Discharge Summary Dictation
House Staff Directory
|Cytotoxic||Cellular swelling due to ischemic or toxic injury||Trauma||Minutes to hours||Resistant to treatment|
|Vasogenic||Extracellular edema due to capillary disruption / breakdown of BBB||Trauma, tumors, abscess||Hours to days|
Mortazavi, Martin M, Andrew K Romeo, Aman Deep, Christoph J Griessenauer, Mohammadali M Shoja, R Shane Tubbs, and Winfield Fisher. 2012. ‘Hypertonic Saline For Treating Raised Intracranial Pressure: Literature Review With Meta-Analysis: A Review’. Journal Of Neurosurgery 116 (1): 210–221.
Phenytoin has significant protein binding, so hypoalbuminemia will lead to increased free phenytoin.
Adjust for hypoalbuminemia using the following formula = Total Phenytoin Level / [(0.2*albumin)+0.1]
*0.2 is a correction factor
In renal failure, aside from hypoalbuminia leading to increased free phenytoin, phenytoin binding is further reduced, and this formula will tend to underestimate the free phenytoin levels. To correct for this, use 0.1 as correction factor if GFR is <10 ml/min.
Drug monitoring: (http://emedicine.medscape.com/article/2090306-overview#a2)
How to measure hematoma volume (ABC/2 method) where:
A = greatest diameter of the largest hemorrhage slice
B = diameter perpendicular to A
C = approx # of axial slices with hemorrhage multiplied by the slice thickness
1. Mode of ventilation – start with A/C mode, SIMV if tachypneic
2. Tidal Volume – use 8ml/Kg of predicted BW then reduce to 6ml/Kg over next 2 hours
**Monitor peak alveolar pressure (goal </=30cmH20)
**Inspiratory Flow Rate – set at 60mL/min; higher (>/=80mL/min) if respiratory distress or high MV (>/=10L/min)
**I:E ratio – normally >/=1:2, if <1:2 then inc IFR or dec TV or dec RR
3. Respiratory Rate – set at patient’s MV prior to intubation, not to exceed 35 /min; check PCO2 after 30 minutes
4. PEEP – initial PEEP at 5 cmH20
**If with occult PEEP, then increase I:E ratio or ad extrinsic PEEP