ABG - ARTERIAL BLOOD GAS

Susah sangat nak faham ABG, beberapa bulan kerja pun

macam tak berapa nak faham, tahu2 nak tunjuk result kat MO

je...

Sebenarnya depend kepada case juga kenapa kita ambil

ABG ni, atau VBG.

Kalau patient resporatory problem, kita hantar ABG.

i.e

• PH 7.25 (7.35-7.45)

• PO2 60 (80-100)

• PCO2 60 (35-45)

• BE Bergantung pada bicarb level ( +2 to -2)

• Lactate less than 2

• HCO3 22 (22-26)

Ni kiranya patient ni ada respiratory acidosis, sebab PCO2

tinggi, Bicarb (HCO3) normal je.

Acidosis boleh disebabkan oleh, high po2 atau low hco3

(sebab Co2 boleh buat acidic, hco3 buatkan jadi basic), kurang

hco3 buatkan blood jadi lebih acidic.

Kalau patient ESRF kita nak tengok HCO3, sebab indication

nak dialyse adalah persistent metabolic acidosis.

In DKA pun kita nak tgk pt acidic tak, mostly berkaitan dgn

metabolic.

So, point nya... depend what case sebenarnya nak tengok

ABG ni.

Susah kalau tiba-tiba tak tahu case, pastu nak baca ABG.

Dan biasanya Anest selalu ambil ABG sebab nak adjust dan

weaning down oxygen.

Kalau tak okey guna non invasive ventilation po2 levelnya,

mereka kena intubate, kemudian nak adjust Fio2 tu depend

tahap ABG yang diambil. Memang saya tak pandailah yang ni.

Kena banyak lagi bab-bab ABG ni, oxygenation bagai

Boleh faham basic-basic macam ni dah syukur sangat

sebenarnya.

SHOCK FOR BEGINNER

Pre HO Medicorp KB

Cardiogenic Shock

• Pt concious

• BP < 90/60

• Most common cause : Myocardial Infarction

• Kena buat ECG - Contohnya nampak ada changes,

ST Elevation

• Principle of treatment ;

1. Tx underlying cause (eg Myocardial Infarction)

Thrombolytic Therapy

• PCI

• Streptokinase -100 mega unit/ 100 cc /Hour

2. Symptomatic TX (eg : Chest pain)

» Pain Killer

IV Morphine 2-2.5mg every 5 min

(Targeted pain score 0-1) - well controlled pain

No maximum dose for morphine

(As long as sedation score 0-1, no limit to give morphine)

 (If sedation score 2,3 can give IV Fentanyl 50 mcg - 100

mcg)

! kena optimize pain control, sebab boleh worsen MI kalau

sakit persistent. Nak pain score 0- 1.

∆ Oxygen?

Precaution to use, sebab can cause worsen necrosis,

oxidative stress to heart.

Unless if spo2 drop, can start with 1L first, then 2L per

minute

∆ Nitrates

» ? Contraindicated in cardiogenic shock

∆ Inotropes

Example : Dopamine, Dobupamine, Noradrenaline

√ 1st line inotropes in cardiogenic shock, dopamine

√ Other type of shock, 1st line - noradrenaline.

BP : Stroke Volume x Total Peripheral Resistance

69

Haemorhagic Shock

What if patient that post op (eg laparotomy), suddenly BP drop?

• Check Temp

» Fever : Septic shock

• Check Hb

» HB low: Haemorrhagic shock

What to do as HO (if haemorrhagic shock?)

• Prepare patient

• Form

• Symptomatic -  Blood tx - after d/w MO

• Berapa pint? Whole blood ke pack cell?

• Pack cell. Hb aim > 10, 1 pint akan membuat HB

naik sampai 1 - 1.5g

Sambil awaiting pack cell?

(Sejam biasanya blood bank nak prepare blood)

» Can give IV bolus normal saline : 20cc/kg/

Hour

Hypovolumic Shock

Example in case :

1. DKA

2. Burn

DKA

• CBS >11 (Capillary blood sugar)

• PH < 7.3

• HCO3 < 15

◊ IX

• UFEME

• VBG

◊ Why dalam DKA BP drop?

Fluid enter intracellular due to hyperlgycemia in cell.

So treatment underlying cause is by reduce high glucose.

◊ Inotropes of choice?

IV Noradrenaline.

◊ If patient burn?

Loss circulating volume due to burn.

◊ Tx underlying factor?

• Put pt on dressing, pt on antibiotic

• Prevent infection

• IV NS 20 cc/ KG/ Hr

◊ Septic shock :

 Tx same as hypovolemic shock but +

Antibiotic

****

◊ Apa beza allergic reaction/anaphylaxtic/ anaphylaxis shock

• Allergic : Urticaria (skin n mucus membrane)

• Anaphylaxtic : urticaria (skin n mucus membrane n

systemic( respiratory +/- cardiovascular)

• Anaphylaxic shock : anaphylaxtic reaction and BP

drop

» Tx : IM Adrenaline : 0.5 mg at lateral tigh,

wait for 5 min, if sx resolve, tak perlu buat

apa-apa

» If not resolve, give second dose but in

contralateral side

» If still not resolve : IV Adrenaline ( only can

be given if planned by specialist)

◊ IV adrenaline most case use if patient yang case asystole je

◊ Symptomatic tx

» IV Hydrocort 200mg

» T Prednisolone 30mg (Both same efficacy)

» IV Piriton / Syr Piriton

» IV Ranitidine (help reduce hypersensitivity

and GI symptom)

» Inotropes : IV Noradrenaline : need to give

only if pt given IM Adrenaline already. If pt on

triple inotropes, refer anest.

Spinal Shock

Cause cth: MVA - vetebral injury and fracture

BP okey?

Boleh tunggu turn for operation.

Tapi some case BP can drop.

Why in spinal shock BP boleh drop?

• Sebab injury to nerve innervate blood vessel

• Spinal cord f(x) nya maintain blood vessel tone

• Treatment by IV Noradrenaline : help in

vasoconstrict and increase BP

Kredit to Dr Hilmi (Husband Dr Iliana) in PreHO KB by

Medicorp kerana ajar kami tajuk ni.

ECG FOR BEGINNER

• Rate : kita kira berapa kotak besar diantara R-R,

then lepas dapat tu baru 300 divide by kotak besar.

Eg : 300/5 : 60 bpm.

• Rhythm : susah siket yang ni, biasanya tengok di

lead no II, sama macam Rate sebab panjang siket,

lagi jelas nak tengok any abnormality.

Sinus Rythm adalah : P followed by QRS. Kalau P

kemudian takde QRS atau QRS tanpa P, bukanlah Sinus

Rythm namanya. Benda lain pula tu.

Boleh jadi Sinus Tachy, kalau laju sangat heart rate,

macam 150bpm tapi still nampak P, QRS nya.

• Axis :

Biasa boleh tengok di lead I dan II

Prominent Q atau S ke arah negative atau positive

Left axis deviation ingat mnemonic ni (They LEFT Each

Other )

Right axis Deviation (They have RIGHT to see each other)

Adalah specific significant kenapa ada axis changes sekian

dan sekian, boleh cari ya.

• P- R interval ; biasanya 3-5 small box ( kalau

prolong mungkin heart block)

• QRS : tak boleh lebih 3 small box

• (If broad QRS maybe in case Ventricullar

Fibrillation or Ventricullar Tacycardia)

• ST Elevation - More than 2 small box (1mm) in 2

concurrent lead indicate infarction.

• ST depression - More than 1 small box (>0.5mm)

in 2 lead indicate ischemic.

• T wave

» T inversion di AVR, VI normal, tapi kalau

significant dan banyak di lead lain mungkin

ischemia atau infarct.

» Tall tented in HyperKalemia

» Flatten in Hypokalemia

• Location ECG Changes

(Ada orang ajar saya, kalau ingat kedudukan lead di

chest masa pasang lagi senang nak ingat ecg changes, tapi

saya suka hafal gambar je)

» II, III, AVF : Inferior MI

» V1, V2 : Septal MI

» V3, V4, Anterior MI

» V5,V6,I, AVL : Lateral MI

Ada yang changes V3-V6, I, AVL : anterolateral.

Ada yang changes inferolateral.

If more than 6 lead ada ST elevation, tu dah dikiran

Extensive MI.

Saya blur sangat pasal ECG, masuk 3rd posting baru

faham siket2. My bad.

Example Assessments

1. Acute on CKD

• Dehydration

• Sepsis

• HD naive

• No oliguric

• No metabolic acidosis

• No hyperkalemia

2. HAP with type 1 respiratory failure

• ETT cnS 2/1/19 Acinobacter XDR

• Completed IV Unasyn high dose

• Blood CnS (2/1/19 So Far No Growth

• ETT CnS 12/1/19 No Growth

• TWC reducing trend

• CRP 180 > 50 > 30

• Status Afebrile

3. Dengue fever with warning sign

 • D4 of illness

• Febrile phase/ Entering critical phase (15 Hour

Afebrile)

• Not in shock

• Hemodynamically stable

4. Acute coronary Syndrome

• Based on Clinical symptom

• No ECG changes

• TIMI

• Cardiac Enzyme – pending (Kalau CE raised : Non

STEMI, Kalau CE not raised : Unstable Angina,

kalau pending: ACS)

• Not in failure

5. Non STEMI

• TIMI?

• CKMB/CK ratio 17% > 7% ( Reduce in trend)

• On IVI Heparin / Sc Fonda Day 3

6. Chronic Atrial Fibrillation

• Previously on T Dabigatran/ T Warfarin/ T

Apixaban

• Currently rate controlled

• HASBLED ?

7. End Stage Renal Failure with regular HD

• Last HD 3/1/19

• Completed 3 Hour, uneventful/ Complicated

with intradialytic Hypotension, started on single

inotrope

• Via Right BCF/ AVF/ Right IJC/ Left Femoral etc

• Oliguric, metabolic acidosis, hyperkalemia

• Awaiting HD due today

• With I pint pack cell tranfusion

8. Normocytic Normochromic Anemia secondary

to chronic illness

• No active bleeding

• Hb : static 9.2 -- 9.1

• Stool occult blood negative

9. Community Aqcuired Pneumonia with

bronchospasm

• CURB ?

• On Neb Salbutamol 4 Hourly

• Status : improving

• On IV Tazosin/ Unasyn/ Augmentin day 3

(depends on sensitivity and severity)

10.Septicemic shock secondary to CAP/infected

sacral sore with type 1 resp failure

• CURB ?

• Hemodynamicall supported with single inotrope

• TWC increasing trend.

• CRP 200

11.Raised transaminases for IX

Ddx :

• Deranged liver enzyme secondary to 1(eg dengue)

• Drug induce

• Acute ischemic hepatitis

• Status LFT : worsening (AST/ALT)

12.Unilateral Left Lower limb swelling

Ddx

DVT

Soft Tissue Swelling secondary hypoalbuminemia (Alb 20

Cellulitis

13.Unstable angina with LV failure ppt by HPT

Ddx anemia induce angina

» Status - angina free

» TIMI 2

» On double antiplatelet

» On SC Fondaparinux 2.5mg Day 2

MEDICAL NOTES

Ini nota untuk kita yang beginner dan “budak tadika” dalam

medical posting. Dapat tahu benda-benda ni boleh buka mata

sedikit daripada kebluran yang memanjang, kadang-kadang

jadi robot je kerja takde ilmu sangat. Terutamanya mula- mula

masuk posting.

1. Apa beza treatment unstable angina, non stemi

dan STEMI? Kan semuanya ACS?

Biasanya unstable angina ubatnya sama je dengan non

stemi, cuma tempoh berapa hari SC Fondaparinux yang berbeza.

UA : SC Fondaparinux/Arixtra 2.5mg OD x3/7

NSTEMI : SC Fonda 5/7

STEMI : PCI atau Thrombolysis

Patient STEMI akan masuk CCU, for cont cardiac monitoring.

In ward, biasanya patient given

• Double antiplatelet

• Statin

• Beta blocker - if HR permissible

• Ace i - If no renal impairment

• Ca Channel Blocker

• PPI

Contoh ubat

• T Cardiprin 100mg OD / Aspirin

• T Plavix 75 mg OD / clopidogrel

• T Atorvastatin 40mg ON /statin

• T Ramipril 2.5mg ON /ACE-inhibitor

• T Felodipine 5mg OD /Calcium Channel Blocker

• T Pantoprazole 40mg OD /Proton Pump Inhibitor

• T Vastarel MR 35 mg OD/Trimetazidine

• T Bisoprolol 2.5mg OD/Beta Blocker

Patient WAJIB balik dengan antiplatelet dan sublingual

GTN.

Biasanya di CCU, patient post angiogram, Cardiologist akan

tulis siap-siap plan - eg for double antiplatelet for 1 year, then

single antiplatelet lifelong - berdasarkan how severe vessel

block and stented.

2. Kalau patient ada SVT, Atrial Fibrillation, Heart

Block, VF, kena buat apa? Kena prepare in mind

yang MO akan suruh prepare ubat apa?

(Different patient and different hospital might have different

management. Ini adalah mengikut ilmu seciput saya melalui

observasi. Baru tengok satu dua kes, so, jangan percaya dan

tiru bulat-bulat ya)

• SVT :

1. Buat carotid massage first (ada some case

contraindicated)

2. Prepare iv adenosin - to put in large vein, push

then need flush with normal saline- because

easily hydrolyze peripherally

3. IV Adenosine 6mg —> 12mg (ada some case,

guna Verapamil)

4. Kena prepare cardiac monitor - heart may stop

temporarily or bradycardia. Kena bagitahu

patient what to expect.

Atrial Fibrillation

1. IV Amiodarone

(IN ACUTE CASES. BETA BLOCKER PREFERRED, DIGOXIN LOWER

DOEN THE LIST)

2.       T Warfarin / T Apixaban (chronic AF)

• Heart Block

» Patient akan masuk CCU

» Ada certain case Dr bagi Atropine

» Kena put on external pacemaker

» Patient akan sakit, so kena bagi sedation

» Kalau still persistent brady HR <40, mungkin

akan kena masuk Temporary Pacemaker :

macam masukkan IJC, tapi connected to

battery

» Then mungkin ada certain case cardiologist

akan suruh bagi Isoprenaline infusion

» Then kalau family member boleh bayar akan

change temporary pacemaker to permanent

pacemaker hampir 10K atau berbelas K

harganya.

 (Shockable rythm)

Pulseless Ventricular Tachycardia/ Ventricullar

Fibrillation

» Defibrillation

Ada certain Ventricullar Tacycardia, cardiologist

order to give amiodarone.

3. Macam mana nak access dan history taking if

patient presented with fever? In more systematic

way?

Fever?

• CNS?

» Ada orang perasan awak ada meracau atau

tak sedar? Tro meningitis

• URTI?

» Batuk? Warna kahak? Kahak berdarah?

» Sesak nafas?

• Skin lesion? - can be source of infection

• GI? Loose stool? Vomiting? Diarrhea?

• UTI? Dysuria, frequency, urgency?

4. Apa differential diagnosis Fever, SOB, chest

pain?

Fever

• Infection

• Bacterial - Leptospirosis, Meliodosis

• Parasit – Malaria

• Viral – Dengue

• Malignancy - Lymphoma, Leukaemia

• SOB

» Pneumonia

» COPD

» Asthma

» Lung ca

» TB

» Chronic Lung Disease

» Pulm Embolism

» Pneumothorax/ Hemothorax

» CCF/MI/ Cardiomyopathy

» Pleural Effusion

» Anemia

• Chest Pain

» ACS

» Pulm Embolism

» Pneumothorax

» Aortic dissection

» Costochondritis

» Pericarditis

» GERD

» Pancreatitis

» Gastritis – epigastric

5. Kenapa patient before CT contrast kena bagi

NAC- N Acetyl cystein - in ptient yg impaired

Renal function, kalau yang RFT normal, biasanya

tak bagi pun NAC?

Protective to renal, contrast can worsen renal function.

6. Apa itu safety triangle - for chest tube insertion?

Superior- base of axilla

Ant - lateral border of pectoralis major

Post - lateral border latismus dorsi

Inferior - nipple line, at 5th intercostal space,

https://www.researchgate.net/figure/Safe-triangle-forthe-recommended-site-of-chest-entry_fig2_298339124

Cucuk above inferior rib, sebab below superior rib ada

neuromuscular bundle- can prevent injury

7. Masa pleural tapping nak hantar sample untuk

investigation apa?

MTB C+S

Biochemical - Protein, LDH, glucose

PH

FEME

CNS

Cytology

AFB – microscopic (smear) and culture

8. Macam mana nak tengok chest tube functioning

ke tak?

Fluctuation and bubbling dalam under water sealed (bekas

yg ada air) patient during breathing, if not obvious can ask

patient to cough

9. Kenapa ada patient yang dalam list meds nya

Spirinolactone 150 mg? High dose ni untuk

apa?

Medication for portal hypertension - pt liver cirrhosis

10.Kenapa ada patient ACS kita bagi SC

fondaparinux, kenapa ada yang kita bagi IVI

Heparin?

Kalau EGFR less than 30 kita bagi IVI Heparin rather than

sc Fondaparinux . Ada yang complete dalam masa 48 jam, ada

yang kena completekan 72 jam

11.Femoral catheter - bila masa guna triple lumen,

double lumen?

Double lumen - biasanya for the access patient untuk

dialysis

Triple lumen - ada lumen tambahan incase nak masuk

medication ke (patient that have difficult peripheral vein)

12.Macam mana nak tahu nak cucuk kat mana

masa insert femoral catheter?

Mana most medial, vein or artery?

Ingat VAN

Most medial adalah Vein,

Then Artery then Nerve.

Palpate Artery, then about 1-2cm medially adalah vein,

cucuk ke arah umbilicus.

Kredit gambar : Google

13.Kalau nak cucuk intramuscular at buttock?

Which area to poke? To prevent sciatic nerve

injury?

Imagine buttock tu ada 4 petak, cucuk kat upper outer

Quadrant

14.Kalau patient ada syphilis biasa kita bagi ubat

apa?

IM Benzathine Penicillin 2.4 Million Unit weekly for 3 week.

15.Apa formula corrected calcium, apa

significantnya?

Ada some calcium yang bind to albumin, once hypo

albuminemia, secara direct total calcium akan kelihatan low.

Padahal kalau kira corrected calcium, mungkin normal je free ca

dalam badan dia.

Corrected Ca :

Calcium + (0.02 (40- Albumin))

Ambil blood calcium pt, result menunjukkan calcium 1.3,

tapi sebenarnya dia hypo albumin, tup-tup lepas kira corrected

calcium, dapat 2.0, normal lah sebenarnya calcium tu bagi dia.

Unless kalau kira formula corrected calcium ni, still dapat

nilai yang rendah. Tu baru kita boleh cakap yang memang

calcium dia low.

Double check balik ya. Correct if there any mistake.

16.Food to avoid in hyperK patient?

Dates

Banana

Chocolates

17. What is lytic cocktail?

One choice of treatment if patient hyperkalemia.

• IV Calcium Gluconate 10% 10cc

• IV Actrapid 10unit stat

• 50cc Dextrose 50%

Repeat RFT 1 hour post correction.

Pernah juga tengok patient yang plan untuk IJC under

intervention radiologist, patient ESRF and hyperkalaemia,

sebab nak optimize juga dia puna potassium level, Dr bagi

Lytic Cocktail 4 hourly - sebab memang expect akan sentiasa

increase potasium - kecuali patient dah pergi dialisis, biasa

akan cantik potasium level post HD

18.What medication dan reduce potasium level?

Salbutamol

Insulin

Calcium resonium or Kalimate

19.Indication dialysis?

 AEIOU

• Acidosis - metabolic acidosis

• Electrolyte imbalance - persistent hyperkalemia

• Intoxication – drugs

• Overload - that not respons although given

diuresis

• Uremia - encephalopathy, pericarditis, uremic

bleeding, neuropathy

20.Femoral catheter or IJC for dialysis? Which one

pt can go home with? How long need to remove?

Usually temporary - in ward, access for Dialysis by using

temporary catheter. For example patient first time dialysis ke

atau maybe no need long term regular HD.

Sebelum patient balik, kita kena remove temporary femoral

catheter patient, tak boleh bawa balik sebab risk of infection

(groin area)

If patient plan long term for fistula creation ke, sementara

menunggu tarikh operation, mungkin Dr akan masukkan

internal jugular catheter terlebih dulu. Kalau non infected, boleh

bertahan selama 3 bulan, baru need to exchange a new one -

can be change by using guidewire.

Fistula biasanya list operationnya lama, beberapa bulan

juga, dan once dah buat, memakan masa beberapa bulan juga

(depends juga, ada yang cepat) untuk fistula tersebut matang

dan boleh dilakukan trial of fistula.

***

Itu kalau patient opted untuk Hemodialysis, kalau patient

keen untuk CAPD pula?

Uro Surgery akan bagi tarikh untuk buat tenkoff insertion,

kemudian patient akan diajar cara dan dilakukan trial of CAPD

in CKD clinic.

Patient nak HD ke CAPD ke? Depend on pilihan patient

21.In which case cant give PCM?

If patient complaint of fever ke, lepas assess patient,

check dulu transaminase level (LFT- AST, ALT), kalau derange,

suruh patient tepid sponging je for fever, sebab takut worsen

transaminitis.

22.Choice of meds if pt hypokalemia?

Mist KCL 15ml TDS x 3/7

T Slow K 1/1 TDS

Fast Correct

Better in large peripheral line or CVL line

• IV KCL 1g in 100cc NS over 1 Hour

• IV KCL 2g in 200cc NS over 2 Hour

(Kena kira deficit dulu sebelum correct)

23.Causes hyponaterimia? Investigation?

Yang ni rasanya kena specific tajuk lain untuk dia ni

24.Apa beza SU, SLED? HD? CAPD? CVVH

• SU - Biasanya untuk “tarik air”, in patient with

fluid overload, tapi electrolyte still normal- dialisis

yang bukan untuk cuci darah to reduce urea and

creat macam dialisis lain. (Boleh cari lebih detail

ya infonya)

• SLEDD -sustained low-efficiency daily dialysisIni

biasanya dibuat jika pesakit yang HD naive,

belum pernah dialisis sebelum ini. Untuk badan

“tak terkejut sangat”, kita buat SLEDD dulu. Boleh

2 jam, 3 jam. Tapi takdelah sampai 4 jam macam

HD. Ini juga kalau patient yang high risk seperti

post stroke atau ACS, sebab kita takut badan

cannot tolerate the stress during dialysis, usually

used this type dialysis

SU dan SLEDD macam HD, menggunakan femoral catheter

atau Internal Jugular Catheter atau Fistula as vascular access.

Berbeza dengan CAPD, ia adalah Continous Ambulatory

Peritoneal Dialysis.

Patient akan menjalani operation tenkoff, kemudian boleh

digunakan untuk dialisis di rumah sahaja.

Kena ada penjaga yang sentiasa membantu dalam

peritoneal dialisis ini, setiap hari kena cuci menggunakan

“air”. Kelebihanya, tak perlu ke pusat dialisis setiap hari, cuma

kekurangannya setiap hari kena lakukan dialisis di rumah. Kena

beli alatannya dan seorang caretaker kena belajar melakukan

dialisis ini kepada pesakit di rumah.

• Continous Venovenous Hemofiltration (CVVH)

Pernah nampak plan nephro tentang ini masa

review patient ICU, tapi kurang pasti macam

mana caranya.

Biasanya digunakan untuk correct urea creat patient yang

unstable and cannot tolerate hemodialysis. This is one type

of hemodialysis juga sebenarnya. Patient yang intubated, not

stable.

25.What is tenkoff?

Satu catheter yang di masukkan kedalam peritoneal cavity

sebagai access untuk Peritoneal Dialysis.

26.How to use MDI (Meter Dose Inhaler)?

» Buang cap

» Pegang MDI

» Berdiri

» Dongak kepala keatas sedikit

» Hembus nafas terlebih dahulu - menjauhi

inhaler

» Masukkan inhaler kedalam mulut

» Tarik nafas dengan perlahan, pada masa

yang sama tekan inhaler

» Tahan nafas selama 10 saat.

» Hembus nafas perlahan lahan menggunakan

hidung atau mulut

https://m.youtube.com/watch?v=fHYTz-ZoRLw

27.What is spiriva? Airflusal? Seretide? Budesonide,

ventolin??

Seretide= Salmeterol +Fluticasone (usually for COPD)

COMBIVENT = Ipratropium bromide +albuterol

SPIRIVA =Tiotropium bromide

Airflusal= combination of salmeterol +Fluticasone

Budesonide - Corticosteroid

Symbicort - Budesonide + Formoterol

Ventolin = salbutamol

28.Post ischemic stroke? How our BP target at

least in 72 Hour post stroke?

Tak boleh reduce macam normal sangat, because can

worsen ischemic stroke, aim 160-180/90-100

29.Macam mana kita nak cakap “patient collapse”?

Apa beza dengan pitam atau sycope?

Sebelum jerit kepada orang ramai yang “Patient collapse!!!”

Kita kena check dulu pulse. Kalau ada pulse, breathing

okey - chest rise. Mungkin patient hypo? Mungkin orang tu

pengsan je. Bukan collapse pun.

30.Kalau pt BP high? What meds fast action to

lower BP?

Biasanya kalau BP high despite several antihypertensive,

biasa dr bagi stat dose Calcium Channel Blocker. Amlodipine.

Felodipine. (Tapi memang kena assess samada HPT emergency/

urgency juga.

31.Why some pt on ACEi? ARB? beta blocker,Calcium

channel blocker?

Yang ini agak detail. Kena baca dalam CPG. Hehe.

32.Selepas bagi ACei, blood investigation apa nak

kena repeat?

Cth patient first time given T Ramipril, if patient discharge,

write memo to KK to repeat RFT, to see any renal impairment

post ACE-inhibitor.

If increase creatinine level more than 30% from baseline,

maybe need to reduce dose or stop ACE-i. Masa nak start mulamula tu kena check juga RFT to exclude renal impairment.

33.Macam mana nak convert pada sc insulin if

initially pr on ivi insulin?

Kira berapa dose ivi insulin patient requirement in 24 hour,

then boleh change to sc insulin. Kalau patient require 30 unit

insulin in 24H, biasa kita adjust biar subcutaneous insulin pun

lebih kurang totalnya macam tu.

34.If pt on ivi insulin, what to target cbs? Expect to

reduce how much and how to adjust?

In DKA usually patient on ivi insulin (actrapid).

Start with 2unit/H then aim CBS reduce 2-4/Hour.

If <2 increase CBS reading per hour, increase 2 unit/H

So jadi 4Unit/H

If reducing of CBS 2-4, maintain current dose.

If CBS reduced > 4, reduce our dose insulin 2 unit/Hour.

35.Apa fluid regime in DKA?

(Fluid regime ini hanyalah sebagai guide, in real life kena

asses patient clinically, assess respond and adjust accordingly)

Fluid treatment is priority in DKA

Bagi Normal Saline 0.9%

If patient severely dehydrated, start with step 1

(Ingat 1,2,4,8)

Step 1 - 1 pint over 30 min | 1 Hour : 1 L

Step 2 - 1 pint over 1 Hour | 2 Hour : 1 L

Step 3 - 1 Pint over 2 Hour | 4 Hour : 1 L

Step 4 - 1 Pint over 4 Hour | 8 Hour : 1 L

Kalau patient tak severely dehydrated, ada yang start with

step 2. Depends clinically. Biasa MO yang decide.

Dan kena review after every step.

Sejam kemudian. 2 Jam kemudian. 4 Jam Kemudian. 8

Jam kemudian.

Treatment DKA ada 3 prinsip

» Replacement Tx

» Insulin infusion

» Elecrolyte Mx - replace hypoKalemia due to

insulin infusion

Banyak kan nak kena tahu? Saya tukang tulis ni pun belum

tentu ingat. Huhu.

Semoga bermanfaat.

Please double check dengan sumber yang lagi sahih.

Mungkin certain hospital lain managementnya. Ada yang

melalui observasi saya je ni.