100-300 mg IV given as 50 mg in NS over 10 min IV q5min, then 100 mg IV q5min prn. Class Ic: -Flecainide (Tambocor) 50-100 mg PO q12h, max 400 mg/d [50, 100, 150 mg]. -
Propafenone (Rythmol) 150-300 mg PO q8h, max 1200 mg/d [150, 225, 300 mg]. Class II: -Propranolol (Inderal) 1-3 mg IV in NS (max 0.15 mg/kg) or 20-80 mg PO tid-qid [10, 20,
40, 60, 80 mg]; propranolol-LA (Inderal-LA), 80-120 mg PO qd [60, 80, 120, 160 mg] -Esmolol (Brevibloc) loading dose 500mcg/kg over 1 min, then 50-200 mcg/kg/min IV infusion -Atenolol (Tenormin) 50-100 mg/d PO [25, 50, 100 mg]. -Nadolol (Corgard) 40-100 mg PO qdbid [20, 40, 80, 120, 160 mg]. -Metoprolol (Lopressor) 50-100 mg PO bid-tid [50, 100 mg], or metoprolol XL (Toprol-XL) 50-200 Class III: -Amiodarone (Cordarone), PO loading 400-1200 mg/d in divided doses for 2-4 weeks,
then 200-400 mg PO qd (5-10 mg/kg) [200 mg] or amiodarone (Cordarone) 300 mg in 100 mL of D5W, IV infusion over 10-20 min, then 900 mg in 500 mL of D5W, at 1 mg/min for 6 hrs, then CDMO cum Civil Surgeon
at 0.5 mg/min thereafter. -Sotalol (Betapace) 40-80 mg PO bid, max 320 mg/d in 2-3 divided doses [80, 160 mg]. 4. Extras: CXR, ECG, Holter monitor, signal averaged ECG, cardiology consult.
5. Labs: SMA 7&12, Mg, calcium, CBC, drug levels. UA.
Hypertensive Emergency
1. Admit to:
2. Diagnosis: Hypertensive emergency
3. Condition:
4. Vital Signs: q30min until BP controlled, then q4h.
5. Activity: Bed rest
6. Nursing: Intra-arterial BP monitoring, daily weights, inputs and outputs.
7. Diet: Clear liquids.
8. IV Fluids: D5W at TKO.
Special Medications:-
Nitroglycerin drip in ns pint is given @ 6-10 drops / min til B.P. is normal
 Nitroprusside sodium 0.25-10 mcg/kg/min IV (50 mg in 250 mL of D5W), titrate to  Labetalol (Trandate, Normodyne) 20 mg IV bolus (0.25 mg/kg), then 2080 mg boluses IV q10-15min titrate to desired BP or continuous IV infusion of 1.0-2.0 mg/min titrate to desired BP. Ideal in patients with an aortic aneurysm.  Nicardipine (Cardene IV) 5 mg/hr IV infusion, increase rate by 2.5 mg/hr every 15 min up  Enalapril 1.25- 5.0 mg IV q6h. Do not use in presence of AMI.  Esmolol (Brevibloc) 500 mcg/kg/min IV infusion for 1 minute, then 50 mcg/kg/min; titrate by 50 mcg/kg/min increments to 300 mcg/kg/min (2.5 gm in D5W 250 mL).  Clonidine (Catapres), initial 0.1-0.2 mg PO followed by 0.05-0.1 mg per hour until DBP  Phentolamine (pheochromocytoma), 5-10 mg IV, repeated as needed up to 20 mg. 10. Symptomatic Medications:
CDMO cum Civil Surgeon
 Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn headache.  Zolpidem (Ambien) 5-10 mg qhs prn insomnia.  Docusate sodium (Colace) 100-200 mg PO qhs. 11.Extras: Portable CXR, ECG, impedance cardiography, echocardiogram.
12. Labs: CBC, SMA 7, UA with micro. TSH, free T4, 24h urine for metanephrine. Plasma
catecholamines, urine drug screen.
I. Initial Diagnostic Evaluation of Hypertension
A. 15 Lead electrocardiography may document evidence of ischemic heart disease, rhythm and
conduction disturbances, or left ventricular hypertrophy. B. Screening labs include a complete blood count, glucose, potassium, calcium, creatinine,
BUN, uric acid, and fasting lipid panel. C. Urinalysis. Dipstick testing should include glucose, protein, and hemoglobin.
D. Selected patients may require plasma renin activity, 24 hour urine catecholamines, or renal
function testing (glomerular filtration rate and blood flow). II. Antihypertensive Drugs
A. Thiazide Diuretics
1. Hydrochlorothiazide (HCTZ, HydroDiuril), 12.5-25 mg qd [25 mg].
2. Chlorothiazide (Diuril) 250 mg qd [250, 500 mg].
3. Thiazide/Potassium Sparing
Diuretic Combinations
a. Maxzide (hydrochlorothiazide 50/triamterene 75 mg) 1 tab qd.
b. Moduretic (hydrochlorothiazide 50 mg/amiloride 5 mg) 1 tab qd.
c. Dyazide (hydrochlorothiazide 25 mg/triamterene 37.5) 1 cap qd.
B. Beta-Adrenergic Blockers
1. Cardioselective Beta-Blockers
CDMO cum Civil Surgeon

a. Atenolol (Tenormin) initial dose 50 mg qd, then 50-100 mg qd, max 200 mg/d [25, 50, 100
b. Metoprolol XL (Toprol XL) 100-200 mg qd [50, 100, 200 mg tab ER].
c. Bisoprolol (Zebeta) 2.5-10 mg qd; max 20 mg qd [5,10 mg].
2. Non-Cardioselective Beta-Blockers
a. Propranolol LA (Inderal LA), 80-160 mg qd [60, 80, 120, 160 mg].
b. Nadolol (Corgard) 40-80 mg qd, max 320 mg/d [20, 40, 80, 120, 160 mg].
c. Pindolol (Visken) 5-20 mg qd, max 60 mg/d [5, 10 mg].
d. Carteolol (Cartrol) 2.5-10 mg qd [2.5, 5 mg].
C. Angiotensin-Converting Enzyme (ACE) Inhibitors
1. Ramipril (Altace) 2.5-10 mg qd, max 20 mg/day [1.25, 2.5, 5, 10 mg].
2. Quinapril (Accupril) 20-80 mg qd [5, 10, 20, 40 mg].
3. Lisinopril (Zestril, Prinivil) 1040 mg qd [2.5, 5, 10, 20, 40 mg].
4. Benazepril (Lotensin) 10-40 mg qd, max 80 mg/day [5, 10, 20, 40 mg].
5. Fosinopril (Monopril) 10-40 mg qd [10, 20 mg].
6. Enalapril (Vasotec) 5-40 mg qd, max 40 mg/day [2.5, 5, 10, 20 mg].
7. Moexipril (Univasc) 7.5-15 mg qd [7.5 mg].
D. Angiotensin Receptor Blockers
1. Losartan (Cozaar) 25-50 mg bid [25, 50 mg].
2. Valsartan (Diovan) 80-160 mg qd; max 320 mg qd [80, 160 mg].
3. Irbesartan (Avapro) 150 mg qd; max 300 mg qd [75, 150, 300 mg].
4. Candesartan (Atacand) 8-16 mg qd-bid [4, 8, 16, 32 mg].
5. Telmisartan (Micardis) 40-80 mg qd [40, 80 mg].
E. Calcium Entry Blockers
1. Diltiazem SR (Cardizem SR) 60-120 mg bid [60, 90, 120 mg] or Cardizem CD 180-360 mg
qd [120, 180, 240, 300 mg].
CDMO cum Civil Surgeon

2. Nifedipine XL (Procardia-XL, Adalat-CC) 30-90 mg qd [30, 60, 90 mg].
3. Verapamil SR (Calan SR, Covera-HS) 120-240 mg qd [120, 180, 240 mg].
4. Amlodipine (Norvasc) 2.5-10 mg qd [2.5, 5, 10 mg].
5. Felodipine (Plendil) 5-10 mg qd [2.5, 5, 10 mg].
1. Admit to: Monitored ward
2. Diagnosis: Syncope
3. Condition:
4. Vital Signs: q1h, postural BP and pulse q12h. Call physician if BP >160/90, <90/60; P >120,
<50; R>25, <10
5. Activity: Bed rest.
6. Nursing: Fingerstick glucose.
7. Diet: Regular
8. IV Fluids: Normal saline at TKO.
9. Special Medications:
High-grade AV Block with Syncope:
 Atropine 1 mg IV x 2.
 Isoproterenol 0.5-1 mcg/min initially, then slowly titrate to 10 mcg/min
Drug-induced Syncope: -Discontinue vasodilators, centrally acting
hypotensive agents, tranquilizers, antidepressants, and alcohol use.  Postural Syncope: -Midodrine (ProAmatine) 2.5 mg PO tid, then increase to
5-10 mg PO tid [2.5, 5 mg]; contraindicated in coronary artery disease. -Fludrocortisone 0.1-1.0 mg PO qd. 10. Symptomatic Medications: -Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn
headache. -Docusate sodium (Colace) 100-200 mg PO qhs. 11. Extras: CXR, ECG, 24h Holter monitor, electrophysiologic study, tilt test, CT/MRI, EEG,
impedance cardiography, echocardiogram.
12. Labs: CBC, SMA 7&12, CK-MB, troponin T, Mg, calcium, drug levels. UA, urine drug
CDMO cum Civil Surgeon
Infection Control Programme
 Al equipments wil be cleaned with spirit daily.  Al staff members and patients relatives have to remove their footwear outside and wear ICCU  BMW should be segregated at the place of generation.  The Staff handling with BMW must wear the gloves and masks.  Fumigation of al the rooms as and when they get vacant at least once in a month. CDMO cum Civil Surgeon


HALLAZGOS Y REFLEXIONES A UN MES DE ATENCION DE LA LINEA “ABORTO: MAS INFORMACION, MENOS RIESGOS” Es necesario hablar de aborto sin eufemismos ni moralinas. El aborto ya fue: Uno por cada minuto que pasa. El aborto nos inscribe a todas las mujeres en una experiencia común. Según el Ministerio de Salud, en promedio, todas las mujeres pasamos por dos procesos de aborto durante nuestra

Bacterium background Rhizobia, is a col ective name of the genera Rhizobium, Sinorhizobium, Mesorhizobium and Bradyrhizobium , which are soil and rhizosphere bacteria of agronomic importance because they perform nitrogen-fixing symbioses with leguminous plants. Rhizobium and Sinorhizobium are in the family Rhizobiaceae, while Mesorhizobium and Bradyrhizobium members of Phyllobac

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