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

2. 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???

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

5. 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.

6. 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?

7. NEUROLOGY
Altered Mental Status
Seizures
Falls
Delirium Tremens

8. Altered Mental Status **Caution with Benzos/ambien in the elderly
Try naloxone (Narcan), usually 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

9. “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

10. 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 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)

11. 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

12. 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 !

13. PULMONARY
Shortness of Breath
Hypoxia

14. 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

15. 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!

16. 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

17. 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

18. 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

19. CARDIOLOGY
Chest pain
Hypotension
Hypertension
Arrhythmias

20. 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

21. 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

22. Management of Hypotension
Anaphylaxis: sob/wheezing
epinephrine 
benadryl 
supplemental 02
 Adrenal Insufficiency
check, cortisol/ACTH level
ACTH stim test
replace volume rapidly
Hydrocortisone mg 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!!

23. 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

24. 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

25. 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) mg IV q6h
labetalol 10-20mg IV
 *Remember, no need to acutely reduce BP unless emergency

26. 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 mg
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 ug/kg/min
nitroglycerin ug/min
Labetolol 20-80mg bolus
Hydralazine 10-20mg 
Phentolamine 5-15mg bolus

27. 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!!

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

29. 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 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)

30. 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!

31. 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

32. 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

33. 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

34. RENAL/ELECTROLYTES Decreased urine output Hyperkalemia
Foley catheter problems

35. 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

36. 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 mg IV

37. 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)

38. 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

39. 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!!!

40. Infectious Disease
Positive Blood Culture
Fever

41. 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

42. 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

43. HEME
Anticoagulation
Blood replacement products

44. 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

45. 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)

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

47. 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

48. 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!!!

49. 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

50. 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

51. 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

52. 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

53. 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

54. 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.

55. 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!!