Today on rounds, a rapid response team was called because someone was suffering from status epilepticus. My preceptor asked me what I would give first, and then next if that didn't work...and I had no idea. Then I thought to myself, if I was the actual pharmacist on that team, and they were counting on me to know the doses of these medications...the patient may not have made it. So0o, definitely went home and looked up the drugs and doses...
Psych
If someone is have tonic clonic seizures for more than 30 minutes, then consider status epilepticus as the diagnosis. It can be caused by antiseizure medication withdrawal as well. First, give lorazepam 0.1mg/kg or diazepam 0.2mg/kg over 2 minutes. This will work right away but won't last very long, so phenytoin or fosphenytoin should be started as well. Fosphenytoin is better than phenytoin in the following ways: minimizes CV depression, improved IV infusion tolerance, and it's also available as an IM route. It's dosed as phenytoin equivalents (PE: 1.5 fosphenytoin is equivalent to 1.0 phenytoin). The dose is 15-20mg PE/kg and max of 150 PE/minute. If the concentration is needed, then it should be taken 2 hours after the end of the IV infusion to give time for the fosphenytoin to be converted to phenytoin. If this doesn't work, then phenobarbital could be added at 20mg/kg at a rate no greater than 1.5mg/kg/minute. As a side note, the therapeutic range for valproic acid is 50-125mcg/ml.
Renal
CIN stands for contrast induced nephropathy. Say there's a patient who has kidney dysfunction and needs to go into the cath lab after having a heart attack. Well, CIN is a possibility...but two drugs can be used to minimize this. Acetylcysteine PO 600-1200mg or bicarbonate infusion (30amps in dextrose) at 3ml/kg/hr.
Heart
What's the physiological difference between NSTEMI and STEMI? STEMI is a complete occlusion, while NSTEMI is a partial occlusion in the heart. Also for a STEMI, the "door to balloon (balloon angioplasty)" time is 90 minutes or less. Switching gears, there's a patient at the hospital who has been admitted and readmitted multiple times due to his heart. The EF is 25%, he's tried everything, and is allergic to ACEs and ARBs. So, cardiology was considering starting ranolazine (an anti-anginal drug). The dose is 500-1000mg BID, starting dose is 500 BID. Basically, it changes sodium current in the body to ultimately decrease calcium overload. The nice thing about ranolazine is that it doesn't change HR and BP. The not so nice thing about it is that it's contraindicated in patients with hypokalemia, hepatic failure, renal failure, and prolonged QTc. The QTc was already 570, so ranolazine was not started.
Liver
In a healthy person, the AST/ALT ratio is 1:1. In a patient with a sudden ratio of 2:1, it's likely due to an alcohol binge. What are three lab values to look out for to determine liver function? INR, Tbili, and albumin.
Diabetes
A patient diagnosed with DKA was in the hospital a few days ago. A few things to remember about DKA - insulin is the only treatment for DKA. If you start the insulin drip, the patient's glucose level goes back down to normal, you can't stop the insulin, because glucose levels will go back up. The end goal is to correct the acidosis in the patient. Also, KCl is usually added to the patient's fluids. This is because the acidosis will eventually be resolved, so you would expect the potassium to decrease. With the KCl, you're ready for this, and can replenish the patient's potassium simultaneously. Also don't forget about MUDPILES as the causes for metabolic acidosis. Methanol, Uremia, Diabetic ketoacidosis, Propylene glycol, Isoniazid, Lactic acidosis, Ethylene glycol, Salicylates.
P.S. lame title today, I know! :)
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