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Surviving Your First Call

Surviving Your First Call. M. Bradley Brough Capt, USAF, MC, FS. What to expect. Sign Out Consents Common Problems Emergencies Pronouncing a patient. Sign Out. Use inpatient list…KEEP IT UP TO DATE!!! Diagnosis, PMH, labs, Contact name/number

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Surviving Your First Call

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  1. Surviving Your First Call M. Bradley Brough Capt, USAF, MC, FS

  2. What to expect • Sign Out • Consents • Common Problems • Emergencies • Pronouncing a patient

  3. Sign Out • Use inpatient list…KEEP IT UP TO DATE!!! • Diagnosis, PMH, labs, Contact name/number • Room #, Code status, pertinent labs, pending labs, Meds, things to do • What calls do you anticipate • Password – inpatient • Each service has own check out (OB/Children’s)

  4. Reasons for calls • Pharmacy • Medication dosing/accuracy • Other services • Cards/Renal/GI with pt updates • If ER calls, tell them to call supervisor • Nursing staff • Everything else: Pt issues, family concerns, discharge

  5. CONSENTS • Transfusions • Procedures • Basically anything invasive your going to do • Must explain Risks/Benefits/Alternatives of procedure. • Must be witnessed by another (non-physician).

  6. Code status MUST be addressed any time pt. is admitted. It’s NOT LIKE TV’s ER!!! State mandates that ALL DNR orders are to be signed by ATTENDING physician within 24 hours. Make sure you get a contact # !!! DNR

  7. IV Fluids Pain ‘Something to sleep’ Constipation Hyperglycemia Vomiting Fever Decreased Urine Output Anxiety Common problems

  8. IV Fluids(remember maintenance = 4/2/1) • Adults • D5 NS +/- 20 KCL (Sx prefers LR) • D5 ½ NS +/- 20 KCL (maintenance) • Peds - D5 ¼ NS +/- 20 KCL (maintenance) • Special considerations • CHF/ESRD • Do they need fluids?

  9. PAINWhy/where’s the pain? • Evaluate cause 1st line: Tylenol (acetaminophen) 650 mg PO/PR Q4-6 PRN (max dose of 4 g/day) Motrin -> careful (GI/renal issues) 2nd line: Percocet (Oxycodone + acet) 5/325 mg Q4-6 PRN or Ultram 50 mg Q6 (careful in CNS pt) 3rd line: Morphine 1-2 mg IV; Dilaudid (Hydromorphone) 0.5-2 mg IM/IV 4th line: PCA Morphine pump - call Pain Management in AM

  10. INSOMNIAWhy can’t they sleep? • Benadryl (Diphenhydramine) 25-50 mg PO/IV/IM q6 PRN • Careful in elderly (or they will be running around naked) • Ambien 5-10 mg PO QHS prn insomnia

  11. Insomnia • Benzos • Ativan (Lorazepam) 0.5-1 mg PO/IM/IV Q8 prn insomnia • Restoril (Temazepam) 7.5-15 mg PO QHS prn insomnia • Again, careful in elderly/COPD/sleep apnea/cirrhosis; watch for resp depression • Trazodone 50 mg PO QHS • Really good if they have psych/depression history • Prefer not to give past 1-2 AM

  12. Anxiety/Agitation • Etiology? • Hypoxic, hepatic encephalopathy, withdrawal/intoxication, psych, environment • H & P with Neuro √. CT scan of head? • Chemical restraints • Haldol 2-5 mg IM (reassess) • Ativan 0.5-2 mg IV/IM/PO Q6-8 PRN agitation (reassess) • Physical restraints: Not preferred • 2-4 point soft restraints • Pt must be evaluated and restraint forms resigned daily.

  13. CONSTIPATIONWhy? R/O obstruction- • Stool softener • Colace (Docusate Sodium) 100-400 mg in 1-4 divided doses • Laxatives • Dulcolax Supp. (Bisacodyl) 10 mg PR • M.O.M (Milk of Magnesia) 30-60 mL PRN (avoid in Renal failure) • Lactulose 15-30 mL PO PRN • Miralax 17 gm PO Q3-6 hrs PRN • Enema • Fleet (Not in Renal failure: phosphate load) • Soap Water

  14. HYPERGLYCEMIA • Make sure all diabetics have accu √ • Improved glycemic control improves outcomes • SSI BS Insulin dose 50-150 None 151-200 2 units 201-250 4 units 251-300 6 units 301-350 8 units <60 or >350 call HO

  15. HYPOGLYCEMIA • Is pt diabetic? • If BS is 50-60 and asymptomatic • Give apple/orange juice • Give 1/2 amp D50 if NPO • If BS is <50 or symptomatic • Give 1 amp of D50 and recheck BS in 1 hour • Hold hypoglycemic agents

  16. Nausea/Vomiting • Etiology? = address the problem • Gastritis, Obstruction, UGI Bleed, GERD, Pancreatitis, Gastroparesis • Don’t forget Non-GI causes = CNS bleed, inferior wall MI • Compazine 10 mg PO/IM/IV Q6 PRN • Phenergan (Promethazine) 25 mg IM/IV Q8 PRN • Don’t give in kids • Reglan (Metoclopromide) 10 mg PO/IV Q8 PRN • Zofran (Ondansetron) 4-8 mg PO/IV Q8 PRN

  17. FEVER • Etiology? • Infection, DVT/PE, Atelectasis, Meds (heparin) or Drug rx (ie blood tranfusion) • Is it new? Already on Antibiotics? Post-Op? • CBC, Blood C/S, UA, CXR, LP?? • Tylenol 650 mg PO/PR Q6 • Incentive spirometry

  18. Chest Pain Arrythmias SOB Transfusion Reactions GI Bleeds Hyper/Hypo K+ Change in Mental Status Hypotension Hypertension Falls EMERGENCIES

  19. Emergencies • Remember there is always a supervisor • And for supervisors…there’s always a staff • When starting call, make sure you know the pager number of the ‘sup’ • 888-1948 • Always inform attending physician and family regarding any significant change in patient’s condition

  20. Chest Pain • The call comes – Ask for vitals; EKG STAT, CE STAT, CXR • GO SEE PT • Differential • Unstable Angina, MI, Tension Pneumo, Aortic Dissection, PE, GER • Pertinent H & P • Give (if needed) • ASA 325 mg PO x1 now • Nitro 0.4 mg SL q 5 mins x 3 • Metoprolol 5 mg IV q 5 mins x 3 (watch BP and HR) • Consider O2 to keep sats > 90%; GI cocktail; Morphine if pain • Follow up labs, EKG

  21. Hypertension crisisSBP > 210 or DBP >110 • Emergency = ↑ BP with end organ damage…↓ MAP by 25% in mins to 1 hr • Encephalopathy, SAH, papilledema, MS ∆, CHF, Aortic dissection, ARF, hematuria • Urgency = ↑ BP with no organ damage (must r/o end organ damage with PE)…↓ BP in hrs using PO • TX: Did the pt get his meds??? • Give additional dose of what pt is already on. • Clonidine 0.1 to 0.3 mg PO (remember rebound HTN for 45-60 mins after dose) • Hydralazine 10 mg IV q 6 hr PRN • Labetolol 10-20 mg IV over 2 mins (may repeat q1 hr/max 300 mg QD…watch HR) • Consider Labetolol, NTG drip

  22. Hypotension • Asymptomatic • Check BP trend, assess Vol status • Hold BP meds and give IV Fluid bolus • Symptomatic • Confusion, MS∆, Dizzy, Angina, ↓ UOP, Tachy • NS bolus (500 cc?); Stat EKG and H & H. • Watch closely • Vasopressors??? (Call supervisor)

  23. Falls • Legal issue = must evaluate patient • Vitals, Exam, and Neuro √ • Etiology of fall? • Complications • Get XR (CT of head if needed) • Document in chart • Incident reports

  24. Shortness of Breath • Call comes in: • What was admitting diagnosis? Gradual or sudden? • What are vitals (including continous pulse ox) • Get ABG, CXR, EKG, CE and start O2 • Then Go See the PT • Etiology? COPD, CHF, Asthma, Pneumonia, PE, Pneumothorax, Medication Reaction

  25. Shortness of Breathcontd. • Pt eval – same as admitting dx or new? • Need Spiral CT? Other labs? • Give O2 = watch out for your CO2 retainers • Nasal cannula = 24-40% • Venti mask = 24-60% • Non Rebreather = 95% • Does pt need mechanical ventilation (with or without intubation) • If pt needs CPAP/Intubation – Call ICU team

  26. Shortness of BreathContd. • COPD • Duoneb (albuterol/ipratroprium) q4 hrs PRN • Solumedrol 60 mg IV q6 hrs • Moxifloxacin 400 mg IV q 24 hrs • CHF • On an Ace-I/ARB, Bblocker? • Lasix 40-80 mg IV (watch Cr/K+) • Nebs

  27. Transfusion Reactions • 1-6% of pts will have sx of rx • Hypotension, CP, Tachypnea, Fever w/ chills • Acute Hemolytic Transfusion Rx (Fever/Flank pain/ Brown red urine) • Prep: Give benadryl 25 mg PO and tylenol 650 mg PO prior to starting transfusion • If sx occurs → STOP TRANFUSION • Begin IV Normal Saline infusion- maintain good UOP • Call blood bank (check clerical errors), R/O hemolysis • If anaphylaxis → Epinephrine and Steroids

  28. ArrythmiasEtiology? • Call comes in – • Is pt sx or asx? Vitals. Get EKG, rhythm strip • GO SEE THE PATIENT- stable or unstable? • Cardioversion? • What’s the arrythmia? • Afib (new or chronic) • EKG, CE, CXR, Echo, TSH, CBC • Diltiazem 20 mg IV then 10 mg/hr drip • Bblocker now first-line therapy • Heparin (protocol) if plan to cardiovert • If rhythm control, call Cards: sotalol, amio, dofetilide

  29. GI Bleed • Where’s the bleed? • UGI/LGI; NG lavage? • CBC stat (repeat?), PT/PTT, type and cross 2-4 units • CALL GI • Correct coagulopathies if needed • 2 large-bore IV with NS running open. • PUD: IV Prevacid 60 mg IV followed by 6 mg/hr drip • ICU?

  30. Hyperkalemia • Have lab repeat K+, EKG STAT, check tele • Eval pt • Check meds (D/C ACE, Aldactone) • K+ = 5-5.5 • Kayexelate 30 gm PO or PR • K+ >6 + • Ca gluconate 1 g IV over 5 mins • D50 1 amp + 10 units insulin • Kayexelate 30 gm PO or PR • NaHCO3 1 amp over 3 mins

  31. Hypokalemia • Also check Mg level • KCL 40 meq PO BID; add KCL to IV fluids • (only give 10 meq/hr with peripheral IV) • Recheck K+ in 4-6 hrs • (Don’t give k+ in renal failure)

  32. Mental Status ∆ • Etiology? • Delirium/Dementia • Withdrawal/Intoxication • H & P • Meds (Benzo’s, Narcs, Psych) • Accu √, Pulse ox, Chemistry, CBC • Imaging studies

  33. Pronouncing Death and Autopsy • Time/Date: Called to pronounce John Doe. Patient unresponsive to verbal and tactile stimulation. No heart sounds, pulse, respiration or breath sounds. Pupils fixed and dilated. John Doe pronounced dead at 2218 on August 1, 2007. Mrs. Doe at bedside and informed of his demise. • Call attending. • Talk to next of kin: explain initial cause of death, ask permission for autopsy.

  34. CONCLUSION • Remember…YOUR NEVER ALONE • (Even though it may sure feel like it) • Other interns/residents • Supervisor • Attending • & GO SEE THE PATIENT!!!

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