Intern Prep Top Calls: Part Deux

1. Intern PrepTop Calls:Part Deux

2. . . . . . Where We Have Been 1) Issues Pertaining to Blood Pressure 2) Issues Pertaining to the Respiratory System 3) Issues Pertaining to Fever 4) Issues Pertaining to Urine Output 5) Issues Pertaining to �The Death Call�

3. Where We Are Going . . . . . 6) Chest Pain/Arrhythmias 7) Abdominal Issues 8) Mental Status Changes 9) Insomnia 10) Patient Fall 11) Feeding Tube Issues 12) Electrolyte Issues

4. 6) Chest Pain/Arrhymias Ben RN calls at 3am: �The telehut just called and said that Mr. J is having runs of Vtach.�

5. 6. Chest Pain / Arrhythmias Questions New and comparison 12�lead EKG? Cardiac History? ASA and �-Blocker today? K and Mg levels and when were they drawn? Life�Threatening Causes MI PE Pneumothorax Aneurysm

6. Chest Pain / Arrhythmias Talk to the patient If suspicious for cardiac: SL NTG q5 minutes until chest-pain free (up to 3 times) Aspirin (chew two 81mg tabs) Morphine 2�4 mg IV for pain relief O2, serial ECGs Cardiac enzymes (troponin) Heparinize if no contraindications Consider CCU and nitro drip (start at 10 mcg/min and titrate up)

7. 7. Abdominal Pain/N/V/D/C Questions New / Recurrent Blood? New Meds Is there a student on the case? (i.e. is the patient impacted?) Don�t Miss �Acute Abdomen� Ischemia Clostridium difficile

8. Abdominal Pain/N/V/D/C Treatment Options Nausea/Vomiting Zofran 4 � 8 mg PO/IV q 4�6 PRN Reglan 10 mg PO/IV q 4�6 PRN Phenergan 12.5-25 mg PO/IM q4 PRN Compazine 5�10 mg IV q6 PRN Ativan 0.5-2 mg PO/IV q8 PRN Benadryl 25-50 mg PO q6 PRN Consider an NGT

9. Abdominal Pain/N/V/D/C (continued) Diarrhea Psyllium 1tsp-1tbsp (in 8 oz) daily-TID Loperamide 4 mg PO Contraindicated if infectious etiology Check C. diff toxin assay Constipation Colace 100 mg PO BID (prevents - doesn�t treat) MOM 15-30 cc PO Dulcolax 10 mg PO PRN Magnesium Citrate 120-240 ml Lactulose Enemas (tap water, soap suds)

10. 8. Unresponsive/Agitated Patient �Mental Status Changes� Questions Vital signs (+ SpO2) Acute vs. Baseline New Meds Accucheck

11. Differential for Mental Status Changes A: Alcohol/Intoxication E: Electrolytes/Dehydration I: Ischemia O: Over-riding Infection U: Uremia

12. Unresponsive/Agitated Patient Reflex Evaluation Narcan? Simple �Sun�Downing� Haldol 2 mg IV/IM/PO Stop meds CT if ANY focal findings Consider 1:1 sitter Turn off TV and lights, etc.

13. 9. Patient Can�t Sleep Special Concerns Before Medicating? Suggested �Sleepers� Is there an order for a sleeping med? What has worked before? Criticize Colleagues in the AM Specific Recommendations Ambien 2.5 � 10 mg PO Benadryl 25 � 50 mg PO/IV Restoril 7.5 � 30 mg PO Haldol: 1 � 2 mg IV (esp. if > 75, MS changes, dementia)

14. 10. �Patient Fell� Examine the patient and recreate the scene Consider CT scan of the head Patient on anticoagulants Head trauma Mental status changes Neurologic deficits Assess medications Were the guard rails up? Are restraints needed?

15. 11. �NG/Dobhoff tube is out� Why does the patient have an NG? What medications are ordered per NG? Can they be switched to IV? Should I replace the NG? Don�t forget to re-confirm placement?

16. How do you confirm the placement of a feeding tube?

17. Good Doboff Placement?

18. Good Doboff Placement?

19. Good Doboff Placement?

20. 12. Electrolyte Disturbances High Potassium Check renal function ? ECG Treatment? IV insulin/glucose Calcium gluconate Kayexelate Bicarbonate Dialysis Low Potassium Cardiac History? Check Creatinine Replacement? 10 mEq = 0.1 mmol/L Low Magnesium 1 g = 0.1 mg/dL

21. Electrolyte Disturbances, continued ?? Sodium Assess volume status Exam Net I/O ? Weight ? Sodium Treatment ? = free water ? = restrict

22. 13. Expiring Meds/Restraint Orders Who is the primary service? When was the last dose? Next dose? Are the meds being allowed to expire on purpose? Does the patient need restraints?

23. 14. Blood/Procedure Consent Ben RN calls (again): �Mr H is supposed to get blood tonight and the primary service has not consented him. You just wanna come down here?�

24. 14. Blood/Procedure Consent Who is the primary service? When is the blood to be given/procedure to be done? Necessary? Foreseen? Already done? Is the patient able to give consent?

25. Blood Transfusions Premeds May consider if previous reaction to packed red blood cells Platelet Transfusions Tylenol 650 mg PO Benadryl 25�50 PO (not IV) If fluid overload is a concern: Lasix 20�40 mg IV between units Give unit over 3�4 hours

26. Blood Transfusions Mild chills/rigors Demerol 25�50 IV Serious reaction (temperature spike, pain, hemodynamic instability) STOP transfusion Give IVF Call Blood Bank

27. 15. Pain Meds What kind of pain? New versus Chronic/Recurrent? What has worked before? Is there an order for a pain med? What�s on signout?

28. 16. Alcohol Withdrawal Minor Symptoms Tremor Irritability Anorexia Nausea Major Symptoms Seizures Confusion Agitation Autonomic instability Fever

29. Treatment of alcohol withdrawal Ativan 1-2 mg IV q 4 minutes Titrate as needed until calm but awake Start a drip if necessary (Diazepam, too) Librium PO is long acting alternative Contraindicated with renal dysfunction Thiamine/Folate/MVI (banana bag) Clonidine 0.1 mg PO QID for autonomic instability (may increase to 0.4 mg QID) Last Resort: Propofol 1-5 mg/kg/hr Consider intubation if needed

30. 17. Hyper/hypoglycemia 70 � 200 is Fine! Nobody dies of a BG > 200 overnight. Too low, however, is a fiasco. Too High Regular Insulin or Aspart/Lispro 200 � 250 give 2�4U; 250�300 give 4�6U, etc. If >400, make sure patient is not in DKA

31. Hyper/hypoglycemia Too Low Juice if they can eat or 1 amp D50 Repeat accucheck in 15 minutes If still low/recurs, start D5 or D10 drip HOLD oral agents and insulin! Recheck at least hourly and consider ICU transfer

32. 18. Seizures Give Ativan 2 mg IV/IM immediately Repeat Q 2-5 minutes as needed If persists > 10 minutes = �status� Fosphenytoin 20 mg/kg IV given at 150 mg/min Call Neurology Work�Up ABG, glucose, CBC, electrolytes, tox screen, CT scan R/O trauma, CVA, infection, drugs, metabolic disturbances