Nina Zatikyan Ann Malbas Chief Residents A Day in the life… and Cross-Cover Nina Zatikyan Ann Malbas Chief Residents

Overview- cross cover Making your Cross-cover list Emergency vs. non-emergency When should I go and see the patient? Common calls/questions When do I need to call my resident???

How to make your cross cover list Log on to www.caregate.net Go to your “Patient lists” Click on to “Sign out Rpt” button

Cross-Cover notes Always check-out FACE-TO-FACE!! Write down in “ My Report” all the instructions for your Cross-Cover. If you are cross-covering and something happened and/or you performed any diagnostic/therapeutic interventions write it in “ My Report” for the primary team to see. Inform the primary team in AM about overnight events.

What do I do when I’m called? Review basics by organ systems today Infectious Disease Heme Radiology Death Neuro Pulmonary Cardiology Gastrointestinal Renal -Ask yourself, does this patient sound stable or unstable? -Ask for vitals -Is this a new change?

NEUROLOGY Altered Mental Status Seizures Falls Delirium Tremens

Altered Mental Status **Caution with Benzos/ambien in the elderly Try naloxone (Narcan), usually 0.4-1.2 mg IV, if there is any possibility of opiate OD If elderly person is agitated/sundowning  Family member at bedside- the best Medications Haloperidol 2mg IV/IM Ziprasidone (Geodon) 10-20mg IM Quetiapine (Seroquel) 25mg po qhs Restraints (last resort) non-violent/non-behavioral Always go to the bedside!!! Is this a new change? Duration? Recent/new medications Check VITALS, Neuro Exam Review Labs: cardiac enzymes, electrolytes, +cultures Check stat Accucheck, 02 sat, ABG, NH3, TSH Consider checking non-contrast head CT   **Caution with Benzos/ambien in the elderly

“Move Stupid” Metabolic – B12 or thiamine deficiency Oxygen – hypoxemia/hypercapnea 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 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 Assess ABCs give 02, intubate if necessary Place patient in left lateral decubitus position Labs electrolytes (Ca+), glucose, CBC, renal/liver fxn, tox screen, anticonvulsant drug levels, check Accucheck Treatment: Give thiamine 100 mg IV first, then 1 amp D50 Antipyretics for fever or cooling blankets Lorazepam 0.1mg/kg IV at 2mg/min If seizures continue; Load phenytoin 15-20 mg/kg IV in 3 divided doses at 50 mg/min (usually 1 g total) or fosphenytoin 20mg/kg IV at 150mg/min Phenytoin is not compatible with glucose-containing solutions or benzos; 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)

Falls Go to the bedside!!! Check mental status/Neuro exam Check vital signs including pulse ox Review med list (benzos, pain meds etc) Accucheck! Examine for fractures/hematomas/hemarthromas Check orthostatics if appropriate If on coumadin/elevated INR or altered—consider non-contrast head CT to r/o subdural hematoma Order fall precautions

Delirium Tremens (DTs) See if patient has alcohol history Give thiamine 100mg, folate 1mg, MVI Check blood alcohol level DTs usually occur ~ 3 days after last ingestion Make sure airway is protected (vomiting risk) Use Lorazepam (Ativan) 2-4mg IV 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 NO HALOPERIDOL – increases seizure threshold !

PULMONARY Shortness of Breath Hypoxia

Shortness of Breath Go to the bedside!!! History of heart failure? Recent surgery? COPD? Look at I/Os Physical Exam (heart and lungs especially) Check an oxygen saturation and ABG if indicated Check CXR if indicated Lasix 40mg IV x1 if volume overloaded Increase supplemental 02, if no improvement start on BiPAP, call resident Move to ICU/intubate if necessary

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. Use humidified if giving more than >2L 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, FiO2 100 %. IPAP helps overcome work of breathing and helps to change PCO2 EPAP helps change pO2  

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 2-4 cm above the carina) Check ABG 30 min after patient intubated and adjust settings accordingly

CARDIOLOGY Chest pain Hypotension Hypertension Arrhythmias

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: MONA Give SL nitroglycerin if pain still present (except if low blood pressure, give morphine instead) Supplemental oxygen Aspirin 325 mg Cycle enzymes Call Cardiology if there is new ST elevation, LBBB, or if there is an elevation in cardiac enzymes

Hypotension Go and see the patient!!! Repeat BP and HR, manually Compare 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 Anaphylaxis: sob/wheezing epinephrine  benadryl  supplemental 02  Adrenal Insufficiency check, cortisol/ACTH level ACTH stim test replace volume rapidly Hydrocortisone 50-100mg IV q6-8h   Hypovolemia volume resuscitation if CHF,bolus 500ml NS transfuse blood Cardiogenic fluids inotropic agents Sepsis: febrile >101.5 blood cultures x 2 empiric antibiotics *Stop BP meds!   *Don't forget about tamponade, PE and pneumothorax!!

Commonly Used Pressors 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; Causes Arrhythmias Dobutamine B1, B2 1–20 mcg/kg/min Positive inotropy and chronotropy; Causes Hypotension

Hypertension Is there history of HTN? Check BP trends Is patient symptomatic? ie chest pain, anxiety, headache, SOB? Confirm patient is not post-stroke—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 HTN 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 PRN meds: hydralazine 10-20mg IV enalapril (vasotec) 1.25-5mg IV q6h labetalol 10-20mg IV    *Remember, no need to acutely reduce BP unless emergency

Hypertension (continued) URGENCY SBP>210 or DBP>120 with no end organ damage OK to treat with PO agents (decr BP in hours) hydralazine 10-25mg captopril 25-50mg labetolol 200-1200mg clonidine 0.2mg EMERGENCY SBP>210 or DBP>120 with acute end organ damage Treat with IV agents (Decrease MAP by 25% in min to 2hrs; then decrease to goal of <160/100 over 2-6 hrs) nitroprusside 0.25-10ug/kg/min nitroglycerin 17-1000ug/min Labetolol 20-80mg bolus Hydralazine 10-20mg  Phentolamine 5-15mg bolus

Arrhythmias Bradycardia Assess ABCs Afib/flutter RVR give 02 monitor BP Sinus block: 1st, 2nd or 3rd degree Hold BB meds Prepare for transcutaneous pacing Atropine 0.5mg IV  x3 Consider low dose Epi (2-10mcg/min)  dopamine(2-10mcg/kg/min) Tachyarrhythmias Afib/flutter RVR  rate control (BB/diltiazem/digoxin if BP low) consider anti-arrhythmic (amiodarone) SVT/SVT with aberrancy vagal maneuver adenosine 6-12mg IV Ventricular fib/flutter  check Mg level, replace if needed (>3.0) amiodarone drip *Remember, if unstable shock!!

Gastrointestinal Nausea/Vomiting GI Bleed Acute Abdominal Pain Diarrhea/Constipation

Nausea/Vomiting Vital signs, blood sugar, recent meds (pain meds)? Make sure airway is protected EXAM: abdominal exam, rectal (considering obstruction, pancreatitis, cholecystitis),neuro exam (increased ICP?) May check KUB Treatment: Phenergan 12.5-25mg IV/PR (lower in elderly) Zofran 4-8mg IV Reglan 10-20 mg IV (especially if suspect gastroparesis) If no relief, consider NG tube (especially if suspect bowel obstruction)

GI Bleed UPPER LOWER Hematemesis, melena Check vitals Place NG tube NPO Wide open fluids, type&cross for blood Check H/H serially If suspect  PUD: Protonix gtt varices: octreotide gtt **Call Resident and GI LOWER BRBPR, hematochezia Check vitals NPO Rectal exam Wide open fluids if low BP Check H/H serially Transfuse if appropriate Pain out of proportion? Don’t forget ischemic colitis!

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 carefully in elderly, ensure pt on adequate bowel regimen

Diarrhea Constipation Is this new? check stool studies: c.diff culture o&p wbc FOBT x 3 Do not treat with loperamide if you think it might be C.diff!!! Is this new? check KUB Ileus/bowel obstruction: place NPO Treat: Laxative of choice MOM Miralax enema tap water soap Bowel regimen colace 100mg bid dulcolax 5-15mg

RENAL/ELECTROLYTES Decreased urine output Hyperkalemia Foley catheter problems

Decreased Urine Output Oliguria: <20 ml/hour (<400 ml/day) Check for volume status, renal failure, accurate I/O, meds Consider bladder scan (place foley if residual >300ml) Labs: UA: WBC (UTI); elevated specific gravity (dehydration); RBC (UTI/urolithiasis); tubular epithelial cells (ATN); WBC casts (interstitial nephritis); Eosinophils (AIN) Chemistries: BUN/Cr, K, Na

Treatment of Decreased UOP Decreased Volume Status: Bolus 500ml NS Repeat if no effect Normal/Increased Volume: May ask nursing to check bladder scan for residual urine Check Foley placement Lasix 20-40 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 resistance: 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, medications (ACEI/ARBs, heparin, NSAIDs, cyclosporine, trimethoprim, pentamidine, K-sparing diuretics, BBs, KCl, etc) Check EKG for acute changes: peaked T-waves  flattened P waves PR prolongation followed by loss of P waves QRS widening

Treatment of Hyperkalemia Mild (<6.0 mEq/L)         Decrease total body stores Lasix 40-80mg IV Kayexalate 30-90g PO/PR Moderate (6-7mEq/L)         Shift K+ in cells NaHCO3 50mEq (1-3amps) D50+10units insulin IV albuterol 10-20mg neb Severe (>7mEq/L) or EKG changes         Protect myocardium Calcium gluconate 1-2amps IV over 2-5min   **Emergent dialysis should be considered in life-threatening situations. **Remember this is a progressive treatment plan, so if your patient has EKG changes you need to treat for severe/mod/mild!!!

Infectious Disease 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 ½ Blood Cx are positive, consider repeating another set 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, PE, drug rxn, transfusion rxn If the last time cultures were checked >24 hrs ago  order blood cultures x 2 from different IV sites  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

HEME Anticoagulation Blood replacement products

Anticoagulation Appropriate for: DVT/PE Acute Coronary Syndrome Usually start with low molecular weight heparin  Lovenox 1 mg/kg every 12 hours and renally adjust  If need to turn on/off quickly (e.g., pt going for procedure) heparin drip—protocol in EPIC Risk factors for bleeding on heparin: Surgery, trauma, or stroke within the previous 14 days H/o PUD or GIB Plts<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 <10K in non bleeding patient. use when platelets <50K in bleeding pt, pre-op pt, or before a procedure FFP: contains all factors DIC or liver failure with elevated coags and concomitant bleeding Reversal of INR (ie for procedure)

RADIOLOGY Which test should I order? Plain Films CT scans MRI

Plain Films CXR: Portable if pt in unit or bed bound PA/Lateral is best for looking for effusions/infiltrates Decubitus to see if the 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 CT Angiogram Abdominal CT Non-contrast best for bleeding, CVA, trauma Contrast best for anything that effects the blood brain barrier (ie 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 * If you are going to give contrast, check your Cr!!!

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 Patient may be pronounced by 2 RNs 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!!