Presentation on theme: "Nadia Habal, MD Presbyterian Hospital of Dallas X-COVER?!?"— Presentation transcript:
Nadia Habal, MD Presbyterian Hospital of Dallas X-COVER?!?
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???
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
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.
Example, continued: Cross Cover To Do F/u ERCP results ALL: NKDA RX: allopurinol, aspirin, atenolol, Lipitor … You get the idea!
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!!!
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”
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
“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
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
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.
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
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
PULMONARY Shortness of Breath Oxygen De-saturations
Shortness of Breath Go to the bedside!!! Check an oxygen saturation and ABG if indicated Check CXR if indicated
Causes of SOB Pulmonary: 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!
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
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
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
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
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
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!
Commonly Used Pressors NameReceptor AffectedDoseAction Phenylephrine (Neosynephrine) Alpha 110–200 mcg/minPure vasoconstrictor; causes ischemia in extremities Norepinephrine (Levophed) A1, B12–64 mcg/minVasoconstriction, positive inotropy; causes arrhythmias DopamineDopa1–2 mcg/kg/minSplanchnic vasodilation ("renal dose dopamine" even though many doubt such effect exists) B12–10 mcg/kg/minPositive inotropy; Causes Arrhythmias A110–20 mcg/kg/min Vasoconstriction; Causes Arrhythmias DobutamineB1, B21–20 mcg/kg/minPositive inotropy and chronotropy; Causes Hypotension
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
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
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.
GI Nausea/Vomiting GI Bleed Constipation Diarrhea Acute Abdominal Pain
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)
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!
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
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
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
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
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
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)
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
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
ENDOCRINOLOGY DKA HONC (Will be covered in detail at later time)
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
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)
ID Positive Blood Culture Fever
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
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
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
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
RADIOLOGY What test do I order for what problem? Plain Films CT scans MRI
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
CT Head 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
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
DEATH Pronouncing a patient Notify the patient’s family Request an autopsy How to write a death note
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
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
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
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.
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!