Intern Night Float Survival Guide, Schemes and Mind Maps of Surgical Pathology

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Intern Night Float Survival Guide

‘Your guide through the dark’

SUNY Upstate Medical University

List of Topics: Page Number

• Leaving Against Medical Advice (AMA)
• Constipation
• Pain Control
• Acute Anemia
• Low Urine Output
• Hypoglycemia
• Chest Pain
• Arrhythmias/ACLS
• Atrial Fibrillation
• Hypertension
• Acute GI bleed
• Shortness of Breath
• Oxygen Delivery system
• Electrolyte Replacement
• Hyponatremia
• Hyperkalemia
• Abdominal pain
• Hypernatremia
• Insomnia
• Hyperglycemia
• Agitation/Confusion
• Fever
• Sepsis
• Phone Numbers

PATIENT LEAVING AGAINST MEDICAL ADVICE

• Discharge against medical advice (AMA) is a

situation in which a patient chooses to leave the

hospital before the treating team recommends

discharge.

• Review patient’s chart and ensure that patient does

not have a condition that impairs his / her capacity to

make decisions. e.g psychiatric problems, mental

retardation, encephalopathy, delirium.

• Suicidal patient, or patients admitted after attempting

to commit suicide are not allowed to leave unless

specifically recommended by psychiatry.

• Review sign out for instructions from primary team.
• Talk to patient. Most common scenarios when

patients decide to do this are:

• dissatisfaction with their care.
• dissatisfaction with staff taking care of them.
• feeling uninvolved. Feeling of not being updated

on clinical progress.

• inadequate pain control
• personal problems.
• Attempt to answer patient’s questions as directly as

possible. Attempt to alleviate concerns by providing

information. Resolve any medical concerns such as

pain control if deemed reasonable.

• If patient decides to leave anyway, explain to him /

her all possible consequences of leaving prior to

completing treatment. Provide them with the

appropriate AMA form to sign.

• Let the senior NF/ nocturnist know. Complete

medical reconciliation to the best of your ability.

Provide scripts if needed. NEVER prescribe

controlled substance. Advise appropriate follow ups.

• Document your conversation with patient. You don’t

have to do the discharge summary but mention in

brief why the patient chose to leave and that you

explained the potential risks which he / she

understood. Make sure to document that patient had

the capacity to understand the decisions regarding

his medical care.

• Inform the team and concerned attending in the

morning.

CONSTIPATION

• Defined as decrease in frequency ( < 3 BMs / week) or

change in consistency to hard / lumpy stool or difficulty

in evacuation with feeling of incomplete evacuation.

• Prior to prescribing medications, ensure patient is not

obstructed. Is the patient passing flatus? Any vomiting

? Abdominal pain? If concerned, examine for signs of

surgical abdomen.

• Review the chart to for medications which can cause

constipation: opioids, anticholinergics, 1 st^ degree

antihistaminics.

• Evaluate patient’s bowel medications. (All patients

with opioids should be on bowel regimen)

• Once dynamic obstruction is ruled out, may order

medications as follows:

Stool softeners :

• Docusate 100 mg BID: Takes 24 - 72 hours for

onset of action.

Stimulants :

• Senna (2 to 4 tablets daily): Works in 6 -12 hours.
• Bisacodyl
  • 10 to 30 mg tablet daily: Works in 6-

hours.

• 10 mg suppository works in 15-60 minutes.

Osmotic agents:

• Magnesium sulfate 1 - 2 teaspoons in water: Acts

in 0.5 – 3 hours (Avoid in renal insufficiency).

• Polyethylene glycol 8 to 34 gms daily: Acts in 1-

days.

• Lactulose (10-20 gms): Works in 2 - 4 hours.

Enemas: If patient is on reasonably good bowel

regimen with no BMs in 3 - 4 days with no signs of

obstruction, consider enemas. Can use bisacodyl, tap

water, lactulose enema. Avoid phosphate enemas in

renal dysfunction and elderly.

• Remember, reverse underlying pathologies causing

the constipation: pain, urinary retention, recent

surgery, opioid use, dehydration.

• In intractable cases, may consider manual fecal

disimpaction.

PAIN CONTROL

#1. Information from nursing:

• Acuity: New onset vs. exacerbation of known pain?
• PQRST?
• Red flags: Fever, focal deficits, LOC, dizziness, chest pain, dyspnea, increased oxygen requirement.
• Wounds? Recent surgery? Incisional pain?
• Hemodynamic stability especially for chest pain, abdominal pain.

#2. Information from chart/sign out:

• Try to find out a cause of the reported pain. Is it known?
• Existing regimen? Recommendations from primary team.
• Review home pain regimen.
• Review common reasons for contraindication to meds:
  • NSAIDs: GI bleed, GERD, recent ACS, allergy, AKI.
  • Tylenol: Acute / fulminant liver failure, toxicity.
  • Narcotics: Allergy, intolerance, poor respiratory reserve, old age, renal dysfunction.

#3. Triage: Does the patient need to be seen? and

initial assessment:

• Chest pain: Please refer to segment on chest pain.
• Headache: New onset, intractable, auras, focal deficits.
• Back pain: Neurological deficits, saddle anesthesia, incontinence.
• Post operative pain: Incisional healing, signs of infection.
• Fall: Evaluate for acute fractures. Does patient need neck stabilization?
• Abdominal pain: Surgical signs? No flatus / feces? Guarding / rigidity?
• H/O of sickle cell disease: Crisis? acute chest? bone crisis?
• ALWAYS ASSESS PAIN IN THE SETTING OF HEMODYNAMIC INSTABILITY.

#4. Management:

• Work up emergent causes of pain if being considered (as explained in #3) - Non opioid options:
  • Tylenol: MDD: 4 gm, MDD with liver failure: 2 gm. Maybe used PRN (650 mg Q6H PRN). If not effective, consider standing doses for 24 hours (inform team). Standing tylenol works better than PRN. Can also be administered per rectal.
  • NSAIDs: Work well for acute pain.
  • Local agents: Lidocaine patch / gel / ointment, diclofenac gel.
• Opiods:^ Use sparingly. Work well for acute pain, especially post operative pain. Order one time doses only. Inform team in AM. - Already on opioids: If no C/I, give a one time dose after enquiring about the last dose. Try to give same drug as being used. Do not order long acting doses. - Opioid naive: Consider one time doses of lowest dose of

#5. Opioid administration: opioid (see #4)

If patient can take PO and no risk of aspiration: Use lowest dose as one time order.

• Tramadol: Synthetic. Use 50 mg doses PRN.
• Hydrocodone/tylenol: 5/325 or 5/500 mg (may repeat Q4 - 6 hours)
• Oxycodone:5 mg (may repeat Q4 - 6 hours)
• Morphine IR: 15 or 30 mg dose.

If unable to take PO / aspiration risk:

• Fentanyl 25 to 50 mg IV (based on BMI). May repeat Q2 - 4 hours (shorter acting drug)
• Morphine 2 or 4 mg IV (based on BMI). May repeat Q 2- 4 hours if needed.

#5. Important considerations:

• Avoid ordering standing doses. Avoid long acting formulations.
• Always sign out pain control issues to primary service so they may address it on rounds.
• Always assess sign out. Primary service may recommend not using a certain medication for specific reasons.
• Handy tool to convert doasage (roughly) from one opioid medication to another: http:// opioidcalculator.practicalpainmanagement.com/

LOW URINE OUTPUT

#1. Information from nursing:

• Acuity? Duration?
• Does patient have Foley catheter? Is it draining?
• If not: What is the post - void residual urine?
  • If < 100 cc: evaluate etiology.
  • If > 200 cc: straight cath.
  • If > 400 cc: place a foley catheter and leave it in place.
• If patient has ascites, bladder scanning overestimates the bladder volume.
• Associated symptoms: fever, signs of infection?

#2. Information from chart review / sign out:

• Oliguria (<500 cc/day or <0.5 cc/kg/hr) / anuria (No urine output).
• Fluid status: I/Os, including cumulatives. Does patient have a reason to be hypovolemic?
• Med review: Diuretics, IV fluids, drugs with anti - cholinergic properties (cause retention).
• Other factors: Pain / recent surgery / constipation (impair bladder emptying).
• Labs: BUN / Cr and Sr. Osm (does it suggest intravascular depletion or overload ?)

#3. Assessment:

• Volume status assessment: Intravascularly depleted or volume overloaded? - Intravascular depletion: Mucus membranes, skin, BP, HR, UOP, mental status. Remember orthostatic signs are sensitive for detecting depletion especially in cases of bleeding. - Overload: JVD, crackles, edema, S3.
• Look for underlying causes:
  • Intravascular depletion: Sepsis, poor PO intake, excessive diuresis etc.
  • Overload: Fluids, ACS, arrhythmias, CHF.

#4. Treatment:

• Patient already has Foley? Ensure it is draining. Ask nursing staff to flush and confirm patency.
• Intravascularly depleted?
  • IV fluid boluses: 250 - 500 ml. If improvement noted, place on maintenance fluids (for 1000 ml) and inform primary team.
  • Treat primary cause: Sepsis, diarrhea, etc.
• Overload state:
  • Consider diuresis.
  • Treat primary cause or concomitant issues (arrhythmias).
• Remove offending factors: Anti cholinergic meds, pain meds, constipation.

NOTES

HYPOGLYCEMIA

#1. Information from nursing:

• How low is the fingerstick?
• First time or recurrent?
• Is patient symptomatic? Diaphoresis, confusion, tremor, fatigue, loss of consciousness.
• When was last insulin dose administered, what type? Last long acting insulin dose? Last meal and general PO intake?

#2. Information from chart review / sign out:

• Is patient diabetic?
• Trend review: IS patient recurrently low on FSGLU (finger stick glucose) at particular times of day?
• Medication review: Patient on insulin? What is the regimen: home vs inpatient? Any recent changes? When was last dose of insulin administered?
• Is patient NPO? Reason? (pre op vs aspiration precaution etc)
• Does patient have AKI which can lead to decreased excretion of insulin?
• Does patient have any signs of sepsis (infection), hepatic failure (impaired glucose metabolism), adrenal insufficiency (Hyper Na,

#3. Assessment / Treatment: hypokalemia, low BP)?

• Confirm serum glucose by point of care glucometer.
• Symptomatic: diaphoresis, confused, seizures, N/V: IV dextrose amp
• If patient does not have H/O DM and not on anti-hyperglycemic medication: try oral juice and recheck FS in 15 minutes
• For patients who are on glucose lowering agents:
  • Hold further doses of hypoglycemic agents.
  • Can take PO: give 15 gms carbohydrate (4 oz juice)
  • Unable to take PO and has IV access, give^ ½^ amp D50 IV and recheck FS. Repeat as needed
  • Unable to take PO and no IV access, give 1 mg glucagon IM
  • Check FS q15 minutes and repeat above till BG>100 mg/ dl.
• Re-adjust/hold insulin scale as necessary.
• Inform primary team.

#4. Persistant hypoglycemia:

• If patient received large dose of insulin or received normal dose insulin in light of acute kidney insufficiency, or received long acting insulin, hypoglycemia can recur.
• Place patient on D5NS (@ 75-150 ml / hour) OR D10NS gtt (@ 50 - 100 ml / hour) to maintain FSGLU > 100 mg /dl. Hold all insulin regimens. Be aware of volume status, avoid in patients with heart failure. Preferably use D10 in ESRD / CHF patients.
• If refractory to treatment, discuss with SNF.

NOTES:

ARRHYTHMIAS / ACLS

#1. Information from nursing:

• Hemodynamic stability. Vital signs?
• Symptoms. Chest pain, LOC, SOB, fever?
• Duration of arrhythmia: Constant / intermittent?

#2. Information from chart / sign out:

• Cardiac history: A.fib / flutter, SSS, CAD.
• Check past EKGs / echos.
• Current electrolytes. K > 4, Mg > 2?
• Systemic disease that maybe contributing: Sepsis, dehydration, thyroid disorders, pregnancy.
• Risk stratification for common causes: ACS, PE etc.
• Medication review: BB, CCB, digoxin, thyroid medications, clonidine etc.

Decision making flowchart:

1. Pulse? : If no pulse, refer to #3. Activate Code.
2. If pulse present: Unstable or stable? AMS, poor UOP, LOC, desaturations, poor organ perfusion, chest pain, pulmonary edema, shock
   • Stable / unstable bradycardia: Refer to #
   • Unstable tachycardia: Refer to #5.
   • Stable tachycardia: Refer to #6.
3. Always treat underlying cause: Address volume status. Reverse Hs/Ts.
4. ASAP: EKG, CBC, BMP, magnesium, CIPs!
5. Call SNF / MICU to help with situation.

#3. Arrhythmias w/o pulse: CODE BLUE !!

FOLLOW ACLS ALGORITHM (See next page)

Reverse Hs and Ts:

Hypovolemia : Fluid boluses with pressured bag Hypoxia : bag mask ventilation, intubation Hydrogen ion (acidosis) : Bicarb boluses Hypo / Hyperkalemia Hypoglycemia Tension pneumothorax: Needle decompression (SICU bedside) Tamponade (SICU bedside) Toxins / drugs Thrombosis: Pulmonary / Coronary

#4. BRADYCARDIA w/ pulse:

Unstable:

• Atropine (0.5 mg IV Q 3 - 5 minutes, max dose: 3 mg)
• If considerations for beta blocker toxicity: Consider glucagon and insulin IV.
• Apply pads. Prepare for transcutaneous pacing. Call SNF/ MICU. Consider cardiology consult.
• If hypotensive: Bolus fluids. Treat as shock.
• Discontinue all nodal blockers.

Stable: Patient asymptomatic:

• Sleeping: Physiological. Attempt to wake patient and see response.
• Asymptomatic: Obtain EKG.
  • SInus bradycardia: “Does not need treatment”. D/C
  • blockers
  • AV block: Check old EKG. D/C blockers.
  • Consult SNF. If new 2nd or 3rd degree block,

#5. UNSTABLE TACHYCARDIA w/ pulse: • consider cardiology consult.

RRT. Call SNF. Obtain EKG. Attach a Zoll monitor****.

• Regular wide complex^ i.e VT / SVT with aberrancy: Assume VT.
  • Sync cardioversion: 100 J, increment if needed.
  • Post resuscitation, consult cardiology and consider amiodarone / lidocaine gtt.
  • Torsades: Magnesium IV. Avoid amiodarone (prolongs QTc)
• Irregular wide complex:^ VF (rarely with pulse): DESYNC SHOCK! - Regular narrow complex:^ Sinus / SVT / flutter:
  • Sync cardioversion: 50 - 100 J, increment if needed.
  • Treat underlying cause: Volume depletion vs overload (eg sepsis vs. pulmonary edema), pain, recent sx, Hs / Ts.
  • Adenosine (6 mg - 12 mg - 12 mg).
  • See stable tachycardias for other management.
• Irregular narrow complex : A. fib, flutter with variable block, MAT:
  • Sync cardioversion: 120 - 200 J, in increments.
  • Treat underlying cause as mentioned above.
  • See stable tachycardias for further management.

#6. STABLE TACHYCARDIA: Usually narrow complex

• Rx underlying cause. Hs / Ts. Volume status is very important: Give fluids / diurese! - Pharmacology, narrow complex:
  • If not hypotensive:
    • Cardizem bolus (1 mg/kg, max dose: 20 mg) * 2 Q 10 minutes. Start on Cardizem gtt.
    • Metoprolol 2.5 or 5 mg IV.
  • If hypotensive: Amiodarone 150 mg loading IV, then gtt.
  • If known systolic CHF: consider digoxin (usually avoided 2/ toxicities)
  • If considering septic shock and have central access: Transfer to ICU, consider esmolol gtt with levophed support (after adequate fluids)

ATRIAL FIBRILLATION

CALL FOR: IRREGULARLY IRREGULAR PULSE / TELE

#1. Information from nursing:

• Acuity: New or old?
• Is the call because patient’s rate is now uncontrolled or because of new A.fib.
• Vitals / hemodynamics.
• Is there a known cause? (Please see section on causes).

#2. Information from chart review / sign out:

• Acuity: New or old?
• Are there any recommendations from the team regarding rate control? What’s been tried and what worked?
• Review of existing rate controlling meds : BB, CCB, amiodarone, digoxin. Did patient miss any medications?
• Review old EKGs, old cardiology notes.

#3. Assessment:^ •^ Check most recent K, Mg, TSH levels.

• Vitals: Ensure hemodynamic stability.
• Examine / ask questions to rule out causes of PE (see the section on causes)

#4. Initial interventions:

• stat 12 lead EKG: irregular narrow complex tachycardia with no identifiable P waves - atrial fibrillation. Look for signs of ischemia
  • peaked T waves, ST segment elevation / depression, T wave inversions, Q waves.
• Repeat BMP, magnesium levels in not sent within the last 4 hours.
• Send a TSH levels if none done recently.
• CIPs to rule out ACS especially if concerning symptoms / signs present.
• If hypoxic, or symptomatic with risk factors, consider CTA for PE protocol.

#5. Causes / etiologies:

Mnemonic: MARTHA PID

• Medications: missed doses of rate controlled agent. Use of theophylline, caffeine.
• Acute Coronary Syndrome, acute CHF or existing CAD.
• Respiratory (PE, hypoxia, COPD).
• Thyrotoxicosis.
• Hypokalemia, hypomagnesemia.
• Alcohol,^ illicit^ drugs^ (cocaine,^ amphetamine,^ bath^ salts,^ etc). Always remember withdrawal states!
• Pain. Recent sx / injury? Open areas?
• Infection / sepsis.
• Dehydration. Patient not taking PO? Assess why.

#6. Treatment / underlying cause:

• Correct underlying cause:
  • Medications: Assess why patient not taking his PO rate controllers. Consider IV formulations from same family.
  • Acute Coronary Syndrome: Trend CIPs (refer to section on chest pain)
  • Acute CHF: Consider diuresis.
  • PE: stat imaging. Consider empiric anticoagulation if high risk.
  • COPD exacerbation: Treat with bronchodilators, however exercise caution since beta agonists can exacerbate atrial fibrillation.
  • Hypokalemia, hypomagnesemia: Replace (see section on electrolyte replacement)
  • Cocaine use: Consider benzodiazepines.
  • Alcohol withdrawal: CIWA protocol.
  • Pain: See section on pain control.
  • Infection / sepsis: See section on sepsis.
  • Dehydration: IV hydration.

#7. Treatment / rate control:

If blood pressure acceptable:

• Metoprolol 5 or 10 mg IV and repeat as necessary. Once controlled, immediately give PO 12.5 / 25 / 50 mg based on BP.
• Cardizem 0.25 mg / kg over 2 mins (Max: 20 mg) IV. Usual dose 10 mg. May repeat after 15 minutes. Once controlled, can start cardizem 30 mg PO q 6 H. If not controlled, start on cardizem drip at 5 / 10 / 15 mg / hr depending on BP.

If BP low: CALL SNF.

• May use lower doses of IV metoprolol or cardizem.
• Amiodarone 150 mg bolus, followed by gtt @ 1 mg / kg for 6 hours, followed by 0.5 mg / kg for 18 hours. Inform team to consult cardiology for further recs.
• Esmolol 0.5 mg / kg bolus dose. can use esmolol gtt, but needs MICU consult since may need pressor support.

If hemodynamically unstable: acute drop in BP / patient unresponsive – synchronized cardioversion (evaluate risk of causing CVA) : Refer to section on tachycardias for details.

#8. Special considerations:

• If A.fib lasts > 48 hours, patient will need anticoagulation depending on CHADS2 / CHADS2 - VaSc score, relay to team regarding considering anticoagulation.

ACUTE GI BLEED

#1. Information from nursing:

• Hemodynamically stable? : Tachycardia, hypotension. Orthostasis?
• Symptoms: Upper vs. lower: melena / hematochezia / hematemesis. Associated symptoms?
• 1^ st^ time or recurrent?

#2. Information from chart / sign out:

• Review Hb / Hct trend.
• Known source of GIB? Past GI history?
• History of liver failure?
• Last EGD / colonoscopy?
• Known coagulopathy? Check medications.

#3. Initial assessment:

• Symptoms: Site of bleeding, dizziness / orthostatics, abdominal pain.
• Examination: Abdominal, oral, rectal.
• Assess intravascular depletion: Skin exam, mucosal exam, tachycardia (early), orthostatics / leg raising (15% loss), supine hypotension (40% loss).
• Assess severity: Rockall score (see reference tables).
• Delineate source, consider etiology (see graphic below)

#4. Initial interventions:

• Ensure^ adequate IV access : 2 wide bore IVs. Consent patient for potential PRBC transfusion. - Investigations / labs:^ CBC (Hct might not decrease initially), PTT / INR, type and cross, LFTs, BUN / Cr
• Hemodynamically unstable : Start fluid resuscitation. Consider PRBC transfusion (see below). Call SNF. Discontinue anticoagulation, consider reversal.
• Keep^ transfusion^ threshold at Hb < 7 and Hct < 21 or follow primary team’s instructions. For patients with active ACS, transfusion threshold is low (around 8 and 24). Can transfuse 1-2 units at a time. - Reversal of anticoagulation : in case of liver disease or Coumadin use when INR>1.6. Use PCC 25 units/kg for INR< and 35-50 units/kg when INR>4. If unavailable can use FFPs 10-15 ml/kg. (see section on reversal of anti coagulation for details)

#5. Specific interventions:

• Suspected^ upper GI bleed :
  • Non variceal: pantoprazole 80 mg stat followed by 8 mg/hr gtt.
  • Variceal: As above plus octreotide 50 mcg IV stat followed by 50 mcg/hr gtt.
• Suspected^ lower GI bleed :
  • Source location:
    • Tagged RBC scan: detect rates of 0.1 - 0.5 ml/hr
    • CTA abdomen/ pelvis: rates > 0.5 ml / hr
    • Colonoscopy
  • If suspecting ischemic colitis: Stat lactate and imaging. Consider surgical consult.
• If patient has^ ascites : Antibiotic ppx with ceftriaxone 1 gm Q 12 hours IV
• Consult GI.
• Inform SNF especially if hemodynamically significant bleeding.
• Please refer to section on acute anemia / drop in H/H for further details.

Notes:

SHORTNESS OF BREATH

#1. Information from nursing:

• Symptoms: Onset and progression. Associated complaints?
• Vitals ?: Pulse ox, hemodynamic stability, fever
• Is patient on tele?
• Are fluids running ?: Type and rate.
• Is it known? Is patient being treated for a potential cause?

#2. Information from chart review / sign out:

• Code status: DNR / DNI?
• Baseline / home oxygen requirements?
• Pulmonary / cardiac review:
  • Relevant PMH: COPD / asthma, CHF, PE, recent surgery, anxiety.
  • CXR, PFTs, echo, EKG, previous caths.

#3. Initial assessment:

• Quick ROS: Attempt to differentiate primary pulmonary vs. cardiac etiology.
• Hemodynamic assessment with oxygen requirements.
• Assess severity:
  • RS: Tachypnea, accessory muscle use, cyanosis, ronchii / wheezing. Obtundation / twitching (CO2 retention)
  • CVS: S3, JVD, crackles, edema. New murmurs?
• Pertinent differentials w/ clinical findings:
  • CHF exacerbation / flash pulm edema: JVD, crackles, S3, edema, fluid overload state, high BP.
  • ACS: Chest pain, new cardiac findings.
  • PE: Well’s, tachycardia, tachypnea, pleuritic CP, normal lung exam.
  • Pneumothorax: Absent lung sounds, tamponade physiology.
  • Aspiration: New ronchii, tachypnea.
  • COPD exacerbation: wheezing, signs of hypercapnia. Silent chest is indicative of imminent collapse.
  • PNA: fever, leucocytosis, ronchii.
  • Atelectasis: recent surgery?, bed bound.
  • OSA: Asymptomatic, snoring, nocturnal desats on tele.

#4. Initial interventions:

• Place in head propped up position. Oxygen as required to maintain saturation: NC —> FM —> NRB. (Please see section on oxygen delivery)
• Initial investigations / imaging: CXR, continuous pulse ox, EKG, CIPs (if suspecting ACS), ABG.
• Use ABGs to assess hypercapnia states. Useful in hypoxia to assess for A - a gradient for shunt pathology. - Normal pH: 7.34 - 7. - PaO2: 80 - 100 mmHg - PaCO2: 35 - 45 mmHg
• Pertinent differentials being entertained:
  • CHF exacerbation / flash pulm edema: Clinical + CXR. Consider BNP / pro BNP, EKG, CIPs, echo in AM.
  • ACS: EKG, CIPs
  • PE: stat CTA. If AKI or dye allergy, consider V/Q scan.
  • Pneumothorax: Clinical + CXR.
  • Aspiration: CXR. Consider swallow eval in AM.
  • COPD exacerbation: Clinical. ABG to assess for hypercapnia.
  • PNA: CBC, CXR.

#5. Definitive management of potentially immediately

fatal etiologies:

• ACS: Please refer to section on chest pain.
• PE: Imaging as mentioned in #4. If unable to obtain imaging and clinical suspicion high, ensure absence of contra indications and deliver empiric anticoagulation. If imaging +, start on high dose heparin gatt or Lovenox 1 mg / kg BID (provided no renal dysfunction).
• Pneumothorax: If imminent collapse, bedside needle decompression. If stable, consult surgery.

#6. Definitive management of other etiologies:

• CHF exac: Diuresis (Lasix: creatinine * 20 mg IV eg. For creatinine level of 2.0, Lasix dose will be 40 mg IV), morphine, nitro gtt, hemodialysis. Consider MICU consult for CPAP.
• PNA: Appropriate antibiotics (CAP vs HCAP)
• COPD exacerbation: Duonebs Q 4 H, albuterol Q2H PRN, consider IV hydrocortisone bolus, BiPAP if ABG shows respiratory acidosis. Consult MICU.
• Aspiration: Initiate aspiration precautions. Make patient NPO. Sign out to team to order swallow evaluation.
• Anxiety: Consider one time dose of anxiolytic.

Important considerations:

• Consult SNF if unstable patient or sudden increase in oxygen requirements. Consider MICU consult is patient requiring > 50% FiO2.
• If patient requires positive pressure: BiPAP / CPAP or considering intubation, consult SNF and MICU. Call RT and SWAT to assist.

NOTES:

ELECTROLYTE REPLACEMENT

POTASSIUM REPLACEMENT

Oral: Potassium chloride (K - Dur in epic as a pill, also available as a liquid) IV: Potassium phosphate IVPB (10 mEq in 100 ml) or double strength (20 mEq in 100 ml)

- Check renal function and in patients with ESRD / CKD / AKI, be less aggressive in K replacement since these kidneys won’t excrete potassium as a normal kidney would.

• If administering intravenous 20 mEq in 100 ml concentration, ensure patient is in ICU on EKG monitoring.
• Check Mg (Intracellular Mg prevents outward K flux in ascending loop via ROMK channel and thus prevents its excretion in urine.^ Low Mg leads to increase urinary K loss )
• 10 mEq replacement will raise serum K by 0.1. In absence of gut dysfunction:^ PO = IV.
• ICU protocols for patients with Cr<1.5.
• Repeat potassium levels after 2 hours of completion of regimen. Do not exceed 400 meq / 24 hours replacement.

MAGNESIUM REPLACEMENT

Each 1 gm magnesium will raise serum level by 0.

• If level 1.8 - 2:^ give 1 gm IV MgSO^4 ( = 8 meq) over 1 hour or Mg Oxide PO 400 mg daily for 2 days
• If level 1.6 - 1.7:^ Give 2 gm IV MgSO^4 over 2 hours or Mg Oxide 400 mg PO BID for 2 days
• If level < 1.5:^ Give 2 gm MgSO^4 over 2 hours x 2 doses.

PHOSPHORUS REPLACEMENT

• Consider using K phos orally if levels > 2
• If level < 2: 15 mmol sodium phos IV over 4 hours
• If level <1.5: 30 mmol sodium phos IV over 6 hours
• If level <1: 45 mmol sodium phos IV over 8 hours

CALCIUM REPLACEMENT

• Check ionized calcium. Corrects with 1-2 amps of IV calcium gluconate

HYPONATREMIA: Na < 135 mEq / dl

#1. Information from nursing:

• Get a sense of fluid status: Overloaded , dehydrated , euvolemic.
• I/Os. Cumulative since admission?
• Any fluids running? Type and rate?
• Symptoms / signs:
  • Dehydration: Thirst, dry mouth, decreasing UOP.
  • Overload: Edema, crackles, dyspnea.
  • Specifically ask for neurological features: Increasing confusion, changes in mental status, seizures.

#2. Information from chart review / sign out:

• Acuity of change: Acute ( < 48 hours) vs chronic ( > 48 hours).
• Has patient been hyponatremic in past? Why?
• Review fluid balance.
• Seek etiologies:
  • Hypovolemic pathologies: DKA, HHS, sepsis, dehydration, alcoholism, advanced dementia, vomiting / diarrhea, excessive diuresis
  • Hypervolemic pathologies: Cirrhosis, CHF, renal failure, excessive alcohol use.
• Medication review: diuretics, medications causing obtundation.
• Check blood glucose, lipids and protein levels for pseudohyponatremia.

#3. Initial assessment:

• Symptoms: As above. Specifically check for neurological features: AMS, seizures. In light of acute hyponatremia, they represent a MEDICAL EMERGENCY.
• Examination: Assess intravascular volume.
• Consider etiology / differential diagnosis: Refer to diagram below.

#4. Interventions:

Acute w/ obtundation / seizures: 3% saline, 100 ml bolus over 15 minutes. Check BMP @ 2 hours. Call SNF and MICU consult.

Acute w/o obtundation / seizures: 3% NS at 15-30 ml/hr. Avoid correcting > 12 mEq / 24 hours or > 6 mEq / 12 hours.

Chronic: Treatment based on etiology (see underneath). Obtain BMP with serum osmolality; urine Na, Cr, Osm. Avoid correcting > 10 mEq / 24 hours.

Chronic hypotonic: Hypovolemic: NS fluid replacement. Hold diuretics / offending meds.

• (^) FENa < 1, Ur. Na < 10: GI loss / poor PO intake.
• (^) FENa > 1, Ur. Na > 20: Renal losses.
• (^) If Euvolemic: SIADH (Urine Osm>100) vs. primary polydypsia (Urine Osm < 100)

Euvolemic: Free water restriction. Hypervolemic: Free water restriction. Consider diuresis (especially in CHF state)

Chronic hypertonic: Correct underlying pathology

Chronic isotonic: Usually pseudohyponatremia needs no Rx. If obtundation / seizures after TURP / lap with acute hyponatremia: 3% saline, 100 ml bolus over 15 minutes. Call SNF and MICU consult.

ABDOMINAL PAIN

Very broad topic and beyond the scope of this manual. Here are some of things one should be extremely careful not to miss as cross cover / night float.

If you suspect the following, obtain a surgical consult along

with ongoing work up and consult SNF + / -­‐ MICU as well:

• Peritonitis / perforated viscous:^ Severe pain, rigid abdomen with rebound and guarding. Absent bowel sounds. Unstable vital signs. Upright X-ray shows air under diaphragm. Rx: NPO + IV fluid boluses + broad spectrum antibiotics + surgery.
• Ischemic bowel:^ Pain out of proportion to physical exam findings. Bloody stool. Lactic acidosis. Rx: NPO + broad spectrum antibiotics + surgery.
• Obstruction:^ Nausea / vomiting, bloating, distention, hyperactive / absent bowel sounds. X-ray shows air fluid levels. Rx: NPO + NG suction (decompression) + surgery.
• Cholangitis:^ Fever, RUQ pain, jaundice. LFTs show obstructive pattern. GI emergency. Rx: NPO + broad spectrum antibiotics + IV fluid boluses. Needs urgent ERCP if septic.

Other commonly encountered differential

diagnosis:

- Diffuse abdominal pain: - Gastroenteri+s (nauseas & vomi+ng , diarrhea) - Metabolic (acidosis, DKA) (check BMP, glucose, BHB) - Func+onal? - Localized: - Epigastric: PUD, gastri+s (NSAID use) , pancrea++s (lipase, amylase) , MI (EKG, CIPs) - RUQ: cholecys++s / biliary colic (USG, LFTs) , hepa++s (LFTs, US), pneumonia (CXR) - LUQ: Pancrea++s, gastri+s. - RLQ: Appendici+s (Mac burney point tenderness, CT) , Renal colic (CT) - LLQ: Diver+culi+s (CT), renal colic, IBD , IBS - Hypogastric: UTI (UA) , ureteric stone , bladder disten+on (Foley, clogged cath?)

INSOMNIA

• Ask about reason for insomnia. E.g. pain, delirium, withdrawal of any home medication. Correct these before prescribing medication.
• Do not give any sleep medicines towards early morning as patient might be sleepy during primary team’s rounds which will impair their evaluation.
• If you have to choose, consider one of the following:
  • Trazodone 25 - 50 – 100 mg. Start low.
  • Ambien (5 mg) – extreme caution in elderly
  • Benadryl (25-50 mg) – in young healthy patients.
  • Never use benzodiazepines for insomnia as it might increases the risk of delirium.

HYPERNATREMIA

• More common in ICU setting, in sedated, sick patients. Also seen in patients who are NPO.
• Usually does not happen in patients who have access to free water (who can drink), or are on TPN.
• Usually not an emergency and it’s safe to pass on to the team.
• If sodium levels increasing very rapidly, consider treatment
• Calculate free water deficit: 0.6 x weight (kg) x (current Na / 140 -1)
• Administer the calculated total volume of D5 free water at 75 - 100 ml / hr to correct Na 8-10 mEq over 24 hours. Avoid correct at rapid rates.
• Inform the primary service in AM.

HYPERGLYCEMIA

• Evaluate for DKA / HHS : Glucose levels > 400 mg / dl or patient symptomatic with abdominal pain, nausea / vomiting. Check last BMP for anion gap / betahydroxybutarate if AG positive. MICU consult if DKA is diagnosed.
• Trend fingerstick glucose levels in last 24 hours. In hospitalized patients levels between 140 -180 mg / dl are acceptable. Avoid hypoglycemia.
• Review patient’s insulin therapy (short acting vs. both short and long acting). Check if patient is getting them regularly (was there a missed dose? ). Is the hospital regimen different from home regimen (if so, why? ).
• Is patient receiving any fluids with D5 and if so change it. Make sure patient is on carb control diet.
• In asymptomatic patients with elevated sugar, you can cover with dose of short acting insulin based on sliding scale( e.g. for glucose of 300 if patient should receive 10 units regular insulin, cover patient with the same dose). If this occurs > 1 occasion, let team know in AM to re-adjust insulin regimen. DO NOT change insulin regimen. Only give one time orders.

CONFUSION / AGITATION :

Delirium - Maybe hyperactive or hypoactive: Fluctuating disturbance in attention, awareness and cognition that develops over a short period of time, representing a change from baseline, not explained by preexisting or evolving neurocognitive conditions.

#1. Information from nursing:

• Acuity: New development vs ongoing
• Altered level of consciousness and / or disorganized thinking?
• Physically violent: Harm self or others?
• Vitals: EWS score?
• Pain : Recent Sx / open wounds / trauma?
• Urinary / bowel retention?
• Recently administered medications?

#2. Information from chart review / sign out:

• Med review: Anticholinergics, steroids, anticonvulsants, dopamine agonists, antibiotics.
• Neuro: Stroke, seizures (status)
• Toxidrome / withdrawal state
• Systemic / general medical: CO2 retention, hypoxia, dehydration, sepsis / infection
• Change in environment (ICU delirium) vs above causes
• Dyselectrolytemia

#4. Non pharmacological interventions:

• Reorient and decrease stimuli if agitated.
• Involve family and other known faces if available.
• Address comfort: pain / constipation / incontinence
• Provide fluids if asking if no aspiration risk.
• Take off wires / tubes unless absolutely required.

#3. Night float assessment and testing

• Vitals and pain assessment
• Respirations: rate, effort, evaluate for pathology: ?PNA / aspiration
• CVS assessment
• Abd: Distention / surgical abdomen
• Skin: Dehydration, cellulitis, edema
• CNS: GCS, threat response, orientability, focal deficits
• CBC, BMP, electrolytes
• Sepsis work up if appropriate
• Drug levels: Digoxin, lithium, quinidine

#5. Interventions per cause:

• D/C offending medications. Reverse opioid overdose with naloxone if causing respiratory depression with CO2 retention.
• Stat CT head w/o cont if worried for CVA. Consider stroke code after consulting with senior.? Neuro
• Ativan IV if seizing. Consult senior stat. ?Neuro
• Ativan for EtOH withdrawal / cocaine use.
• Goal directed Rx for sepsis (see related section).
• Treat pain: if surgical - standing tylenol, PRN oxycodone. Avoid IV pain medications
• Rx constipation: Consider enema if tolerated.
• Acute urinary retention: Straight cath, monitor post void residual urine.

#6. Pharmacological restraint in agitation:

Tolerating PO: (increasing sedative effects, lowest dose first)

• (^) Seroquel 12.5 mg / 25 mg
• (^) Haloperidol 0.5 mg / 1 mg
• (^) Risperidone 0.5 mg / 1 mg
• (^) Olanzapine 2.5 mg / 5 mg
• (^) If Qt. > 500: Aripiprazole 2-5 mg Q2hours PRN. Check EKG after 2nd dose.

Unable to take PO:

• (^) 1st line: Haloperidol 0.5 - 1 mg Q2hours PRN IV/IM
• (^) 2nd line: Olanzapine 2.5 - 5 mg Q2hours PRN IM
• (^) If QTc > 500: Valproic acid 125 - 250 mg Q8hours PRN

Important considerations:

• All antipsychotics carry increased risk of cardiovascular mortality especially in dementia.
• Restraints (discuss with family if possible).

AVOID unless absolutely necessary:

• Benzodiazepines and anticholinergics.
• Restraints (discuss with family if possible).