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  1. A Day in the life… and Cross-Cover Nina Zatikyan Ann Malbas Chief Residents

  2. 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

  3. Log on to www.caregate.net • Go to your “Patient lists” • Click on to “Sign out Rpt” button How to make your cross cover list

  4. 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. Cross-Cover notes

  5. Review basics by organ systems today • Infectious Disease • Heme • Radiology • Death Neuro Pulmonary Cardiology Gastrointestinal Renal What do I do when I’m called? • -Ask yourself, does this patient sound stable or unstable? • -Ask for vitals • -Is this a new change?

  6. Altered Mental Status • Seizures • Falls • Delirium Tremens NEUROLOGY

  7. 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 • Family member at bedside- the best • Medications • Haloperidol 2mg IV/IM • Ziprasidone(Geodon) 10-20mg IM • Quetiapine (Seroquel) 25mg poqhs • Restraints (last resort) non-violent/non-behavioral **Caution with Benzos/ambien in the elderly

  8. 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 “Move Stupid”

  9. 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+), 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

  10. 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 non-contrast head CT to r/o subdural hematoma • Order fall precautions Falls

  11. 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 ! Delirium Tremens (DTs)

  12. Shortness of Breath • Hypoxia PULMONARY

  13. 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

  14. 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

  15. 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, FiO2 100 %. • IPAP helps overcome work of breathing and helps to change PCO2 • EPAP helps change pO2 Oxygen Desaturations

  16. 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

  17. 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 2-4 cm above the carina) • Check ABG 30 min after patient intubated and adjust settings accordingly Mechanical Ventilation

  18. Chest pain • Hypotension • Hypertension • Arrhythmias CARDIOLOGY

  19. 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

  20. 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

  21. 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 *Stop BP meds! *Don't forget about tamponade, PE and pneumothorax!!

  22. Phenylephrine (Neosynephrine) 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 Commonly Used Pressors A1 10–20 mcg/kg/min Vasoconstriction; Causes Arrhythmias Dobutamine B1, B2 1–20 mcg/kg/min Positive inotropy and chronotropy; Causes Hypotension

  23. 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

  24. 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 • 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

  25. 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)

  26. 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) *Remember, if unstable shock!!

  27. Nausea/Vomiting • GI Bleed • Acute Abdominal Pain • Diarrhea/Constipation Gastrointestinal

  28. 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

  29. 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

  30. 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

  31. 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 carefully in elderly, ensure pt on adequate bowel regimen Acute Abdomen

  32. Diarrhea Constipation • Is this new? • check stool studies: • c.diff • 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

  33. Decreased urine output • Hyperkalemia • Foley catheter problems RENAL/ELECTROLYTES

  34. 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

  35. 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

  36. 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) Foley Catheter Problems:

  37. 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

  38. 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 **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!!!

  39. Positive Blood Culture • Fever Infectious Disease

  40. 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

  41. 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

  42. Anticoagulation • Blood replacement products HEME

  43. 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

  44. 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 non bleeding 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

  45. Which test should I order? • Plain Films • CT scans • MRI RADIOLOGY

  46. 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 Plain Films

  47. 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

  48. 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

  49. Pronouncing a patient • Patient may be pronounced by 2 RNs • Notify the patient’s family • Request an autopsy • How to write a death note DEATH