Transcript When Things Go Bump in the Night

When Things
Go Bump in the Night
Surviving Surgical Night Call
in the age of Cross-Cover
Robert O. Carpenter, MD, MPH
General Surgery Resident
General Tips
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When in doubt, which should be often,
go see the patient!
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When in doubt, which should be often,
call your upper level resident
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Never transfuse, order expensive tests,
admit a patient, or transfer a patient to the
ICU without telling the resident & attending
If the ship is sinking--LOAD THE BOAT!
That’s right boys and girls … it
can be a tough world on call!
You 7/1/07
Topics
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Abdominal Pain
Nausea/Vomiting
Constipation
Diarrhea
Bleeding
Hypotension
Hematemesis
Hematochezia
Post-op Pain
Abdominal Pain
Acute vs. chronic
 If acute – always examine the patient
 Multiple causes - need to rule out life
threatening ones
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– Perforated viscous / dead bowel
– Ruptured aneurysm
Abdominal Pain
History
 Physical exam
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» Abdomen
» Lungs, rectal--guiac, hernias, testicles
» Pelvic exam in female
Labs—CBC, CMP, Amylase/Lipase, lactate
 X-rays—CXR, KUB with flat/upright or
left lateral decubitus to rule out free air
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Doh! Free Air!
Abdominal pain
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CT scan if indicated—talk to attending first
– Consider contrast … PO, IV, BOTH?
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Consider surgical consult early
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Don’t forget chest etiology in upper
abdominal pain – pneumonia, cardiac
angina
Nausea & Vomiting
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Causes: Systemic illness, CNS, GI diseases,
Medications, Viral Illness, Obstruction, Pregnancy
Don’t forget cardiac angina equivalent
Promethazine (Phenergan)
– Careful in elderly
» 12.5-25 mg po/iv q4-6 h prn
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Metoclopramide (Reglan)
» 5-10 mg po/iv q3-4 h prn
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Serotonin antagonists$$$ (Anzemet, Kytril,
Zofran)
No longer at VUMC!!!
Nausea & Vomiting (cont)
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If does not resolve
– think of obstructive causes
Initial work up similar to abdominal pain
 Limit oral intake
 NGT / IVF if persistent …
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– EARLY! Avoid aspiration!!!
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Watch for electrolyte abnormalities
» Hypokalemia, metabolic alkalosis
Then – Fall 2002
Constipation
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Laxatives
– Biscodyl (Dulcolax)
» 5 mg po or 10 mg pr (suppository)
» Motility agent
– Docusate Sodium (Colace)
» 50-100 mg qd or bid
» Stool softener
» Prevention (narcotics)
Constipation (cont)
– Milk of Magnesia (MgOH)
» 30-60 ml po
» Osmotic
» Bean Alert
– Docusate/Casanthranol (Peri-Colace) 1-2 caps bid
(100/30 mg)
– Psyllium (Metamucil) 1 tsp in liquid bid/tid
Bulk Agent
Prophylactic vs Treatment
Constipation (cont)
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Lactulose 15-30 ml (10-20 grams)
-osmotic agent
Magnesium Citrate (300 cc bottle)
- Osmotic
- Bean Alert
Enemas
-Fleet’s Enema (caution CHF/Renal failure)
-Tap water/Soap Suds if necessary
-Don’t give in patient with rectal anastamosis
Constipation (last one)
Glove up: patient may need manual
disimpaction
 Avoid Mg/PO4 products in renal failure
 Avoid PR meds or enemas in patients with
rectal anastamoses (ex. s/p LAR)
 Evaluate medication list for culprits
 Prevention = Sleep
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NOW – February 2007
Diarrhea (acute)
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Associated with fever?
– C Diff, hemorrhagic colitis, chemo/XRT
Diarrhea vs. loose stools
 Leakage around impaction
 Send C. Diff Ag if recent Abx
 Stool O&P, fecal leukocytes and Cx if
clinically indicated
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Diarrhea (treatment)
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Avoid anti-diarrheals acutely …
– toxic megacolon
– Use only if diarrhea is non infectious
Watch for dehydration
 Lomotil (Diphenoxylate hydrochloride)
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– 5mg po qid --respiratory side effects with OD
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Imodium (Loperamide hydrochloride)
– 2-4mg after loose stools (max 8mg/day)
Bleeding
Surgical vs Medical
 Check pcv, plts, and coags –correct
coagulopathy; physical exam/hemocult
 Hold pressure if at a certain site
 Get help and gather supplies
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– NGH case & TICU Case
Get good light
 Expose the area … find bleeder, & Press!!!
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Hypotension
Assess quickly and recheck manual pressure
 Does patient look ill?
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– Use your senses!!!
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ABC’s first—call for help if necessary
– Trauma case
Reverse Trendelenburg position
 Need good IV access--at least 16g IV’s x 2!
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» Triple lumen catheter = 3 22g IV’s
» Introducer
Hypotension (cont)
Look for causes
 Preload, Contractility, Afterload
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– Hypovolemia, Cardiogenic causes, Sepsis,
Anaphylaxis
Give fluid unless cardiac failure
 Check pcv, ABG, bmp
 Consider transfer to ICU
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Best Advice I Can Give You
Eat When You Can
 Sleep When You Can
 GO When You Can!
 Call Loved Ones When On Call
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and …
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Don’t F … Mess With the Pancrease!!!
Hematemesis
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ABC’s first
– MICU case
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Good IV access
Abnormal vital signs?
– Hypotensive, tachycardic, tachypnic
– Patients can bleed to death
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Coffee ground vs. bright red blood
History of esophageal varices or ulcers
Send CBC/plt, PT/PTT, T&C 2-4 units
– Correct any coagulopathy (No clot … no stop!)
Hematemesis (cont)
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Consult GI for therapeutic endoscopy
?NGT
If known varices and unstable may need
Minnesota tube (Sengstaken-Blakemore)
Pharmacologic therapy
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H2 Blocker
PPI (IV form or continuous infusion)
Sengstaken-Blakemore
Hematochezia
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ABC’s first
Good IV access … at least 16g IV’s x 2!!!
Abnormal vital signs?
– Hypotensive, tachycardic, tachypnic
– Patients can bleed to death
» VA patient, Saint T patient
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BRB, Melena
Send CBC/plt, PT/PTT, T&C 2-4 units
– Correct any coagulopathy (No clot … no stop!)
Hematochezia
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Most common cause melena – UGI source
NGT aspirate, Posterior nose bleed
Lower GI source
– Diverticulosis, cancer, hemorrhoids
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If actively bleeding … tagged RBC scan /
Angiography may be able to localize
Bowel prep / colonoscopy /upper endoscopy
Transfuse > 6 units – means OR TIME!!!
– PLEASE … get surgeons involved before then
Post-op Pain
IV pain meds if unable to take PO
 PO usually lasts longer
 Give patient control with PCA
 Frequent IV Meds (Frequency variable)
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Morphine 2-10mg IV/IM
Demerol 25-100mg IV/IM
Dilaudid 0.5-2mg IV/IM
Fentanyl 50-100 mcg IV
Post-op Pain
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PO Narcotics
» Lortab, Percocet, Tylenol #3, Darvocet, Oxycontin
» Most contain Tylenol, watch for OD
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Toradol 30 mg iv q6h (NSAID)
» Bean alert!!!
» Slight increase risk of bleeding
» GI –ulcer complications
 No
One Parting Shot!!!
EXCUSES …
just do it!
They taught
you …
Take the TIME…
Make the EFFORT…
Remember …
of the Five
edicts …
FAMILY is
the KEY!!!
Thank You