Approach to Fluid overload that is refractory to usual diuretics therapy:

1. Start Furosemide infusion (5-40 mg/hr).
   Some recommends oral torasemide 100 mg/12 hrs.

2. If still no response, start with sequential nephronal block:
   -- add oral metolazone 5-10 mg/day given 30 min before loop diuretics.
   -- add spironolactone 25-100 mg/day.

3. Maintain serum albumin higher than 2.5 g/dL by infusion of 50-100% ml 25% albumin infusion.

4. Restrict sodium: <2 g/day.
   Restrict fluids to (urine output - 500).

5. Correct hypokalemia and hypomagnesemia to enhance diuretic efficacy.

6. if hyponatremia developed, tolvaptan (ADH antagonist) can be used.

7. For refractory cases, consider ultrafiltration in settings like congestive heart failure or renal failure when diuretics fail to mobilize fluid.

Massive Transfusion Protocol (MTP):

MTP is a systematic approach to the resuscitation of patients with massive hemorrhage, often defined as requiring the replacement of one blood volume within 24 hours, >10 units of packed red blood cells (PRBCs) within 24 hours, or >3 units in 1 hour with continued bleeding.

Goals:

Restore hemodynamic stability.

Achieve and maintain hemostasis.

Minimize complications such as coagulopathy, hypothermia, and acidosis (the "lethal triad").

Components of MTP:

1. Initial Activation Criteria

Suspected massive hemorrhage (e.g., trauma, obstetric hemorrhage, GI bleed).

Clinical signs: hypotension, tachycardia, or clinical shock with uncontrolled bleeding.

Laboratory triggers:

Base deficit >6 mmol/L.

INR >1.5.

Hemoglobin <7 g/dL.

1. Resuscitation Ratios

Administer blood products in a balanced ratio to prevent coagulopathy:

PRBCs : Fresh Frozen Plasma (FFP) : Platelets = 1:1:1 or 2:1:1.

PRBCs: To restore oxygen-carrying capacity.

FFP: To replenish coagulation factors (start with 4 units after 4 PRBCs).

Platelets: Maintain platelet count >50,000/μL (>100,000/μL in neurosurgical or obstetric cases).

1. Adjunctive Therapies

Tranexamic Acid (TXA):

Dose: 1 g IV over 10 minutes, followed by 1 g over 8 hours.

Administer within 3 hours of trauma if indicated.

Cryoprecipitate: Administer if fibrinogen <100-150 mg/dL.

Dose: 10 units or target fibrinogen >200 mg/dL.

Calcium Replacement:

Use calcium gluconate or calcium chloride to prevent hypocalcemia from citrate in blood products.

Goal ionized calcium >1.1 mmol/L.

Correct Hypothermia:

Use warming devices to keep body temperature >36°C.

Correct Acidosis:

Target pH >7.2 using bicarbonate if necessary.

1. Laboratory Monitoring

Perform serial labs every 30–60 minutes or after every major intervention:

Complete blood count (CBC).

Coagulation studies (PT/INR, aPTT).

Fibrinogen levels.

Electrolytes, calcium, and lactate.

1. Endpoints of Resuscitation

Hemodynamic stability achieved.

Control of bleeding (surgical or radiologic).

Normalization of lab parameters:

INR <1.5.

Fibrinogen >200 mg/dL.

Platelets >50,000/μL.

Complications to Monitor For:

Volume overload (e.g., pulmonary edema).

Hyperkalemia or citrate toxicity.

Disseminated Intravascular Coagulation (DIC).

Cessation of MTP:

Stop MTP when bleeding is controlled, or laboratory targets are met.

Transition to standard care for anemia and ongoing management.

This protocol is adapted and customizable to institutional policies and patient-specific factors.

Insulin in DKA:

1. the initial dose is 0.1 unit/kg, with target RBS refuction by 50-90 mg/dl per hr.
   No max dose.
   و يا ريت العالم تقتنع بهالشي.
   بيشنت الرندوم ماله ما ينزل عن 500، و مبقينه 7 وحدات بالساعة، من تحاجيهم يبقى يعترض بشي هو اصلا جاهل بيه.

2. Adminstration:
   IV route is preferred.
   SC or IM route can be used in mild to moderate DKA.

IV:
The preferred way is to add 50 units insulin in 50 cc NS (final conc is 1 unit/1 ml).
الكثير يخلي 50 وحده ب 500 سيسي.
يعني اذا تريد تنطي 14 وحده انسولين، لازم تنطي 140 سيسي
و هذا يعتبر
hidden not calculated fluid
ممكن يدخل البيشنت بمضاعفات انت ما ماخذ بالك منها.
فمن تنطي 140 سيسي، لازم الفلود الي حاسبه تقلل منه 140، و هذا الشي لم و لن يطبق.

1. contraindications:
   insulin should be #discontinued if serum K was <3.3 even if he has severe acidosis !!!!

According to UpToDate, the target of albumin therapy is not primarily to normalize serum albumin levels. Instead, the goals depend on the clinical context:

A. Restoring intravascular volume: In cases like shock or hypovolemia, the focus is on improving hemodynamic stability and maintaining adequate perfusion, rather than achieving a specific serum albumin level.

B. Managing hypoalbuminemia in specific conditions: In conditions such as nephrotic syndrome or liver disease, albumin therapy is used to help maintain oncotic pressure, reduce edema, and improve fluid balance, not necessarily to normalize serum albumin.

C. Post-paracentesis in cirrhosis: Albumin is given to prevent circulatory dysfunction and renal impairment after large-volume paracentesis rather than targeting albumin levels.

In summary, the therapeutic aim is usually symptom control (e.g., stabilizing circulation, reducing edema) and preventing complications rather than strictly normalizing serum albumin levels. Monitoring clinical response (e.g., blood pressure, urine output) is often more critical than achieving a target albumin concentration.

اول محاضرة بكورس الاطفال راح تكون

Neonatal care, resuscitation, indication for admission to NICU.

راح تكون هنا بالقناة
دقائق و نبدء أن شاء الله

للأشخاص الي مهتمين بكورس الأطفال.
راح نبدأ خلال هالفترة، نهاية هالأسبوع او بداية الأسبوع القادم.

الكورس مثل ما اتفقنا يا دكاترة
يعلمك شلون تتعامل مع الكيس #الطارىء بطريقة علمية و بحسب ما متوفر عدنا.
يعلمك الدوزات و طريقة اعطاء الادوية و تخفيفها
و من كل سستم، راح نآخذ المواضيع الطارئة
مثل من ال endocrine ناخذ DKA و hypoglycemia و hypocalcemia
من الريسبارتري ناخذ asthma
و هكذا

نفس كورس طوارىء الباطنية بالضبط

طريقة الأشتراك موضحة بهذا البوست.

كل التوفيق

أن شاء الله و بقوة الله
بعد العيد، يبدء التحضير للكورس.
كورس
pediatric emergency and ICU cases
يغنيك عن قرآة المصادر و هوستها.
و يوجهك للطريق الصحيح بكيفية التعامل مع الكيس الطارىء خطوة بخطوة و بكل ثقة و بكل علمية و بما يتماشى مع المتوفر في الطوارىء.

أن شاء الله يكون مثل كورس طوارىء الباطنية و افضل.

لأي أستفسار التواصل معي ع المعرف
@AhmedAbdSamm