plans

admission bundles.

16 plans

cardiology

(2)
ACS admission bundle
  • ECG within 10 min → if STEMI, activate cath lab
  • hs-cTn at 0h and 3h (or 0/1h rapid rule-out)
  • ASA 160 mg chewed + ticagrelor 180 mg load (clopidogrel if fibrinolysis or ticagrelor CI)
  • UFH weight-based bolus (or enoxaparin 1 mg/kg SC q12h)
  • continuous telemetry, IV access ×2
  • serial ECGs q15–30 min if ongoing pain or dynamic changes
  • labs: CBC, lytes, Cr, glucose, Mg²⁺, PO₄³⁻, INR, aPTT, fasting lipids, A1C
  • echocardiogram (RWMA, LVEF), CXR
  • metoprolol 12.5–25 mg PO BID → titrate HR 55–60 (hold if HR <50, SBP <100, decompensated HF)
  • ramipril 2.5 mg BID or perindopril 2 mg OD (anterior MI, LVEF <40%, HTN, DM, CKD)
  • atorvastatin 80 mg daily (or rosuvastatin 40 mg)
  • NTG SL PRN; IV NTG if persistent pain or hypertensive
  • O₂ only if SpO₂ <90%
  • DVT prophylaxis if not fully anticoagulated
  • LDL target <1.8 mmol/L or ≥50% reduction → add ezetimibe → add PCSK9i if needed (CCS 2021)
  • BP target <130/80 → ACEi/ARB first-line; add CCB or thiazide PRN (Hypertension Canada)
  • if DM: A1C ≤7.0% (individualise) → SGLT2 Inhibitors or GLP-1RA preferred (CV benefit)
  • if DM + ASCVD: SGLT2i regardless of A1C (cardiorenal benefit)
  • smoking cessation: counselling + NRT or varenicline before discharge
  • DAPT × 12 months (ASA + ticagrelor 90 mg BID) → see post-MI care for adjustments
  • cardiac rehab referral before discharge
  • LVEF reassessment at 6–12 weeks
  • driving restrictions per CCS/provincial guidelines
  • if AF/OAC indication → triple therapy 1–30 days then dual pathway (clopidogrel + DOAC, drop ASA)
ADHF admission bundle
  • ABCs, sit upright, O₂ only if SpO₂ <90%
  • IV access, cardiac monitor, 12-lead ECG
  • labs: troponin, BNP/NT-proBNP, lytes, Cr, CBC, lactate, VBG
  • CXR
  • haemodynamic profile: warm/cold × wet/dry (Nohria-Stevenson)
  • identify precipitant — FAILURES mnemonic
  • IV furosemide dose by GFR (eGFR >45: 80 mg; 30–45: 120 mg; <30: 160–200 mg)
  • spot urine Na⁺ at 2 h (target >50 mmol/L) — escalate if inadequate
  • NIV (CPAP/BiPAP) if respiratory distress despite initial Rx
  • NTG infusion if SBP >110 and flash pulmonary oedema
  • start SGLT2i day 1 if SBP >100 and eGFR ≥20
  • hold nephrotoxins: NSAIDs, reassess non-essential antihypertensives
  • VTE prophylaxis
  • daily weights, strict fluid balance
  • initiate/resume GDMT (ARNi, BB, MRA) as haemodynamics allow

endocrinology

(1)
DKA admission bundle
  • 1 L isotonic crystalloid over 1 hr (15–20 mL/kg)
  • labs: glucose, VBG, BHB, lytes (Na⁺, K⁺, Cl⁻, Ca²⁺, Mg²⁺, PO₄³⁻), Cr, urea, HbA1c, UA, CBC
  • ECG + telemetry
  • anion gap calculation
  • precipitant search: cultures, CXR, troponin, lipase as indicated
  • K⁺ <3.3 → hold insulin, KCl 40 mmol/hr IV; K⁺ 3.3–5.3 → 20–30 mmol KCl/L in fluids; K⁺ >5.3 → hold K⁺
  • insulin 0.1 U/kg/hr IV (no bolus) — only after K⁺ ≥3.3
  • glucose <14 mmol/L → add D5–D10W, reduce insulin to 0.05 U/kg/hr
  • monitoring: glucose hourly, K⁺ q2h, lytes/VBG/AG q2–4h
  • if on SGLT2i → stop it, start D10W early regardless of glucose

gastroenterology

(2)
new cirrhosis diagnosis workup
  • aetiology — core: HBsAg, anti-HBc, anti-HCV, ANA, ASMA, IgG, AMA, ferritin, Tsat
  • if Tsat >45% → HFE genotyping
  • if age <40 or unexplained → ceruloplasmin, alpha-1 antitrypsin level
  • LSM (FibroScan) if not done — confirm cACLD (≥15 kPa)
  • portal hypertension assessment: LSM + platelet count → Baveno VII criteria
  • if portal hypertension present or indeterminate → screening OGD
  • HCC surveillance: abdominal US ± AFP q6 months
  • if clinically significant portal hypertension → NSBB: carvedilol 6.25–12.5 mg daily
  • vaccinations: HAV, HBV (check titres), pneumococcal, influenza
  • stop hepatotoxins: NSAIDs, limit acetaminophen ≤2 g/day, review supplements
  • nutrition: protein 1.2–1.5 g/kg/day, late evening snack; DEXA if cholestatic
decompensated cirrhosis admission bundle
  • diagnostic paracentesis within 6 hr (cell count, albumin, protein, culture in blood culture bottles)
  • sepsis screen: blood cultures, urinalysis, CXR; empiric antibiotics if infection suspected
  • hold nephrotoxins: NSAIDs, ACEi/ARBs, aminoglycosides; reassess diuretics
  • lactulose if any encephalopathy — do not wait for ammonia
  • calculate MELD 3.0 and Child-Pugh on admission (baseline for trajectory and transplant discussion)
  • nutrition: 35 kcal/kg/day, protein 1.2–1.5 g/kg/day, late evening snack
  • alcohol assessment + withdrawal prophylaxis if applicable
  • VTE prophylaxis: LMWH unless active bleeding or platelets <50 × 10⁹/L
  • transplant referral if new decompensation and not already listed

infectious diseases

(9)
bacterial meningitis empiric antibiotics
  • dexamethasone 0.15 mg/kg IV q6h × 4 days — give BEFORE or WITH first antibiotic dose (not after)
  • first-line: ceftriaxone 2 g IV q12h + vancomycin 15–20 mg/kg IV q8–12h (target trough 15–20 mg/L)
  • if age ≥50 or immunocompromised: ADD ampicillin 2 g IV q4h (*Listeria* cover)
  • if severe penicillin/cephalosporin allergy: meropenem 2 g IV q8h + vancomycin (or chloramphenicol if carbapenem allergy — rare)
  • LP before antibiotics ONLY if no delay — blood cultures then antibiotics immediately if LP will be delayed
  • CT before LP only if: focal neuro deficit, altered consciousness, papilloedema, seizures, immunocompromised
  • tailor therapy to CSF culture + susceptibilities within 48–72 h
CAP empiric antibiotics — ward admission
  • first-line: ceftriaxone 2 g IV daily + azithromycin 500 mg PO/IV daily
  • alternative first-line: ampicillin 2 g IV q6h + azithromycin (or doxycycline 100 mg PO BID)
  • if penicillin/cephalosporin allergy: levofloxacin 750 mg PO/IV daily (or moxifloxacin 400 mg PO daily)
  • if aspiration risk: amoxicillin-clavulanate 1.2 g IV q8h — routine anaerobic cover not recommended for simple aspiration
  • if ICU admission: ceftriaxone 2 g IV daily + azithromycin 500 mg IV daily (never fluoroquinolone monotherapy)
  • if ICU + pseudomonal risk factors: piperacillin-tazobactam 4.5 g IV q6h + azithromycin 500 mg IV daily (or levofloxacin 750 mg IV daily)
  • step down to PO when: afebrile ≥48 h, tolerating oral intake, improving clinically
  • duration: minimum 5 days — afebrile ≥48 h + no more than 1 sign of clinical instability before stopping
intra-abdominal infection empiric antibiotics
  • first-line (community-acquired, mild-moderate): ceftriaxone 2 g IV daily + metronidazole 500 mg IV q8h
  • alternative first-line: piperacillin-tazobactam 4.5 g IV q6h (monotherapy — covers gram-negatives + anaerobes)
  • if penicillin/cephalosporin allergy: ciprofloxacin 400 mg IV q12h + metronidazole 500 mg IV q8h
  • if healthcare-associated / post-op / resistant organisms: pip-taz 4.5 g IV q6h or meropenem 1 g IV q8h ± vancomycin
  • if critically ill / septic shock: meropenem 1 g IV q8h ± vancomycin
  • SOURCE CONTROL within 24 h — antibiotics do not substitute for drainage/surgery
  • duration: 4 days after adequate source control (STOP-IT)
sepsis of unknown source — initial management
  • blood cultures × 2 sets (peripheral + line if CVC present) BEFORE antibiotics — do not delay antibiotics >45 min for cultures
  • empiric antibiotics within 1 h (septic shock) or 3 h (sepsis without shock)
  • first-line: piperacillin-tazobactam 4.5 g IV q6h
  • if penicillin allergy: ceftriaxone 2 g IV daily + metronidazole 500 mg IV q8h (or meropenem if anaphylaxis)
  • add vancomycin 25–30 mg/kg IV load if: line infection, MRSA risk, skin/soft tissue source, shock
  • if immunocompromised / neutropaenic: see febrile neutropaenia — antipseudomonal monotherapy
  • IV crystalloid 30 mL/kg within first 3 h for hypotension or lactate ≥4 mmol/L
  • noradrenaline first-line vasopressor — target MAP ≥65 mmHg
  • source investigation: CXR, urinalysis + culture, lactate, consider CT abdomen/pelvis, examine skin and lines
  • NARROW antibiotics as soon as source and susceptibilities identified — reassess at 48–72 h
cellulitis/erysipelas empiric antibiotics
  • mild (outpatient): cephalexin 500 mg PO QID × 5–7 days
  • moderate (inpatient): cefazolin 2 g IV q8h
  • if penicillin/cephalosporin allergy: clindamycin 300–450 mg PO QID (rising resistance — check local rates) or doxycycline 100 mg PO BID
  • severe allergy + inpatient: vancomycin 15–20 mg/kg IV q8–12h
  • do NOT add MRSA cover for non-purulent cellulitis — no outcome benefit
  • step down to PO cephalexin when improving; total 5–7 days
purulent SSTI / abscess empiric antibiotics
  • primary treatment: incision and drainage (antibiotics adjunctive, not substitute)
  • mild (post-I&D, outpatient): TMP-SMX DS PO BID × 5–7 days or doxycycline 100 mg PO BID × 5–7 days
  • moderate/severe: vancomycin 15–20 mg/kg IV q8–12h (or linezolid 600 mg PO/IV BID if oral option needed)
  • if concern for mixed gram-negative flora (perineal, diabetic foot): add piperacillin-tazobactam 4.5 g IV q6h
necrotising fasciitis empiric antibiotics
  • SURGICAL EMERGENCY → urgent surgical consultation for debridement — antibiotics do not substitute for source control
  • broad-spectrum: vancomycin 25–30 mg/kg IV load + piperacillin-tazobactam 4.5 g IV q6h (or meropenem 1 g IV q8h)
  • add clindamycin 900 mg IV q8h (toxin suppression — particularly for group A strep and *Clostridium*)
  • if confirmed monomicrobial group A strep: penicillin G 4 MU IV q4h + clindamycin 900 mg IV q8h
uncomplicated cystitis empiric antibiotics
  • first-line: nitrofurantoin 100 mg PO BID × 5 days
  • alternative: TMP-SMX 160/800 mg (DS) PO BID × 3 days (if local resistance <20%)
  • if allergy/resistance to above: fosfomycin 3 g PO single dose (inferior cure rates)
  • avoid: fluoroquinolones for uncomplicated cystitis (save for pyelonephritis/complicated UTI)
  • no culture needed for classic uncomplicated cystitis in women — treat empirically
acute pyelonephritis empiric antibiotics
  • outpatient (mild, tolerating PO): ciprofloxacin 500 mg PO BID × 7 days or TMP-SMX DS PO BID × 14 days (if susceptible)
  • inpatient first-line: ceftriaxone 2 g IV daily
  • if penicillin/cephalosporin allergy: ciprofloxacin 400 mg IV q12h (or levofloxacin 750 mg IV daily)
  • if septic / prior resistant organisms: piperacillin-tazobactam 4.5 g IV q6h or meropenem 1 g IV q8h
  • step down to PO when afebrile ≥48 h + improving — complete total 7–14 days based on agent and response
  • ALWAYS obtain urine culture before antibiotics for pyelonephritis — tailor therapy to susceptibilities

neurology

(2)
acute ischaemic stroke admission bundle
  • NIHSS on arrival → repeat q1h × 6 h, then q2h × 18 h
  • STAT non-contrast CT + CTA arch-to-vertex (add CT perfusion if >6 h or wake-up stroke)
  • blood work: glucose, CBC, INR/aPTT, electrolytes, creatinine, troponin, lipid panel, HbA1c — do not delay imaging for labs
  • fingerstick glucose → treat hypoglycaemia immediately; insulin sliding scale targeting 7.8–10 mmol/L
  • supplemental O₂ to maintain SpO₂ >94%
  • if thrombolysis-eligible (≤4.5 h): BP <185/110 → TNK 0.25 mg/kg IV bolus (or alteplase 0.9 mg/kg) → BP <180/105 × 24 h
  • if LVO on CTA → thrombectomy pathway (in-house or transfer) → EVT up to 24 h with perfusion selection → BP ≤180/105 × 24 h
  • if no thrombolysis or EVT candidate: treat BP only if >220/120 → reduce ~15% over 24 h
  • if thrombolysed: no antiplatelets × 24 h → CT head to exclude haemorrhage → then ASA 160 mg load
  • if not thrombolysed: ASA 160 mg loading dose immediately
  • minor stroke (NIHSS ≤3) or high-risk TIA, non-cardioembolic → DAPT: ASA + clopidogrel × 21 days
  • statin (atorvastatin 40–80 mg) within 24 h → target LDL <1.8 mmol/L
  • 12-lead ECG
  • telemetry × 48 h minimum → if cryptogenic, arrange prolonged cardiac monitoring (≥14 days) → see Cryptogenic and Young Stroke
  • TTE if cardioembolic source suspected
  • if AF detected → plan DOAC with timing based on infarct size; do not anticoagulate ESUS empirically
  • NPO until dysphagia screen (validated tool, within 24 h)
  • oral hygiene protocol to reduce aspiration pneumonia risk
  • temperature monitoring → treat fever aggressively
  • DVT prophylaxis: pneumatic compression devices day 1 → pharmacological when safe
  • mobilisation assessment within 24–48 h (avoid very early high-dose mobilisation per AVERT)
  • multidisciplinary rehabilitation referral (PT/OT/SLP) within 24–48 h
  • neurological deterioration → STAT CT → malignant MCA oedema or cerebellar mass effect → neurosurgery for decompression or EVD
young / cryptogenic stroke workup bundle
  • standard stroke labs + ESR, CRP, ANA, lupus anticoagulant, anticardiolipin, anti-β2-glycoprotein I
  • fasting lipids, A1C, homocysteine
  • toxicology screen if <45 (cocaine, amphetamines)
  • CTA head and neck (or MRA) → assess for dissection, vasculopathy
  • TTE with agitated saline (bubble study) → if positive or high suspicion and negative, proceed to TEE
  • if PFO found → calculate RoPE score → if ≥7 and age 18–60 → refer for PFO closure discussion
  • prolonged cardiac monitoring ≥14 days (implantable loop recorder if initial monitoring negative and no cause found)
  • if vasculitis suspected (multiterritory infarcts, young, systemic features): vessel wall MRI, complement, ANCA, extractable nuclear antigens
  • thrombophilia screen (≥2 wk post-event, off anticoagulation): protein C/S, antithrombin, factor V Leiden, prothrombin gene
  • consider LP if CNS vasculitis, infection, or malignancy suspected