Ward & On Call Survival Skills CORE Exec 08-09 & 09-10

1. Ward & On CallSurvival SkillsCORE Exec 08-09 & 09-10

2. General Ward Management • Electrolyte imbalance • Post Op Fever • Chest pain & SOB • ECG analysis • Post-op cardiac complications

3. Hypokalemia • What is the cause? • Loss through GI tract (diarrhea,vomiting) • Diuretics (lasix) • Metabolic / Respiratory Alkalosis • Hyperaldosteronism • Diabetic ketoacidosis (with osmotic diuresis) • Other renal losses - RTA

4. 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

5. Hyperkalemia What is the causes? • Pseudohyperkalemia: • Hemolysis • Excessive Intake: • K+ supplements (oral or IV), Blood transfusions • Decreased Excretion: • Renal failure (acute or chronic) • Drugs: • K+ sparing diuretics (spironolactone) • ACE inhibitors • NSAIDS • Trimetoprim / sulfamethoxazole (TMP/SMX) • Cyclosporine • Renal tubular acidosis • Redistribution: • Acidosis • Cellular breakdown (Rhabdomyolysis, Hemolysis, Tumor lysis syndrome, Burns) • Drugs (digoxin, beta blockers, succinylcholine) • Insulin deficiency

6. Hyperkalemia • Repeat lytes • Stat IV • ECG • 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

7. Post-Op Fever • The 5 W’s: • Wind (atelectasis & pneumonia) • Water (UTI) • Wound • Walk (DVT, PE) • What did we do? • (surgery, drugs, IV sites, blood products)

8. Chest Pain &/or SOB • Assess pt: • ABC’s, vitals • Hx • PE • Do you need further investigations: • CXR • CK and Trops • ECG for to r/o MI or AFib • Remember: • Always think PE in the setting of desaturation & tachycardia • Call for help early if pt unstable or you feel uncomfortable: chief / SMR / CCRT/ RACE team

9. 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

10. Post-op Acute MI • ABC’s • MONA • Morphine • Oxygen • Nitroglycerin • Aspirin (160mg chewed) • ECG + Monitored bed • 2 large bore IVs • CK and Trop q8h x3 • CXR • Meds: ASA, anticoagulation (consider risk of post-op bleed), ACEi, B-blocker, CCB, Statin, Diet • Call Race team, CCRT or SMR, ?PCI

11. Post-op Afib • Appropriate Hx & Physical • Distinguishing features • AFib vs. MAT • New onset AFib vs. known hx • Rate controlled vs. rapid • Symptomatic vs. not • Exacerbating factors (MI, lytes, TSH, MS) • Acute Treatment • Metoprolol IV boluses or push (x3 q 15 min) • Diltiazem IV push • Digoxin IV push (with concomitant CHF) • Start oral B-Blockers for long term rate control • Repeat ECG & consult medicine • Echo when stabilized • Anticoagulation based on risk of CVA as per CHADS-2

12. Common General Surgery Consults • Appendicitis • Acute Cholecystitis • Ascending Cholangitis • Acute Pancreatitis • Small Bowel Obstruction • Ischemic Bowel

13. Appendicitis Symptoms: 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 Signs: fever, localized RLQ peritonitis, increased WBC Imaging: 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 Management: 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.

14. Acute Cholecystitis Symptoms: steady RUQ pain (usually > 12 hr duration), bloating, nausea/vomiting, onset after big/fatty meal Signs: Murphy’s sign, distended abdo, fever, increased WBC, may see increased conjugated bili and alk phos/GGTs – may indicate passed stone Imaging: 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 Management: 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.

15. Ascending Cholangitis • Symptoms: • RUQ pain, jaundice, fever – Charcot’s triad; plus hypotension and confusion – Reynold’s pentad (indicates shock state); may also have nausea/vomiting • Signs: • jaundice; Murphys sign; increased WBC; fever; increased conjugated bilirubin, alk phos/GGT, and transaminases • Imaging: • 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 • Management: • Aggressive IV fluid resuscitation, blood cultures, antibiotics, analgesia, NPO, urgent biliary tree decompression (ERCP/PTC drain), may require ICU admission

16. 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

17. 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

18. Ischemic Bowel • Symptoms: • mid-abdominal pain out of proportion to physical findings, nausea/vomiting, diarrhea, blood per rectum • Signs: • abdo distention, diffuse peritonitis, fever, +ve FOB, increased WBC (often > 20 000), increased lactate, metabolic acidosis • Imaging: • 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: • 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 anti-thrombolytics 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.

19. 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

20. General Surgery Topics • 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)

21. Orthopaedic Emergencies • Ortho Emergencies: • Open #’s • Compartment Syndrome • Lower Limb Nec Fasc • # Dislocations • Cauda Equina • Septic Joints • C-Spine Injuries

22. 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

23. 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 job Id on it • Post-call: get a feel for things, use your own judgment • Similar for Gen Surg

24. 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.!

25. Open Fractures • Splint • Tetanus • Abx • Nv • Dressing

26. Compartment Syndrome • Clinical Diagnosis • Pain • Pain on passive stretch • Paraesthesia • Paralysis • Pulselessness • Poikilothermia

27. Compartment Syndrome • PAIN • PAIN • PAIN • PAIN • PAIN • PAIN

28. Nec. Fasc.

29. Orthopaedics • Common Ortho Meds to Know: • Ancef • Percocet • What else could you possibly need???

30. 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)

31. 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!

32. 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

33. Orthopaedics • Resources: • 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

34. Common Urology Consults • Ward : • Difficult catheters  Try yourself with coude • Suprapubic catheters  In setting prostatis or no foley • Post-op retention  in dwelling catheter + Flomax • ER : • Stones (office apt. vs. consult)  3 S’s (Size, Septic, Symptoms) • Hematuria  CBI and trial of void if u/o clear • Trauma  Urethral injury, false passage, renal injury • Pyelonephritis  Consider septic stone & ? Solitary kidney

35. ENT Emergencies • Epistaxis • Anterior Bleeds • Posterior Bleeds • Peritonsillar Abscess

36. 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?

37. Anterior Bleeds • Very common, occur from vessels which anastomose & create Kiesselbach’s plexus • Ask the patient to gently blow the nose to clear out any clots. • Use suction if needed to rid yourself of clots/excess blood. • Use cotton swabs with lidocaine and epinephrine to achieve a vasoconstrictive effect. • Take a look with your nasal speculum and see if there are areas of bleeding. • Use silver nitrate cautery if there is a bleeding vessel, do NOT! Cauterize both sides of the septum. • If bleeding does not stop move on to packing with Vaseline gauze or murocel packs. • 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. • 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.

38. Posterior Bleeds • Technique - Foley catheter (10-14F 30-mL balloon) a) Apply ‘muco’ nasal ointment 2% to the catheter. b) Insert the catheter into the nostril. c) Visualize the catheter tip in the back of the throat. d) 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.

39. Peritonsillar Abscess • 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.

40. 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

41. Plastics General Info • 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

42. Plastics • 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

43. 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)

44. Plastics • 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

45. 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

46. General Tips • Keep up with reading/knowledge • Be on time & Be responsible • 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!

47. General Tips • Teach the Clerks • Take advice from your seniors • 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!!!

48. Phone #s Dictation: 5000 MUMC • Main #: 905-521-2100 • Paging: 76443 HGH • Main #: 905-527-0271 • Paging: 46311 HDGH • Main #: 905-389-4411 • Paging: 42111

49. SJH Phone #s • Main #: 905-522-1155 • Paging: 33311 • Admitting: 33183 • Dictation: 32078 • doesn’t give you prompts so use the yellow card the first few times

50. Paging • HHS • 87 – pager # * priority • Online Text • “corpweb” • Far right of screen, link to “PHONEBOOK”