1. Cover Shift Issues part 2 – 22/1/19 Dr Carol Chong
Diabetes BSL management
Chest pain
If time…
(Nausea and Vomiting
Gi Bleeding
consent/ person responsible)

2. BSLs
Mr LL’s BSL is What do you want to do?

3. BSLS Mr L’s BSL is 27.0. What do you want to do?
GET MORE INFORMATION FIRST!!

4. Case 1 – Mr LL BSl 27.0 at 17:00 just about to eat.
Usual insulin is novomix units s/c b.d

5. Case 1 Pt is a type II diabetic
Admitted for a diabetic foot ulcer treated with tazocin.
Usual insulin is novomix units s/c b.d
Not on any hypoglycaemic agents.

6. Trend in BSLS
The key to making decision about whether extra insulin is needed.
Trend in BSLs for Mr LL
Yesterday afternoon it was 24.0 given usual 16 units s/c novomix

7. Case 1 – Mr LL with a BSL of 27.0 Date BSL Time 15/1/19 24.0 17:00
15/1/ :00
15/1/ :00
16/1/ :00
16/1/ :00
16/1/ :00
?give extra insulin or not????
What type of insulin?

8. Case 1 – Mr LL with a BSL of 27.0 Date BSL Time 15/1/19 24.0 17:00
15/1/ :00
15/1/ :00
16/1/ :00
16/1/ :00
16/1/ :00
?give extra insulin or not- in this case it’s not necessary, as yesterday 15/1/19 despite BSL of 24.0 at 17:00, the next day it came down to 8.0 without extra insulin.
What type of insulin? If you are going to give some insulin, short acting novorapid prior to dinner can be given eg. 4 or 6 units s/c stat

9. Plan:
In this scenario, the trend from the day before is important, pt might not need extra insulin.
Small doses of novorapid might be indicated as long as BSLS are checked regularly

10. Case 1b – but what if Mr LL’s BSL trend had been like this
Date BSL Time
15/1/ :00 given 8units novorapid
15/1/ :00
16/1/ :00
16/1/ :00
16/1/ :00
?give extra insulin or not????
What should the unit consider in them morning?

11. Case 1b – but what if Mr LL’s BSL trend had been like this
Date BSL Time
15/1/ :00given 8units novorapid
15/1/ :00
16/1/ :00
16/1/ :00
16/1/ :00
?give extra insulin or not
– yes. He was given 8 units yesterday at 17:00 so can give a top up now, 8 units novorapid.
What should the unit consider in them morning?
Can consider increasing AM novomix

12. Thoughts BSLs trending up during the day.
Probably warrants increased AM novomix so BSLs don’t go so high in the afternoon.
BSL could be high due to sepsis, so need to be aware that insulin requirements will eventually decrease.

13. Case 1c - Mr LL another scenario
Date BSL Time
15/1/ :00
15/1/ :00
16/1/ :00
16/1/ :00
16/1/ :00
?give extra novorapid or not????

14. Case 1c - another scenario
Date BSL Time
15/1/ :00
15/1/ :00
16/1/ :00
16/1/ :00
16/1/ :00
?give extra novorapid or not- in this case, it’s clear from the chart that the BSL is unlikely to drop within 6-10 by the morning, given the trend from 15/1/17
So should give extra novorapid.

15. Plan:
Given trend to hyperglycemia all of the day before, better to give extra insulin now so that AM BSLS will not be so high tomorrow

16. Diabetes
52 year old with cellulitis. Type II Diabetic on metformin 1g o b.d. Otherwise well.
Septic. T 38 degrees, right leg cellulitis. WCC 16.0.
BSLs 17.0 at 20:00.
Had usual meds.
What other questions to ask?

17. Hyperglycaemia Need to know trends in BSLS. Just came from ED.
BSLs was 15.0 at 17:00, given usual metformin.
Eating and drinking normally.
Normal renal function.
BSLs usually around 7-10 at home.
BSL is 17.0 –what do you want to do?

18. Your choices A few options
Do nothing – ask nurse to check BSL again in 2 hours
Give novorapid 4 units s/c stat
C) Give novorapid 6 units s/c stat
D) Give actrapid 4 or 6 units s/c stat

19. Your choices A few options
Do nothing – ask nurse to check BSL again in 2 hours
- This is fine, you don’t know the trend yet.
Give novorapid 4 units s/c stat
- This is fine too
C) Give novorapid 6 units s/c stat
- Fine.
D) Give actrapid 4 or 6 units s/c stat
- Fine but we tend to use novorapid here- acts faster, more physiological

20. Guidelines
If BSL is between on cover – don’t need to lower straight away – okay for nursing staff to just monitor.
IF BSL between – depends on time of last insulin dose or medications. Again, might be better not to lower the BSLs but depends on trends on the BSL chart.
If BSL >20.0, in general, patient’s may benefit from extra insulin (novorapid top up is best).

21. Any special considerations with metformin – especially if patient is not well?

22. Metformin
Carefully consider if this needs withholding if patient is unwell eg. Septic and not eating or renal impairment.
Risk of lactic acidosis
Consider ceasing metformin if not eating, renal impairment and write up a sliding scale.
On cover, consider withholding in the morning if pt has been unwell eg. Over the weekend.

23. Other Scenarios Call before lunch – patient’s BSL is 12.0
Type II diabetes
On mixtard 30/70 20 units s/c b.d
In hospital for pneumonia

24. Case Date BSL Time 22/1/19 11.0 11:00 22/1/19 16.0 17:00
22/1/ :00
22/1/ :00
23/1/ :00
Now 23/1/ :00
?give extra insulin or not????

25. Case Date BSL Time 22/1/19 11.0 11:00 22/1/19 16.0 17:00
22/1/ :00
22/1/ :00
23/1/ :00
Now 23/1/ :00
?give extra insulin or not – don’t need to, probably best to monitor, risk of hypoglycaemia if you give too much extra insulin

26. Case - what if BSL 18.0? Date BSL Time 22/1/19 11.0 11:00
22/1/ :00
22/1/ :00
23/1/ :00
Now 23/1/ :00
?give extra insulin or not????

27. Case Date BSL Time 22/1/19 11.0 11:00 22/1/19 16.0 17:00
22/1/ :00
22/1/ :00
23/1/ :00
Now 23/1/ :00
?give extra insulin or not – could watch and monitor or could give small dose novorapid 4-6 units s/c stat

28. Case - what if this was the trend?
Date BSL Time
22/1/ :00
22/1/ :00
22/1/ :00
23/1/ :00
23 /1/18
?give extra insulin or not????

29. Case Date BSL Time 22/1/18 11.0 11:00 22/1/18 16.0 17:00
22/1/ :00
22/1/ :00
23/1/ :00
23/1/ :00
23 /1/18
?give extra insulin or not – yes , can give 4 – 6 units of novorapid given BSL trend for the last 24 hours shows persistent hyperglycaemia.

30. Case
Date BSL Time
22/1/ :00
22/1/ given 6 units novorapid 17:00
23/1/ :00
Now 23/1/ :00
?give extra insulin or not????

31. Hyperglycaemia
Find out if patient is Type I or Type II – very important.
Causes. Think of causes before treating
Look at trends. Trends are very important.
Then consider insulin eg. novorapid.

32. Guidelines
If BSL is between on cover – don’t need to lower straight away – okay for nursing staff to just monitor.
IF BSL between – depends on time of last insulin dose or medications. Again, might be better not to lower the BSLs
If BSL >20.0, in general, patient’s may benefit from extra insulin (novorapid top up.)
If worried about hypo with evening additional insulin- check 2am BSL

33. How to write a sliding scale
Many different ways!
Find one way and stick to it.
Type 1 diabetic vs Type 2
Refer to medication booklet
Don’t forget top-up novorapid
E.g if BSL>15.0 pre-meals, give 6 units novorapid subcut.

34. Sliding scale example
If BSL <8.0 give no novorapid (if type 1DM give 2 units)
give 2 units
give 4 units
give 6 units
give 8 units
>24.1 give 10 units + call RMO

35. Type 1 diabetes 45 year old in hospital with CCF post NonSTEMI
On mixed insulin novomix 30
40 units s/c mane and 24 units s/c dinner
BSL is 20.0 at 17:00 pre-dinner
What are you going to do?

36. Type 1 diabetes The risk is DKA. Needs better BSL control.
Don’t take a watch and see approach is BSL > 15.0
Need to lower BSL and check for ketones.
Give novorapid eg. Extra 8 units on top of usual insulin. Could you give novomix as top up?
If post- eating BSL 20.0 eg.21:00 - what to do ?–

37. Type 1 diabetes The risk is DKA. Needs better BSL control.
Don’t take a watch and see approach is BSL > 15.0
Need to lower BSL and check for ketones.
Give novorapid eg. Extra 8 units on top of usual insulin. Could you give novomix as top up?
No, as novomix has long acting insulin. Want to give a short acting insulin as top up
If post- eating BSL 20.0 eg.21:00 - what to do ?–
Give more novorapid eg. 8 units as this is short acting, but also check ketones.
May consider overnight BSL checks

40. Rung about ketones…
Find out if the patient is a type 1 or type II diabetic.
Need to ask for BSL
Trends in BSLS as we’ve done earlier.
Find out what medications they are on.

42. BSLS
Would you worry more if the BSL was 2.4 or 24?

43. BSLS Would you worry more if the BSL was 2.4 or 24?
Definitely a BSL of 2.4 is a worry – they can die from hypoglycaemia and coma

44. HYPOGLYCAEMIA

45. Hypoglycaemia Dangerous. Treat ASAP.
Nurses often treat before they ring you.
Sugar drinks, glucose, lollies etc if patient conscious.
If not …. What to do?

46. Hypoglycaemia BSL 1.8. Pt unconcious. MET CALLed.
You get to the scene first – what do you do?

47. Treatment of hypoglycaemia
ABC
Glucagon pen 1mg injection.
Can be given very quickly!
Other option – quickly insert I.v cannula and give dextrose … which one….
5% or 50%?

48. i.v dextrose
For hypoglycaemia – can give 25mls of 50% dextrose stat then run a dextrose 5% infusion as maintenance if necessary.
Keep the extra 25mls up your sleeve – you may need to give it again
Ask nurses to recheck bsls regularly for the next few hours. Eg. ½ hourly for 2 hours then hourly for 2 hours then back to normal

49. The patient Wakes up!! Woohoo!!! FOLLOW UP plan. Re-check BSLs
Think about cause of hypoglycaemia and treat this.
Short and long acting carbohydrates help
Glucose/lollies then Sandwiches
back

50. Thanks to Dr Edwina Holbeach for her slides in this section
Chest Pain!
Thanks to Dr Edwina Holbeach for her slides in this section

51. Chest pain
Common and important ward call.
Must see the patient.

52. Chest pain Mr S.S has got chest pain. It started 5 minutes ago. Help!
What other information do you want to know?

53. More info needed! Nature and characteristics of pain
Presenting problem
Do they have comorbidities?
Obs
What management has occurred to date?
Causes of chest pain?

54. Important causes of chest pain
Cardiac – AMI, unstable angina, angina (ACS)
Less serious – musculoskeletal (uncommon in hospital)
Pulmonary – P.E, Pneumonia
Gastric – gastritis, ulcer, GORD
Aortic dissection. Serious don’t miss it.
Others: panic attack

55. Before you see the patient…
Phone call from nurse re:chest pain.
What can you ask for …
An ECG whilst you get to the ward
If Hx of IHD … what can you order over the phone?
See if they have had anginine before, could give a stat order (1/2 anginine tablet sublingual stat) check BP prior

56. Could it be an AMI?
Features of an AMI?

57. Prompt guideline: chest pain
Can give total x3 ½ anginine over 15mins. Aim PAIN FREE. If not, give morphine (2.5mg s/c, or 2mg IV)

58. Prompt guidelines Chest Pain

59. Order ECG/ anginine over the phone if not given already
So…
Order ECG/ anginine over the phone if not given already
Come and assess patient.
1. Look at ECG, compare with old (if STs up code STEMI)
2. Take brief initial history- if sounds cardiac and not resolved, start getting IV access, call for help (reg/ MET) and continue taking more history. Ask for more anginine if still has pain and BP>90
3. Take bloods when you put in cannula:
Trop, CK, FBE, Coags, UEC (+/- G+H if possible bleeding) if not sure if cardiac, may also do lipase/ LFTs/ CRP
4. others:
CXR (portable), +/- ABG
5. if CP not resolving MET call, cardiology involvemetn
6. if CP resolved
REPEAT ECG- really really helpful to have a pain free ECG to compare- looking for “dynamic” changes
Chase C.Enzymes. May arrange repeat c. enzymes and HAND OVER to have results followed up with plan: ie- if more than ‘x’, will need anticoagulation. Clarify this plan with your reg before you go
Med reg to make follow up plan/ review meds etc/ decide on telemetry etc

60. Angina/AMI Important point:
If the history is consistent with an AMI, you don’t need to wait for ECG changes or a troponin elevation to get the patient to CCU.

61. ECGs- ISCHAEMIA Others: ST elevation
ST depression (down sloping or horizontal)
TWI (T wave inversion) or Twave Flattening
Which leads is it normal to have TWI?
leads III, aVR and V1.
Others:
- Hyperacute T-waves (eg-flip to positive)
- new BBB

62. The following ECGs are all care of Life In The Fast Lane (LITFL) online ECG library, part of FOAMed movement…
Highly recommend!!

63. 1 Inferolateral STEMI. Posterior extension is suggested by:
Horizontal ST depression in V1-3
Tall, broad R waves (> 30ms) in V2-3
Dominant R wave (R/S ratio > 1) in V2
Upright T waves in V2-3

64. 2 Widespread ST depression
A pattern of widespread ST depression plus ST elevation in aVR > 1 mm is suggestive of left main coronary artery occlusion.

65. 3

66. 4
The most striking abnormality is the widespread ST depression, seen in leads I, II and V5-6. This is consistent with widespread subendocardial ischaemia.
There is also some subtle ST elevation in V1-2 and aVR with small Q waves in V1-2, suggesting that the cause of the widespread ischaemia is a proximal LAD occlusion.

67. 5 ST elevation is maximal in the anteroseptal leads (V1-4).
Q waves are present in the septal leads (V1-2).
There is also some subtle STE in I, aVL and V5, with reciprocal ST depression in lead III.
There are hyperacute (peaked ) T waves in V2-4.
These features indicate a hyperacute anteroseptal STEMI

68. 6
There are abnormal T waves in V1-4 — biphasic in V1-3 and inverted in V4.
This pattern is known as Type 2 Wellens’ Syndrome and is highly specific for a critical stenosis of the proximal LAD artery.

69. 7
There is a septal STEMI with ST elevation maximal in V1-2 (extending out to V3).
There is a new RBBB with marked ST elevation (> 2.5 mm) in V1 plus STE in aVR — these features suggest occlusion proximal to S1.

70. 8 Dynamic ST depression in a patient with chest pain:
Widespread ST depression (leads I, II, V5-6) indicates subendocardial ischaemia.
Q wave in lead III with slightly elevated ST segment suggests the possibility of early inferior STEMI.

71. Other causes of chest pain
Gastritis/ GORD – features from history
Treatment

72. Other causes of chest pain
Gastritis/ GORD – features from history
-burning epigastric pain, can radiate upwards into the chest, related to meals etc.
Treatment
Try mylanta 20ml stat or gastrogel 20ml stat with panadol 2 tablets stat.
Pinkmix/ Pink lady (mylanta/gastrogel + lidocaine) 20mL stat
DOCUMENT if effective! Can be diagnostic if not sure if its cardiac or gastric CP

73. Other causes of chest pain
Pleuritic type chest pain – causes?
Pneumonia, P.E, pleuritis, rib fractures as well!
Investigations and Treatment? –
CXR – consolidation? Wedge shaped infarct?
ABG - ?hypoxic
Bloods – FBE, U+E, LFTs, CRP, COAG
Speak to your friendly med reg if you think it is likely PE re: organising urgent V/Q or CTPA whilst starting anticoagulation – clexane 1mg/kg s/c b.d if renal function is normal (dose reduce for renal impairment to 1mg/kg/day)

74. N+V

75. Nausea and Vomiting
Causes
Central, gastrointestinal, drugs, other …

76. PROMPT: Vomiting – has a good flow chart for post-operative vomiting and more information

78. Medications for nausea
Maxolon 10mg o, s/c, i.m, i.v
Stemetil 12.5mg o tds or 5mg iv tds.
Ondansetron 4 or 8mg iv.
Granisetron 1mg iv stat
Haloperidol 0.5mg (mainly in palliative setting)
Heaps of others! Speak with pall care if appropriate…

79. GI bleeding Upper vs Lower. Is the patient in shock? Iv access
Investigations to order – bloods, xmatch
Organising a g’scopy
Rockall’s score

84. CONSENT

85. CONSENT
Common consents – interns should not be doing consents unsupervised.
Gastroscopy
Colonoscopy
U/s guided or CT guided biopsy
Pleural taps
What are the risks that we have to warn patients about?

86. CONSENT
Eg. Common consents – interns should not be doing consents unsupervised.
Gastroscopy – bleeding, aspiration, perforation
Colonoscopy - perforation , bleeding, incomplete surveillance
U/s guided or CT guided biopsy – bleeding, infection
Pleural taps - bleeding, pneumothorax, infection

87. Consent The consent form
Surgical consents – usually done by reg or consultant in O.P.
Make sure you document the important
risks you’ve/ they’ve explained to the patient.
Also document which other family members were present at the consultation

88. Is the patient competent
General assessment if patient understands the procedure.
If patient can’t consent….who can?
Guardian appointed by VCAT, enduring power of attorney or …

89. The patient's spouse or domestic partner 7
The patient's spouse or domestic partner 7.      The patient's primary carer, including carers in receipt of a Centrelink Carer's payment but excluding paid carers or service providers 8.      The patient's nearest relative over the age of 18, which means (in order of preference): a.      son or daughter b.      father or mother c.      brother or sister (including adopted persons and 'step' relationships) d.      grandfather or grandmother e.      grandson or granddaughter f.        uncle or aunt g.      nephew or niece. Note: Where there are two relatives in the same position (for example, a brother and sister) the elder will be the person responsible.