1. Nadia Habal, MD Presbyterian Hospital of Dallas
X-COVER?!?
Nadia Habal, MD
Presbyterian Hospital of Dallas

2. What is going on? Goals of Lecture: How do I make my X-cover list?
How do I identify emergency from non-emergency?
How do I know when I need to go and see the patient?
How do I handle common calls/questions?
When do I need to call my resident???

3. How to make your CareGate list:
Log on to CareGate
Go to Cross Cover
Under “problems”, put one liner about the patient
Then list all important problems and what has been done about them
Under “to do” section put MR number, pt allergies, important meds, anything for X-cover to follow up on

4. Example: 69 y/o with PCKD and transplant kidney p/w painless hematuria
1. Renal: pt continues to have hematuria: likely ruptured renal cysts 2/2 PCKD, considering CT abd and MRI results. Also worrying about infx, CA, etc. Continue immunosuppression with Cellcept, prednisone. CMV/EBV by PCR neg. Urology following - possible cystoscopy to r/o bladder source.
2.Htn: BP well controlled.
3.Paroxysmal AF: atenolol and Cardizem. Short episode of afib with RVR overnight, with rates of 120s. Continue ASA for prophylaxis.
4.Hypothyroidism - continue replacement.
5.Anxiety - continue Ativan.
6.RA-pain relief.
7.Insomnia: Ambien.
8.Wt loss: cancer w/u.
9.Choledocholithiasis and pancreatic duct stones: ERCP today.

5. Example, continued: Cross Cover To Do ALL: NKDA
F/u ERCP results
ALL: NKDA
RX: allopurinol, aspirin, atenolol, Lipitor
… You get the idea!

6. Not Acceptable:
“Patient intubated, sedated, in 1 ICU”… when the pt has been extubated and on the floor for 4 days
Must update room numbers on x-cover list
Must update DNR status
Must put pertinent changes in status (e.g., if a patient went into afib or had GI bleed or is having a procedure)
Must put all pending tests on the list
If someone is really sick, include family contact info in the event of a code or critical change in medical status
YOU MUST UPDATE THE WHOLE LIST EVERYDAY!!!

7. What do I do when I’m called?
We will go through some basics by organ systems today
Future subjects to be covered during Internship 101
lecture series:
ID:      June 30: Pneumonia
CV:     July 3:    Arrhythmias
GI:      July 7:    GI bleeding
Pulm:  July 10:  Sepsis/SIRS
Endo:  July 17:  Hyperglycemic states (DKA and HONC) 
Neuro: July 31: Altered mental status and “Brain Code”

8. NEUROLOGY Altered Mental Status Seizures Cord Compression Falls
Delirium Tremens

9. Altered Mental Status Always go to the bedside!!!
Try to redirect patient: drowsy, stuporous, making inappropriate comments?
Is this a new change? How long?
Check for any recent/new medications administered
Check VITALS, alertness/orientation, pupils, nuchal rigidity, heart/lungs/abdomen, strength
Scan recent labs in chart including: cardiac enzymes, electrolytes, +cultures
If labs unavailable, get stat Accucheck, oxygen saturation
Try naloxone (Narcan), usually mg IV, if there is any possibility of opiate OD

10. “Move Stupid” Metabolic – B12 or thiamine deficiency
Oxygen – hypoxemia is a common cause of confusion
Others - including anemia, decreased cerebral blood flow (e.g., low cardiac output),
CO poisoning
Vascular – CVA, intracerebral hemorrhage, vasculitis, TTP, DIC, hyperviscosity,
hypertensive encephalopathy
Endocrine – hyper/hypoglycemia, hyper/hypothyroidism, high /low cortisol states and Electrolytes – particularly sodium or calcium
Seizures –post–ictal confusion, unresponsive in status epilepticus; also consider Structural problems – lesions with mass effect, hydrocephalus
Tumor, Trauma, or Temperature (either fever or hypothermia)
Uremia – and another disorder, hepatic encephalopathy
Psychiatric – diagnosis of exclusion; ICU psychosis and "sundowning" are common
Infection – any sort, including CNS, systemic, or simple UTI in an elderly patient
Drugs – including intoxication or withdrawal from alcohol, illicit or prescribed drugs

11. Seizures Go to bedside to determine if patient still actively seizing
Call your resident
Check your ABCs
Place patient in left lateral decubitus position
Immediate Accucheck
If still seizing, give diazepam 2mg/min IV until seizure stops or max of 20mg (alternative: lorazepam 2-4mg IV over 2-5min)
Give thiamine 100 mg IV first, then 1 amp D50
Load phenytoin mg/kg in 3 divided doses at 50 mg/min (usually 1 g total)
Remember, phenytoin is not compatible with glucose-containing solutions or with diazepam; if you have given these meds earlier, you need a second IV!
If still seizing >30min, pt is in status—call Neuro (they can order bedside EEG)
Get Head CT if appropriate and if pt stabilized

12. Cord Compression
Suspect in patients with new weakness or change in sensation (especially if they have a demonstrable level), new bowel/bladder retention or incontinence.
Prognosis is dismal for pts w/no function for >24h.
Prognosis is best for pts with new, incomplete loss (i.e. weakness).
Surgical emergency: call Neurosurgery.
Stabilize the spine: collars for C-spine, Turtle shells (TLSO) for T/L-spine.
Dexamethasone not always indicated (in case of traumatic fracture, for instance).
If tumor, needs immediate radiotherapy.

13. Falls Go to the bedside!!! Check mental status
Check vital signs including pulse ox
Check med list
Check blood glucose
Examine pt to ensure no fractures
Thorough neuro check
Check tilt blood pressures if appropriate
If on coumadin/elevated INR—consider head CT to r/o bleed

14. Delirium Tremens (DTs)
Give thiamine 100mg, folate 1mg, MVI
See if patient has alcohol history
Check blood alcohol level
DTs usually occur ~ 3 days after last ingestion
Make sure airway is protected (vomiting risk)
Use Ativan 2mg at a time until pt calm, may need Ativan drip, make sure you do not cause respiratory depression
Monitor in ICU for seizure activity
Always keep electrolytes replaced

15. PULMONARY
Shortness of Breath
Oxygen De-saturations

16. Shortness of Breath Go to the bedside!!!
Check an oxygen saturation and ABG if indicated
Check CXR if indicated

17. Causes of SOB Pulmonary: Cardiac: Metabolic: Hematologic: Psychiatric:
Pneumonia, pneumothorax, PE, aspiration, bronchospasm, upper airway obstruction, ARDS
Cardiac:
MI/ischemia, CHF, arrhythmia, tamponade
Metabolic:
Acidosis, sepsis
Hematologic:
Anemia, methemoglobinemia
Psychiatric:
Anxiety – common, but a diagnosis of exclusion!

18. Oxygen Desaturations Supplemental Oxygen
Nasal cannula: for mild desats
Face mask/Ventimask: offers up to 55% FIO2
Non-rebreather: offers up to 100% FIO2
BIPAP: good for COPD
Start settings at: IPAP 10 and EPAP 5
IPAP helps overcome work of breathing and helps to change PCO2
EPAP helps change pO2
CPAP: good for pulmonary edema, hypercapnea, OSA
Start at 5-7

19. Indications for Intubation
Uncorrectable hypoxemia (pO2 < 70 on 100% O2 NRB)
Hypercapnea (pCO2 > 55) with acidosis (remember that people with COPD often live with pCO2 50–70 +)
Ineffective respiration (max inspiratory force < 25 cm H2O)
Fatigue (RR>35 with increasing pCO2)
Airway protection
Upper airway obstruction

20. Mechanical Ventilation
If patient needs to be intubated, start with mask-ventilation until help from upper level Arrives
Initial settings for Vent:
A/C FIO2 100 Vt 700 Peep 5 (unless increased ICP, then no peep) RR 12
Check CXR to ensure proper ETT placement (should be around 4cm above the carina)
Check ABG 30 min after pt intubated and adjust settings accordingly

21. CARDIOLOGY
Chest pain
Hypotension
Hypertension
Arrhythmias

22. Chest Pain Go and see the patient!!! Why is the patient in house?
Recent procedure?
STAT EKG and compare to old ones
Is the pain cardiac/pulmonary/GI?—from H+P
Vital signs: BP, pulse, SpO2
If you think it’s cardiac:
Give SL nitroglycerin if pain still present (except if low blood pressure, give morphine instead)
Supplemental oxygen
Aspirin 325 mg

23. Hypotension Go and see the patient!!! Repeat Manual BP and HR
Look at recent vitals trends
Look for recent ECHO/ meds pt has been given.
EXAM:
Vitals: orthostatic? tachycardic?
Neuro: AMS
HEENT: dry mucosa?
Neck: flat vs. JVD (=CHF)
Chest: dyspnea, wheezes (?anaphylaxis), crackles (=CHF)
Heart: manual pulse, S3 (CHF)
Ext: cool, clammy, edema

24. Management of Hypotension
If offending med, stop the med!
If volume down/bleeding: give wide open IV NS
Correct hypoxia
Recent steroid use? Adrenal insufficiency
Is there a neuro cause for hypotension?
If appropriate, consider: PE, tamponade, pneumothorax
If fever, consider sepsis—need for empiric antibiotics
If hives and wheezing, consider anaphylaxis—tx with oxygen, epinephrine, Benadryl
Need for pressors? Transfer to ICU!

25. Commonly Used Pressors
Name
Receptor Affected
Dose
Action
Phenylephrine
(Neosynephrine)
Alpha 1
10–200 mcg/min
Pure vasoconstrictor; causes ischemia in extremities
Norepinephrine
(Levophed)
A1, B1
2–64 mcg/min
Vasoconstriction, positive inotropy; causes arrhythmias
Dopamine
Dopa
1–2 mcg/kg/min
Splanchnic vasodilation ("renal dose dopamine" even though many doubt such effect exists) B1
2–10 mcg/kg/min
Positive inotropy;
Causes Arrhythmias A1
10–20 mcg/kg/min
Vasoconstriction;
Dobutamine
B1, B2
1–20 mcg/kg/min
Positive inotropy and
chronotropy;
Causes Hypotension

26. Hypertension Is there history of HTN? Check BP trends
Is patient having pain, anxiety, headache, SOB?
Confirm patient is not post-stroke pt—BP parameters are different: initial goal is BP>180/100 to maintain adequate cerebral perfusion
EXAM:
Manual BP in both arms
Fundoscopic exam: look for papilledema and hemorrhages
Neuro: AMS, focal weakness or paresis
Neck: JVD, stiffness
Lungs: crackles
Cardiac: S3

27. Management of Hypertension
If patient is asymptomatic and exam is WNL:
See if any doses of BP meds were missed; if so, give now
If no doses missed, may give an early dose of current med
Remember, no need to acutely reduce BP unless emergency
So, start a medication that you would have normally picked in this patient as the next agent of choice according to JNC/co-morbidities/allergies

28. Hypertension (continued)
URGENCY
SBP>210 or DBP>120
No end organ damage
OK to treat with PO agents
EMERGENCY
SBP>210 or DBP>120
Acute end organ damage
Treat with IV agents
Decrease MAP by 25% in one hour; then decrease to goal of <160/100 over 2-6 hrs.

29. GI
Nausea/Vomiting
GI Bleed
Constipation
Diarrhea
Acute Abdominal Pain

30. Nausea/Vomiting Vital signs, blood sugar, recent meds?
Make sure airway is protected
EXAM: abdominal exam, rectal (considering obstruction, pancreatitis, cholecystitis),neuro exam (increased ICP?)
May check KUB
Treatment:
Phenergan mg IV/PR (lower in elderly)
Zofran 4-8mg IV
Reglan mg IV (especially if suspect gastroparesis)
If no relief, consider NG tube (especially if suspect bowel obstruction)

31. GI Bleed (to be discussed in detail at a later date):
UPPER
Hematemesis, melena
Check vitals
Place NG tube
NPO
Wide open fluids vs. blood
Check H/H serially
If suspect PUD: Protonix drip
If suspect varices: octreotide
Call Resident and GI
LOWER
BRBPR, hematochezia
Check vitals
Rectal exam
Wide open fluids if low BP
NPO
Check H/H serially
Transfuse if appropriate
Pain out of proportion? Don’t forget ischemic colitis!

32. Constipation Very common call!
Check: electrolytes, pain meds, bowel regimen
Check KUB if suspect ileus/obstruction
Rectal exam to check for fecal impaction/mechanical obstruction
Treatment:
If not acute process, can order “laxative of choice”
Fleets enema for immediate relief (unless renal failure b/c high phos—then can order water/soap suds enema)
Lactulose/mag citrate PO if no mechanical obstruction

33. Diarrhea Check: electrolytes, vitals, meds
Quantify volume, number, description of stools
Labs: fecal leukocytes, stool culture, guaiac, C.diff toxin if recent antibiotic or nursing home resident
Treatment:
Colitis: flagyl 500mg po tid
GI bleed: per GI section
If don’t suspect infection: loperamide initially 4mg then 2mg after each unformed stool up to 16mg daily

34. Acute Abdominal Pain Go to the bedside!!!
Assess vitals, rapidity of onset, location, quality and severity of pain
LOCATION:
Epigastric: gastritis, PUD, pancreatitis, AAA, ischemia
RUQ: gallbladder, hepatitis, hepatic tumor, pneumonia
LUQ: spleen, pneumonia
Peri-umbilical: gastroenteritis, ischemia, infarction, appendix
RLQ: appendix, nephrolithiasis
LLQ: diverticulitis, colitis, nephrolithiasis, IBD
Suprapubic: PID, UTI, ovarian cyst/torsion

35. Acute Abdomen? Assess severity of pain, rapidity of onset
If acute abdomen suspected, call Surgery
Do you need to do a DRE?
KUB vs. Abdominal Ultrasound vs. CT
Treatment:
Pain management—may use morphine if no contraindication
Remember, if any narcotics are started, use sparingly in elderly, ensure pt on adequate bowel regimen

36. RENAL/ELECTROLYTES Decreased urine output Hyperkalemia
Foley catheter problems

37. Decreased Urine Output
Oliguria: <20 cc/hour (<400 cc/day)
Check for volume status, renal failure, accurate I/O, meds
Consider bladder scan
Labs:
UA: WBC (UTI); elevated specific gravity (dehydration); RBC (UTI/urolithiasis); tubular epithelial cells (ATN); WBC casts (interstitial nephritis); Eosinophils (interstitial casts)
Chemistries: BUN/Cr, K, Na

38. Treatment of Decreased UOP
Decreased Volume Status:
Bolus 500 cc NS
Repeat if no effect
Normal/Increased Volume:
May ask nursing to check bladder scan for residual urine
Check Foley placement
Lasix 20 mg IV

39. Foley Catheter Problems:
Why/when was it placed?
Does the patient still need it?
Confirm no kinks or clamps
Confirm bag is not full
Examine output for blood clots or sediment
Do not force Foley in if giving resistanc: call Urology
Nursing may flush out Foley if it must stay in
The sooner it’s out, the better (when appropriate)

40. Hyperkalemia Ensure correct value—not hemolysis in lab
Check for renal insufficiency, meds
Check EKG for acute changes, peaked T-waves, PR prolongation followed by loss of P waves, QRS widening

41. Treatment of Hyperkalemia
Immediate Rx (works in minutes): for EKG changes, stabilize myocardium with 1-2 amps calcium gluconate
Temporary Rx (shift K into cells):
2 amps D50 plus 10 units regular insulin IV: decreases K by mEq/L and lasts several hours
2 amps NaHCO3: best reserved for non-ESRD patients with severe hyperkalemia and acidosis
B2-agonists: effects similar to insulin/D50
Long-lasting Elimination:
Kayexalate 30g po (repeat if no BM) or retention enema
NS and Lasix
Dialysis

42. ENDOCRINOLOGY
DKA
HONC
(Will be covered in detail at later time)

43. DKA
Identify precipitating factor (e.g., infection, MI, noncompliance with meds)
Check for anion gap
Check for ketones in urine or serum
Give bolus 1 Liter NS, then run IVF at 200 ml/hour if no contraindication
Start insulin drip DKA protocol in ICU (EPIC order)
Check electrolytes every 4 hours and replace as appropriate

44. HONC Similar to DKA but for Type II diabetes and no ketones
There is also an insulin drip NON-DKA protocol in ICU (EPIC order)

45. ID
Positive Blood Culture
Fever

46. Positive Blood Culture
You get called by the lab because a blood culture has become Positive.
Check if primary team had been waiting on blood culture.
Is the patient very sick/ ICU?
Is the culture “1 out of 2” and/or “coag negative staph”? This is likely a contaminant.
If pt is on abx, make sure appropriate coverage based on culture and sensitivity
If you believe it to be true Positive then give appropriate empiric treatment for organism and likely source of infection/co-morbidities of patient and discuss with primary team in the AM

47. Fever Has the patient been having fevers?
DDX: infection, inflammation/stress rxn, ETOH withdrawal, drug rxn, transfusion rxn
If the last time cultures were checked >24 hrs ago, then order blood cultures x 2, UA/culture, CXR, respiratory culture if appropriate
If cultures are all negative to date, likely no need to empirically start abx unless a source is apparent and you are treating a specific etiology

48. HEME
Anticoagulation
Blood replacement products

49. Anticoagulation Appropriate for DVT, PE, Acute Coronary Syndrome
Usually start with low molecular weight heparin—(Lovenox) 1 mg/kg every 12 hours and adjust for renal fxn
If need to turn on/off quickly (e.g., pt going for procedure) use heparin drip—there is a protocol in EPIC
Risk factors for bleeding on heparin:
Surgery, trauma, or stroke within the previous 14 days
History of peptic ulcer disease, GI bleeding or GU bleeding
Platelet count less than 150K
Age > 70 yrs
Hepatic failure, uremia, bleeding diathesis, brain mets

50. Blood Replacement Products
PRBC: One unit should raise Hct 3 points or Hgb 1 g/dl
Platelets: One unit should raise platelet count by 10K; there are usually 6 units per bag ("six-pack")
use when platelets <10-20K in nonbleeding patient.
use when platelets <50K in bleeding pt, pre-op pt, or before a procedure
FFP: contains all factors
use when patient in DIC or liver failure with elevated coags and concomitant bleeding or for needed reversal of INR

51. RADIOLOGY What test do I order for what problem? Plain Films CT scans
MRI

52. Plain Films CXR: Portable if pt in unit or bed bound
PA/Lat is best for looking for effusions/infiltrates
Decubitus to see if an effusion layers; needs to layer >1cm in order to be safe to tap
Abdominal X-ray:
Acute abdominal series: includes PA CXR, upright KUB and flat KUB

53. CT Head CT CT Angiogram Abdominal CT
Non-contrast best for bleeding, CVA, trauma
Contrast best for anything that effects the blood brain barrier, tumors, infection
CT Angiogram
If suspect PE and no contraindication to contrast (e.g., elevated creatinine)
Abdominal CT
Always a good idea to call the radiologist if unsure whether contrast is needed/depending on what you are looking for
Renal stone protocol to look for nephrolithiasis
If you have a pt who has had upper GI study with contrast, radiology won’t do CT until contrast is gone—have to check KUB to see if contrast has passed first

54. MRI Increased sensitivity for soft tissue pathology Best choice for:
Brain: neoplasms, abscesses, cysts, plaques, atrophy, infarcts, white matter disease
Spine: myelopathy, disk herniation, spinal stenosis
Contraindications: pacemaker, defibrillator, aneurysm clips, neurostimulator, insulin/infusion pump, implanted drug infusion device, cochlear implant, any metallic foreign body

55. DEATH Pronouncing a patient Notify the patient’s family
Request an autopsy
How to write a death note

56. Pronouncing a Patient Check for: Spontaneous movement
If on telemetry—any meaningful activity
Response to verbal stimuli
Response to tactile stimuli (nipple pinch or sternal rub)
Pupillary light reflex (should be dilated and fixed)
Respirations over all lung fields
Heart sounds over entire precordium
Carotid, femoral pulses

57. Notify the Patient’s Family
Call family if not present and ask to come in, or if family is present:
Explain to them what happened
Ask if they have any questions
Ask if they would like someone from pastoral care to be called
Let them know they may have time with the deceased
Nursing will put ribbon over the door to give family privacy

58. Request an Autopsy Ask family if they would like an autopsy
Medical Examiner will be called if:
Patient hospitalized <24 hours
Death associated with unusual circumstances
Death associated with trauma

59. How to Write a Death Note
DOCUMENTATION:
“Called to bedside by nurse to pronounce (name of pt).”
Chart all findings previously discussed:
“No spontaneous movements were present, pupils were dilated and fixed, no breath sounds were appreciated, etc.”
“Patient pronounced dead at (date and time).”
“Family and attending physician were notified.”
“Family accepts/declines autopsy.”
Document if patient was DNR/DNI vs. Full Code.

60. Bottom Line: When in doubt, call your Resident
It is OK to call your attending if over your head
You are Never All Alone 
Write a NOTE about what has happened for the primary team
Call primary team in the AM about important events.
Have fun…it’s gonna be a great year!