Transcript Ward & On Call Survival Skills

Ward & On Call
Survival Skills
By:
Gen Surg R2s
Plastics R2
Urology R2s
ENT R2
Ortho R2s
Laura VanderBeek
Carmen Barnette
Heather MacLeod
Jola Omole
Colin White
Jason Kovac
Zak Klinghoffer
Rajveer Hundal
Ted Scriven
Jihad Abouali
Vick Khanna
General Ward
Management
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Electrolyte imbalance
Post Op Fever
Chest pain/SOB
ECG
Acute MI
Common General Surgery
Consults
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Appendicitis
Acute Cholecystitis
Ascending Cholangitis
Acute Pancreatitis
Small Bowel Obstruction
Ischemic Bowel
Helpful Pointers
• Urology
• Orthopaedics
• ENT
– Epistaxis
– Peritonsillar Abscess
• Plastics
• Useful #s and General Tips
Hypokalemia
• What is the cause?
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Diuretics (lasix)
Metabolic / Respiratory Alkalosis
Hyperaldosteronism
Diabetic ketoacidosis (with osmotic diuresis)
Loss through GI tract (diarrhea,vomiting)
Other renal losses - eg. various renal tubular
acidoses
Hypokalemia
• ECG (PAC, PVC, flat Ts, U waves, ST depression)
• Replenish Potassium:
– IV:
• Add 20-40mEq KCl/L to IV solution
• 10 mEq in 100cc H2O (x 3) ~> each over 1 hr
• hurts, remember KCl scleroses veins
– Oral:
• KCl elixir 20 mmol/15ml
• K-lyte 25mmol/packet
• i-ii Slow K tabs (8mmol)
– Replace Mg if deficient
• Repeat lytes
Hyperkalemia
What is the causes?
• Pseudohyperkalemia:
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Hemolysis
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K+ supplements (oral or IV), Blood transfusions
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Renal failure (acute or chronic)
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K+ sparing diuretics (spironolactone)
ACE inhibitors
NSAIDS
Trimetoprim / sulfamethoxazole (TMP/SMX)
Cyclosporine
Renal tubular acidosis
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Acidosis
Cellular breakdown (Rhabdomyolysis, Hemolysis, Tumor lysis syndrome,
Burns)
Drugs (digoxin, beta blockers, succinylcholine)
Insulin deficiency
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Excessive Intake:
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Decreased Excretion:
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Drugs:
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Redistribution:
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Hyperkalemia
• Repeat lytes
• Stat IV
• ECG
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– Peaked Ts, ↓ R waves, prolonged PR, no P waves, sudden VT
Stop any K+ or contributing drugs
Notify your chief resident/SMR
Continuous cardiac monitoring
1 amp CaCl or Ca gluconate 10%
1 amp D50W IV then Humulin R 10 units IV
Ventolin
Lasix 20-40mg IV
1 amp sodium bicarbonate (NaHCO3)
kayexalate: 30 g PO/PR q4h
Persistently high, call nephrology for dialysis
Post-Op Fever
• The 5 W’s:
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Wind (pneumonia)
Water (UTI)
Wound
Walk (DVT, PE)
What did we do?
• (surgery, drugs, IV sites, blood products)
Chest Pain &/or SOB
• Assess pt:
– ABC’s, vitals
– Hx
– PE
• Do you need further investigations:
– CXR
– CK and Trops
– ECG
• Remember:
– Call for help early if pt unstable or you feel
uncomfortable:
• chief resident / SMR / CCRT/ RACE team
ECG
• Rate
– 300-150-100-75-60-50
• Rhythm
– P before every QRS, QRS after every P
– PR interval (AV blocks), QRS interval (BBB)
• Axis
– Positive QRS in leads I and aVF
• Intervals
– QRS <0.12, PR 0.12-0.20
• Hypertrophy
– RVH: R wave progression decreases from V1 to V6
– LVH: S in V1 + R in V5 > 35 mm
• Infarct
– ST depression, ST elevation
– T wave inversions, Q waves
Acute MI
• ABC’s
• MONA
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Morphine
Oxygen
Nitroglycerin
Asprin (160mg chewed)
ECG
2 large bore IVs
CK and Trop q8h x3
CXR
Meds: ASA, anticoagulation, ACEi, B-blocker, CCB, Statin,
Diet
• Call Race team, CCRT or SMR, ?PCI
Gen Surg Consults
• Constipation
– Does not have to be a referal
– ER docs can manage them, but they often are referred
and hard not too accept as they could be a more serious
underlying problem
• GI Bleeds
– Go to GI, some exceptions
• Abd pain and Crohns, even if it is SBO
– Go to GI, some exceptions
Appendicitis
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Symptoms:
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Signs:
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Imaging:
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Management:
– anorexia usually first symptom, followed by vague peri-umbilical  RLQ
abdo pain, then vomiting occurs after the onset of pain; if no anorexia
or if vomiting before pain, then question the diagnosis
– fever, localized RLQ peritonitis, increased WBC
– Plain film – may see ileus
– U/S – (sens 55-95%; spec 85-98%) look for non-compressible
appendix, > 6mm diameter, presence of a fecalith, peri-appendiceal
fluid, and thickened appendiceal wall
– CT – (sens 92-97%; spec 85-94%) dilated appendix > 5mm, thickened
appendiceal wall, fat-stranding, thickened mesoappendix, and obvious
phlegmon
– IV fluid resuscitation, antibiotic coverage (cipro/flagyl, 2nd gen
cephalopsporin), NPO, analgesia, prepare for OR (consent, book OR),
lap/open appendectomy equivalent. If perforated with abscess,
treatment is percutaneous drain and interval appendectomy.
Acute Cholecystitis
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Symptoms:
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Signs:
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Imaging:
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Management:
– steady RUQ pain (usually > 12 hr duration), bloating, nausea/vomiting,
onset after big/fatty meal
– Murphy’s sign, distended abdo, fever, increased WBC, may see increased
conjugated bili and alk phos/GGTs – may indicate passed stone
– CXR – exclude RLL pneumonia, may be able to see calcified stone
– U/S – (sens 88%; spec 80%) gallstones, distended gallbladder, thickened
wall ( > 3mm), pericholecystic fluid, and sonographic Murphys sign
– CT – wall thickening, pericholecystic fluid, subserosal edema
– HIDA – (sens 97%; spec 90%) failure to see contrast in gallbladder/cystic
duct
– IV fluid rehydration, NPO, antibiotics (cipro/flagyl, amp/gent/ flagyl),
analgesia (toradol/morphine), conservative management or
cholecystectomy if presentation within first 48 hrs or if patient
deteriorates. May consider percutaneous cholecystostomy tube if patient
not good operative candidate.
Ascending Cholangitis
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Symptoms:
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Signs:
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Imaging:
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Management:
– RUQ pain, jaundice, fever – Charcot’s triad; plus hypotension and
confusion – Reynold’s pentad (indicates shock state); may also have
nausea/vomiting
– jaundice; Murphys sign; increased WBC; fever; increased conjugated
bilirubin, alk phos/GGT, and transaminases
– U/S – distended gallbladder, dilated bile ducts, choledocolithiasis
– CT – dilated biliary system, pancreatic head masses
– ERCP/PTC – dilated biliary system, choledocolithiasis, site of biliary
tree obstruction
– Aggressive IV fluid resuscitation, blood cultures, antibiotics, analgesia,
NPO, urgent biliary tree decompression (ERCP/PTC drain), may require
ICU admission
Acute Pancreatitis
• Symptoms:
– severe, steady epigastric/LUQ pain that radiates to the back,
nausea/vomiting, pain may be relieved by leaning forward
• Signs:
– epigastric tenderness with voluntary/involuntary guarding,
fever, leukocytosis, increased amylase/lipase, LFTs may be
increased if gallstone disease
• Imaging
– U/S – R/O gallstones
– CT – use to differentiate between mild and severe pancreatitis
and to monitor for complications of severe pancreatitis
• Management:
– Aggressive IV fluid resuscitation, correct electrolytes, foley
in, analgesia, NPO/clear fluid diet, antibiotics in severe
pancreatitis, monitor lab markers as per Ranson’s Criteria or
APACHE-II score, may require ICU admission
Small Bowel Obstruction
• Symptoms:
– colicky abdo pain, nausea, vomiting, and obstipation
• Signs:
– abdo distention (esp. if distal obstruction), dehydration, mild
leukocytosis
• Imaging:
– Plain films – (sens 70-80%; low spec) dilated small bowel loops
(>3cm), air-fluid levels ( > 5), absence of gas in the colon/rectum
– CT – (sens 80-90%; spec 70-90%) transition zone with dilated
bowel proximal and collapsed bowel distal, intraluminal contrast
not present distal to transition point, and little gas or fluid in
the colon
• Management:
– IV fluid resuscitation, electrolyte correction, foley catheter in,
NG tube esp. if vomiting, NPO, urgent OR if suspect
strangulation/ischemia, otherwise trial of conservative
management with serial abdo x-rays
Ischemic Bowel
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Symptoms:
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Signs:
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Imaging:
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mid-abdominal pain out of proportion to physical findings, nausea/vomiting,
diarrhea, blood per rectum
abdo distention, diffuse peritonitis, fever, +ve FOB, increased WBC (often > 20
000), increased lactate, metabolic acidosis
Plain films: ileus, thumbprinting, gas in bowel wall or portal venous system
CT (with IV contrast)– (imaging modality of choice) bowel wall edema, gas in the
bowel wall, decreased bowel wall enhancement, occlusion of SMA/LMA, gas in the
portal venous system
Angiography – site of occlusion of mesenteric vessels, can determine whether
embolic occlusion, thrombotic occlusion or vasospasm,
Management:
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Aggressive IV fluid resuscitation, foley in, analgesia, correction of electrolyte
imbalances, antibiotics (tazocin), +/- CTA of abdo/pelvis, ICU admission, urgent
laparotomy for resection of necrotic bowel – if entire small bowel compromised
patient is palliative, revascularization may be required intra-op or via antithrombolytics depending on etiology. Second look laparotomy in 24-48 hours to
check for further necrotic bowel, esp. if during first laparotomy bowel was
resected or there were areas of questionable viability.
General Surgery Topics
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Hernias
Breast cancer
Colon Cancer
Soft tissue and Skin Malignancy
GERD and esophageal diseases
Hepatobillary Diseases (very brief
and only if at St. Joes or MUMC)
Urology
• Ward :
– Difficult catheters
– Suprapubic catheters
– Post-op retention
• ER :
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Stones (office apt. vs. consult)
Hematuria
Trauma
Pyelonephritis
Orthopaedics
• Site Specialties:
– HGH:
• Trauma, Upper Extremity, Foot&Ankle, Spine
• Lots of ‘Barton Street Specials’
– MUMC:
• Peds, Sports
• Lots of ‘entitled’ local residents
– HDGH:
• Mainly arthroplasty, Sports (just a bit)
• Lots of old people with broken hips
– SJH:
• Arthroplasty, Upper extremity, Spine, Foot&Ankle
• Lots of ‘crazys’ thanks to psych
Orthopaedics
• On Call:
– Weekdays: Day call 8-5, Night call 5-8
– Weekends: 8-8 (check for 8am OR’s 1st!!)
– Always 2nd call backup by Sr – don’t hesitate
to call them (esp before calling staff)!
– Consults: get a copy of the bradma to give to
staff with dictation jobid on it
– Post-call: get a feel for things, use your own
judgment
• Similar for Gen Surg
Orthopaedics
• On Call:
– HGH: in house, terrible call rooms, very busy
with trauma
– HDGH: home call, check with wards before
leaving, lots of hip #’s
– MUMC: VERY busy with ER consults, lots of
reductions, issues with RNs, conscious
sedation in ER
– SJH: Home call
– Make SURE you handover all issues/admits
in the a.m.!
Orthopaedics
• Ortho Emergencies:
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Open #’s
Compartment Syndrome
Lower Limb Nec Fasc
# Dislocations
Cauda Equina
Septic Joints
NV Compromise
C-Spine Injuries
Orthopaedics
• Common Ortho Meds to Know:
– Ancef
– Percocet
– What else could you possibly need???
Orthopaedics
• Admissions:
– Never admit without 1st talking with Sr or
Staff
– Many sites have pre-printed order sheets (ex:
HDGH, 6W @ HGH)
– Don’t forget NPO, abx oncall, pre-op consults
(medicine, thrombo, anesthesia)
– Many medicine consults, but use your head 1st!!!
(ex: timing, appropriateness)
Orthopaedics
• Department Activities:
– Wednesday a.m. Grand Rounds
• 7-7:30am: spine or oncology
• 7:30-8:30: Grand rounds
– Each resident assigned a staff for 1 presentation/year
– Staff presents cases and grills chiefs, resident
presents ~15min at the end
– Try to find out case details from staff to pass along to
residents (esp chiefs) in advance!
– Journal Club:
• Monthly, different staff’s house each month.
• Schedule out in advance, R3’s coordinate
• May be excused from call to attend!
Orthopaedics
• Department Activities:
– Quarterly JBJS MCQ
• Subscriptions given out in July/Aug
(Candice)
• Quarterly quizes found online (jbjs.org?)
• Submit to Dr. Bednar on due date
(Wednesdays)
• Must complete ¾ yearly
– OITE
• Novemberish
• Everyone fails BADLY!
Orthopaedics
• Department Activities:
– Funding:
• ~$1200 yearly for courses/books – use it or
lose it!
– Research:
• Present twice in 5 years
• Coordinator is Dr. Ghert
• Need ideas/proposals by fall of R2
Orthopaedics
• Resources:
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JAAOS online – good reviews
Hopenfeld – surgical approaches
AO Foundation for Trauma
Wheeless online
Rockwood – wordy but comprehensive for #’s
Campbells – good luck! Good insomnia tx
Miller Review – good for review, very brief
Epistaxis
• When assessing a
patient in the ER, it
is important to
determine if the
patient is still
bleeding, is this an
anterior or
posterior bleed?
Anterior Bleeds
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Very common, occur from vessels which anastomose & create
Kiesselbach’s plexus
1. Ask the patient to gently blow the nose to clear out any clots.
2. Use suction if needed to rid yourself of clots/excess blood.
3. Use cotton swabs with lidocaine and epinephrine to achieve a
vasoconstrictive effect.
4. Take a look with your nasal speculum and see if there are areas of
bleeding.
5. Use silver nitrate cautery if there is a bleeding vessel, do NOT!
Cauterize both sides of the septum.
6. If bleeding does not stop move on to packing with Vaseline gauze or
murocel packs.
7. Remember to give medications for pain (Tylenol 3/Percocet) and Keflex
to prevent toxic shock syndrome from the packing. Have the patient
return in ~2 days to remove packs.
8. Sometimes the bleeding still doesn’t stop and you may have a posterior
bleed which will require a nasal pack. Posterior bleeds are usually caused
by the sphenopalatine artery.
Posterior Bleeds
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Technique - Foley catheter (10-14F 30-mL balloon)
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Apply ‘muco’ nasal ointment 2% to the catheter.
Insert the catheter into the nostril.
Visualize the catheter tip in the back of the throat.
Inflate the balloon with up to 10 mL of sterile water. (Do not
fully inflate the balloon to 30 mL.)
Withdraw the balloon gently until it seats posteriorly.
Pack the anterior nasal cavity with a balloon device, nasal
tampon (eg, Rhino Rocket), or layered ribbon gauze.
Apply a padded umbilical clamp across the catheter to
prevent alar necrosis and to keep the balloon from dislodging.
Peritonsillar Abscess
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Needle aspiration: Needle aspiration is used
for symptom relief and is the criterion
standard for diagnosis. Lidocaine with
epinephrine should be used to anesthetize the
area. A 16- to 18-gauge needle with a 10-mL
syringe should be used to aspirate from the
area that is most fluctuant. A needle
guard may be used to prevent accidental
carotid artery puncture due to the tip of the
needle migrating too far posteriorly. Only 0.5
cm of the needle needs to be exposed. If a
needle guard is unavailable, a curved clamp can
be used to expose a small portion of the
needle before inserting it into the area for
aspiration. Since the superior pole is the most
common place for the abscess to develop, that
is usually the first place aspirated if the
entire tonsil looks or feels boggy. Aspiration
of the middle one third and then the lower
one third should then be attempted if pus is
not returned from the superior pole.
Peritonsillar Abscess
• Abscess I&D:
– After lidocaine with epinephrine local infiltration, a No.
11 blade scalpel may be used to incise a very large PTA,
allowing the purulent drainage to flow freely as the
abscess cavity decompresses. Allow the patient to hold
the Yankauer catheter tip and to suction the pus, rather
than swallow it. Give analgesia medications and
Clindamycin 600 mg po TID for ~10 days.
• Tonsillectomy:
– may be used for recurrent peritonsillar abscesses
Plastics
• First year of plastic residency is mostly
off service:
• Ortho, Medicine, Plastics, ER, Gen Surg (4
mths)
• Plastics rotation is based out of SJH
• Journal Club each month (don’t miss this)
• Core and Plastics rounds (don’t be late)
• Call at SJH
Plastics
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Off service residents going thur plastics:
Gen Surg – usually at General
- trauma, hand fractures
Ortho – usually during second year at SJH
- know hand and breast anatomy
• Ways to prep Toronto Notes & The little
red book of plastics secrets
Plastics
• Need to know how to do…
– extensor tendon repairs
– manage various hand fractures (ie the
different ways of casting)
– local hand nerve blocks
– drain abscesses appropriately
– Expected to be able to conduct
procedures independently in ER (ie
sterile technique etc)
Plastics
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Know the plastics emergencies
Know the reasons for referrals
Get meditech at home for looking at Xrays
Know different dressing types and
associated +/- of each
• Consults – wide range of cases
• Have office phone numbers & addresses on
hand for arranging follow up
Plastics
• SJH staff are very particular with
punctuality and dress for clinic
• White coats must always be worn if in
greens and outside of the OR
• Always be on time for the start of staff
clinics and especially for SJH resident
clinics Friday mornings
• Its a preceptor based system at SJH so if
you are sick make sure you let your staff
or staff office know
Phone #s
Dictation:
MUMC
• Main #:
• Paging:
HGH
• Main #:
• Paging:
HDGH
• Main #:
• Paging:
5000
905-521-2100
76443
905-527-0271
46311
905-389-4411
42111
SJH Phone #s
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Main #:
Paging:
Admitting:
Dictation:
905-522-1155
33311
33183
32078
– doesn’t give you prompts so use the
yellow card the first few times
Paging
• HHS
– 87 – pager # * priority
• Online Text
– “corpweb”
– Far right of screen, link to
“PHONEBOOK”
– Type in last name of person to be paged
Turning Off Your Pager
• Turning your pager off does not work
• Call paging and let them know you are post
call, on vacation, at teaching… etc
• Call 905-521-2100
– Ext 87
– Enter your pager #
– Enter 08
• Do the same thing to turn pager back on
General Tips
• Keep up with reading/knowledge, you won’t
operate if you don’t know what you’re
talking about
• Be on time
• Get to the OR before your staff does
• Work hard, don’t be lazy
• Enjoy time off when you get it
• RNs can be your best friends or your
worst enemy!
General Tips
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Teach the Clerks
Take advice from your seniors
Make sure to vent often, and if necessary loudly!
If you think about calling your senior or staff,
CALL them
• If you are overwhelmed with a sick pt call your
senior, the CCRT, RACE team, and/or the SMR
• If someone is nasty to you, chances are they are
nasty to everyone!
• Keep a balanced life
– family, friends, physical activity, hobbies, etc
• Take all your vacations!!!
• Have Fun!!!