Presentation on theme: "Nadia Habal, MD Presbyterian Hospital of Dallas"— Presentation transcript:
1Nadia Habal, MD Presbyterian Hospital of Dallas X-COVER?!?Nadia Habal, MDPresbyterian Hospital of Dallas
2What 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???
3How to make your CareGate list: Log on to CareGateGo to Cross CoverUnder “problems”, put one liner about the patientThen list all important problems and what has been done about themUnder “to do” section put MR number, pt allergies, important meds, anything for X-cover to follow up on
4Example: 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.
5Example, continued: Cross Cover To Do ALL: NKDA F/u ERCP resultsALL: NKDARX: allopurinol, aspirin, atenolol, Lipitor… You get the idea!
6Not Acceptable:“Patient intubated, sedated, in 1 ICU”… when the pt has been extubated and on the floor for 4 daysMust update room numbers on x-cover listMust update DNR statusMust 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 listIf someone is really sick, include family contact info in the event of a code or critical change in medical statusYOU MUST UPDATE THE WHOLE LIST EVERYDAY!!!
7What do I do when I’m called? We will go through some basics by organ systems todayFuture subjects to be covered during Internship 101lecture series:ID: June 30: PneumoniaCV: July 3: ArrhythmiasGI: July 7: GI bleedingPulm: July 10: Sepsis/SIRSEndo: July 17: Hyperglycemic states (DKA and HONC) Neuro: July 31: Altered mental status and “Brain Code”
8NEUROLOGY Altered Mental Status Seizures Cord Compression Falls Delirium Tremens
9Altered 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 administeredCheck VITALS, alertness/orientation, pupils, nuchal rigidity, heart/lungs/abdomen, strengthScan recent labs in chart including: cardiac enzymes, electrolytes, +culturesIf labs unavailable, get stat Accucheck, oxygen saturationTry 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 confusionOthers - including anemia, decreased cerebral blood flow (e.g., low cardiac output),CO poisoningVascular – CVA, intracerebral hemorrhage, vasculitis, TTP, DIC, hyperviscosity,hypertensive encephalopathyEndocrine – hyper/hypoglycemia, hyper/hypothyroidism, high /low cortisol states and Electrolytes – particularly sodium or calciumSeizures –post–ictal confusion, unresponsive in status epilepticus; also consider Structural problems – lesions with mass effect, hydrocephalusTumor, Trauma, or Temperature (either fever or hypothermia)Uremia – and another disorder, hepatic encephalopathyPsychiatric – diagnosis of exclusion; ICU psychosis and "sundowning" are commonInfection – any sort, including CNS, systemic, or simple UTI in an elderly patientDrugs – including intoxication or withdrawal from alcohol, illicit or prescribed drugs
11Seizures Go to bedside to determine if patient still actively seizing Call your residentCheck your ABCsPlace patient in left lateral decubitus positionImmediate AccucheckIf 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 D50Load 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
12Cord CompressionSuspect 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.
13Falls Go to the bedside!!! Check mental status Check vital signs including pulse oxCheck med listCheck blood glucoseExamine pt to ensure no fracturesThorough neuro checkCheck tilt blood pressures if appropriateIf on coumadin/elevated INR—consider head CT to r/o bleed
14Delirium Tremens (DTs) Give thiamine 100mg, folate 1mg, MVISee if patient has alcohol historyCheck blood alcohol levelDTs usually occur ~ 3 days after last ingestionMake 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 depressionMonitor in ICU for seizure activityAlways keep electrolytes replaced
15PULMONARYShortness of BreathOxygen De-saturations
16Shortness of Breath Go to the bedside!!! Check an oxygen saturation and ABG if indicatedCheck CXR if indicated
17Causes of SOB Pulmonary: Cardiac: Metabolic: Hematologic: Psychiatric: Pneumonia, pneumothorax, PE, aspiration, bronchospasm, upper airway obstruction, ARDSCardiac:MI/ischemia, CHF, arrhythmia, tamponadeMetabolic:Acidosis, sepsisHematologic:Anemia, methemoglobinemiaPsychiatric:Anxiety – common, but a diagnosis of exclusion!
18Oxygen Desaturations Supplemental Oxygen Nasal cannula: for mild desatsFace mask/Ventimask: offers up to 55% FIO2Non-rebreather: offers up to 100% FIO2BIPAP: good for COPDStart settings at: IPAP 10 and EPAP 5IPAP helps overcome work of breathing and helps to change PCO2EPAP helps change pO2CPAP: good for pulmonary edema, hypercapnea, OSAStart at 5-7
19Indications 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 protectionUpper airway obstruction
20Mechanical Ventilation If patient needs to be intubated, start with mask-ventilation until help from upper level ArrivesInitial settings for Vent:A/C FIO2 100 Vt 700 Peep 5 (unless increased ICP, then no peep) RR 12Check CXR to ensure proper ETT placement (should be around 4cm above the carina)Check ABG 30 min after pt intubated and adjust settings accordingly
22Chest Pain Go and see the patient!!! Why is the patient in house? Recent procedure?STAT EKG and compare to old onesIs the pain cardiac/pulmonary/GI?—from H+PVital signs: BP, pulse, SpO2If you think it’s cardiac:Give SL nitroglycerin if pain still present (except if low blood pressure, give morphine instead)Supplemental oxygenAspirin 325 mg
23Hypotension Go and see the patient!!! Repeat Manual BP and HR Look at recent vitals trendsLook for recent ECHO/ meds pt has been given.EXAM:Vitals: orthostatic? tachycardic?Neuro: AMSHEENT: dry mucosa?Neck: flat vs. JVD (=CHF)Chest: dyspnea, wheezes (?anaphylaxis), crackles (=CHF)Heart: manual pulse, S3 (CHF)Ext: cool, clammy, edema
24Management of Hypotension If offending med, stop the med!If volume down/bleeding: give wide open IV NSCorrect hypoxiaRecent steroid use? Adrenal insufficiencyIs there a neuro cause for hypotension?If appropriate, consider: PE, tamponade, pneumothoraxIf fever, consider sepsis—need for empiric antibioticsIf hives and wheezing, consider anaphylaxis—tx with oxygen, epinephrine, BenadrylNeed for pressors? Transfer to ICU!
25Commonly Used Pressors NameReceptor AffectedDoseActionPhenylephrine(Neosynephrine)Alpha 110–200 mcg/minPure vasoconstrictor; causes ischemia in extremitiesNorepinephrine(Levophed)A1, B12–64 mcg/minVasoconstriction, positive inotropy; causes arrhythmiasDopamineDopa1–2 mcg/kg/minSplanchnic vasodilation ("renal dose dopamine" even though many doubt such effect exists)B12–10 mcg/kg/minPositive inotropy;Causes ArrhythmiasA110–20 mcg/kg/minVasoconstriction;DobutamineB1, B21–20 mcg/kg/minPositive inotropy andchronotropy;Causes Hypotension
26Hypertension 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 perfusionEXAM:Manual BP in both armsFundoscopic exam: look for papilledema and hemorrhagesNeuro: AMS, focal weakness or paresisNeck: JVD, stiffnessLungs: cracklesCardiac: S3
27Management of Hypertension If patient is asymptomatic and exam is WNL:See if any doses of BP meds were missed; if so, give nowIf no doses missed, may give an early dose of current medRemember, no need to acutely reduce BP unless emergencySo, start a medication that you would have normally picked in this patient as the next agent of choice according to JNC/co-morbidities/allergies
28Hypertension (continued) URGENCYSBP>210 or DBP>120No end organ damageOK to treat with PO agentsEMERGENCYSBP>210 or DBP>120Acute end organ damageTreat with IV agentsDecrease MAP by 25% in one hour; then decrease to goal of <160/100 over 2-6 hrs.
30Nausea/Vomiting Vital signs, blood sugar, recent meds? Make sure airway is protectedEXAM: abdominal exam, rectal (considering obstruction, pancreatitis, cholecystitis),neuro exam (increased ICP?)May check KUBTreatment:Phenergan mg IV/PR (lower in elderly)Zofran 4-8mg IVReglan mg IV (especially if suspect gastroparesis)If no relief, consider NG tube (especially if suspect bowel obstruction)
31GI Bleed (to be discussed in detail at a later date): UPPERHematemesis, melenaCheck vitalsPlace NG tubeNPOWide open fluids vs. bloodCheck H/H seriallyIf suspect PUD: Protonix dripIf suspect varices: octreotideCall Resident and GILOWERBRBPR, hematocheziaCheck vitalsRectal examWide open fluids if low BPNPOCheck H/H seriallyTransfuse if appropriatePain out of proportion? Don’t forget ischemic colitis!
32Constipation Very common call! Check: electrolytes, pain meds, bowel regimenCheck KUB if suspect ileus/obstructionRectal exam to check for fecal impaction/mechanical obstructionTreatment: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
33Diarrhea Check: electrolytes, vitals, meds Quantify volume, number, description of stoolsLabs: fecal leukocytes, stool culture, guaiac, C.diff toxin if recent antibiotic or nursing home residentTreatment:Colitis: flagyl 500mg po tidGI bleed: per GI sectionIf don’t suspect infection: loperamide initially 4mg then 2mg after each unformed stool up to 16mg daily
34Acute Abdominal Pain Go to the bedside!!! Assess vitals, rapidity of onset, location, quality and severity of painLOCATION:Epigastric: gastritis, PUD, pancreatitis, AAA, ischemiaRUQ: gallbladder, hepatitis, hepatic tumor, pneumoniaLUQ: spleen, pneumoniaPeri-umbilical: gastroenteritis, ischemia, infarction, appendixRLQ: appendix, nephrolithiasisLLQ: diverticulitis, colitis, nephrolithiasis, IBDSuprapubic: PID, UTI, ovarian cyst/torsion
35Acute Abdomen? Assess severity of pain, rapidity of onset If acute abdomen suspected, call SurgeryDo you need to do a DRE?KUB vs. Abdominal Ultrasound vs. CTTreatment:Pain management—may use morphine if no contraindicationRemember, if any narcotics are started, use sparingly in elderly, ensure pt on adequate bowel regimen
37Decreased Urine Output Oliguria: <20 cc/hour (<400 cc/day)Check for volume status, renal failure, accurate I/O, medsConsider bladder scanLabs: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
38Treatment of Decreased UOP Decreased Volume Status:Bolus 500 cc NSRepeat if no effectNormal/Increased Volume:May ask nursing to check bladder scan for residual urineCheck Foley placementLasix 20 mg IV
39Foley Catheter Problems: Why/when was it placed?Does the patient still need it?Confirm no kinks or clampsConfirm bag is not fullExamine output for blood clots or sedimentDo not force Foley in if giving resistanc: call UrologyNursing may flush out Foley if it must stay inThe sooner it’s out, the better (when appropriate)
40Hyperkalemia Ensure correct value—not hemolysis in lab Check for renal insufficiency, medsCheck EKG for acute changes, peaked T-waves, PR prolongation followed by loss of P waves, QRS widening
41Treatment of Hyperkalemia Immediate Rx (works in minutes): for EKG changes, stabilize myocardium with 1-2 amps calcium gluconateTemporary Rx (shift K into cells):2 amps D50 plus 10 units regular insulin IV: decreases K by mEq/L and lasts several hours2 amps NaHCO3: best reserved for non-ESRD patients with severe hyperkalemia and acidosisB2-agonists: effects similar to insulin/D50Long-lasting Elimination:Kayexalate 30g po (repeat if no BM) or retention enemaNS and LasixDialysis
42ENDOCRINOLOGYDKAHONC(Will be covered in detail at later time)
43DKAIdentify precipitating factor (e.g., infection, MI, noncompliance with meds)Check for anion gapCheck for ketones in urine or serumGive bolus 1 Liter NS, then run IVF at 200 ml/hour if no contraindicationStart insulin drip DKA protocol in ICU (EPIC order)Check electrolytes every 4 hours and replace as appropriate
44HONC Similar to DKA but for Type II diabetes and no ketones There is also an insulin drip NON-DKA protocol in ICU (EPIC order)
46Positive 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 sensitivityIf 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
47Fever Has the patient been having fevers? DDX: infection, inflammation/stress rxn, ETOH withdrawal, drug rxn, transfusion rxnIf the last time cultures were checked >24 hrs ago, then order blood cultures x 2, UA/culture, CXR, respiratory culture if appropriateIf 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
49Anticoagulation 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 fxnIf need to turn on/off quickly (e.g., pt going for procedure) use heparin drip—there is a protocol in EPICRisk factors for bleeding on heparin:Surgery, trauma, or stroke within the previous 14 daysHistory of peptic ulcer disease, GI bleeding or GU bleedingPlatelet count less than 150KAge > 70 yrsHepatic failure, uremia, bleeding diathesis, brain mets
50Blood Replacement Products PRBC: One unit should raise Hct 3 points or Hgb 1 g/dlPlatelets: 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 procedureFFP: contains all factorsuse when patient in DIC or liver failure with elevated coags and concomitant bleeding or for needed reversal of INR
51RADIOLOGY What test do I order for what problem? Plain Films CT scans MRI
52Plain Films CXR: Portable if pt in unit or bed bound PA/Lat is best for looking for effusions/infiltratesDecubitus to see if an effusion layers; needs to layer >1cm in order to be safe to tapAbdominal X-ray:Acute abdominal series: includes PA CXR, upright KUB and flat KUB
53CT Head CT CT Angiogram Abdominal CT Non-contrast best for bleeding, CVA, traumaContrast best for anything that effects the blood brain barrier, tumors, infectionCT AngiogramIf suspect PE and no contraindication to contrast (e.g., elevated creatinine)Abdominal CTAlways a good idea to call the radiologist if unsure whether contrast is needed/depending on what you are looking forRenal stone protocol to look for nephrolithiasisIf 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
54MRI Increased sensitivity for soft tissue pathology Best choice for: Brain: neoplasms, abscesses, cysts, plaques, atrophy, infarcts, white matter diseaseSpine: myelopathy, disk herniation, spinal stenosisContraindications: pacemaker, defibrillator, aneurysm clips, neurostimulator, insulin/infusion pump, implanted drug infusion device, cochlear implant, any metallic foreign body
55DEATH Pronouncing a patient Notify the patient’s family Request an autopsyHow to write a death note
56Pronouncing a Patient Check for: Spontaneous movement If on telemetry—any meaningful activityResponse to verbal stimuliResponse to tactile stimuli (nipple pinch or sternal rub)Pupillary light reflex (should be dilated and fixed)Respirations over all lung fieldsHeart sounds over entire precordiumCarotid, femoral pulses
57Notify the Patient’s Family Call family if not present and ask to come in, or if family is present:Explain to them what happenedAsk if they have any questionsAsk if they would like someone from pastoral care to be calledLet them know they may have time with the deceasedNursing will put ribbon over the door to give family privacy
58Request an Autopsy Ask family if they would like an autopsy Medical Examiner will be called if:Patient hospitalized <24 hoursDeath associated with unusual circumstancesDeath associated with trauma
59How 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.
60Bottom Line: When in doubt, call your Resident It is OK to call your attending if over your headYou are Never All Alone Write a NOTE about what has happened for the primary teamCall primary team in the AM about important events.Have fun…it’s gonna be a great year!