1. How to Survive Your First Night On Call Suggestions from a former intern Matthew Deneke, MD April 12, 2006

2. Your first night on call The pager goes off…

3. Potential news on the other end of the phone “You have (another) admission in the ER.” “Your patient in 305 is crashing.” “The lady in 663 would like something to help her sleep.”

4. When it is scenario #3 Many calls you receive will be for non- urgent patient complaints When called for such complaints, you have several options: –Ignore them –Be careless –Be overly cautious –Respond appropriately

5. Cross-Cover When on call, many (if not most) of the patients for whom you are responsible will not be YOUR patients. You must depend upon your colleagues to tell you what you need to know about these patients when they check out Once your colleagues leave, it’s all YOU

6. Check Out List List of patients on a service Used by on call person (usually intern) when called about a patient –Often the only information the person on call will know about the patient Usually includes patient names, locations, principal diagnoses, and any issues that need to be followed up overnight.

7. Check Out Should also include any other information someone might need on call –Diabetes –Renal dysfunction –Hepatic dysfunction (cirrhosis) –Unstable psychiatric conditions –Any medications you want or don’t want given –Known potential for instability/overnight issues

8. Check Out Unless not possible, should also include a face-to-face discussion of major issues Remember, check out unto others as you would have them check out unto you.

9. Specific issues Pain Nausea/Vomiting Insomnia Anxiety Agitation Constipation Heartburn Pruritus A couple of more urgent issues Electrolytes

10. Obviously, for any new, unexpected change in a patient, the first thing to do is to GO SEE THE PATIENT.

11. The “simple,” “mundane,” and often annoying…

12. Pain Opioids –Morphine 2mg IV May repeat q 4 hrs prn –Oxycodone 5-10mg PO May repeat q 4 hrs prn –Avoid Demerol if possible Increased euphoria, risk of seizures

13. Pain Opioids (cont) –Dose adjustments Start with ½ dose in elderly or in renal/hepatic dysfunction Use caution in patients with respiratory illness May have to use more in patients on chronic opiates PO:IV conversion for morphine is 3:1 If you give too much, remember: Narcan 0.4mg IV

14. Pain Acetaminophen –650mg PO/PR –Avoid in liver dysfunction –Also good for fever

15. Pain Opioid/acetaminophen combinations –Percocet Oxycodone 5mg/APAP 325mg –Tylox Oxycodone 5mg/APAP 500mg –Lortab/Vicodin Hydrocodone 5-10mg/APAP 500mg

16. Pain Implications –2 Percocet q 4 hrs (6 x/day) = 3900mg APAP –2 Tylox (or Lortab/Vicodin) q 4 hrs = 6000mg APAP Maximum dose of APAP in 24 hrs is 4g So, if giving 2 Tylox/Lortab/Vicodin, do not give more often than q 6 hrs

17. Pain NSAIDs –Naproxen 500mg PO q 12 hrs –Ibuprofen 800mg PO q 8 hrs –Ketorolac (Toradol) 60mg IM/IV once, then 30mg IV q 6 hrs Cannot use for > 5 days –Avoid in renal dysfuction (acute or chronic) or uncontrolled HTN, caution in CHF

18. Nausea/Vomiting Promethazine (Phenergan) –25mg IV q 4 hrs prn –50mg PO/PR q 4 hrs prn –Use lower doses in elderly due to increase side effects

19. Nausea/Vomiting Metoclopramide (Reglan) –10mg IV/PO q 6 hrs prn –Remember it stimulates gut motility Avoid in suspected bowel obstruction or diarrhea –Use half dose in dialysis patients or elderly –Dystonic reaction Treat with Benadryl 25mg IV

20. Nausea/Vomiting Ondansetron (Zofran) –4mg IV q 8 hrs prn –8mg po q 8 hrs prn –Best effect is in chemotherapy induced nausea –Very expensive –Safest side effect profile for elderly

21. Insomnia Diphenhydramine (Benadryl) –50mg po –25mg IV –Avoid in elderly (anticholinergic)

22. Insomnia Trazodone –50-100mg qHS –Safe in elderly –Side effects Hypotension Priapism

23. Insomnia Zolpidem (Ambien) –10mg qHS –5mg in elderly –Expensive

24. Acute Anxiety Short-acting benzodiazepines –Lorazepam (Ativan) 1-2mg PO/IV q 4-6 hrs prn –Alprazolam (Xanax) 0.5-1mg PO TID prn Do not use in patients with liver disease Avoid in elderly or use very low doses Can try trazodone in elderly first Can use hydroxyzine if drug-seeking

25. Agitation Haloperidol (Haldol) –2mg-5mg PO/IM/IV –In elderly, use 0.5-1mg PO/IM/IV –Watch for dystonic reaction Ativan –2mg PO/IV –Avoid in confused elderly patients May need higher dose if patient uses medication chronically

26. Constipation Milk of Magnesia –30 mL PO Magnesium Citrate –8 oz (240mL) bottle PO Fleet’s enema –One enema PR AVOID THESE IN DIALYSIS PATIENTS Risk of hyperMg/hyperPO4

27. Constipation Lactulose –30mL PO –Can cause bloating/gas Bisacodyl (Dulcolax) –10mg PO/PR –Can cause cramping Combinations also work well

28. Heartburn MgOH/AlOH (Maalox) –30mL PO –Avoid in dialysis patients CaCO3 (Tums) –2 tablets PO –Safe in dialysis patients Ranitidine (Zantac) –150mg po BID prn –Dose once daily in dialysis patients

29. Heartburn GI cocktail –Usually combination of Maalox, viscous lidocaine, and another medication (Benadryl or Donnatal) –Usually complicated to order and is delayed by Pharmacy –Some studies say no better than Maalox alone Do not give PPI alone for acute heartburn –Onset of action is delayed by several hours

30. Pruritus Benadryl –25-50mg PO/IV q 4 hrs –Avoid or reduce dose in elderly Hydroxyzine (Atarax, Vistaril) –25-100mg PO/IM q 6 hrs –Avoid in elderly –Cannot be given IV If one does not work, try the other

31. More Urgent Issues

32. Chest Pain Give nitroglycerin 0.4mg sublingual –Response does not predict cardiac source, but may give the patient relief EKG Troponin/cardiac enzymes If no response to NTG x 3 and EKG is negative, can try Maalox or GI cocktail

33. Chest Pain 7 lethal causes –Acute MI –Pulmonary embolus –Pericarditis with tamponade –Tension pneumothorax –Aortic dissection –Boerhaave’s syndrome (esophageal rupture) –Severe pneumonia

34. Fever Obtain blood cultures before starting antibiotics Causes in hospitalized patients –UTI (foley) –Pneumonia –Wounds (surgical, trauma, decubiti) –Plastic (IV’s, CVL’s, drainage catheters, etc.) –DVT –C. difficile colitis (if diarrhea present) –Sinusitis (if NG tube has been used)

35. Electrolytes: some quick reminders

36. Electrolytes Potassium –10mEq for every 0.1mEq above 3.0 –20mEq for every 0.2mEq below 3.0 –K 2.8, want to correct to 4.0 (20x2)+(10x10) = 140mEq

37. Electrolytes Potassium (cont.) –For urgent replacement, give PO liquid or IV, do not give PO tablets/capsules –IV rates 10mEq/hr through peripheral 20mEq/hr through CVL –Use caution when replacing patients with chronic kidney disease –Do not replace in dialysis patients unless absolutely necessary

38. Electrolytes Magnesium –Must be replaced IV –Safe to give in large amounts –Can be given quickly –Give 2-4g MgSO4 IV –Only replace if absolutely necessary in dialysis patients

39. Electrolytes Calcium –If low, first check serum albumin –[Measured Ca] + [(4.0 – albumin) x 0.8] = corrected Ca –If replacing, know PO4 first –Replacement Ca gluconate 1 amp (10mL of 10% solution) = 1g 1g Ca gluconate = 4.65 mEq Usual replacement is with 1-2g Ca gluconate IV

40. Electrolytes Phosphorus –If mildly low (>1.5), replace PO Neutra-Phos 2 packets BID-TID Fleet’s phospho-soda 5-10mL TID –If very low or symptomatic, pt needs IV Ask for help Do not replace in dialysis patients unless absolutely necessary (tired of hearing this yet?)

41. Special Thanks Kelly Thomas, PharmD Drs Menna and Thompson My wife n’ kids