Transcript Go to bedside

A Day in the life…
and
Cross-Cover
Nina Zatikyan
Ann Malbas
Chief Residents
OVERVIEW- CROSS COVER
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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???
HOW TO MAKE YOUR
CROSS COVER LIST
• Log on to www.caregate.net
• Go to your “Patient lists”
• Click on to “Sign out Rpt” button
CROSS-COVER NOTES
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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.
WHAT DO I DO WHEN I’M
CALLED?
• Review basics by organ systems today
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Neuro
Pulmonary
Cardiology
Gastrointestinal
Renal
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Infectious Disease
Heme
Radiology
Death
-Ask yourself, does this patient sound stable or unstable?
-Ask for vitals
-Is this a new change?
NEUROLOGY
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Altered Mental Status
Seizures
Falls
Delirium Tremens
ALTERED MENTAL STATUS
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Always go to the bedside!!!
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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 noncontrast head CT
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Try naloxone (Narcan), usually
0.4-1.2 mg IV, if there is any
possibility of opiate OD
If elderly person is
agitated/sundowning
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Family member at bedsidethe best
Medications
 Haloperidol 2mg IV/IM
 Ziprasidone (Geodon) 1020mg IM
 Quetiapine (Seroquel)
25mg po qhs
Restraints (last resort)
non-violent/non-behavioral
**Caution with Benzos/ambien in the elderly
“MOVE STUPID”
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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
SEIZURES
• Go to bedside to determine if patient still actively seizing
• Call your resident
• Assess ABCs
o give 02, intubate if necessary
o Place patient in left lateral decubitus position
• Labs
o electrolytes (Ca+), glucose, CBC, renal/liver fxn, tox screen,
anticonvulsant drug levels, check Accucheck
• Treatment:
o Give thiamine 100 mg IV first, then 1 amp D50
o Antipyretics for fever or cooling blankets
o Lorazepam 0.1mg/kg IV at 2mg/min
• If seizures continue;
o Load phenytoin 15-20 mg/kg IV in 3 divided doses at 50 mg/min
(usually 1 g total) or fosphenytoin 20mg/kg IV at 150mg/min
o 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)
FALLS
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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 noncontrast head CT to r/o subdural hematoma
• Order fall precautions
DELIRIUM TREMENS (DTS)
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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 !
PULMONARY
• Shortness of Breath
• Hypoxia
SHORTNESS OF BREATH
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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
CAUSES OF SOB
• Pulmonary:
o Pneumonia, pneumothorax, PE, aspiration,
bronchospasm, upper airway obstruction, ARDS
• Cardiac:
o MI/ischemia, CHF, arrhythmia, tamponade
• Metabolic:
o Acidosis, sepsis
• Hematologic:
o Anemia, methemoglobinemia
• Psychiatric:
o Anxiety – common, but a diagnosis of exclusion!
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
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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
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
MECHANICAL VENTILATION
• If patient needs to be intubated, start with maskventilation until help from upper level arrives
• Initial settings for Vent:
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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
CARDIOLOGY
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Chest pain
Hypotension
Hypertension
Arrhythmias
CHEST PAIN
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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
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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
HYPOTENSION
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Go and see the patient!!!
Repeat BP and HR, manually
Compare recent vitals trends
Look for recent ECHO/meds pt has been given.
EXAM:
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Vitals: orthostatic? tachycardic?
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Neuro: AMS
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HEENT: dry mucosa?
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Neck: flat vs. JVD (=CHF)
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Chest: dyspnea, wheezes (?anaphylaxis), crackles (=CHF)
Heart: manual pulse, S3 (CHF)
o Ext: cool, clammy, edema
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MANAGEMENT OF HYPOTENSION
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Hypovolemia
o volume resuscitation
o if CHF,bolus 500ml NS
o transfuse blood
Cardiogenic
o fluids
o inotropic agents
Sepsis: febrile >101.5
o blood cultures x 2
o empiric antibiotics
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Anaphylaxis: sob/wheezing
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epinephrine
benadryl
supplemental 02
Adrenal Insufficiency
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check, cortisol/ACTH level
ACTH stim test
replace volume rapidly
Hydrocortisone 50-100mg IV
q6-8h
*Stop BP meds!
*Don't forget about tamponade, PE and pneumothorax!!
COMMONLY USED
PRESSORS
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
1–20 mcg/kg/min Positive inotropy and
Phenylephrine
(Neosynephrine)
Dobutamine
B1, B2
chronotropy;
Causes Hypotension
HYPERTENSION
• Is there history of HTN?
o Check BP trends
• Is patient symptomatic?
o 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:
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Manual BP in both arms
Fundoscopic exam: look for papilledema and hemorrhages
Neuro: AMS, focal weakness or paresis
Neck: JVD, stiffness
Lungs: crackles
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Cardiac: S3
MANAGEMENT OF HTN
• If patient is asymptomatic and exam is WNL:
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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:
o hydralazine 10-20mg IV
o enalapril (vasotec) 1.25-5mg IV q6h
o labetalol 10-20mg IV
*Remember, no need to acutely reduce BP unless emergency
HYPERTENSION
(CONTINUED)
URGENCY
• SBP>210 or DBP>120
with no end organ
damage
• OK to treat with PO
agents (decr BP in hours)
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hydralazine 10-25mg
captopril 25-50mg
labetolol 200-1200mg
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)
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nitroprusside 0.25-10ug/kg/min
nitroglycerin 17-1000ug/min
Labetolol 20-80mg bolus
Hydralazine 10-20mg
Phentolamine 5-15mg bolus
ARRHYTHMIAS
Tachyarrhythmias
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Afib/flutter RVR
rate control
(BB/diltiazem/digoxin if BP
low)
o consider anti-arrhythmic
(amiodarone)
Bradycardia
• Assess ABCs
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SVT/SVT with aberrancy
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vagal maneuver
adenosine 6-12mg IV
Ventricular fib/flutter
check Mg level, replace if
needed (>3.0)
o amiodarone drip
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*Remember, if unstable shock!!
give 02
monitor BP
Sinus block: 1st, 2nd or 3rd
degree
Hold BB meds
Prepare for transcutaneous
pacing
o Atropine 0.5mg IV x3
o Consider low dose
 Epi (2-10mcg/min)
 dopamine(2-10mcg/kg/min)
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GASTROINTESTINAL
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Nausea/Vomiting
GI Bleed
Acute Abdominal Pain
Diarrhea/Constipation
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:
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Phenergan 12.5-25mg IV/PR (lower in elderly)
Zofran 4-8mg IV
Reglan 10-20 mg IV (especially if suspect gastroparesis)
If no relief, consider NG tube (especially if suspect bowel
obstruction)
GI BLEED
UPPER
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Hematemesis, melena
Check vitals
Place NG tube
NPO
Wide open fluids,
type&cross for blood
• Check H/H serially
• If suspect
o PUD: Protonix gtt
o varices: octreotide gtt
**Call Resident and GI
LOWER
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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!
ACUTE ABDOMINAL PAIN
• Go to the bedside!!!
• Assess vitals, rapidity of onset, location, quality and
severity of pain
LOCATION:
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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
ACUTE ABDOMEN
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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:
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Pain management—may use morphine if no
contraindication
Remember, if any narcotics are started, use carefully
in elderly, ensure pt on adequate bowel regimen
DIARRHEA
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Is this new?
check stool studies:
o c.diff
o culture
o o&p
o wbc
o FOBT x 3
Do not treat with
loperamide if you think it
might be C.diff!!!
CONSTIPATION
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Is this new?
check KUB
Ileus/bowel obstruction:
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place NPO
Treat:
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Laxative of choice
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MOM
Miralax
enema
 tap water
 soap
Bowel regimen
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colace 100mg bid
dulcolax 5-15mg
RENAL/ELECTROLYTES
• Decreased urine output
• Hyperkalemia
• Foley catheter problems
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:
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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
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 20-40 mg IV
FOLEY CATHETER
PROBLEMS:
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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)
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:
o peaked T-waves
o flattened P waves
o PR prolongation followed by loss of P waves
o QRS widening
TREATMENT OF HYPERKALEMIA
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Mild (<6.0 mEq/L)
Decrease total body stores
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Lasix 40-80mg IV
Kayexalate 30-90g PO/PR
Moderate (6-7mEq/L)
Shift K+ in cells
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Severe (>7mEq/L) or EKG
changes
Protect myocardium
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Calcium gluconate 12amps IV over 2-5min
NaHCO3 50mEq (1-3amps)
D50+10units insulin IV
albuterol 10-20mg neb
**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!!!
INFECTIOUS DISEASE
• Positive Blood Culture
• Fever
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”?
o This is likely a contaminant.
o 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
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
o order blood cultures x 2 from different IV sites
o UA/culture
o CXR
o 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
HEME
• Anticoagulation
• Blood replacement products
ANTICOAGULATION
• Appropriate for:
o DVT/PE
o Acute Coronary Syndrome
• Usually start with low molecular weight heparin
o Lovenox 1 mg/kg every 12 hours and renally adjust
• If need to turn on/off quickly (e.g., pt going for procedure)
o heparin drip—protocol in EPIC
• Risk factors for bleeding on heparin:
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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
BLOOD REPLACEMENT
PRODUCTS
• PRBC:
o One unit should raise Hct 3 points or Hgb 1 g/dl
• Platelets:
o 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
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DIC or liver failure with elevated coags and concomitant
bleeding
Reversal of INR (ie for procedure)
RADIOLOGY
Which test should I order?
• Plain Films
• CT scans
• MRI
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
CT
• Head CT
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Non-contrast best for bleeding, CVA, trauma
Contrast best for anything that effects the blood brain barrier
(ie tumors, infection)
• CT Angiogram
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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
o Renal stone protocol to look for nephrolithiasis
o 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
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* If you are going to give contrast, check your Cr!!!
MRI
• Increased sensitivity for soft tissue pathology
• Best choice for:
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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
DEATH
• Pronouncing a patient
• Patient may be pronounced by 2 RNs
• Notify the patient’s family
• Request an autopsy
• How to write a death note
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
NOTIFY THE PATIENT’S
FAMILY
• Call family if not present and ask to come in, or if family
is present:
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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
REQUEST AN AUTOPSY
• Ask family if they would like an autopsy
• Medical Examiner will be called if:
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o
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Patient hospitalized <24 hours
Death associated with unusual circumstances
Death associated with trauma
HOW TO WRITE A DEATH
NOTE
DOCUMENTATION:
• “Called to bedside by nurse to pronounce (name of pt).”
• Chart all findings previously discussed:
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“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.
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!!