Nithya swamy chief resident
This presentation is the property of its rightful owner.
Sponsored Links
1 / 67

Nithya Swamy Chief Resident PowerPoint PPT Presentation


  • 78 Views
  • Uploaded on
  • Presentation posted in: General

A Day in the life… and Cross-Cover. Nithya Swamy Chief Resident. Wards Conferences ICU Electives Important Numbers. Overview: A Day in the life…. Call Days: Day starts at 7a Call is every 4 th night Admissions: 7a-7a Resident will call with new admissions

Download Presentation

Nithya Swamy Chief Resident

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Nithya swamy chief resident

A Day in the life…

and

Cross-Cover

Nithya Swamy

Chief Resident


Overview a day in the life

  • Wards

  • Conferences

  • ICU

  • Electives

  • Important Numbers

Overview: A Day in the life…


Wards

  • Call Days:

  • Day starts at 7a

  • Call is every 4th night

    • Admissions: 7a-7a

    • Resident will call with new admissions

    • Sign-out by 1p on post-call day

  • Intern can admit 5 patients for call. Intern cap: 10 patients.

  • Resident clinic patients requiring admission should be followed by the teaching service.

  • On-Call Team = Code Team (“Code Blue MET”)

  • Call rooms: 10th floor: B&C are intern call rooms, D is the resident call room

  • Call Jeopardy

WARDS


Wards1

  • Non-Call Days:

  • Arrive at 7a

  • See patients in order of priority (ICU then floor)

  • Discuss patients with attendings

  • Teaching rounds MWF 10:30-12p

  • Conference 12-1p

  • Sign out to cross covering intern/resident

  • Check out pager at 5p on weekdays or noon on weekends unless post-call

  • Off Days: 4 days per call month (T, Th, Sa, Sun) all pre-call days.

WARDS


Wards intern responsibilities

  • Interview Patient: H&P, review labs/imaging & formulate plan with resident

  • Admission orders (Teaching Service Order)

  • Present to the Attending

  • H&P write up

  • Call consults

  • Daily progress notes

  • Daily orders

  • F/u with all attendings

  • Cross-cover list/Sign-out

  • Discharge summary

  • On one of your wards months, each of you will be in charge of setting up cases to present for interns conference.

WARDS- Intern Responsibilities


Conferences

To Present:

Journal Club: 30min: Two/year: article of your choice

Residents Conference: 1h presentation: Interesting medical topic of your choice

Potpourri: 30min: Any Interesting case

To Attend:

Noon Conference: 12p-1p: M, T, Th, F

Interns Conference: Tuesdays: 11a-12p

Clinical Grand Rounds: Wed 7:30-8a

IM Grand Rounds: 12:15-1:15p

Coffee with Cardiology: Fridays: 7:30-8a

Teaching Rounds: M,W,F: 10:30a-12 on Wards months

ID Rounds: Meet with Dr. Goodman 1-3p once a month on wards

CONFERENCES


Electives

  • Contact the attending you are working with a few days prior to the start of the rotation to get details on their expectations

  • Hours and responsibilities vary depending on the rotation and attending.

ELECTIVES


Icu rotation

  • 6a-6p Mon-Fri

  • Hamon 3 ICU

  • Resident works with you

  • Round on all your patients by 10a, try to complete all notes

  • 10a: Multidisciplinary rounds: Present all patients to ICU attending, nurses, RT, SW

    • Overnight events, vent settings, vitals, assessment/plan for the day, DVT/GI ppx.

ICU ROTATION


Vacation

  • 20 days per year

  • Can be taken on any month except Wards and ICU

  • Max: 5 days/month (M-F; surrounding weekends do not count)

  • Categoricals: Contact Sonya/Alma in the clinic 1 month prior to let them know you are taking vacation

  • Vacation Form: signed by subspecialty attending (also by Sonya/Alma if you are a categorical). Turn this into Jason for approval ~30d prior to vacation.

VACATION


Important numbers

Residents Lounge Code: 997722

Physician’s Dining Room Code: 214

Residents Clinic Code: 7802

Jason: 6176

Sherie: 7881

Page Operators: 8480

Calling the hospital from the outside: 214-345-XXXX

IMPORTANT NUMBERS


Overview cross cover

  • 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???

Overview - Cross Cover


How to make your cross cover list

  • Log on to www.caregate.net

  • Go to Cross Cover

  • Under “problems”, put one liner about the patient

  • Then list all important problems and what has been done about them

  • Under “to do” section put MR number, pt allergies, important meds, anything for X-cover to follow up on

How to make your Cross Cover list:


Nithya swamy chief resident

Cross cover list is kept current on CareGate www.caregate.net


Cross cover list

Cross-Cover List

ALWAYS check out FACE TO FACE

ALWAYS include MR#, allergies, things to do, meds, code status

Update problem list and meds DAILY!!!

Always include consultants on board, so that if something happens during the day the person covering can call someone else for assistance if needed.

Write a progress note if an event occurs overnight.

ALWAYS call the next morning to update on patient list (EVEN if there were no calls).

If there is something important that you need the cross cover resident to do/follow up on, make sure you tell them in person.


Not acceptable

  • “Patient intubated, sedated, in 1 ICU”… when the pt has been extubated and on the floor for 4 days

  • Update room numbers

  • Update DNR/Code Status

  • Must put pertinent changes in status (e.g., if a patient went into afib or had GI bleed or is having a procedure)

  • Must put all pending tests on the list

  • If someone is really sick, include family contact info in the event of a code or critical change in medical status

  • YOU MUST UPDATE THE WHOLE LIST EVERYDAY!!!

Not Acceptable:


What do i do when i m called

  • Review basics by organ systems today

What do I do when I’m called?

  • Infectious Disease

  • Heme

  • Radiology

  • Death

Neuro

Pulmonary

Cardiology

Gastrointestinal

Renal

  • -Ask yourself, does this patient sound stable or unstable?

  • -Ask for vitals

  • -Is this a new change?


Neurology

  • Altered Mental Status

  • Seizures

  • Falls

  • Delirium Tremens

NEUROLOGY


Altered mental status

Always go to the bedside!!!

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 non-contrast head CT

Try naloxone (Narcan), usually 0.4-1.2 mg IV, if there is any possibility of opiate OD

If elderly person is agitated/sundowning 

try a sitter first 

then medications

haloperidol 2mg IV/IM

ziprasidone (Geodon) 10-20mg IM

Quetiapine (Seroquel) 25mg po qhs

Restraints (last resort)

Altered Mental Status

**Caution with Benzos/ambien in the elderly


Move stupid

  • Metabolic – B12 or thiamine deficiency

  • Oxygen – hypoxemia 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 and

    • 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

  • “Move Stupid”


    Seizures

    • Go to bedside to determine if patient still actively seizing

    • Call your resident

    • Assess ABCs

      • give 02, intubate if necessary

      • Place patient in left lateral decubitus position

    • Labs

      • electrolytes (Ca+/Mg), glucose, CBC, renal/liver fxn, tox screen, anticonvulsant drug levels, check Accucheck

    • Treatment:

      • Give thiamine 100 mg IV first, then 1 amp D50

      • antipyretics for fever or cooling blankets

      • Lorazepam 0.1mg/kg IV at 2mg/min

    • If seizures continue;

      • 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

      • 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)

    Seizures


    Falls

    • 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 tilt blood pressures if appropriate

    • If on coumadin/elevated INR or altered—consider non-contrast head CT to r/o subdural hematoma

    • Consider ordering sitter/fall precautions

    Falls


    Delirium tremens dts

    • 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

    Delirium Tremens (DTs)


    Pulmonary

    • Shortness of Breath

    • Hypoxia

    PULMONARY


    Shortness of breath

    • 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

    Shortness of Breath


    Causes of sob

    • Pulmonary:

      • Pneumonia, pneumothorax, PE, aspiration, bronchospasm, upper airway obstruction, ARDS

    • Cardiac:

      • MI/ischemia, CHF, arrhythmia, tamponade

    • Metabolic:

      • Acidosis, sepsis

    • Hematologic:

      • Anemia, methemoglobinemia

    • Psychiatric:

      • Anxiety – common, but a diagnosis of exclusion!

    Causes of SOB


    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

        • Start settings at: IPAP 10 and EPAP 5

        • IPAP helps overcome work of breathing and helps to change PCO2

        • EPAP helps change pO2

    Oxygen Desaturations


    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

    Indications for Intubation


    Mechanical ventilation

    • If patient needs to be intubated, start with mask-ventilation until help from upper level arrives

    • Initial settings for Vent:

      • 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 2-4cm above the carina)

    • Check ABG 30 min after pt intubated and adjust settings accordingly

    Mechanical Ventilation


    Cardiology

    • Chest pain

    • Hypotension

    • Hypertension

    • Arrhythmias

    CARDIOLOGY


    Chest pain

    • 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

      • 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

    Chest Pain


    Hypotension

    • Go and see the patient!!!

    • Repeat BP and HR, manually

    • Compare recent vitals trends

    • Look for recent ECHO/meds pt has been given.

    • EXAM:

      • Vitals: orthostatic? tachycardic?

      • Neuro: AMS

      • HEENT: dry mucosa?

      • Neck: flat vs. JVD (=CHF)

      • Chest: dyspnea, wheezes (?anaphylaxis), crackles (=CHF)

      • Heart: manual pulse, S3 (CHF)

      • Ext: cool, clammy, edema

    Hypotension


    Management of hypotension

    Hypovolemia

    volume resuscitation

    if CHF,bolus 500ml NS

    transfuse blood

    Cardiogenic

    fluids

    inotropic agents

    Sepsis: febrile >101.5

    blood cultures x 2

    empiric antibiotics

    Anaphylaxis: sob, wheezing

    epinephrine 

    benadryl 

    supplemental 02

     Adrenal Insufficiency

    check, cortisol/ACTH level

    ACTH stim test

    replace volume rapidly

    Hydrocortisone 50-100mg IV q6-8h

    Management of Hypotension

    *Stop BP meds!

    *Don't forget about tamponade, PE and pneumothorax!!


    Commonly used pressors

    Name

    ReceptorAffected

    Dose

    Action

    Phenylephrine

    (Neosynephrine)

    Alpha 1

    10–200 mcg/min

    Pure vasoconstrictor; causes ischemia in extremities

    Commonly Used Pressors

    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

    Dobutamine

    B1, B2

    1–20 mcg/kg/min

    Positive inotropy and

    chronotropy;

    Causes Hypotension


    Hypertension

    • Is there history of HTN?

      • Check BP trends

    • Is patient symptomatic?

      • 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:

      • Manual BP in both arms

      • Fundoscopic exam: look for papilledema and hemorrhages

      • Neuro: AMS, focal weakness or paresis

      • Neck: JVD, stiffness

      • Lungs: crackles

      • Cardiac: S3

    Hypertension


    Management of htn

    • If patient is asymptomatic and exam is WNL:

      • 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

    • Start a med according to JNC 7/co-morbidities/allergies 

    • PRN meds:

      • hydralazine 10-20mg IV

      • enalapril (vasotec) 1.25-5mg IV q6h

      • labetalol 10-20mg IV

  •  *Remember, no need to acutely reduce BP unless emergency

  • Management of HTN


    Hypertension continued

    • URGENCY

      • SBP>210 or DBP>120 with no end organ damage

      • OK to treat with PO agents (decr BP in hours)

        • 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)

        • nitroprusside 0.25-10ug/kg/min

        • nitroglycerin 17-1000ug/min

        • Labetolol 20-80mg bolus

        • Hydralazine 10-20mg 

        • Phentolamine 5-15mg bolus

    Hypertension (continued)


    Arrhythmias

    Tachyarrhythmias

    Afib/flutter RVR 

    rate control (BB/diltiazem/digoxin if BP low)

    consider anti-arrhythmic (amiodarone)

    SVT/SVT with aberrancy

    vagal maneuver

    adenosine 6-12mg IV

    Ventricular fib/flutter 

    check Mg level, replace if needed (>3.0)

    amiodarone drip

    Bradycardia

    Assess ABCs

    give 02

    monitor BP

    Sinus block: 1st, 2nd or 3rd degree

    Hold BB meds

    Prepare for transcutaneous pacing

    Atropine 0.5mg IV  x3

    Consider low dose

    Epi (2-10mcg/min) 

    dopamine(2-10mcg/kg/min)

    Arrhythmias

    *Remember, if unstable shock!!


    Gastrointestinal

    • Nausea/Vomiting

    • GI Bleed

    • Acute Abdominal Pain

    • Diarrhea/Constipation

    Gastrointestinal


    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:

      • 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)

    Nausea/Vomiting


    Gi bleed

    • UPPER

      • Hematemesis, melena

      • Check vitals

      • Place NG tube

      • NPO

      • Wide open fluids, type&cross for blood

      • Check H/H serially

      • If suspect 

        • PUD: Protonix gtt

        • varices: octreotide gtt

    • **Call Resident and GI

    • LOWER

      • 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!

    GI Bleed


    Acute abdominal pain

    • Go to the bedside!!!

    • Assess vitals, rapidity of onset, location, quality and severity of pain

  • LOCATION:

    • 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 Abdominal Pain


    Acute abdomen

    • 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:

      • Pain management—may use morphine if no contraindication

      • Remember, if any narcotics are started, use sparingly in elderly, ensure pt on adequate bowel regimen

    Acute Abdomen


    Diarrhea constipation

    Is this new?

    check stool studies:

    c.diff x 3

    culture

    o&p

    wbc

    FOBT x 3

    Do not treat with loperamide if you think it might be C.diff!!!

    Is this new?

    check KUB

    Ileus/bowel obstruction:

    place NPO

    Treat:

    Laxative of choice

    MOM

    Miralax

    enema

    tap water

    soap

    Bowel regimen

    colace 100mg bid

    dulcolax 5-15mg

    Diarrhea Constipation


    Renal electrolytes

    • Decreased urine output

    • Hyperkalemia

    • Foley catheter problems

    RENAL/ELECTROLYTES


    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:

      • 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

    Decreased Urine Output


    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

    Treatment of Decreased UOP


    Foley catheter problems

    Foley Catheter Problems:

    • 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:

      • peaked T-waves 

      • flattened P waves

      • PR prolongation followed by loss of P waves

      • QRS widening

    Hyperkalemia


    Treatment of hyperkalemia

    Mild (<6.0 mEq/L)

     Decrease total body stores

    Lasix 40-80mg IV

    Kayexalate 30-90g PO/PR

    Moderate (6-7mEq/L)

     Shift K+ in cells

    NaHCO3 50mEq (1-3amps)

    D50+10units insulin IV

    albuterol 10-20mg neb

    Severe (>7mEq/L) or EKG changes

    Protect myocardium

    Calcium gluconate 1-2amps IV over 2-5min

    Treatment of Hyperkalemia

    **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

    Infectious Disease


    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”? 

      • This is likely a contaminant.

      • 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

    Positive Blood Culture


    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 

      • order blood cultures x 2 from different IV sites 

      • UA/culture

      • CXR 

      • 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

    Fever


    Nithya swamy chief resident

    • Anticoagulation

    • Blood replacement products

    HEME


    Anticoagulation

    • Appropriate for:

      • DVT/PE 

      • Acute Coronary Syndrome

    • Usually start with low molecular weight heparin 

      • Lovenox 1 mg/kg every 12 hours and renally adjust 

    • If need to turn on/off quickly (e.g., pt going for procedure)

      • heparin drip—protocol in EPIC

    • Risk factors for bleeding on heparin:

      • 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

    Anticoagulation


    Blood replacement products

    • PRBC:

      • One unit should raise Hct 3 points or Hgb 1 g/dl

    • Platelets: 

      • One unit should raise platelet count by 10K; there are usually 6 units per bag ("six-pack")

        • use when platelets <10K in nonbleeding patient.

        • use when platelets <50K in bleeding pt, pre-op pt, or before a procedure

    • FFP: contains all factors

      • DIC or liver failure with elevated coags and concomitant bleeding

      • Reversal of INR (ie for procedure)

    Blood Replacement Products


    Radiology

    • Which test should I order?

      • Plain Films

      • CT scans

      • MRI

    RADIOLOGY


    Plain films

    • CXR:

      • Portable if pt in unit or bed bound

      • PA/Lateral is best for looking for effusions/infiltrates

      • Decubitus to see if an 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

    Plain Films


    Nithya swamy chief resident

    • Head CT

      • Non-contrast best for bleeding, CVA, trauma

      • Contrast best for anything that effects the blood brain barrier (ie tumors, infection)

    • CT Angiogram

      • 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

      • Renal stone protocol to look for nephrolithiasis

      • 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

        * If you are going to give contrast, check your Cr!!!

    CT


    Nithya swamy chief resident

    • Increased sensitivity for soft tissue pathology

    • Best choice for:

      • 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

    MRI


    Death

    • Pronouncing a patient

    • Notify the patient’s family

    • Request an autopsy

    • How to write a death note

    DEATH


    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

    Pronouncing a Patient


    Notify the patient s family

    • Call family if not present and ask to come in, or if family is present:

      • 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

    Notify the Patient’s Family


    Request an autopsy

    • Ask family if they would like an autopsy

    • Medical Examiner will be called if:

      • Patient hospitalized <24 hours

      • Death associated with unusual circumstances

      • Death associated with trauma

    Request an Autopsy


    How to write a death note

    • DOCUMENTATION:

      • “Called to bedside by nurse to pronounce (name of pt).”

      • Chart all findings previously discussed:

        • “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.

    How to Write a Death Note


    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!

    Bottom Line:


  • Login