plans

admission bundles.

23 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

(11)
bacterial meningitis empiric antibiotics
  • blood cultures × 2 immediately; LP before antibiotics only if it causes no delay
  • dexamethasone 10 mg IV q6h × 4 days — BEFORE or WITH first antibiotic dose
  • ceftriaxone 2 g IV q12h — give first
  • if age >50, pregnancy, or immunocompromised: ampicillin 2 g IV q4h — give second
  • vancomycin 25–30 mg/kg IV load (~2 g), then per local protocol (continuous infusion or AUC-guided) — give last
  • if encephalitis features (behaviour change, focal signs, seizures): acyclovir 10 mg/kg IV q8h
  • ceftriaxone allergy: meropenem 2 g IV q8h + vancomycin — see penicillin allergy
  • droplet precautions until 24 h of effective therapy
  • tailor to CSF culture/PCR at 48–72 h; stop dexamethasone if not pneumococcal
C. difficile infection initial bundle
  • contact precautions; soap-and-water hand hygiene (alcohol does not kill spores)
  • stop inciting antibiotics if possible; narrow any that must continue
  • stop PPI unless clear indication; avoid loperamide and opioids
  • first episode: vancomycin 125 mg PO QID × 10 days (or fidaxomicin 200 mg PO BID × 10 days)
  • fulminant (shock, ileus, megacolon): vancomycin 500 mg PO/NG QID + metronidazole 500 mg IV q8h; + rectal vancomycin if ileus
  • fulminant: general surgery + ID consult
  • no test of cure; do not retest within 7 days
CAP empiric antibiotics — ward admission
  • first-line (ATS/IDSA): ceftriaxone 1–2 g IV q24h + azithromycin 500 mg IV/PO q24h
  • non-severe, no *Legionella* risk: ceftriaxone alone acceptable (CAP-START)
  • always add azithromycin if CURB-65 ≥3, ICU/step-down, *Legionella* risk, or worsening
  • if β-lactams must be avoided (SCAR, serum sickness, AIN, haemolysis): levofloxacin 750 mg IV/PO q24h — see penicillin allergy
  • if prior respiratory MRSA: add vancomycin; stop if MRSA nasal swab and cultures negative
  • if prior respiratory *Pseudomonas*: piperacillin-tazobactam 4.5 g IV q6h instead of ceftriaxone
  • influenza season: influenza/COVID PCR → oseltamivir 75 mg PO BID if influenza positive
  • PO step-down when clinically stable: cefuroxime 500 mg PO BID or amoxicillin-clavulanate 875/125 mg PO BID
  • duration: 5 days (3 if stable at day 3; 7 if not yet stable at day 5)
intra-abdominal infection empiric antibiotics
  • uncomplicated (non-perforated appendicitis): cefazolin 2 g IV q8h + metronidazole 500 mg PO/IV q12h
  • complicated, community-acquired, mild–moderate: ceftriaxone 1–2 g IV q24h + metronidazole 500 mg PO/IV q12h
  • shock / new organ failure / ICU: piperacillin-tazobactam 4.5 g IV q6h (meropenem 1 g IV q8h if prior ESBL)
  • healthcare-associated (≥5 days in hospital), mild–moderate: ceftriaxone + metronidazole
  • if β-lactams must be avoided: ciprofloxacin 400 mg IV q12h + metronidazole — see penicillin allergy
  • SOURCE CONTROL within 24 h — antibiotics do not substitute for drainage/surgery
  • duration: 4 days after source control; no source control → 7–10 days with repeat imaging
sepsis of unknown source — initial management
  • blood cultures × 2 sets (peripheral + each CVC lumen) 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
  • penicillin allergy: ceftriaxone 2 g IV q24h + metronidazole 500 mg IV q12h, or meropenem — see penicillin allergy
  • add vancomycin 25–30 mg/kg IV load if: suspected line infection, MRSA risk, purulent SSTI, or septic shock
  • neutropaenic: see febrile neutropaenia
  • IV balanced crystalloid 30 mL/kg within 3 h for hypotension or lactate ≥4 mmol/L — reassess after each bolus
  • noradrenaline first-line — target MAP ≥65 mmHg
  • source work-up: CXR, urinalysis + culture, lactate, examine skin/lines/joints/surgical sites; CT abdomen/pelvis if no source
  • NARROW at 48–72 h once source and susceptibilities known
cellulitis/erysipelas empiric antibiotics
  • mild (outpatient): cephalexin 500 mg PO QID
  • moderate (inpatient): cefazolin 2 g IV q8h → step down to cephalexin when improving
  • penicillin allergy: cefazolin/cephalexin usually still appropriate — see penicillin allergy
  • if β-lactams must be avoided: vancomycin IV, or clindamycin 300–450 mg PO QID (check local resistance)
  • do NOT add MRSA cover for non-purulent cellulitis
  • elevate limb; treat tinea pedis/interdigital maceration
  • duration: 5–7 days total
purulent SSTI / abscess empiric antibiotics
  • primary treatment: incision and drainage (send pus for culture)
  • mild, post-I&D: TMP-SMX 1–2 DS tabs PO BID (weight-based) or doxycycline 100 mg PO BID × 5–7 days
  • systemically unwell: vancomycin IV (linezolid 600 mg PO/IV BID if oral option needed)
  • perineal or diabetic foot with mixed flora: piperacillin-tazobactam 4.5 g IV q6h ± vancomycin
necrotising soft tissue infection empiric antibiotics
  • SURGICAL EMERGENCY → urgent surgical consult for debridement; ID consult
  • vancomycin + piperacillin-tazobactam 4.5 g IV q6h + clindamycin 900 mg IV q8h (toxin suppression) — IDSA
  • stop vancomycin once MRSA excluded
  • confirmed group A strep: penicillin G 4 MU IV q4h + clindamycin 900 mg IV q8h
  • streptococcal toxic shock: consider IVIG 1 g/kg day 1, then 0.5 g/kg days 2–3 (with ID)
S. aureus bacteraemia bundle
  • ID consult
  • repeat blood cultures × 2 at 48 h, then q24–48h until negative — day of first negative culture = day 1 of therapy
  • empiric vancomycin 25–30 mg/kg IV load, then AUC-guided (400–600 mg·h/L) until susceptibilities
  • MSSA → cefazolin 2 g IV q8h or cloxacillin 2 g IV q4h (stop vancomycin)
  • TTE in all; TEE if intracardiac device, predisposing valve disease, cultures positive ≥48 h, embolic events, or multiple foci
  • remove CVC promptly; drain collections; examine spine, joints, prosthetic material, and skin
  • if increased-risk and no focus found: whole-body imaging (FDG-PET/CT, or targeted CT/ultrasound)
  • duration: 14 days minimum from first negative culture; 4–6 weeks if deep-seated focus or endocarditis
uncomplicated cystitis empiric antibiotics
  • first-line: nitrofurantoin monohydrate/macrocrystals 100 mg PO BID × 5 days (avoid if CrCl <30–40 mL/min)
  • alternative: TMP-SMX DS PO BID × 3 days (if local *E. coli* resistance <20%)
  • alternatives: pivmecillinam, or fosfomycin 3 g PO single dose (lower cure rates)
  • avoid fluoroquinolones for cystitis
  • no culture needed for classic cystitis in non-pregnant women
  • men: 7 days (TMP-SMX, ciprofloxacin, or nitrofurantoin if no prostatic involvement)
acute pyelonephritis empiric antibiotics
  • urine culture before antibiotics — always
  • outpatient: ciprofloxacin 500 mg PO BID × 7 days, or TMP-SMX DS PO BID × 7 days if susceptible
  • local *E. coli* FQ resistance >10% (common): one dose ceftriaxone or gentamicin IV first, then PO per culture
  • inpatient first-line: ceftriaxone 1–2 g IV q24h
  • if male, catheter, or haemodynamic instability: add ampicillin 2 g IV q6h (*Enterococcus*)
  • if β-lactams must be avoided: gentamicin 7 mg/kg IV q24h or ciprofloxacin — see penicillin allergy
  • if known ESBL, ESBL in urine within 6 months, or septic shock: ertapenem 1 g IV q24h (meropenem if shock)
  • PO step-down per susceptibilities when afebrile and haemodynamically stable
  • duration: 7 days total if improving (5–7 days if fluoroquinolone)

nephrology

(5)
AKI workup bundle
  • focused history, volume/perfusion exam, and full medication reconciliation (including OTC NSAIDs, herbals, recent contrast)
  • retrieve baseline creatinine (lowest stable value in prior 3 months) → distinguish new AKI from AKI-on-CKD
  • bladder scan or point-of-care US → rule out obstruction first; if relieved, monitor for post-obstructive diuresis (>200 mL/h — replace ~half hourly output with half-normal saline)
  • urine dip + microscopy (casts, cells) and urine lytes (Na, Cr, urea) → FeNa or FeUrea (use FeUrea if on diuretics)
  • formal renal US if obstruction suspected, cause unclear, or to assess kidney size/echogenicity
  • ECG if K⁺ >5.5 mmol/L → calcium gluconate for membrane stabilisation if ECG changes; treat hyperkalaemia before investigating
  • hold nephrotoxins: NSAIDs, ACEi/ARB (hold in significant AKI; may cautiously continue in mild AKI/CRS), aminoglycosides, iodinated contrast
  • renally dose-adjust all medications
  • volume assessment → isotonic crystalloid if prerenal; diuresis if overloaded
  • if active sediment (RBC casts, dysmorphic RBCs) → urgent nephrology consult + send ANA, ANCA, anti-GBM, C3/C4, SPEP/UPEP
  • if suspected rhabdomyolysis → CK, aggressive IV crystalloid targeting UO 1–3 mL/kg/h (up to 300 mL/h)
  • monitor urine output (Foley or strict I/O) and trend creatinine q12–24h
  • consider RRT if refractory hyperkalaemia, acidosis, pulmonary oedema, or uraemic symptoms (AEIOU)
HD catheter infection workup
  • blood cultures × 2 (one peripheral, one from each catheter lumen) — draw before antibiotics
  • CBC, exit site swab if purulent
  • inspect tunnel tract for inflammation extending along the subcutaneous tunnel (tunnel infection → likely needs catheter removal)
  • empiric: vancomycin 20–25 mg/kg IV load (give during last hour of HD session; subsequent dosing guided by pre-HD levels) + ceftazidime 2 g IV (gram-negative cover)
  • narrow antibiotics to culture and sensitivity within 48–72 h
  • duration: uncomplicated CRBSI 2–3 weeks; S. aureus or metastatic infection 4–6 weeks
  • if exit site only (no bacteraemia) → cefazolin 1–2 g IV post-HD; catheter stays
  • if uncomplicated CRBSI → catheter exchange over guidewire ± antibiotic lock therapy
  • remove catheter for: persistent bacteraemia, haemodynamic instability, metastatic infection, tunnel infection, Pseudomonas, or fungal organisms
  • before removing → confirm alternative access plan (catheter may be patient's last option)
PD peritonitis workup and treatment
  • PD fluid: cell count + differential (WBC >100 × 10⁶/L with >50% PMN after dwell ≥2 h = peritonitis) + culture (send in blood culture bottles)
  • blood cultures, CBC, exit site swab
  • empiric IP antibiotics: cefazolin 1 g IP daily + ceftazidime 1 g IP daily × 2 weeks (extend to 3 weeks for severe, S. aureus, or Pseudomonas)
  • if MRSA or PCN allergy: vancomycin IP, redose to maintain trough >15 µg/mL (~every 3–5 days depending on residual renal function)
  • if Pseudomonas → dual anti-pseudomonal therapy (e.g. ceftazidime + IP aminoglycoside or oral ciprofloxacin)
  • oral nystatin prophylaxis during antibiotic course (prevent fungal peritonitis)
  • catheter removal for: fungal peritonitis, Pseudomonas, refractory (not clearing by day 5), relapsing peritonitis, concurrent exit-site/tunnel infection with same organism
severe hyperkalaemia — C BIG K
  • ECG immediately — do not wait for repeat K⁺
  • stop offending agents now: ACEi/ARB, MRA, K-sparing diuretics, NSAIDs, trimethoprim, K⁺ supplements
  • Calcium gluconate 10 mL of 10% IV over 2–3 min if ECG changes or K⁺ ≥6.5 mmol/L (repeat if ECG changes persist; lasts ~30–60 min — may need redosing); alternative: CaCl₂ 10 mL of 10% via central line. Stabilises myocardium but does not lower K⁺. Caution with digoxin — give slowly/diluted
  • Beta-agonist: salbutamol 10–20 mg nebulised
  • Insulin: 10 units regular insulin IV + 25 g dextrose (D50W 50 mL) given together; use 5 units if eGFR <30; withhold dextrose if glucose >14 mmol/L
  • Glucose monitoring: BSL q1h × 6 h post-insulin
  • shift agents (insulin, salbutamol) are temporising — K⁺ rebounds in 2–6 h; definitive lowering requires binders, diuresis, or dialysis
  • K⁺ binders: sodium zirconium cyclosilicate (Lokelma) 10 g PO or patiromer 8.4 g PO (onset 1–6 h — not emergency monotherapy; avoid sodium polystyrene sulfonate)
  • NaHCO₃ only if concurrent metabolic acidosis — minimal K⁺-lowering effect alone
  • loop diuretic if volume-replete with adequate renal function
  • repeat K⁺ and ECG at 1–2 h
  • if refractory or anuric → emergency haemodialysis
severe hyponatraemia — emergency management
  • if seizures or obtundation → 100 mL 3% NaCl IV bolus over 10 min, repeat up to 3× (max 300 mL) — do not delay for labs
  • target: raise Na⁺ by 4–6 mmol/L in first 1–2 h to arrest symptoms
  • check Na⁺ after each bolus, then q4–6h for the first 24 h
  • serum osmolality → confirm true hypotonic hyponatraemia (<275 mOsm/kg)
  • urine Na + urine osmolality — send before intervention but never delay hypertonic saline for results
  • volume status assessment → guides cause (hypovolaemic vs euvolaemic vs hypervolaemic)
  • check morning cortisol and TSH → cortisol deficiency mimics SIADH
  • correction rate limit: ≤10 mmol/L in 24 h (≤8 mmol/L if high-risk: Na⁺ <120, hypokalaemia, alcoholism, liver disease, malnutrition)
  • if Na⁺ rises ≥10 mmol/L in 24 h or ≥18 mmol/L in 48 h → D5W 10 mL/kg over 1 h ± desmopressin 2–4 µg IV q6–8h to re-lower
  • K⁺ repletion counts toward Na⁺ correction rate — factor into calculations
  • hold thiazides; review all medications for SIADH-causing drugs (SSRIs, carbamazepine)

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