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Handbook of internal medicine

HANDBOOK
of
INTERNAL MEDICINE

COC(Medicine)
Hospital Authority
6th Edition
2011



Disclaimer

DISCLAIMER
This handbook has been prepared by the COC (Medicine), Hospital
Authority and contains information and materials for reference
only. All information is compiled with every care that should
have applied. This handbook is intended as a general guide and
reference only and not as an authoritative statement of every
conceivable step or circumstances which may or could relate to the
diagnosis and management of medical diseases.

The information in this handbook provides on how certain
problems may be addressed is prepared generally without
considering the specific circumstances and background of each of
the patient. The Hospital Authority and the compilers of this
handbook shall not be held responsible to users of this handbook on
any consequential effects, nor be liable for any loss or damage
howsoever caused.



Since the Handbook of Internal Medicine is published its
popularity is rapidly gaining and has become an indispensable tool
for clinicians and interns. Throughout these years we have received
many requests for copies from other specialties and from doctors
outside HA or even outside Hong Kong. However the purpose of
this handbook is mainly for internal use as a quick reference. We
have no intention to turn it into a formal guideline for internal
medicine.
Again this new edition includes update guidelines on the major
diseases. There is a new chapter on Medical Oncology dealing with
emergency conditions encountered in this field. I would like to
thank every one in the Editorial Board and all the specialists who
have reviewed and update the various sections. Without their effort
this handbook would not have been materialized. It represents a
joint effort from our large family of physicians and I hope this
spirit of fraternity can guide us to move ahead in development of
our specialty.

Dr Y W Yeung
Chairman
Quality Assurance Subcommittee
Co-ordinating Committee in
Internal Medicine

Preface

PREFACE TO 6th EDITION




Editorial Board Members

Dr. Cheung Hei CHOI
Dr. Moon Sing LAI
Dr. Wai Cheung LAO
Dr. Owen TSANG
Dr. Kong Chiu WONG
Dr. Jonas YEUNG

Co-ordinating Committee in Internal Medicine
Hospital Authority

Editorial Board
Members

Dr. Ngai Yin CHAN



CONTENTS
Cardiology

Endocrinology

Diabetic Ketoacidosis (DKA)
Diabetic Hyperosmolar Hyperglycemic States
Peri-operative Management of Diabetes Mellitus
Insulin Therapy for DM Control
Hypoglycemia
Thyroid Storm
Myxoedema Coma
Phaeochromocytoma
Addisonian Crisis
Acute Post-operative/Post-traumatic Diabetes Insipidus
Pituitary Apoplexy

Gastroenterology and Hepatology
Acute Liver Failure
Hepatic Encephalopathy
Ascites
Orthotopic Liver Transplantation
Variceal Haemorrhage
Upper Gastrointestinal Bleeding
Peptic Ulcers

C
C
C
C
C
C
C
C
C
C
C

1-3
4-12
13-15
16-23
24
25-27
28-29
30-31
32-33
34
35-39

E
E
E
E
E
E
E
E
E
E
E

1-2
3
4-5
6-7
8
9
10
10
11-12
13
13

G
G
G
G
G
G
G

1-4
5-6
7
8-9
10-11
12
13

Contents

Cardiopulmonary Resuscitation (CPR)
Arrhythmias
Unstable Angina / Non –ST Elevation MI
Acute ST Elevation Myocardial Infarction
Acute Pulmonary Oedema
Hypertensive Crisis
Aortic Dissection
Pulmonary Embolism
Cardiac Tamponade
Antibiotics Prophylaxis for Infective Endocarditis
Perioperative Cardiovascular Evaluation for
Noncardiac Surgery


Management of Gastro-oesophageal Reflux Disease
Inflammatory Bowel Diseases
Acute Pancreatitis

G 14-15
G 16-19
G 20-23

Haematology

Contents

Haematological Malignancies
Leukemia
Lymphoma
Multiple Myeloma
Extravasation of Cytotoxic Drugs
Intrathecal Chemotherapy
Performance Status
Non-Malignant Haematological Emergencies/Conditions
Acute Hemolytic Disorders
Idiopathic Thrombocytopenic Purpura (ITP)
Thrombocytopenic Thrombotic Purpura (TTP)
Pancytopenia
Thrombophilia Screening
Prophylaxis of Venous Thrombosis in Pregnancy
Special Drug Formulary and Blood Products
Anti-emetic Therapy
Haemopoietic Growth Factors
Immunoglobulin Therapy
Anti-thymocyte Globulin (ATG)
rFVIIa (Novoseven)
Replacement for Hereditary Coagulation Disorders
Transfusion
Acute Transfusion Reactions
Transfusion Therapy
Actions after Transfusion Incident & Adverse Reactions

Nephrology

Renal Transplant – Donor Recruitment
Electrolyte Disorders
Systematic Approach to the Analysis of Acid-Base Disorders
Peri-operative Management of Uraemic Patients

H
H
H
H
H
H

1-2
2-3
3-4
4-5
5-6
6

H
H
H
H
H
H

7-8
9-10
10-11
11
11
12

H
H
H
H
H
H

13
13
13-14
14
14
15-17

H 18-19
H 20-21
H 22
K
K
K
K

1-3
4-14
15-18
19


Renal Failure
Emergencies in Renal Transplant Patient
Drug Dosage Adjustment in Renal Failure
Protocol for Treatment of CAPD Peritonitis
Protocol for Treatment of CAPD Exit Site Infection

Neurology

Respiratory Medicine

Mechanical Ventilation
Oxygen Therapy
Massive Haemoptysis
Spontaneous Pneumothorax
Adult Acute Asthma
Long Term Management of Asthma
Chronic Obstructive Pulmonary Disease (COPD)
Pleural Effusion
Obstructive Sleep Apnoea
Pre-operative Evaluation of Pulmonary Functions
Noninvasive Positive Pressure Ventilation (NIPPV)

Rheumatology & Immunology

Approach to Inflammatory Arthritis
Gouty Arthritis
Septic Arthritis
Rheumatoid Arthritis

20-22
23-24
25-27
28-31
32-33

N
N
N
N
N
N
N
N
N
N
N

1-2
3-4
5-8
9-10
11-12
13-14
15
16
17
18
19-20

P
P
P
P
P
P
P
P
P
P
P

1-3
4-5
6
7
8-10
11-13
14-16
17-18
19
20
21-22

R
R
R
R

1-2
3-4
5-6
7-11

Contents

Coma
Acute Confusional State (Delirium)
Acute Stroke
Subarachnoid Haemorrhage
Tonic-Clonic Status Epilepticus
Guillain-Barre Syndrome
Myasthenia Crisis
Acute Spinal Cord Syndrome
Delirium Tremens
Wernicke’s Encephalopathy
Peri-operative Mx of Pts with Neurological Diseases

K
K
K
K
K


Ankylosing Spondylitis
Psoriatic Arthritis
Systemic Lupus Erythematosus
Rheumatological Emergencies
Non-steroidal Anti-inflammatory Drugs

Infections

Contents

Community-Acquired Pneumonia
Hospital Acquired Pneumonia
Pulmonary Tuberculosis
CNS Infection
Urinary Tract Infections
Enteric Infections
Acute Cholangits
Spontaneous Bacterial Peritonitis
Necrotizing Fasciitis
Skin & Soft Tissue Infection
Septic Shock
Anti-microbial Therapy for Neutropenic Patients
Malaria
Chickenpox / Herpes Zoster
HIV / AIDS
Rickettsial Infection
Influenza and Avian Flu
Infection Control
Needlestick Injury/Mucosal Contact to HIV, HBV or HCV

General Internal Medicine

Acute Anaphylaxis
Acute Poisoning
z
General Measures
z
Specific Drug Poisoning
z
Non-pharmacological Poisoning
z
Smoke and Toxic Gas Inhalation
z
Snake Bite

R
R
R
R
R

12-14
15-16
17-22
23-24
25-26

In
In
In
In
In
In
In
In
In
In
In
In
In
In
In
In
In
In
In

1-3
3-4

GM
GM
GM
GM
GM
GM
GM

5

6-7

8

9-10
11
12
13
14
15
16-17
18-19
20

21-26
27
28-29
30-31
32-35

1
2-16
2-3
3-9
9-12
12-13
14-16


Procedures

Endotracheal Intubation
Setting CVP Line
Defibrillation
Temporary Pacing
Lumbar Puncture
Bleeding Time
Bone Marrow Aspiration and Trephine Biopsy
Care of Hickman Catheter
Renal Biopsy
Intermittent Peritoneal Dialysis
Percutaneous Liver Biopsy
Abdominal Paracentesis
Pleural Aspiration
Pleural Biopsy
Chest Drain Insertion

Acknowledgement

GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM
GM

17
18
19
20
21-23
24
25
26-27
28-29
30-31
32
32-34
34-36
37-40
41-43

Pr
Pr
Pr
Pr
Pr
Pr
Pr
Pr
Pr
Pr
Pr
Pr
Pr
Pr
Pr

1-2
3
4
5
6-7
8
9-10
11-12
13
14-15
16-17
18
19
20
21

Contents

Accidental Hypothermia
Heat Stroke / Exhaustion
Near Drowning / Electrical Injury
Rhabdomyolysis
Superior Vena Cava Syndrome
Neoplastic Spinal Cord/Cauda Equina Syndrome
Hypercalcaemia of Malignancy
Tumour Lysis Syndrome
Extravasation of Chemotherapeutic Agents
Anorexia, Nausea & Vomiting in Advanced Cancer
Cancer Pain Management
Prescription of Morphine for Chronic Cancer Pain
Dyspnoea, Delirium & Intestinal Obstruction in Cancer
Palliative Care Emergencies
Brain Death



C - 13

Cardiology
Cardiology


C - 14

Cardiology


C1

C- 1

CARDIOPULMONARY RESUSCITATION (CPR)
1. Determine unresponsiveness
2. Call for Help, Call for Defibrillator
3. Wear PPE: N95/ surgical mask, gown, +/-(gloves, goggles,
face shield for high risk patients)
Primary CDAB Survey (Initiate chest compression before
ventilation; Ref: Field JM et al. Circulation 2010;122[Suppl
3]:S640-656)

D: Defibrillate VF or VT as soon as identified
z Check pulse and leads
z Check all clear
z Deliver 360J for monophasic defibrillator, without lifting
paddles successively if no response; or equivalent 200J
for biphasic defibrillator, if defibrillation waveform is
unknown
A: Assess the Airway
z Clear airway obstruction/secretions
z Head tilt-chin lift or jaw-thrust
z Insert oropharyngeal airway
B: Assess/Manage Breathing
z Ambubag + bacterial/viral filter + 100%O2 @ 15L/min
z Plastic sheeting between mask and bag
z Seal face with mask tightly
z Give 2 rescue breaths, each lasting 2-4 s

Cardiology

C: Circulation Assessment
z Check carotid pulse for 5-10 s & assess other signs of
circulation (breathing, coughing, or movement)
z Chest compressions ≧100/min
z CPR 30 compressions (depth ≧2 inches) to 2 breaths


C- 2

C2

Secondary ABCD Survey
A: Place airway devices; intubation if skilled.
• If not experienced in intubation, continue Ambubag and call
for help
B: Confirm & secure airway; maintain ventilation.
• Primary confirmation: 5-point auscultation.
• Secondary confirmation: End-tidal CO2 detectors,
oesophageal detector devices.
C: Intravenous access; use monitor to identify rhythm.
Cardiology

D: Differential Diagnosis.
Common drugs used in resuscitation
Adrenaline
Vasopressin
Lignocaine
Amiodarone

Atropine
CaCl
NaHCO3
MgSO4

1 mg (10 ml of 1:10,000 solution) q3-5 min iv
40 IU ivi push
1 mg/kg iv bolus, then 1-4 mg/min infusion
In cardiac arrest due to pulseless VT or VF, 300
mg in 20 m1 NS / D5 rapid infusion, further
doses of 150 mg over 10 mins if required,
followed by 1 mg/min infusion for 6 hrs & then
0.5 mg/min, to maximum total daily dose of 2.2 g
1 mg iv push, repeat q3-5min to max dose of
0.04mg/kg
5-10 ml 10% solution iv slow push for
hyperkalaemia and CCB overdose
1 mEq/kg initially (e.g. 50 ml 8.4% solution)
in patients with hyperkalaemia
5-10 mmol iv in torsade de pointes


C3

C- 3

Tracheal administration of Resuscitation Medications
(If iv line cannot be promptly established)
- Lignocaine, Atropine, Epinephrine,Narcan (L-E-A-N)
- Double dosage
- Dilute in 10 ml NS or water
- Put catheter beyond tip of ET tube
- Inject drug solution quickly down ET tube, followed by several
quick insufflations
- Withhold chest compression shortly during these insufflations

Post-resuscitation care:
Cardiology

- Correct hypoxia with 100% oxygen
- Prevent hypercapnia by mechanical ventilation
- Consider maintenance antiarrhythmic drugs
- Treat hypotension with volume expander or vasopressor
- Treat seizure with anticonvulsant (diazepam or phenytoin)
- Maintain blood glucose within normal range
- Routine administration of NaHCO3 not necessary


C- 4

C4

ARRHYTHMIAS
(I)

Ventricular Fibrillation or
Pulseless Ventricular Tachycardia
Primary CDAB Survey

Cardiology

Rapid Defibrillation
DC Shock 360 J (monophasic defibrillation)
or 200J (biphasic shock) if waveform is unknown,
then check pulse
Secondary ABCD Survey
Adrenaline 1 mg iv (10 ml of 1:10,000 solution)
Repeat every 3-5 min
OR
Vasopressin 40 IU IV, single dose, 1 time only
DC Shock 360 J or equivalent biphasic within 30-60s
and check pulse
Consider antiarrhythmics
- Amiodarone 300 mg iv push, can consider a second dose of
150 mg iv (maximum total dose 2.2 g over 24 hr)
- Lignocaine 1-1.5 mg/kg iv push, can repeat in 3-5 minutes
(maximum total dose 3 mg/kg)
- Procainamide 30 mg/min (maximum total dose 17 mg/kg)


C- 5

C5
(II)

Pulseless Electrical Activity
(Electromechanical Dissociation)
Primary CDAB and Secondary ABCD

Consider causes (“6H’s and 6T’s) and give specific treatment
Tablets (drug overdose, accidents)
Tamponade, cardiac
Tension pneumothorax
Thrombosis, coronary (ACS)
Thrombosis, pulmonary (Embolism)
Trauma

Adrenaline 1 mg iv (10 ml of 1:10,000 solution)
Repeat every 3-5 min

= Most common causes of PEA

Cardiology

Hypovolaemia=
Hypoxia=
Hydrogen ion (acidosis)
Hyper / hypokalemia
Hypothermia
Hyper/hypoglycaemia


C- 6

(III)

C6

Asystole

Primary CDAB and Secondary ABCD
Consider causes*
Transcutaneous pacing
If considered, perform immediately
NOT for routine use
Cardiology

Adrenaline 1 mg iv (10 ml of 1:10,000 solution)
Repeat every 3-5 min
Consider to stop CPR for arrest victims who, despite
successful deployment of advanced interventions,
continue in asystole for more than 10 minutes with no
potential reversible cause
* Consider causes: hypoxia, hyperkalemia, hypokalemia, acidosis,
drug overdose, hypothermia


C- 7

C7
Tachycardia

(IV)

- Assess ABCs & vital signs - Review Hx and perform P/E
- Secure airway and iv line - Perform 12-lead ECG
- Administer oxygen
- Portable CXR
- Attach BP, rhythm & O2 Monitors

Unstable?
(chest pain, SOB, decreased conscious state, low BP, shock,
pulmonary congestion, congestive heart failure, acute MI)

Immediate Synchronized
DC cardioversion 100J/200J/300J/360J
(except sinus tachycardia)
n Atrial fibrillation
Atrial flutter

o Regular Narrow
Complex Tachycardia

No or
Borderline

p Regular Wide
Complex Tachycardia

- For immediate cardioversion
y Consider sedation
y Note possible need to resynchronize after each
cardioversion
y If delays in synchronization, go immediately to
unsynchronized shocks

Cardiology

Yes


C- 8
n

C8
Atrial fibrillation / Atrial flutter

1. Correct underlying causes
- hypoxia, electrolyte disorders, sepsis, thyrotoxicosis etc

Cardiology

2. Control of ventricular rate
• Digoxin*
0.25-0.5 mg iv over 5-10 min or
in 50 ml NS/D5 infuse over 10-20 min or
0.25 mg po, then q8h po for 3 more doses
(total loading of 1 mg)
Maintenance dose 0.125-0.25 mg daily
(reduce dose in elderly and CRF)
• Diltiazem*
10-15 mg iv over 5-10 min, then
iv infusion 5-15 μg/kg/min
• Verapamil*
5 mg iv slowly, can repeat once in 10 min
Risk of hypotension, check BP before 2nd dose
• Metoprolol* 5 mg iv stat, can repeat every 2 min up to
15 mg
• Amiodarone 150 mg/100 ml D5 iv over 1 hr, then 150 mg in
100 ml D5, infuse over 4-8 hr
Maintenance infusion 600-1200 mg/day.
* Contraindicated in WPW Sx
- In AF complicating acute illness e.g. thyrotoxicosis,
β-blockers and verapamil may be more effective than
digoxin
- For impaired cardiac function (EF < 40%, CHF), use
digoxin or amiodarone

3. Anticoagulation

Heparin to maintain aPTT 1.5-2 times control or LWMH
Warfarin to maintain PT 2-3 times control (depends on general
condition and compliance of patient and underlying heart disease)


C9

C- 9

5.

Prevention of Recurrence


Class Ia, Ic, sotalol or amiodarone.

Cardiology

4. Termination of Arrhythmia
• For persistent AF (> 2 days), anticoagulate for 3 weeks
before conversion and
continue for 4 weeks after (delayed cardioversion approach)
• Pharmacological conversion :
Procainamide 15 mg/kg iv loading at 20 mg/min (max 1 g),
then 2-6 mg/min iv maintenance,
or 250 mg po q4h
Amiodarone same dose as in C8
• Synchronized DC cardioversion
- Atrial fibrillation 100-200J and up
- Atrial flutter 50-100J and up


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