Transcript Night Float Topics by Justin Morrison

Night Float Topics
CASED-BASED PRESENTATION
Case1
• You are paged about an 85 y.o. female on the geriatrics team who
was initially admitted for constipation. The RN said she is feeling a
fluttering in the chest. The RN said about 2 hours earlier, the patient
was hypertensive to the 180s and was given 10 mg IV hydralazine. At
home, it appears she is only on amlodipine 5 mg daily.
•What are your next steps?
Case 1
• You ask for her vitals
• T AF, HR 138, BP 116/64, RR 20, 97% on 2L NC
•You ask for an ECG
•You quickly review her medical history as your walking to see her:
• OSA on CPAP, BMI 36, paroxysmal Afib on warfarin, HTN, DLD and OA
Case 1
• What are you going to do
now?
• Should you treat?
• Should you observe?
Treatment Option in Afib with RVR
• Treat the underlying etiology
• Rate Control
• Metoprolol or another beta blocker
• Calcium Channel Blocker -> Diltiazem
• Digoxin
• Rhythm Control
• Amiodarone
• Dofetilide
• Flecainide
• DCCV
• When should this be performed?
• How do you do this?
Treatment Option in Afib with RVR
• Treat the underlying etiology
• Rate Control
• Metoprolol (5 mg IV x3 vs. 12.5-25 mg PO)
• Calcium Channel Blocker -> Diltiazem (10-20 mg IV and start gtt at 5-15 mg/hr)
• Digoxin (0.500 mg|0.25 mg|0.25 mg -> 1 mg load over 18 hours)
• Rhythm Control
• Amiodarone (150 mg IV bolus and start gtt at 0.5 mg/hr)
• Dofetilide
• Flecainide
• DCCV
• When should this be performed?
• How do you do this?
Case 2
• You are paged about a patient on Wearn team who is having chest
pain. The patient is Mr. K who is a 64 y.o. male with past medical
history of HTN, DLD, and DM II who was initially admitted for CAP
and is on IV antibiotics.
• What do you do next?
Case 2
• Vitals: T AF, HR 98, BP 168/98, RR 24 and SpO2 93% on RA
•Physical Exam
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GENERAL: Patient appears to be in distress and diaphoretic but A&O x3
CHEST: Decreased breath sounds in the RLL but otherwise clear
CV: Tachycardia; Normal S1 and S2; II/VI SEM at the RUSB; No JVD
EXTREMITIES: Warm and clammy; 2+ radial and DP pulses; No appreciable edema
• ECG…
Case 2
• What are your next steps?
Case 2
• Order labs: CBC, INR, RFP, and MI PANEL
• Portable CXR (unremarkable)
• You administer the following medications:
Case 2
• Order labs: CBC, INR, RFP, and MI PANEL
• Portable CXR (unremarkable)
• You administer the following medications:
• ASA 324 mg
• Plavix 600 mg
• Heparin 4000 subQ bolus and start a gtt
• Atorvastatin 80 mg qsh
• 0.4 SL nitro
Case 2
• Following administration of the SL nitro x3, the patient continues to
complain of anginal chest pain but is slightly improved. His BP
remains elevated at 168/92 and HR 94.
• What do you do now?
• Following management options are reasonable:
• Morphine
• Nitro gtt
• PO/IV metoprolol
Case 3
• You are covering the Eckel team and are asked to follow-up an evening RFP on an ESRD patient
who was admitted for AVF malfunction and missed HD.
• RFP
• Na 142 K 6.9 Cl 104 HCO3 22 BUN 67 Cr 3.12
• What do you do now?
• Vitals
• T AF HR 68 BP 158/90 RR 14 & 100% on RA
Case 3
•
What do you do now?
Treatment Options for Hyper-K
• Temporizing Measures
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Calcium gluconate
Insulin and Dextrose
Albuterol
Sodium Bicarbonate
• Removal of K
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Kayexalate
Lasix
HD
CVVH?
Case 3 (cont.)
• What do you do now?
Case 4
• You are called about a patient on Hellerstein who was admitted for ADHF. The RN says the
patient has become dyspneic and hypoxic to 85% on RA and is now 92% on 4L.
•What are your next steps?
• Vitals
• T AF, HR 98 (baseline 70s), BP 156/88, RR 30, 92% on 4L
• You go see the patient…
Case 4
• When you arrive to see the patient, he is on continuous pulse ox and it is now reading 86% on
4L. What do you do now?
• You titrate his oxygen supplementation to 6L and his pulse ox reads 86%. What do you now?
• You place a Venti Mask on 50% and his pulse ox now reads 94%. What do you do now?
• Physical Exam
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GENERAL: Moderate respiratory distress and looks uncomfortable
CHEST: Crackles throughout posterior lung fields
CV: Sinus tachy; Normal S1 and S2 with S4; JVD present
EXT: 3+ pitting edema to knees b/lk
• How are you going to workup and manage this patient?
Case 4
• What is your diagnosis and how are you going
to manage this patient?
Case 4
• You administer IV Lasix.
• You return to your team room and see the ABG that you obtained has
now returned:
• 7.45/36/88
• You return to the patient 45 minutes later and he has made 300 mL of urine.
• His pulse ox shows 88% on 50% Venti
•What do you do now?
• Repeat ABG on NRB is: 7.34/48/58
• WHAT DO YOU DO NOW?
Case 5
• You are called about a patient on Naff team who has developed a fever of 38.1 C. The 78 y.o.
patient originally presented from a NH with encephalopathy in the AM. Workup has been
negative thus far including gram stain, metabolic abnormalities, and neurological etiologies.
•Vitals
• T 38.1 C, HR 94, BP 110/70, RR 18 and SpO2 95%
• What are your next steps?
• You were bold and repeated the vitals in 1 hour -> T 39.2 C, HR 102, BP 88/60
• What are your next steps?
Case 5
• What workup are you going to initiate?
• What antibiotics are you going to start?
• The patient is allergic to penicillin?
• The patient had a severe red man reaction to vancomycin?
• Would your antibiotics change if the patient came from home?
Case 5
• You start the patient on vancomycin and Zosyn and give the patient
1L of NS.
• The repeat BP is 88/62.
• The repeat BP is 86/58.
• The repeat BP is 78/48.
Case 6
• You are called about a patient on Wearn whose BP is 195/100. She initially presented to the
hospital with acute cholecystitis but is now s/p antibiotics and cholecystectomy. She has a past
medical history of HTN, DLD, and obesity.
•Vitals:
• T AF, HR 98, BP 195/100, RR 18 and 98% on RA
• What do you do next?
Case 6
How would your management change in the following
situations?
• The patient is completely asymptomatic?
• The patient is complaining of a headache?
• The patient is complaining of chest pain?
HTN Medication
• Fast Acting PO Formulations
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Hydralazine (25 mg)
Nifedipine (30 mg)
Isosorbide dinitrate (10 mg)
Clonidine (0.1 mg)
Labetolol (200-400 mg)
• IV Options on the Floor
• Hydralazine 5 mg
• Labetolol 10-20 mg
Case 7
• You are called by the RN about a patient on the Naff team who just
had a bloody emesis. The patient is a 58 y.o female who initially
presented to the CICU 10 days ago with influenza and cardiogenic
shock. She was transferred to the service 3 days ago and is awaiting
placement. She has a past medical history of HTN, DLD, OA, humeral
fracture, hip fracture, and depression. Last Hgb was 12.8 in the AM.
• What are your next steps?
Case 7
• Vitals
• T AF, HR 84, BP 125/82, RR 14 and 97% on RA
• Physical Exam
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GENERAL: NAD, A&O x3, Actively nauseous
CHEST: Clear to auscultation b/l
CV: NRNR; Normal S1 and S2; No murmurs, rubs, or gallops; No JVD
ABDOMEN: Mild tenderness to palpation in the epigastric region; Otherwise soft, ND and hyperactive
BS
• Vomitus is a very dark brown
•You order a STAT CBC and Type and Screen
• You establish IV access x2
Case 7
How is your management going to differ in the following situations?
1. The CBC returns with a Hgb of 12.5.
2. The CBC returns with a Hgb is 9.8 with an unchanged BP.
3. The patient’s next BP reading is 95/62.
4. The patient continues to vomit but now it is bright red blood.
Scenarios
• You get a call from an RN and a patient is complaining of intractable hiccups?
• Thorazine 25 mg
• Patient asks for something to help them sleep?
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Melatonin 3 mg
Trazodone 25-50 mg
Benadryl 25 mg PO
Ativan 0.5 mg
Zolpidem 5 mg
• Patient wants something for anxiety?
• Hydroxyzine 25-50 mg
More Scenarios
• Patient is constipated?
• Oral Options
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Colace 100 mg q12h
Miralax 17g
Senna 8.6 mg
Bisacodyl 5-10 mg
Magnesium Citrate 150-300 mL
Lactulose 20 mg
Mineral Oil
• Rectal Options
• Bisacodyl 10 mg suppository
• Water/Saline (Fleet’s) Enema
• Mineral Oil Enema
There are always more Scenarios
• Patient is complaining of nausea
• Prochlorperazine (Compazine)
• 10 mg PO or 5-10 mg IVPB
• Promethazine (Phenergan)
• 12.5-25 mg PO or 25 mg IVPB
• Odansetron (Zofran)
• 4 mg IV or 4-8 mg PO
• Metoclopramide (Reglan)
• 5-10 mg IVPB or PO
• Patient is complaining of MSK pain
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Lidocaine patch/gel/cream
Tylenol
NSAIDs
Diclofenac cream ($$$)
Tramadol
Narcotics