Diastolic Dysfunction Classifier for Normal LVEF and detemination Filling Pressures for Myocardial Disease or Low LVEF

ASE 2016 – Diastolic Function (Normal EF) Classifier

Fill in what you have. Missing items are not counted in the denominator. Thresholds reflect ASE 2016.

Average E/e' ratio

Abnormal if > 14

TR peak velocity (m/s)

Abnormal if > 2.8 m/s

LA volume index (mL/m²)

Abnormal if > 34 mL/m²

Mitral annular e' velocity (cm/s)

Abnormal if < 7

Abnormal if < 10

This counts as one variable. If either septal or lateral meets the abnormal cutoff, this variable is positive.

How it works (ASE 2016 logic)

Applies only to patients with normal LVEF. Four variables are evaluated and only the ones you filled in are counted:

• Average E/e' ratio > 14
• Mitral annular e' velocity reduced: septal e' < 7 cm/s or lateral e' < 10 cm/s (counts as one variable)
• TR peak velocity > 2.8 m/s
• LA volume index > 34 mL/m²

Decision rule (use only the available variables):

• > 50% of available variables are positive → Diastolic dysfunction present
• = 50% positive → Indeterminate
• < 50% positive → Normal diastolic function

ASE 2016 – Diastolic Function Grading (Reduced EF / Myocardial Disease)

Start with mitral inflow (E and A). Use supportive criteria only when needed. Missing items are not counted; PV S/D can substitute when one main item is unavailable.

Mitral E velocity (cm/s)

Used with E/A and the 50 cm/s threshold

Mitral A velocity (cm/s)

E/A is computed from E ÷ A

Average E/e' ratio

Abnormal if > 14

TR peak velocity (m/s)

Abnormal if > 2.8 m/s

LA volume index (mL/m²)

Abnormal if > 34 mL/m²

Pulmonary vein S/D ratio (optional)

Abnormal if < 1; used only when one main item is missing

How it works (ASE 2016 logic)

For reduced EF or myocardial disease & sinus rhythm:

• E/A ≤ 0.8 and E ≤ 50 cm/s → Grade I
• E/A ≥ 2 → Grade III
• Else (E/A ≤ 0.8 with E > 50, or 0.8 < E/A < 2): evaluate 3 supportive criteria: Avg E/e' > 14, TR Vmax > 2.8 m/s, LAVI > 34 mL/m².

Supportive decision (use only available items; PV S/D < 1 may substitute when one main item is unavailable):

• 2 or 3 positive → Grade II (pseudonormal)
• 0 or 1 positive → Grade I
• If only one supportive item available → Indeterminate

Use of of Antiarrhytmics in the ICU for Atrial Fibrillation : Sepsis and Septic Shock

Preferred Caution / Consider Avoid (or avoid in shock)

Drug	Typical ICU Dose	Onset	Hemodynamically Unstable Role	Hemodynamically Stable Role	Contraindications (major)	Sepsis / ICU Notes
Propafenone (Class IC)	IV: 2 mg/kg over 10–20 min (max ~150 mg) (IV availability varies) PO (pill-in-the-pocket): 600 mg once (only for truly stable, preserved LV function)	Minutes–hours (IV); hours (PO)	Caution Consider only if EF normal, no structural heart disease, ischemia excluded, and BP supported; avoid otherwise.	Preferred (select) Rapid rhythm conversion if no structural heart disease, EF normal, and sepsis physiology allows.	Structural heart disease, LV dysfunction, recent MI, significant conduction disease w/o pacer	In septic shock with preserved LV, shown to convert faster and with fewer recurrences than amiodarone; niche use only.
Ibutilide (Class III)	>60 kg: 1 mg IV over 10 min ≤60 kg: 0.01 mg/kg IV over 10 min May repeat once after 10 min if no conversion	~20–30 min	Caution Cardioversion first; consider if CV fails/unavailable and QTc acceptable.	Preferred Very effective for recent-onset AF/AFL; continuous ECG monitoring required.	Baseline QTc > 440–450 ms, history of torsades, severe LV dysfunction, recent MI	High torsades risk in sepsis; correct K > 4.0 and Mg > 2.0 before dosing; monitor ≥ 4 h post-dose.
Amiodarone (Class III)	Load: 150 mg IV over 10 min (may repeat) Infusion: 1 mg/min x 6 h → 0.5 mg/min x 18 h Oral: 200–400 mg daily	~1–2 h for rate; slower for conversion	Preferred Useful when hypotensive or after failed cardioversion; watch for bradycardia/hypotension.	Caution Versatile when others fail/contraindicated; slower conversion than ibutilide.	Severe bradycardia, high-grade AV block w/o pacer, true iodine allergy	Common in ICU; observational data suggest β-blockers may have mortality benefit for rate control when BP tolerates.
Esmolol (β1-blocker)	500–1000 mcg/kg IV bolus → 50–200 mcg/kg/min infusion (titrate)	Minutes	Avoid in shock May worsen hypotension; consider only if BP supported and need tight rate control.	Preferred Rate control with outcome benefits in sepsis if BP tolerates; rapid titration.	Bradycardia, hypotension, severe bronchospasm, acute decomp HF	Very short half-life allows fine control; reassess frequently as sepsis evolves.
Landiolol (β1-blocker)	Start 1 mcg/kg/min → titrate to HR goal (often up to ~10 mcg/kg/min)	Minutes	Caution Less hypotension than esmolol, but still use carefully in unstable shock.	Preferred Rapid HR control with minimal BP drop; availability varies by region.	Similar to esmolol (bradycardia, hypotension, bronchospasm, acute decomp HF)	Good option in septic AF with borderline BP when available.
Digoxin (cardiac glycoside)	IV load total 8–12 mcg/kg: give 50% initially, then 25% q6h x 2 doses Adjust for renal function; monitor levels and conduction.	Hours	Caution / Adjunct Useful for rate control in LV dysfunction with hypotension; not a converter.	Adjunct Slower rate control; combine with other agents as needed.	2nd/3rd-degree AV block w/o pacer, WPW with AF, digoxin toxicity	Less effective in high sympathetic tone early in sepsis; minimal BP effect makes it attractive in hypotension.
Diltiazem (Cardizem, non-DHP CCB)	IV bolus: 0.25 mg/kg over 2 min → may repeat in 15 min at 0.35 mg/kg Maintenance: 5–15 mg/h infusion	Minutes	Avoid in shock Can worsen hypotension; avoid in severe LV dysfunction.	Preferred Effective rate control in stable patients with preserved BP.	Severe LV dysfunction (EF < 40%), hypotension, WPW with AF, bradycardia, AV block	Rapid rate control in stable AF; hypotension frequently limits use in septic ICU patients.
Verapamil (non-DHP CCB)	IV bolus: 2.5–5 mg over 2 min; may repeat 5–10 mg after 15–30 min Maintenance: 5–10 mg/h infusion	Minutes	Avoid in shock Negative inotropy/vasodilation may worsen hemodynamics.	Caution Can control rate in stable AF, but more hypotension risk than diltiazem.	Severe LV dysfunction, hypotension, WPW with AF, bradycardia, AV block	Less favored in septic AF due to hypotension risk; avoid in severe LV dysfunction.

Practical pearls: Treat sepsis source, correct hypoxia/acidosis, and replete electrolytes (target K > 4.0, Mg > 2.0) before pharmacologic conversion. In true hemodynamic instability, electrical cardioversion remains first-line; drugs here are adjuncts or alternatives when CV fails or is not feasible.

Bites & Envenomation Quick Guide

Clinical reference for domestic and wild exposures (USA / North Carolina focus). Tap any blue bar to expand details. No JavaScript required.

Section A — Quick Reference

Category	Common Example	Scientific Name	Key Risks	Details
Domestic (Mammal)	Cat	Felis catus	Deep punctures; Pasteurella multocida	View Treatment Copious irrigation; gentle debridement. Prophylaxis: amoxicillin–clavulanate 875/125 mg PO BID × 5–7 days. Beta-lactam allergy: see “Antibiotic Alternatives” below. Tetanus booster if >5 years; rabies PEP if cat unavailable for observation/testing.
Domestic (Mammal)	Dog	Canis lupus familiaris	Crush/tear injuries; mixed flora	View Treatment Irrigation; debride devitalized tissue; explore for tendon/joint violation. Amoxicillin–clavulanate first-line; consider broader coverage for hand wounds, deep punctures, or immunocompromise. Tetanus update; rabies risk assessment. Primary closure often acceptable except high-risk locations (e.g., hand).
Human	Closed-fist injury (“fight bite”)	Homo sapiens	Eikenella corrodens; joint inoculation risk	View Treatment Avoid primary closure on the hand; evaluate for tendon, joint, bone involvement; consider imaging. Oral: amoxicillin–clavulanate. IV: ampicillin–sulbactam if needed. Beta-lactam allergy: see “Antibiotic Alternatives.” Tetanus update; assess blood-borne pathogen exposure as indicated.
Arthropod (Tick)	Blacklegged tick	Ixodes scapularis	Lyme, babesiosis, anaplasmosis	View Treatment Remove with fine-tipped tweezers at skin line; steady upward traction. Lyme prophylaxis: doxycycline 200 mg PO once within 72 h if high-risk criteria met (engorged Ixodes, attachment ~≥36 h, local risk supports PEP). Observe for rash/systemic symptoms for 30 days.
Arthropod (Spider)	Black widow	Latrodectus mactans	Neurotoxin; pain, spasm	View Treatment Supportive care; opioids for pain; benzodiazepines for spasm. Antivenom for severe/refractory cases after risk-benefit discussion.
Arthropod (Spider)	Brown recluse	Loxosceles reclusa	Local necrosis; systemic loxoscelism uncommon	View Treatment Local care, analgesia; avoid early wide excision. Delayed debridement if needed; evaluate for hemolysis if systemic signs.
Reptile (Snake)	Copperhead	Agkistrodon contortrix	Common NC envenomation; local pain/swelling	View Treatment Immobilize limb; remove constrictive items; keep at heart level. Hospital eval; antivenom if progressive swelling, systemic toxicity, or coagulopathy. Avoid incision, suction, ice, tourniquets.

Section B — Expanded Species List (USA / North Carolina Focus)

Common Name	Scientific Name	Risk Notes	Details
Raccoon	Procyon lotor	Rabies reservoir in NC	View Treatment Immediate soap/water wash; irrigate thoroughly. Rabies PEP unless the animal tests negative via public health. Tetanus booster as indicated.
Bat (various)	Chiroptera	Rabies risk; wounds may be occult	View Treatment Rabies PEP if bat not available for testing or exposure cannot be ruled out (asleep in room with bat, child, intoxicated, cognitively impaired). Tetanus update.
Cottonmouth (Water Moccasin)	Agkistrodon piscivorus	Hemotoxic venom; tissue injury	View Treatment Immobilize; prompt hospital care; serial limb measurements. Antivenom if progression/systemic effects. Labs: CBC, BMP, PT/INR, fibrinogen, CK.
Eastern Diamondback Rattlesnake	Crotalus adamanteus	Severe envenomation; coagulopathy risk	View Treatment Immobilize limb; rapid transport; avoid harmful field techniques. Antivenom per protocol; monitor for recurrent coagulopathy.
Timber Rattlesnake	Crotalus horridus	Hemotoxic ± neurotoxic effects	View Treatment Hospital observation; antivenom guided by progression. Continuous cardiopulmonary and coagulation monitoring.
Eastern Coral Snake (regional)	Micrurus fulvius	Neurotoxic; cranial nerve/respiratory risk	View Treatment Rapid evaluation; observe for delayed neurotoxicity. Antivenom if available/indicated; airway support as needed.
American Dog Tick	Dermacentor variabilis	RMSF vector in NC	View Treatment Prompt tick removal; do not crush body. Empiric doxycycline for suspected RMSF regardless of age when clinically indicated.
Black Widow	Latrodectus mactans	Pain, spasm, autonomic symptoms	View Treatment Analgesia and benzodiazepines; consider antivenom for severe cases with shared decision making.
Brown Recluse	Loxosceles reclusa	Necrotic ulcers possible; true bites uncommon in NC	View Treatment Local care, tetanus as indicated, delayed debridement if necessary. Assess for hemolysis/systemic symptoms if suspected.

Antibiotic Alternatives for Penicillin Allergy

Show Allergy-Safe Regimens for Mammalian Bites

Goal coverage: Pasteurella spp., streptococci, staphylococci (consider community MRSA), and oral anaerobes. Tailor to severity, site, comorbidities, and local stewardship.

• Adults (oral):
  • Doxycycline + metronidazole
  • Clindamycin + ciprofloxacin or clindamycin + levofloxacin
  • Moxifloxacin monotherapy (adults only; check QT/pregnancy)
  • Trimethoprim–sulfamethoxazole + metronidazole
• Adults (IV):
  • Clindamycin + a fluoroquinolone for severe beta-lactam allergy
  • Doxycycline + metronidazole if appropriate/available IV
  • Non-anaphylactic PCN reactions: consider ceftriaxone + metronidazole per allergy history/stewardship
• Pediatrics: discuss with pediatrics/ID for age-specific dosing; options may include TMP-SMX + clindamycin or TMP-SMX + metronidazole tailored to Pasteurella, streptococci, and anaerobes.
• Human bites (hand/closed-fist): adult options include clindamycin + ciprofloxacin, clindamycin + levofloxacin, or doxycycline + metronidazole; ensure early surgical eval for suspected joint/tendon sheath violation.
• Duration: typically 3–5 days for prophylaxis of high-risk wounds; 5–7+ days for infection, extended per clinical course.

Notes: Avoid fluoroquinolones in pregnancy when possible; moxifloxacin not for children. Doxycycline generally avoided in pregnancy (short courses for certain tick-borne illnesses are exceptions). Adjust for renal function/drug interactions.

North Carolina Rabies PEP Quick Flow

Show PEP Decision Steps & Dosing

1. Immediate wound care: Wash with soap/water; irrigate copiously.
2. Animal type & availability:
   • Dog/cat/ferret healthy & available: 10-day observation; PEP only if animal becomes ill or cannot be observed.
   • Wild carnivores (raccoon, fox, skunk) or bats: if exposure possible and animal not promptly testable, begin PEP; coordinate with public health.
   • Others (livestock, small rodents, lagomorphs): consult public health.
3. Exposure scenarios: Bite or saliva to mucosa/broken skin = exposure. Bat encounters where a bite can’t be ruled out = treat as exposure.
4. PEP (not previously vaccinated):
   • Vaccine IM on days 0, 3, 7, 14 (deltoid adults; anterolateral thigh young children).
   • HRIG 20 IU/kg once on day 0: infiltrate into/around wounds; remainder IM at a site distant from vaccine.
   • Immunocompromised: add day-28 vaccine dose; verify response per public health.
5. PEP (previously vaccinated or pre-exposed): vaccine IM on days 0 and 3; no HRIG.
6. Coordination: contact your local NC health department for testing/exposure classification and schedule support.

Administration tips: Separate syringes/sites for vaccine and HRIG; don’t mix; avoid gluteal vaccine administration.

Abbreviation Key

Show Medical Abbreviation Key

• PEP: Post-exposure prophylaxis
• PO: By mouth
• IV: Intravenous
• IM: Intramuscular
• BID: Twice daily
• TID: Three times daily
• q (e.g., q8h): Every (every 8 hours)
• RMSF: Rocky Mountain spotted fever
• CK: Creatine kinase
• NC: North Carolina

Always follow local public health guidance. Adjust choices for renal function, pregnancy, pediatrics, allergies, and antimicrobial stewardship.

Animal Bites

Domestic animal bites (cats & dogs) — Felis catus (cat) Canis lupus familiaris (dog)

Initial care (non-medical)

• Irrigate copiously with normal saline; avoid harsh antiseptics inside the wound.
• Debride devitalized tissue; assess depth, tendon, joint, neurovascular status.
• Elevation; remove rings/watches; hemostasis by gentle pressure.
• Primary closure usually avoided for puncture wounds/hand bites; consider delayed closure. Facial or genital wounds may be closed after thorough irrigation.
• Tetanus: give booster if >5 years for dirty wounds (Td/Tdap).
• Rabies observation: healthy dog/cat that can be observed for 10 days → defer PEP unless animal becomes ill; unknown/ill animal → consult public health.

When to use antibiotics

• All cat bites (high risk for Pasteurella multocida).
• Dog bites to hand/face/genitals; deep puncture, crush injury, edema, immunocompromised, diabetes, asplenia, delayed presentation >12h (extremity) or >24h (face).

Avoid clindamycin monotherapy for cat/dog bites (poor Pasteurella coverage).

Scenario	First-line (adult)	Alternatives / allergies	Duration
Prophylaxis (no infection)	Amoxicillin-clavulanate 875/125 mg PO q12h	Penicillin allergy: • Doxycycline 100 mg PO q12h (avoid in pregnancy) • or TMP-SMX DS PO q12h + metronidazole 500 mg q8h (or clindamycin 300 mg q6–8h)	3–5 days
Established cellulitis	Amoxicillin-clavulanate 875/125 mg PO q12h	As above; if severe β-lactam allergy: moxifloxacin 400 mg PO daily (adult)	5–7 days (extend if slow response)
Severe infection / systemic signs	Ampicillin-sulbactam 3 g IV q6h	Pip-tazo 4.5 g IV q6–8h; or ceftriaxone 2 g IV daily + metronidazole 500 mg q8h. Add MRSA coverage if indicated (e.g., vancomycin per protocol).	7–14+ days based on source/depth
Special situations	Hand bites: low threshold for surgery if abscess, tenosynovitis, septic arthritis, osteomyelitis, or deep space infection. Obtain imaging for foreign body or bone involvement as indicated.

Common microbes: Pasteurella multocida (cats), Capnocytophaga canimorsus (dogs), streptococci, staphylococci (incl. MRSA risk), anaerobes.

Tick bites (USA) — Ixodes scapularis Amblyomma americanum Dermacentor variabilis

Immediate care

• Remove with fine tweezers close to skin; steady upward pull. Clean with soap/water.
• Save/photograph tick if possible (species/attachment time).
• No heat, nail polish, petroleum jelly.

Post-exposure prophylaxis (Lyme)

If all are true: (1) Ixodes species likely, (2) local Lyme risk moderate–high, (3) attached ≥36 h, (4) prophylaxis within 72 h of removal, (5) doxycycline safe → give single-dose doxycycline.

Indication	Adult	Pediatric	Notes
Lyme prophylaxis	Doxycycline 200 mg PO once	Doxycycline 4.4 mg/kg PO once (max 200 mg)	Not for pregnancy/breastfeeding; instead observe and treat if symptoms develop.
Early Lyme disease (erythema migrans)	Doxycycline 100 mg PO q12h × 10 days	Doxycycline 4.4 mg/kg/day divided q12h × 10 days (max 100 mg q12h)	Alternatives: amoxicillin or cefuroxime if doxy contraindicated.
Other tick-borne diseases	Consider ehrlichiosis, anaplasmosis, RMSF; doxycycline is first-line for suspected rickettsial illness in adults and children.

Wild animal bites (USA woods/fields) — Procyon lotor (raccoon) Vulpes vulpes (fox) Mephitis mephitis (skunk) Chiroptera (bats)

Rabies risk & action

• High risk: bats, raccoons, skunks, foxes, unknown wild carnivores — initiate PEP unless animal tests negative.
• Rodents & lagomorphs (squirrels, mice, rats, rabbits): rabies PEP generally not indicated.
• Rabies PEP (unvaccinated): HRIG 20 IU/kg: infiltrate around wound; remainder IM distant site + vaccine IM days 0, 3, 7, 14.
• Previously vaccinated: vaccine IM days 0 & 3; no HRIG.

Antibiotics

• Use dog/cat bite regimens (mixed flora incl. aerobes/anaerobes). See table below.

Scenario	Antibiotic choice	Duration
Prophylaxis (high-risk wounds)	Amoxicillin-clavulanate 875/125 mg PO q12h (adult) β-lactam allergy: doxycycline; or TMP-SMX + metronidazole/clindamycin.	3–5 days
Cellulitis	As above; consider MRSA risk and add coverage if needed.	5–7 days
Severe/systemic	Ampicillin-sulbactam IV; or pip-tazo IV; tailor per cultures.	7–14+ days

Always perform thorough irrigation, assess tetanus, and coordinate with public health for testing and PEP decisions.

Snakebites (with North Carolina focus) — Agkistrodon contortrix (copperhead) Agkistrodon piscivorus (cottonmouth) Crotalus horridus (timber rattlesnake) Sistrurus miliarius (pygmy rattlesnake)

Immediate actions (field/ED)

• Stay calm, immobilize limb at heart level; remove rings/watches; mark advancing edema every 15–20 min.
• Do NOT use tourniquet, ice, incision/suction, electric shock, or attempt to catch snake.
• Rapid transport; establish IV access; pain control; basic labs, coags, fibrinogen, platelets, CK; photograph fang marks and swelling lines.

When to give antivenom

• Progressive swelling beyond bite area, systemic symptoms (hypotension, vomiting, neuro signs), coagulopathy or thrombocytopenia, significant local tissue injury.
• Most NC venomous envenomations are copperhead; antivenom often indicated if swelling progresses.

Antivenom	Initial control	Maintenance / notes
CroFab® (Crotalidae polyvalent immune Fab)	4–6 vials IV; repeat q60 min until initial control (halt of swelling, improving labs) achieved	Then 2 vials IV q6h × 3 doses. Monitor for recurrent coagulopathy.
Anavip® (F(ab')₂)	10 vials IV; may repeat 10 vials if no initial control in 60 min	Longer half-life; fewer recurrence issues; no scheduled maintenance, dose per response.
Supportive care	Tetanus up to date; avoid prophylactic antibiotics (unless wound is grossly contaminated or delayed presentation). Consult poison control/toxicology. Surgical fasciotomy is rarely needed—only for true compartment syndrome after antivenom and pressure measurements.

Coral snakes are not typical in NC; elapid neurotoxicity requires different antivenom and management—consult toxicology if suspected.

Rabies & tetanus quick reference

Topic	Key points
Rabies PEP (unvaccinated)	HRIG 20 IU/kg (infiltrate around wound; remainder IM, different site from vaccine) + vaccine IM days 0, 3, 7, 14.
Rabies PEP (previously vaccinated)	Vaccine IM days 0 & 3; no HRIG.
Tetanus	Dirty wounds: booster if >5 years; clean/minor: booster if >10 years. TIG if unknown/never immunized and wound is dirty.

Scientific terms you can use in notes: Felis catus bite (domestic cat) Canis lupus familiaris bite (domestic dog) Procyon lotor bite (raccoon) Vulpes vulpes bite (red fox) Mephitis mephitis bite (striped skunk)

Clinical content is a quick-reference and not a substitute for local guidelines or toxicology/public-health consultation. Adjust dosing for renal/hepatic function, pregnancy, pediatrics.

Sickle Cell Crisis

Card A — Ketamine + Dexmedetomidine (Precedex) for Acute Sickle Cell Pain

Opioid-sparing analgesia for moderate to severe vaso-occlusive pain not controlled with standard therapy. Intended for step-down or ICU monitoring. Follow local protocols and pharmacy guidance.

No intubation required at analgesic doses

Quick start (no bolus)

Drug	Starting infusion	Titration	Typical max (analgesic range)	Notes
Ketamine	0.1 to 0.3 mg per kg per hour	Increase by 0.05 to 0.1 mg per kg per hour every 30 to 60 minutes	0.5 mg per kg per hour	Optional slow bolus 0.1 to 0.3 mg per kg over at least 10 minutes if protocol allows
Dexmedetomidine	0.2 to 0.4 microgram per kg per hour	Increase by 0.1 to 0.2 microgram per kg per hour every 20 to 30 minutes	0.7 to 1.0 microgram per kg per hour per local policy	No loading dose; avoid rapid bolus to reduce bradycardia and hypotension

Monitoring and targets

• Continuous pulse oximetry; noninvasive blood pressure every 15 minutes during titration, then every hour
• Cardiac monitoring during initiation and dose changes
• Assess pain and sedation at least hourly

Target RASS	Meaning
0 to minus 2	0 = alert and calm; minus 1 = drowsy but sustained eye contact; minus 2 = light sedation, briefly awakens to voice

Expected effects and airway considerations

• Both agents preserve spontaneous ventilation at analgesic doses
• Dexmedetomidine may cause bradycardia or hypotension
• Ketamine may cause mild increase in heart rate and blood pressure; dissociation possible

Adjuncts to continue

• Acetaminophen scheduled if not contraindicated
• NSAID if no acute kidney injury or bleeding risk
• Rescue opioid for breakthrough pain
• Bowel regimen, antiemetic, incentive spirometry, hydration and trigger management

Cautions

• Dexmedetomidine: caution in significant bradycardia or higher-degree heart block without pacer
• Ketamine: caution in uncontrolled hypertension, active ischemia, or acute psychosis; consider lower start in severe hepatic impairment

Disclaimer: Adult reference; verify doses and maximums with local policies and pharmacy.

Card B — Complete Analgesia Options for Acute Sickle Cell Crisis

Multimodal approach: treat pain aggressively while preserving breathing, prevent acute chest syndrome, and address triggers. Use clinical judgment and local order sets.

Pharmacologic and non-pharmacologic

Opioids (first line for moderate to severe pain)

Agent	Typical IV bolus for titration	Common PCA settings (opioid naive)	Notes
Morphine	2 to 4 mg IV every 10 to 15 minutes as needed	Demand 1 to 2 mg; lockout 6 to 10 minutes; no basal initially	Reduce dose in renal impairment; histamine release may cause pruritus
Hydromorphone	0.2 to 0.4 mg IV every 10 to 15 minutes as needed	Demand 0.1 to 0.3 mg; lockout 6 to 10 minutes; no basal initially	Often preferred when renal dysfunction or morphine intolerance
Fentanyl	25 to 50 microgram IV every 5 to 10 minutes as needed	Demand 10 to 25 microgram; lockout 6 to 10 minutes	Short acting; hemodynamically stable option if hypotension limits others

Mini PCA setup cheat sheet

Patient profile	Suggested starting PCA (choose one agent)	Basal infusion	Safety notes
Opioid naive, normal kidney function	Morphine demand 1 to 2 mg, lockout 6 to 10 minutes or Hydromorphone demand 0.1 to 0.2 mg, lockout 6 to 10 minutes or Fentanyl demand 10 to 25 microgram, lockout 6 to 10 minutes	None at start	Assess pain and sedation every 1 hour during first 4 to 6 hours
Opioid tolerant (taking daily opioids before admission)	Use higher end of demand ranges above; consider shorter lockout (6 minutes) Example: Hydromorphone demand 0.2 to 0.3 mg	Consider low basal only if clearly tolerant and monitored: Morphine 0.5 to 1 mg per hour, or Hydromorphone 0.1 to 0.3 mg per hour, or Fentanyl 25 to 50 microgram per hour	Confirm tolerance; continuous pulse oximetry recommended
Renal impairment or high risk for oversedation (elderly, low BMI, OSA)	Prefer Hydromorphone or Fentanyl over Morphine; use lower demand dose: Hydromorphone 0.05 to 0.1 mg; lockout 8 to 10 minutes	None at start	Avoid basal early; reassess frequently; consider capnography if available
Persistent severe pain despite above	Keep PCA for rescue	None or minimal basal unless clearly tolerant	Add multimodal infusions (Ketamine or Dexmedetomidine) per Card A

Always individualize based on age, kidney and liver function, and prior opioid exposure. Basal infusions increase risk of respiratory depression—use only with clear tolerance and close monitoring.

Non-opioid analgesics and adjuvants

Class	Agent	Adult dosing	Key cautions
Acetaminophen	PO or IV	650 to 1000 mg every 6 to 8 hours; max 3000 mg per day in most adults (up to 4000 mg per day if low risk and per policy)	Reduce max dose in liver disease or with alcohol use disorder
NSAID	Ketorolac IV	15 mg IV every 6 hours in older or renally at risk; 30 mg IV every 6 hours in low risk; limit 5 days	Avoid in acute kidney injury, bleeding risk, platelets low, peptic ulcer, or recent surgery
Gabapentinoid	Gabapentin	Start 100 to 300 mg by mouth three times daily; titrate as tolerated; adjust for kidney function	Sedation, dizziness; renal dose adjustment required
Gabapentinoid	Pregabalin	50 to 75 mg by mouth two or three times daily; adjust for kidney function	Sedation, edema; renal dose adjustment required
Antidepressant (chronic overlay)	Duloxetine	30 mg daily, then 60 mg daily if tolerated	Not for rapid acute relief; avoid in severe liver disease
Antidepressant (chronic overlay)	Amitriptyline	10 to 25 mg at bedtime	Anticholinergic effects; avoid in prolonged QT

Analgesic infusions beyond opioids

Agent	Starting infusion	Titration and typical max	Monitoring	Notes
Ketamine	0.1 to 0.3 mg per kg per hour	Titrate by 0.05 to 0.1 mg per kg per hour; typical max 0.5 mg per kg per hour	Cardiac and oximetry monitoring	Preserves breathing; may cause mild dissociation
Dexmedetomidine	0.2 to 0.4 microgram per kg per hour	Titrate by 0.1 to 0.2 microgram per kg per hour; typical max 0.7 to 1.0 microgram per kg per hour	Cardiac and blood pressure monitoring	No loading dose to reduce bradycardia and hypotension
Lidocaine IV	Optional bolus 1 mg per kg over 10 minutes, then 0.5 to 1.5 mg per kg per hour	Titrate within 0.5 to 2 mg per kg per hour per protocol	Continuous ECG and neurologic checks	Avoid in significant heart block without pacer, severe hepatic failure, or seizure disorder; use institutional protocols
Clonidine	0.1 mg by mouth every 8 to 12 hours	Patch 0.1 to 0.2 mg per day weekly if oral not feasible	Blood pressure and heart rate	Adjunct for analgesia and anxiety; caution hypotension and bradycardia

Non-pharmacologic and supportive measures

Measure	How it helps	Practical notes
Heat packs and gentle positioning	Muscle relaxation and local comfort	Protect skin; avoid burns; limit continuous heat time
Incentive spirometry and early mobilization	Prevents atelectasis and acute chest syndrome	Set hourly reminders; document volumes and effort
Hydration and trigger management	Addresses dehydration and acidosis that worsen vaso-occlusion	Avoid overhydration if cardiac or renal dysfunction present
Cognitive and behavioral strategies	Reduces anxiety and pain amplification	Brief coaching: breathing exercises, guided imagery, reassurance
Sleep hygiene and quiet environment	Improves rest and reduces sympathetic tone	Cluster care at night; dim lights; limit alarms if safe

Disease-modifying therapy such as hydroxyurea or transfusion strategies may reduce future crises but do not treat acute pain directly; manage triggers and complications in parallel.

Colitis → Perforated Abdomen (Sepsis)

Management of Colitis vs Perforated Abdomen in the Septic Patient

Start broad-spectrum antibiotics after blood cultures are drawn, give a full loading dose in sepsis, and escalate to perforated-abdomen coverage if there is free air, diffuse peritonitis, or abscess on imaging. Adjust doses for renal function once the patient is stabilized.

Empiric antibiotics: Colitis with sepsis (no perforation)

Option	Regimen and dose	Coverage	Renal adjustment summary
Single agent	Piperacillin-tazobactam 4.5 g IV every 6 to 8 hours. Extended infusion is preferred in severe sepsis when feasible.	Enteric gram-negatives, anaerobes, enterococci, Pseudomonas.	CrCl greater than 40 mL/min: full dose. CrCl 20 to 40 mL/min: 3.375 g every 6 hours. CrCl less than 20 mL/min: 2.25 g every 6 to 8 hours.
Combination	Cefepime 2 g IV every 8 hours + Metronidazole 500 mg IV every 8 hours. Alternative: Ceftriaxone 2 g IV daily + Metronidazole 500 mg IV every 8 hours (community-acquired, lower Pseudomonas risk).	Cefepime combo adds Pseudomonas coverage; ceftriaxone combo covers typical enteric pathogens and anaerobes.	Cefepime adjust by CrCl (see renal table). Ceftriaxone: no renal change (monitor in severe hepatic plus renal dysfunction). Metronidazole: generally no change; consider every 12 hours if CrCl less than 10.
Beta-lactam allergy	Ciprofloxacin 400 mg IV every 12 hours + Metronidazole 500 mg IV every 8 hours. Alternative: Moxifloxacin 400 mg IV daily (less Pseudomonas coverage).	Enteric gram-negatives and anaerobes; no enterococcal coverage.	Ciprofloxacin: CrCl 30 to 50 mL/min every 12 hours; CrCl less than 30 mL/min every 24 hours. Metronidazole: see note above.

Pearl: give a full loading dose up front in sepsis, then apply renal adjustment based on estimated creatinine clearance.

Empiric antibiotics: Perforated abdomen or surgical abdomen

Option	Regimen and dose	Coverage	Renal adjustment summary
Single agent	Piperacillin-tazobactam 4.5 g IV every 6 to 8 hours (extended infusion when feasible), or Meropenem 1 g IV every 8 hours.	Broad enteric gram-negatives, anaerobes, enterococci, Pseudomonas; carbapenem adds ESBL coverage.	Zosyn per CrCl (see renal table). Meropenem: CrCl 26 to 50 mL/min every 12 hours; CrCl 10 to 25 mL/min 500 mg every 12 hours; CrCl less than 10 mL/min 500 mg every 24 hours.
Combination	Cefepime 2 g IV every 8 to 12 hours + Metronidazole 500 mg IV every 8 hours.	Pseudomonas plus anaerobes; add-ons below for MRSA or Candida risks.	Cefepime by CrCl; Metronidazole generally no change.

Urgent source control is critical: surgical consultation for repair, washout, or drainage should proceed in parallel with antibiotics and resuscitation.

Add-on coverage

Indication	Agent and dose	Notes	Renal adjustment summary
MRSA risk factors (hospital-acquired, prior MRSA, post-op GI infection)	Vancomycin 15 to 20 mg per kg IV every 8 to 12 hours	Use AUC-guided or level-guided dosing; combine with base regimen.	Adjust interval and dose per creatinine clearance and serum levels.
High Candida risk (immunocompromised, upper GI perforation with shock, recurrent IAI, yeast on peritoneal Gram stain)	Fluconazole: load 800 mg IV once, then 400 mg IV daily	Consider an echinocandin if unstable or non-albicans risk; de-escalate when species known.	CrCl 50 mL/min or less: reduce maintenance to 200 mg daily.

Renal dosing quick guide

Drug	Sepsis loading / standard	CrCl greater than 40	CrCl 20 to 40	CrCl less than 20	Hemodialysis
Piperacillin-tazobactam	Load 4.5 g IV once	4.5 g every 6 to 8 h	3.375 g every 6 h	2.25 g every 6 to 8 h	2.25 g every 8 h + 0.75 g after HD
Meropenem	1 g IV	1 g every 8 h	1 g every 12 h	500 mg every 24 h	500 mg every 24 h after HD
Cefepime	2 g IV	2 g every 8 to 12 h	2 g every 12 to 24 h	1 g every 24 h	1 g after HD
Ceftriaxone	2 g IV	2 g daily	No renal change; monitor if combined severe hepatic plus renal dysfunction			Not dialyzable; give on schedule
Metronidazole	500 mg IV	500 mg every 8 h	500 mg every 8 h	Consider 500 mg every 12 h	Give after HD on dialysis days
Ciprofloxacin	400 mg IV	400 mg every 12 h	400 mg every 12 h	400 mg every 24 h	Give after HD
Vancomycin	15 to 20 mg per kg IV	Dose per AUC or trough protocol; extend interval with lower CrCl				Redose per levels post-HD
Fluconazole	800 mg load	400 mg daily	If CrCl 50 or less: 200 mg daily		Give post-HD; consider 200 mg daily

Estimate creatinine clearance with Cockcroft-Gault using actual body weight unless patient is very obese, where adjusted body weight may be used per local protocol.

Diagnostic work-up and septic shock management

Phase	Checklist
Initial evaluation	CBC, CMP, magnesium, phosphorus, coagulation panel; serum lactate and repeat within 2 to 4 hours if elevated. Two sets of blood cultures before antibiotics; urinalysis as indicated. Stool tests: C. difficile PCR or toxin, bacterial culture; ova and parasite if travel or exposure risks. CT abdomen and pelvis with IV contrast if feasible to localize inflammation, abscess, or free air. Early surgical consult if peritonitis, free air, uncontrolled sepsis, or evolving organ failure.
Ongoing assessment	Trend lactate and blood gases; monitor urine output and hemodynamics. Reassess abdomen frequently; consider repeat imaging if no improvement in 24 to 48 hours. Send peritoneal fluid for Gram stain and culture if drains placed or ascites present.
Septic shock bundle	Crystalloid 30 mL per kg within first 3 hours (adjust for fluid intolerance). Start norepinephrine to maintain MAP 65 or higher if hypotension persists after fluids. Give broad-spectrum antibiotics within 1 hour of shock recognition; de-escalate when culture data return. Source control: operative repair, washout, or percutaneous drainage without delay when indicated. Consider stress-dose steroids if refractory shock per local protocol.

Duration of therapy is typically 4 to 7 days after adequate source control and clinical improvement; extend if bacteremia with difficult organisms or persistent uncontrolled source.

Disclaimer: This quick guide does not replace clinical judgment. Follow local antibiograms, stewardship policies, and pharmacy dosing protocols.

LV Filling Pressure (E/e') Mini-Calculator (reduced EF logic included)

LV Filling Pressure (E/e') — Minimal Inputs

LVEF (%) Mitral E (cm/s) Septal e' (cm/s) — optional Lateral e' (cm/s) — optional

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Computed ratios: —

Interpretation: Enter values and click Calculate.

Conclusion: —

How it works / reminders

• Uses E/e' septal and/or E/e' lateral from your inputs.
• Lateral: normal < 8; elevated > 12; 8-12 indeterminate.
• Septal: normal < 8; elevated > 15; 8-15 indeterminate.
• Normal EF (>= 50%): low E/e' can support normal filling; elevated E/e' supports elevated filling.
• Reduced EF (< 50%): elevated E/e' supports elevated filling; low/normal E/e' does not exclude elevated filling.
• Formal grading needs LA volume index and TR velocity.