Nadia Habal, MDPresbyterian Hospital of Dallas

X-COVER?!?

What is going on?Goals of Lecture:

How do I make my X-cover list?How do I identify emergency from non-

emergency?How do I know when I need to go and see the

patient?How do I handle common calls/questions?When do I need to call my resident???

How to make your CareGate list:Log on to CareGateGo to Cross CoverUnder “problems”, put one liner about the

patientThen list all important problems and what has

been done about themUnder “to do” section put MR number, pt

allergies, important meds, anything for X-cover to follow up on

Example:69 y/o with PCKD and transplant kidney p/w painless

hematuria1. Renal: pt continues to have hematuria: likely ruptured renal

cysts 2/2 PCKD, considering CT abd and MRI results. Also worrying about infx, CA, etc. Continue immunosuppression with Cellcept, prednisone. CMV/EBV by PCR neg. Urology following - possible cystoscopy to r/o bladder source.

2.Htn: BP well controlled.3.Paroxysmal AF: atenolol and Cardizem. Short episode of afib

with RVR overnight, with rates of 120s. Continue ASA for prophylaxis.

4.Hypothyroidism - continue replacement.5.Anxiety - continue Ativan.6.RA-pain relief.7.Insomnia: Ambien.8.Wt loss: cancer w/u.9.Choledocholithiasis and pancreatic duct stones: ERCP

today.

Example, continued:Cross Cover To Do

F/u ERCP resultsALL: NKDARX: allopurinol, aspirin, atenolol, Lipitor … You get the idea!

Not Acceptable:“Patient intubated, sedated, in 1 ICU”… when the pt

has been extubated and on the floor for 4 daysMust update room numbers on x-cover listMust update DNR statusMust 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 listIf 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!!!

What do I do when I’m called?We will go through some basics by organ

systems today

Future subjects to be covered during Internship 101 lecture series:ID:      June 30: Pneumonia CV:     July 3:    Arrhythmias GI:      July 7:    GI bleeding Pulm:  July 10:  Sepsis/SIRS Endo:  July 17:  Hyperglycemic states (DKA and

HONC) Neuro: July 31: Altered mental status and “Brain

Code”

NEUROLOGYAltered Mental StatusSeizuresCord CompressionFallsDelirium Tremens

Altered Mental StatusAlways go to the bedside!!!Try to redirect patient: drowsy, stuporous, making

inappropriate comments?Is this a new change? How long?Check for any recent/new medications

administeredCheck VITALS, alertness/orientation, pupils,

nuchal rigidity, heart/lungs/abdomen, strengthScan recent labs in chart including: cardiac

enzymes, electrolytes, +culturesIf labs unavailable, get stat Accucheck, oxygen

saturationTry naloxone (Narcan), usually 0.4-1.2 mg IV, if

there is any possibility of opiate OD

“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

SeizuresGo to bedside to determine if patient still actively seizingCall your residentCheck your ABCsPlace patient in left lateral decubitus positionImmediate AccucheckIf still seizing, give diazepam 2mg/min IV until seizure

stops or max of 20mg (alternative: lorazepam 2-4mg IV over 2-5min)

Give thiamine 100 mg IV first, then 1 amp D50Load phenytoin 15-20 mg/kg in 3 divided doses at 50

mg/min (usually 1 g total) Remember, phenytoin is not compatible with glucose-

containing solutions or with diazepam; 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)

Get Head CT if appropriate and if pt stabilized

Cord CompressionSuspect in patients with new weakness or change in

sensation (especially if they have a demonstrable level), new bowel/bladder retention or incontinence.

Prognosis is dismal for pts w/no function for >24h.Prognosis is best for pts with new, incomplete loss (i.e.

weakness). Surgical emergency: call Neurosurgery.Stabilize the spine: collars for C-spine, Turtle shells

(TLSO) for T/L-spine.Dexamethasone not always indicated (in case of

traumatic fracture, for instance).If tumor, needs immediate radiotherapy.

FallsGo to the bedside!!!Check mental statusCheck vital signs including pulse oxCheck med listCheck blood glucoseExamine pt to ensure no fracturesThorough neuro checkCheck tilt blood pressures if appropriateIf on coumadin/elevated INR—consider head CT

to r/o bleed

Delirium Tremens (DTs)Give thiamine 100mg, folate 1mg, MVISee if patient has alcohol historyCheck blood alcohol levelDTs usually occur ~ 3 days after last ingestionMake sure airway is protected (vomiting risk)Use Ativan 2mg at a time until pt calm, may

need Ativan drip, make sure you do not cause respiratory depression

Monitor in ICU for seizure activityAlways keep electrolytes replaced

PULMONARYShortness of BreathOxygen De-saturations

Shortness of BreathGo to the bedside!!!Check an oxygen saturation and ABG if indicatedCheck CXR if indicated

Causes of SOBPulmonary:

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!

Oxygen DesaturationsSupplemental OxygenNasal cannula: for mild desatsFace mask/Ventimask: offers up to 55% FIO2Non-rebreather: offers up to 100% FIO2BIPAP: good for COPD

Start settings at: IPAP 10 and EPAP 5IPAP helps overcome work of breathing and helps to

change PCO2EPAP helps change pO2

CPAP: good for pulmonary edema, hypercapnea, OSAStart at 5-7

Indications for IntubationUncorrectable 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 protectionUpper airway obstruction

Mechanical VentilationIf 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 12Check CXR to ensure proper ETT placement

(should be around 4cm above the carina)Check ABG 30 min after pt intubated and

adjust settings accordingly

CARDIOLOGYChest painHypotensionHypertensionArrhythmias

Chest PainGo and see the patient!!!Why is the patient in house?Recent procedure?STAT EKG and compare to old onesIs the pain cardiac/pulmonary/GI?—from H+PVital signs: BP, pulse, SpO2If you think it’s cardiac:

Give SL nitroglycerin if pain still present (except if low blood pressure, give morphine instead)

Supplemental oxygenAspirin 325 mg

HypotensionGo and see the patient!!!Repeat Manual BP and HRLook at recent vitals trendsLook 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

Management of HypotensionIf offending med, stop the med!If volume down/bleeding: give wide open IV NSCorrect hypoxiaRecent steroid use? Adrenal insufficiencyIs there a neuro cause for hypotension?If appropriate, consider: PE, tamponade,

pneumothoraxIf fever, consider sepsis—need for empiric antibioticsIf hives and wheezing, consider anaphylaxis—tx with

oxygen, epinephrine, BenadrylNeed for pressors? Transfer to ICU!

Commonly Used PressorsName Receptor

AffectedDose Action

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

A1 10–20 mcg/kg/min

Vasoconstriction; Causes Arrhythmias

Dobutamine B1, B2 1–20 mcg/kg/min

Positive inotropy andchronotropy; Causes Hypotension

HypertensionIs there history of HTN?

Check BP trendsIs patient having pain, anxiety, headache, SOB?Confirm patient is not post-stroke pt—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

Management of HypertensionIf 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

Remember, no need to acutely reduce BP unless emergency

So, start a medication that you would have normally picked in this patient as the next agent of choice according to JNC/co-morbidities/allergies

Hypertension (continued)

URGENCYSBP>210 or

DBP>120No end organ

damage

OK to treat with PO agents

EMERGENCYSBP>210 or DBP>120Acute end organ

damage

Treat with IV agentsDecrease MAP by 25%

in one hour; then decrease to goal of <160/100 over 2-6 hrs.

GINausea/VomitingGI BleedConstipationDiarrheaAcute Abdominal Pain

Nausea/VomitingVital signs, blood sugar, recent meds?Make sure airway is protectedEXAM: 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 IVReglan 10-20 mg IV (especially if suspect gastroparesis)If no relief, consider NG tube (especially if suspect

bowel obstruction)

GI Bleed (to be discussed in detail at a later date):

UPPERHematemesis, melenaCheck vitalsPlace NG tubeNPOWide open fluids vs. bloodCheck H/H seriallyIf suspect PUD: Protonix

dripIf suspect varices:

octreotideCall Resident and GI

LOWERBRBPR, hematocheziaCheck vitalsRectal examWide open fluids if low BPNPOCheck H/H seriallyTransfuse if appropriatePain out of proportion?

Don’t forget ischemic colitis!

ConstipationVery common call!Check: electrolytes, pain meds, bowel regimenCheck KUB if suspect ileus/obstructionRectal exam to check for fecal

impaction/mechanical obstructionTreatment:

If not acute process, can order “laxative of choice”Fleets enema for immediate relief (unless renal

failure b/c high phos—then can order water/soap suds enema)

Lactulose/mag citrate PO if no mechanical obstruction

DiarrheaCheck: electrolytes, vitals, medsQuantify volume, number, description of stoolsLabs: fecal leukocytes, stool culture, guaiac,

C.diff toxin if recent antibiotic or nursing home resident

Treatment: Colitis: flagyl 500mg po tidGI bleed: per GI sectionIf don’t suspect infection: loperamide initially 4mg

then 2mg after each unformed stool up to 16mg daily

Acute Abdominal PainGo to the bedside!!!Assess vitals, rapidity of onset, location, quality and

severity of painLOCATION:Epigastric: gastritis, PUD, pancreatitis, AAA, ischemiaRUQ: gallbladder, hepatitis, hepatic tumor, pneumoniaLUQ: spleen, pneumoniaPeri-umbilical: gastroenteritis, ischemia, infarction,

appendixRLQ: appendix, nephrolithiasisLLQ: diverticulitis, colitis, nephrolithiasis, IBDSuprapubic: PID, UTI, ovarian cyst/torsion

Acute Abdomen?Assess severity of pain, rapidity of onsetIf acute abdomen suspected, call SurgeryDo you need to do a DRE?KUB vs. Abdominal Ultrasound vs. CTTreatment:

Pain management—may use morphine if no contraindication

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

RENAL/ELECTROLYTESDecreased urine outputHyperkalemiaFoley catheter problems

Decreased Urine OutputOliguria: <20 cc/hour (<400 cc/day)Check for volume status, renal failure, accurate

I/O, medsConsider bladder scanLabs:

UA: WBC (UTI); elevated specific gravity (dehydration); RBC (UTI/urolithiasis); tubular epithelial cells (ATN); WBC casts (interstitial nephritis); Eosinophils (interstitial casts)

Chemistries: BUN/Cr, K, Na

Treatment of Decreased UOPDecreased Volume

Status:Bolus 500 cc NSRepeat if no effect

Normal/Increased Volume:

May ask nursing to check bladder scan for residual urine

Check Foley placement

Lasix 20 mg IV

Foley Catheter Problems:Why/when was it placed?Does the patient still need it?Confirm no kinks or clampsConfirm bag is not fullExamine output for blood clots or sedimentDo not force Foley in if giving resistanc: call

UrologyNursing may flush out Foley if it must stay inThe sooner it’s out, the better (when

appropriate)

HyperkalemiaEnsure correct value—not hemolysis in labCheck for renal insufficiency, medsCheck EKG for acute changes, peaked T-

waves, PR prolongation followed by loss of P waves, QRS widening

Treatment of HyperkalemiaImmediate Rx (works in minutes): for EKG changes,

stabilize myocardium with 1-2 amps calcium gluconate Temporary Rx (shift K into cells):

2 amps D50 plus 10 units regular insulin IV: decreases K by 0.5-1.5 mEq/L and lasts several hours

2 amps NaHCO3: best reserved for non-ESRD patients with severe hyperkalemia and acidosis

B2-agonists: effects similar to insulin/D50Long-lasting Elimination:

Kayexalate 30g po (repeat if no BM) or retention enemaNS and LasixDialysis

ENDOCRINOLOGYDKAHONC

(Will be covered in detail at later time)

DKAIdentify precipitating factor (e.g., infection, MI,

noncompliance with meds)Check for anion gapCheck for ketones in urine or serumGive bolus 1 Liter NS, then run IVF at 200

ml/hour if no contraindicationStart insulin drip DKA protocol in ICU (EPIC

order)Check electrolytes every 4 hours and replace as

appropriate

HONCSimilar to DKA but for Type II diabetes and no

ketonesThere is also an insulin drip NON-DKA protocol

in ICU (EPIC order)

IDPositive Blood CultureFever

Positive Blood CultureYou 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 pt is on abx, make sure appropriate coverage

based on culture and sensitivityIf 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

FeverHas the patient been having fevers?DDX: infection, inflammation/stress rxn, ETOH

withdrawal, drug rxn, transfusion rxnIf the last time cultures were checked >24 hrs

ago, then order blood cultures x 2, 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

HEMEAnticoagulationBlood replacement products

AnticoagulationAppropriate for DVT, PE, Acute Coronary SyndromeUsually start with low molecular weight heparin—

(Lovenox) 1 mg/kg every 12 hours and adjust for renal fxnIf need to turn on/off quickly (e.g., pt going for procedure)

use heparin drip—there is a protocol in EPICRisk factors for bleeding on heparin:

Surgery, trauma, or stroke within the previous 14 daysHistory of peptic ulcer disease, GI bleeding or GU bleedingPlatelet count less than 150KAge > 70 yrsHepatic failure, uremia, bleeding diathesis, brain mets

Blood Replacement ProductsPRBC: One unit should raise Hct 3 points or Hgb

1 g/dlPlatelets: One unit should raise platelet count by

10K; there are usually 6 units per bag ("six-pack")use when platelets <10-20K in nonbleeding

patient.use when platelets <50K in bleeding pt, pre-op pt,

or before a procedureFFP: contains all factors

use when patient in DIC or liver failure with elevated coags and concomitant bleeding or for needed reversal of INR

RADIOLOGYWhat test do I order for what problem?

Plain FilmsCT scansMRI

Plain FilmsCXR:Portable if pt in unit or bed boundPA/Lat is best for looking for effusions/infiltratesDecubitus 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

CTHead CT

Non-contrast best for bleeding, CVA, traumaContrast best for anything that effects the blood

brain barrier, tumors, infectionCT 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

MRIIncreased sensitivity for soft tissue pathologyBest 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

DEATHPronouncing a patientNotify the patient’s familyRequest an autopsyHow to write a death note

Pronouncing a PatientCheck for:Spontaneous movementIf on telemetry—any meaningful activityResponse to verbal stimuliResponse to tactile stimuli (nipple pinch or

sternal rub)Pupillary light reflex (should be dilated and fixed)Respirations over all lung fieldsHeart sounds over entire precordiumCarotid, femoral pulses

Notify the Patient’s FamilyCall family if not present and ask to come in, or

if family is present:Explain to them what happened Ask if they have any questionsAsk if they would like someone from pastoral care

to be calledLet them know they may have time with the

deceasedNursing will put ribbon over the door to give

family privacy

Request an AutopsyAsk family if they would like an autopsy

Medical Examiner will be called if:Patient hospitalized <24 hoursDeath associated with unusual circumstancesDeath associated with trauma

How to Write a Death NoteDOCUMENTATION:“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.

Bottom Line:When in doubt, call your ResidentIt is OK to call your attending if over your headYou 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!