Intern Basics- Part II

1. Intern Basics- Part II Jacobi medical Center

2. Falls • Assess the patient after the fall • Witnessed or not • Ask the patient about the fall and any injury • Examine the patient with special attention to the area of injury; examine the head to rule out any injury to the head • Imaging studies to rule out any fractures • If any change in the mental status from the baseline is noted, get a head CT • Complete the incident report • Restrains as needed

3. Altered Mental Status • Confusion, delirium, drowsiness, stupor • Look for the possible (and obvious) causes: -medications (opiates, benzodiazepines, other sedatives) -metabolic (hypoglycemia, hyponatremia, hypernatremia, uremia, hypercapnia, hypoxia) -trauma to the head -Stroke -Seizures -Infections -Others: hyperthyroidism, liver failure, Hypertensive encephalopathy

4. AMS (contd.) • Work up: -Any acute change in mental status (stupor), call an RRT (rapid response team), stabilize the patient first. Always check ABC. Make sure the patient has a working IV line -Check finger stick glucose to r/o hypoglycemia -If patient seems unable to protect his airway, then he probably needs intubation (call RRT if not already called; ask the nurse to call anesthesia and respiratory therapist) -labs: CBC, serum electrolytes, BUN/Cr, ABG -If any suspicion of infection, check UA and CXR -Head CT

5. AMS (contd.) • Management: -Delirium: Haldol 2-5mg IM can be given -Underlying cause should be treated. If patient has been intubated, then will need to be transferred to the ICU/CCU. Contact SMR for the transfer.

6. Insomnia • Antihistamines (benadryl): may cause daytime sleepiness the next day, avoid in patients with angina, cardiac arrythmias, BPH, COPD • Benzodiazepine (restoril, ativan): daytime sleepiness, cause respiratory depression, avoid in COPD or any underlying lung problems • Newer hypnotics (ambien): fewer side effects, better tolerated; consider trazodone

7. Constipation • Causes: functional (most common in the hospitals), obstruction, medications (most commonly opioids), neurogenic • Abdominal x-ray if needed • Treatment: colace, senna, dulcolax (bisacodyl), lactulose, enema (tap water, fleets), disimpaction of stool

8. Diarrhea • Acute onset: rule out infection • Check fecal leucocytes, occult blood in stool, stool culture, C. diff toxin • Check CBC for leucocytosis • If any reason to suspect C. Diff infection and patient appears acutely sick, should start metronidazole empirically

9. Initial dose PTT <35 PTT 35-45 PTT 46-70 PTT 70-90 PTT>90 80 U/Kg bolus, then 18U/Kg/hr 80 U/kg bolus, increase drip by 4 U/kg/hr 40 U/kg bolus, increase drip by 2 U/kg/hr No change in rate Decrease drip by 2 U/kg/hr Hold infusion for 1hr, decrease the rate of drip by 3 U/kg/hr Heparin drip adjustments

10. Death notification • Confirm death: pupils, heart, breathing • Note the official time of death (when you pronounce the patient) • Notify the family • Call organ donation (If they reject the case, they will give a case number; also get the name of the person you speak to) • Write a death note in the EMR and complete the discharge summary • When the death certificate is ready, the admitting will call you to get your signature/ finger print (please do that promptly and do not sign that out)

11. Sample death note • Called to the bedside by the nurse. Patient found unresponsive, pupils unreactive, no spontaneous breathing, no heart sounds. Pt pronounced dead at 1100am on 07/24/2010. Pt’s son (name) notified. Called organ donation and spoke with Ms. X. The case was rejected and the case number is XXXXX.

12. Questions??