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I N T E R N NIGHTFLOAT S U R V I VA L GUIDE OLIVE VIEW-UCLA INTERNAL MEDICINE 2016 - 2017 v.5 COVER Intern Nightfloat Survival Guide Olive View – UCLA Internal Medicine 2016 - 2017 Revised June 2016 Page |2 NOTE Welcome to the nightfloat rotation! As the cross cover intern, it can be a very different experience than wards during the day. Cross cover teaches you how to triage patients and identify potential emergencies. You will learn how to multi-task, become more efficient, and trouble shoot issues. While this guide does not encompass everything Medicine such as Pocket Medicine or the UCLA yellow book, it does cover common topics that you may encounter at night during cross cover. This guide is designed to teach you how to approach common nighttime medical issues, rather than as reference guide or algorithm of what to do (hence the lengthiness). Certain topics are better understood when read beforehand than on the spot (such as fever work up or chest pain). While the learning curve is steep as an intern, remember that you are never alone. There are always nightfloat residents and attendings who are available to help you out, no matter how big or small the question. You never stop learning in the field of Medicine and you can never learn if you don’t ask questions. Author / Editor Christine Dang, MD Contributors Catherine Ho, MD Ngozi Iroezi, MD Glen Pearlstein, MD Michael Rotblatt, MD Page |3 TABLE OF CONTENTS CROSS COVERING........................................................................................... 5 ELECTROLYTES ............................................................................................... 6 HYPOKALEMIA ................................................................................................................ 6 HYPERKALEMIA .............................................................................................................. 6 HYPOMAGNESEMIA ........................................................................................................ 7 HYPOCALCEMIA .............................................................................................................. 8 HYPERCALCEMIA ........................................................................................................... 8 HYPOPHOSPHATEMIA.................................................................................................... 9 HYPONATREMIA ........................................................................................................... 10 CHEST PAIN.................................................................................................. 11 Top six chest pain emergencies to rule out at night ......................................................... 12 SHORTNESS OF BREATH ............................................................................... 14 Top SOB emergencies/issues to rule out at night............................................................ 15 ABNORMAL VITAL SIGNS .............................................................................. 18 TEMPERATURE ............................................................................................................. 18 HYPERTENSION ............................................................................................................ 18 HYPOTENSION .............................................................................................................. 20 TACHYCARDIA .............................................................................................................. 24 BRADYCARDIA .............................................................................................................. 28 LOW O2 SATURATION .................................................................................................. 30 TACHYPNEA .................................................................................................................. 32 FEVER (full fever work up / FFWU)................................................................ 34 NEUTROPENIC FEVER ................................................................................................. 35 ALTERED MENTAL STATUS (AMS) ................................................................. 36 BLEEDING .................................................................................................... 38 GI Bleeding ..................................................................................................................... 38 After cardiac catheterization (groin access) ..................................................................... 39 Permacath oozing ........................................................................................................... 39 Nosebleed ....................................................................................................................... 40 After renal biopsy ............................................................................................................ 40 After a line is pulled ......................................................................................................... 40 CONSTIPATION / NAUSEA ............................................................................ 41 CONSTIPATION ............................................................................................................. 41 NAUSEA ......................................................................................................................... 41 PAIN MEDICATION ....................................................................................... 42 PAIN MEDICATION TID BITS ......................................................................................... 43 SLEEP ........................................................................................................... 44 AGITATION .................................................................................................. 44 DECREASE UOP ............................................................................................ 45 SEIZURE ....................................................................................................... 46 HYPERGLYCEMIA.......................................................................................... 48 HYPOGLYCEMIA ........................................................................................... 49 MISCELLANEOUS .......................................................................................... 50 “I FELL DOWN” ............................................................................................................... 50 “I WANT TO LEAVE AMA” .............................................................................................. 50 “I NEED A TRANSFUSION” ............................................................................................ 51 DEATH NOTE ................................................................................................................. 52 REFERENCES ................................................................................................ 54 Page |4 Blank Page |5 CROSS COVERING As the cross cover intern, your job is to help take care of patients while the primary team is gone. Patients that you will cover include Medicine wards patients and Heme/Onc patients. You will be asked to manage everything from constipation to unstable vitals to emergent imaging reads. While it may be difficult because these are not your own personal patients---remember that there is always back up to help you out. 1. Signout from day interns/residents: Things to keep in mind when you are getting signout. Contact information for the intern (aside from the pager), resident, and attending. Ask if it’s okay to page the attending with major changes (such as AMA, death, transfers to the ICU). What needs to be followed up at night (such as labs, consult recs), as well as what to do if certain results come back or things happen (such as if the BP is this high, please give this medication). Code status (and if the patient is DNR/DNI or comfort care, what is the family’s contact info). If the patient is altered, what is the baseline mental status? Who’s the next decision maker and their contact info? Anything that is expected to come up at night for the patient. Who is the sickest on the list to worry about? Try to eyeball sick patients to obtain a baseline. 2. Medications: If the team did not give you specifics on which meds to use, such as pain meds, sleep meds, fluids, and BP meds, call the NF resident if you have doubts. Note that renal/liver patients and the elderly may have problems with metabolism of what seems like benign drugs, so double check before you order them. Try and avoid standing orders for things like pain medication. 3. When to see a patient and leave a note: Simple things such as an extra insulin order usually do not require you to see a patient. Here are some examples of when it’s important to assess a patient and leave a note. Unstable/abnormal vitals (you can sometimes get away without assessing an asymptomatic patient for an elevated BP, unless it’s a very elevated (SBP>190) or if they have symptoms). Any pain complaints (such as chest pain, abdominal pain, etc.). Starting antibiotics or other new or unexpected major medications. If you had to call a new consult (document the reason why, who you talked to, and any recs). If you had to transfer a patient (to TELE/SDU/ICU), RRT’s, codes, AMA, or death (death exam note). 4. Ordering labs/imaging: If you need to order any labs or imaging as part of a work up for a cross cover patient, you need to remember to follow up the results! 5. AMA: When a patient wants to leave AMA, try to persuade him to stay. If he stills want to leave, notify the NF resident and/or Hospitalist to help with the dispo for the patient (AMA form, prescriptions, follow up appointments; because he can still get these even if he leaves AMA). Also notify the primary team (attending or resident if signout notes that they want to be called) so they can tell you what to send the patient out with. 6. If a patient or family wants to talk to an MD regarding the plan of care and they are otherwise stable, it’s okay to defer this to the primary team. 7. Restraining orders: Do not renew NON-expired restraining orders. Let the primary team reassess. 8. When to ask for help (chain of command): If you have any questions or feel uncertain about something during your shift, you should always ask for help. Your chain of command is: 4pm – 7am: NF resident (inhouse 4p-8a) (red or blue) 3pm – 12am: Inhouse Hospitalist attending via medicine on call pager (on AMION) if an attending is needed or if you can’t reach the NF resident. 12am - 7am: If an attending is needed: “Wards back up attending” for Wards and Onc patients. 9. When to notify the Wards back-up attending (after 12am): An RRT/code blue not transferred to the ICU; if the patient unexpectedly passes away; failure in achieving an urgent intervention (such as emergent MAC transfer, emergent consult not calling back); continuing hemodynamic instability that is not correcting appropriately. For any of the aforementioned issues or anything else, you can always notify the inhouse Hospitalist attending before 12am. Page |6 ELECTROLYTES HYPOKALEMIA Common causes: Cellular shifts, GI loss, and renal losses. At night, usually due to diuresis of CHF patients. Repletion: 1. Check the Cr first (the higher the Cr, the less K will be cleared, so K will correct higher than intended). 2. Repletion: Goal is usually >4.0 mmol/L. For every 10 mEq of KCL given, the serum level should increase by about 0.1 mmol/L (ex: 40mEq KCL IV should increase the serum K from 3.6 to 4.0 mmol/L). IV: More reliable that 10 mEq will raise the K by 0.1mmol/L. Can cause a burning sensation in the peripheral IV. The max infusion rate is 10mEq/hr through a peripheral, 20mEq/hr through a central line. PO: A little less reliable that 10mEq will increase the serum by 0.1 mmol/L. IV PO Agent Dose/increments Example Notes KCL 10mEq KCL 40mEq IV x1 IV form most often used. K phos ie 7, 9, or 12 mmol KDUR 10mEq pills Kdur 40mEq PO x1 Long acting, so will not raise K as quickly. Very large pills. KCL elixir 10mEq KCL elixir 40mEq PO x1 Bad taste. May cause nausea. 1mmol K phos = 1.5mEq K 3. To account for an elevated Cr. Take the amount of K you would like to give and divide by the patient’s Cr to obtain the actual K to infuse. Example: K=3, Cr=2; you would like to give 80mEq of KCL (to get K up to 3.8); So: 80mEq/2 = 40mEq is how much KCL should be given 4. When you replete very low K (for example, K in the 2’s), you can give both IV and PO concurrently. Example: K=2.6, Cr=0.9 You can write for KCL 40mEq IV x1 and KCL elixir 40mEq PO x1 5. DO NOT replete K in dialysis patients. Their dialysis should correct this. HYPERKALEMIA Common causes: AKI or acute on CKD, hemolysis of the lab sample, constipation (especially in CKD patients), medications such as ACEI’s/ARBs, spironolactone, tumor lysis, DIC, and RTA’s. How to treat: 1. Make sure it’s not due to hemolysis of the CBC sample (when RBC’s lyse they release K, leading to a falsely elevated serum K). Click on the K result and it should indicate if hemolysis is present. If the K is in the mid 5’s or less with a hemolyzed sample, you are probably okay rechecking the K and not immediately treating. 2. Check an EKG: Look for peaked T waves, wide QRS, increase PR interval, sine wave pattern. Can also lead to PEA (not good....). 3. Treatment: Rapidly reduce the K: For patients with EKG changes, K > 6.5, or if the K is rapidly increasing: Insulin: This helps drive K into the cells via Na-K-ATPase pumps. An amp of D50 glucose is given as well to prevent hypoglycemia from the IV insulin. We usually use insulin/D50 as our rapid acting treatment. The onset of action is 15-30 minutes. - Regular insulin 10 units IV x1 with 1 amp of D50 glucose prior. - Nurses will give the amp of D50 and set up the insulin syringe for you. All you have to do is inject. - Do an accucheck one hour after giving the insulin to monitor for any hypoglycemia. - NOTE: In patients with CKD or on dialysis who are anuric, insulin will take longer to be renally cleared, so they may become hypoglycemic despite the amp D50. In these cases, consider only giving five units of regular insulin and repeat accuchecks q1hr for a couple of checks afterwards. Page |7 Calcium: Helps to stabilize the cardiac membrane but does little for the K. The onset of action is within minutes. Should always give this if there are any EKG changes and/or if the K is in the high 6’s. - Calcium gluconate 1 amp IV x1 over 2-3 minutes infusion Beta 2 agonist (Albuterol): Not used very often by Medicine. The onset of action is 30-90 minutes. - Albuterol: 10-20mg inhaled nebs or 0.5mg IV Sodium Bicarb: Raising the pH leads to cells releasing H+ into the serum to buffer the pH, leading to K going into the cell to balance the charges. The onset of action is 15-30 minutes. - Sodium bicarb 1-3 amps IV To permanently remove K: Kayexalate: Binds to K in the gut and the K leaves via bowel movements. Slower onset of action. You need to make sure the patient actually has a bowel movement after receiving Kayexalate for this to work. We often use this as the permanent method to remove K. Contraindicated in bowel obstructions. - Kayexalate 15 or 30 grams PO x1 (or PR). Then recheck the K. May repeat the dose. Diuretics: Patient urinates out the K. - Lasix 40mg IV x1 (but if the patient is Lasix naive, may consider 20mg IV). Dialysis: When you can't lower the K with medications, then you need to talk to Renal for emergent dialysis. 4. So in practice, you follow up PM labs and find that someone's K is high: Check the EKG: If there are EKG changes (regardless of the actual K level), you should give calcium gluconate, insulin/D50 (to quickly lower the K), and Kayexalate (to lower the K permanently). If there are no EKG changes and K<6, you can usually just give Kayexalate. If K>6, (regardless of EKG changes), usually give insulin/D50 and Kayexalate. Hyperkalemia treatment in a bolus Rapid acting (transient effect) Slower acting (permanent effect) Agent Dose Notes Insulin Regular insulin 10 units IV x1 with 1 amp of D50 IV Consider lower insulin dose if severe CKD (5 units instead) Calcium gluconate 1 amp IV x1 over 2-3 minutes Doesn’t do much for K Beta 2 agonist (albuterol) 10-20mg inhaled nebs OR 0.5mg IV x1 Not used often Sodium bicarb 1-3 amps IV Kayexalate 15-30 grams PO x1 Diuretics (Lasix) 40mg IV x1 (10-20mg if naïve) Dialysis Call Renal consult Contraindicated in obstruction When all else fails HYPOMAGNESEMIA Common causes: GI losses (such as diarrhea) and renal losses (due to loop/thiazide diuretics, alcohol, genetic disorders). PPI’s have also been associated with hypomagnesemia. Symptoms: Neuro/muscular (weakness, tremors, tetany, seizures, delirium) and cardiovascular (tachycardia, HTN, and arrhythmias such as PVCs, Torsades, and Vfib). It is also associated with hypokalemia, hypocalcemia, + and hypercalcemia (both Mg and Ca compete for the same transporter in the Loop of Henle). Repletion: 1. Check the Cr first. (same reason as for K repletion) 2. Repletion: Goal is usually >2 mg/dL. IV: In general, for every 1g of IV Mg, the serum will increase by roughly 0.1mg/dL (ex: 2g of Mg should raise the serum from 1.8 to 2). Infusion through a peripheral IV is 1g/hr; through a central line up to 2g/hr. - Ex: Magnesium Sulfate 2g IV x1 PO: Often used for chronic, asymptomatic, or mild hypomagnesemia. Poorly absorbed by the GI system. Of note, can cause diarrhea. - Ex: Magnesium Oxide (Mag Ox, 400mg pills) Page |8 3. To account for an elevated Cr (same as for K repletion): Take the amount of Mg you would like to give and divide by the patient’s Cr to obtain the actual Mg to infuse. Example: Mg=1.8, Cr=2; you would like to give 2g of Mg (to get Mg up to 2); So: 2g/2 = 1g is how much Mg sulfate should really be ordered 4. DO NOT replete Mg in dialysis patients. Their dialysis should correct this. 5. Try to order no more than 4-5g at a time (they can overcorrect even with a normal Cr). HYPOCALCEMIA + + What is total serum calcium? The total serum Ca is given in a Chem panel. Total serum Ca is made up of + + physiologically active ionized (free) calcium (40%), Ca bound to albumin (45%), and Ca bound to organic/inorganic anions (15%). Common causes: Surgical removal of the parathyroid gland, hypomagnesemia, acute pancreatitis, rhabdomyolysis, tumor lysis, and Vitamin D deficiency. Symptoms: Symptoms include paresthesia, tetany, seizures, Chvostek's sign (tap CN 7 to elicit spasm), Trousseau's sign (inflate the BP cuff to elicit carpal spasm), bradycardia, or prolong QT. + Repletion: We don’t routinely replete unless patients have symptoms or the total Ca is less than 7.5mg/dL. + 1. First calculate the corrected total Ca because for every 1g/dL decrease in albumin, this will decrease the + + + total serum Ca by 0.8 mg/dL [ corrected Ca = serum Ca + 0.8 (4 – serum alb) ]. Fluctuations in albumin + + should have little effect on the free ionized Ca level (active Ca ), which is hormonally regulated. +. 2. Check the free ionized Ca 3. Repletion: + If there are symptoms or Ca <7.5mg/dL, can treat with: Calcium gluconate 1g IV x1 If asymptomatic: Oscal Vit D 500mg PO bid-tid or Calcium carbonate 600mg tabs w/o Vit D. HYPERCALCEMIA + Common causes: Emergency is when the corrected Ca >14mg/dL. + Most of the time, it’s due to an elevation in free ionized Ca . Three common causes are (1) malignancy (many times Heme/Onc is already on board with recs), (2) primary hyperparathyroidism, and (3) milk-alkali syndrome. For inpatients, a common cause for mild hypercalcemia is immobilization. Signs/sx’s: Constipation, anorexia, nausea, renal stones, weakness, AMS, anxiety/depression, and short QT. How to treat: + 1. If it's a first time isolated elevated Ca , would recheck again. Check an ionized calcium. + 2. Treatment: If the Ca >14mg/dL, you need to treat immediately, regardless of symptoms. Most common treatments are IVF, calcitonin, and bisphosphonates. + IVF: Normal saline (about 4-6L/day) leads to an increase in renal Ca excretion. If they can handle it, start off with NS boluses. + Calcitonin: 4-8 units/kg subcut q6-12 hours. This increases the urinary Ca excretion. Decreases bone + resorption. Can decrease the Ca by 1-2 mg/dL within 4-6 hours. The effect will last for a couple of days. Bisphosphonates: Such as Zoledronate (4mg IV over at least 15 minutes), which is commonly used for hypercalcemia due to cancer. Takes effect in one to three days. IV Lasix: Make sure the patient is volume replete first before ordering this. Glucocorticoids: Used more so with patients with excess Vitamin D intake or increase Calcitriol (Vit D 1,25) production from granulomatous disease. Steroids will decrease the Vit D 1,25 production. Takes days to see an effect. Prednisone 20-40mg PO QDAY or Hydrocortisone 100mg PO TID for three to five days. Page |9 HYPOPHOSPHATEMIA Hypophosphatemia is common in ICU/hospitalized patients, sepsis, DKA, chronic alcoholic abuse, and post-op. If a patient is total body depleted, their hypophosphatemia can worsen as they start to eat again (as phos is being utilized). The degree of hypophosphatemia, presence/absence of symptoms, and critically ill status determines the mode of repletion. Mild hypophosphatemia: 2.0 - 2.5mg/dL Moderate hypophosphatemia: 1.0 - 1.9mg/dL Severe hypophosphatemia: < 1.0mg/dL Common causes: Cellular shifts (ie from insulin or respiratory alkalosis), decreased intestinal absorption (ie diarrhea; antacids with Mg and Aluminum will bind to phos and prevent absorption), increased renal urinary excretion, and removal by dialysis. Symptoms: CNS (encephalopathy, delirium, seizures, coma), cardiac (arrhythmias), muscle (proximal myopathy, dysphagia, ileus, rhabdo). Repletion: For non-critically ill patients. Usually replete if phos is < 2.0 mg/dL (regardless of symptoms). Because of cellular shifts, it is difficult to predict for a set amount of mmol’s, how much they will correct. 1. First, make sure this is not pseudohypophosphatemia (2/2 mannitol, multiple myeloma, elevate bilirubin, or acute leukemia). 2. Take note of what the K is, because many phos formulations will contain K. 3. Repletion: Goal is usually above 2.0mg/dL PO: For mild to moderate hypophosphatemia (1.0-2.5 mg/dL). Initial dosing can be 30-80 mmols of phos per day in divided doses. - Ex: Phos-NaK (powder) 1 packet PO TID (w/meals) x4 doses (4 packets = 32 mmol phos total) IV: Mainly for severe hypophosphatemia (<1.0 mg/dL) or mild-mod hypophosphatemia if PO intolerant. - Mild - moderate hypophosphatemia: 0.08 - 0.24 mmol/kg over 6 hrs (70kg, about 6-17mmol IV). Do not exceed 30mmol in 6hrs. - Severe hypophosphatemia: 0.24 - 0.5 mmol/kg over 8-12 hrs (70kg, about 17-35 mmol IV). Do not exceed 80mmol in 8-12hrs. PO Agent Dose/increments Notes Phos-NaK 1 packet PO TID x4 (w/meals) Usually given as a fixed number of doses. 1 packet = 8 mmol phos, 6.9 mEq Na, 7.1 mEq K Skim milk 480 ml (one pint) Contains 15 mmol of phos. Na phos Mild/mod: 0.08-0.24mmol/kg over 6hrs (70kg: ~ 6-17mmol IV) Do not exceed 30mmol in 6hrs, 80mmol in 812 hrs. K phos Severe: 0.24-0.5mmol/kg over 8-12hrs (70kg: ~17-35mmol IV) 1mmol K phos = 1.5 mEq K IV 4. Caution: Repletion can cause hypocalcemia, hypomagnesemia, hypotension, and if hypercalcemic, can lead to calcium-phos precipitation. Reduce dose by 25-50% if hypercalcemic. 5. Potassium: Be cognizant of how much K your phosphorus repletion order contains and the rate at which it is infusing. You do not want to exceed 10mEq/hr of K via a PIV and 20mEq/hr of K via a central line. 6. Note: IV dosing by weight varies from study to study and in those pertaining to ICU patients, the dose is more aggressive than those listed above. P a g e | 10 HYPONATREMIA This is a general overview of hyponatremia and principles of treatment. Most of the time as nighfloat, this has already been worked up by the primary team, and what is signed out to you is to follow up Na checks and do specific things depending on the result. At Olive View, patients with a Na < 120 or with symptoms are usually admitted to the ICU where they are able to do q2hr Na checks with Renal following. What is it? Sodium concentration < 135mEq/L. This is mainly due to a change in the total body water, leading to a change in the sodium concentration. The main players are ADH (which gets turned on to reabsorb water when you are hypovolemic or when your serum Osm goes up) and aldosterone (which gets turned on when you are hypovolemic, leading to Na retention and thus water retention). How to diagnosis and treat: 1. Check a serum Osm (nml is 280-295). This tells you if there are any other solutes causing the hyponatremia. Hypotonic hyponatremia (low serum Osm): What you encounter most often. There is more free water in relation to the Na. Isotonic hyponatremia (normal serum Osm): Things like hyperlipidemia or an elevated protein can give a falsely low Na, because they interfere with the lab’s machine in running the Chem panels. Hypertonic hyponatremia (high serum Osm): There is another solute in the mix with Na that is drawing water into the intravascular space. Most of the time it is glucose. To account for glucose, for every 100 rise in glucose above normal (100), it will bring the serum Na down by 2.4. 2. Hypotonic hyponatermia: Most hyponatremias are due to hypotonic hyponatremia. a. Check the Urine Osm, Urine Na, and volume status which helps to narrow the etiology. b. Causes and treatment of hypotonic hyponatremia. Hypovolemic: Patient is dehydrated. Either through renal Na losses (UNa>20, such as with mineralcorticoid deficiency) or extra-renal losses such as emesis or diarrhea (UNa <10; your body is trying to hold onto Na in order to hold onto water, thus UNa is low). - Treatment: Give IVF (most of the time NS). As the hypovolemia improves, the stimulus for ADH will be turned off. What’s important is the rate at which you give the IVF, because if you give it too fast, the serum Na will correct too quickly, leading to possible cerebral pontine myelinolysis (CPM). Usually the primary team or Renal will tell you what IVF rate to do. Euvolemic: You will need to ask a history to narrow this one down. - SIADH (Uosm>100, UNa>20): ADH is increased, but not appropriately for the situation because the patient is not dehydrated. Other things that stimulate ADH include intra-cranial trauma, N/V, cancer, or drugs. Treatment is to fluid restrict 1-1.5L/day. If you give IVF, the hyponatremia may worsen because the patient will hold onto the additional fluids (because of ADH) but excrete the extra Na into the urine. - Hypothyroidism (Uosm>100): Mostly with severe hypothyroidism. Mechanism is unknown. - Adrenal Insufficiency (Uosm>100): Due to cortisol and aldosterone deficiency. CRH normally stimulates ACTH which stimulates ADH release. Cortisol plays a feedback role in inhibiting CRH (which in turn, inhibits ACTH release and thus removes the stimulus for ADH release). If cortisol is deficient, it then leads to uninhibited ADH release. For aldosterone, insufficiency leads to Na wasting and water wasting, leading to hypovolemia and ADH stimulus. Treatment is water repletion and cortisol replacement (hydrocortisone). - Primary polydipsia (Uosm<100): Mostly seen with psych patients where they drink excessive water (more than what the body can excrete). Treatment is to fluid restrict. - Tea/Toast and beer potomania (Uosm<100): The patient doesn’t eat enough, leading to not enough solutes to help excrete water. Treatment is to increase the PO intake. Hypervolemic: They are total body volume up, but intravascularly dry. Most common conditions are CHF (UNa<10, FENa<1%), cirrhosis (UNa<10, FENa<1%), nephrotic syndrome (UNa<10, FENa<1%), and advanced renal failure (UNa>20, FENa>1%). Treatment is to fluid restrict. In the case of CHF you also want to diurese to remove the extra edema and help improve cardiac output. 3. Na correction rate: The goal correction of Na is about 8-12mEq/L in 24 hours (about ≤0.5mEq/L/hr). For those who are sicker or elderly, you want to aim for the lower end of the correction because they are at higher risk for CPM. If patients are having symptoms from their hyponatremia, such as AMS/seizures, then you would give 3% hypertonic saline to quickly correct the Na. This will likely need ICU monitoring. Renal should also be notified of the patient (they can help you with the correction rate). P a g e | 11 CHEST PAIN If night float teaches you anything, it will be to do a focused history and exam. Most of the time, your job is to rule out the worst case scenarios/emergencies when patients complain of something. Chest pain falls into this category. What to do when patients complain of chest pain: 1. What are the vitals? If something is abnormal, it’s more concerning that something real is going on. 2. What is the patient’s PMH and why were they admitted? This helps you to formulate a possible differential. 3. Always assess the patient. This will entail some history taking if they don’t have an obvious reason for the chest pain. The top six emergent etiologies that you need to rule out as a nightfloat include: ACS: Is it typical chest pain/pressure with radiation, nausea/vomiting/diaphoresis/sob? Dissection: Is it tearing pain or radiating to the back or up/down the back (especially with an elevated BP)? Tamponade: Do they have a history of a pericardial effusion? Is there a JVD or distant heart sounds? PE: Is it pleuritic chest pain? Do they have calf pain/swelling to indicate a DVT? Any thrombosis risk? Pneumothorax: Was it sudden and pleuritic? Are there decreased breath sounds on one side? Esophageal rupture: Did they just have a lot of retching and then suddenly develop chest pain? 4. What to order: If the etiology is still unknown, it’s safe to order at minimum troponins, EKG, and CXR. Troponin and EKG x2 q6hrs: Evaluates for ACS. Note that the first troponin may be too early to tell you anything because it may take at least six hours from the onset of the chest pain/ACS to have a positive troponin. Chest xray: Tells you if there is a pneumothorax, free air for esophageal rupture, PNA, or an enlarged heart (possible effusion). If you have a high suspicion for a PE/dissection: CT chest angiogram. Depending on your suspicion, you need to specify either “r/o PE” or “r/o dissection” because the IV contrast protocol is different for both. If you have a low suspicion for PE/dissection: D-dimer (negative D-dimer rules out PE, dissection). If it’s a poor story but concerning features for dissection, you can check for asymmetric BP’s in both arms. 5. Appropriate treatment. (Refer to the following section). If you have a positive diagnosis, notify the NF resident. 6. If you are very concerned that the patient may have one of these diagnoses, you should notify the NF resident or Hospitalist attending. When patients are already admitted for ACS and develop chest pain: When ACS patients are still having active chest pain, it means their myocardium is experiencing ischemia. The goal is to make them chest pain free. If a patient who had previously been chest pain free develops pain, you should: 1. Ask for vitals and assess the patient. 2. Check troponins and EKG. Sometimes patients may re-infarct while they are inhouse. This does happen! 3. If not contraindicated, try NTG SL (up to three doses) or morphine. If this doesn’t relieve the chest pain, they may need a nitroglycerin drip (will require ICU level of care for the RN to titrate until chest pain free). 4. Call Cardiology. Sometimes they may want to escalate care to things such as an Integrilin drip (Eptifibatide). Chest pain in a bolus 1. Make sure vitals are stable. If looking unstable, ask for help or call an RRT. 2. Look at the PMH, what they are admitted for, and make sure the last set of labs are stable. 3. Assess the patient: Ask about the characteristics of the chest pain, time frame, associated symptoms, and any history of it. Assess the JVP, do a heart and lung exam. 4. At minimum, consider ordering troponin x2, EKGs (ACS), and CXR (pneumothorax). History and vitals will dictate if you need a CTA to rule out a PE or dissection. 5. Treat as needed. 6. Follow up with the patient to make sure they are doing okay. P a g e | 12 Top six chest pain emergencies to rule out at night ACS History and physical: Does this patient have risk factors such as DM, HTN, HL, smoking, or prior CAD? Most of this can be taken from your signout. Things to ask the patient include symptoms such substernal chest pain/pressure, radiation to the neck/jaw and arm, nausea/vomiting or diaphoresis. Any history of exertional chest pain or DOE? Women and the elderly may have atypical symptoms such as epigastric pain or nausea. What to order: - Troponins x2 (you should automatically order troponins q6hrs x2 because if you are thinking of ACS, then you need to rule it out). Plus, the first troponin at chest pain onset may still be normal. - 12 lead EKG: Look for ischemic changes such as TWI, ST elevation/depression, new LBBB, or new Qwaves. Compare it to the patient’s old EKG if available. If there are inferior lead (II, III, AVF) ischemic changes/ST depression/elevation, obtain a right sided EKG to rule out an RV infarct. A quick and dirty way is to move lead V4 over to the right side (now turning it into V4R). If V4R shows an ST elevation, it’s pretty specific for an RV infarct. Treatment: If you have a high suspicion for ACS or troponins/EKG’s are positive, then you need to treat. - Call Cardiology: Especially if patients have ischemic EKG changes/positive troponins/STEMI. You can run the treatment plan by them, as well as find out if they plan to cath the next day. A STEMI will likely require an emergent outside transfer for a LHC. - At minimum, transfer to TELE or SDU. - ASA 325mg PO x1, oxygen, Atorvastatin 80mg PO x1 - Nitroglycerin SL 0.4mg, under the tongue x1 (up to 3 doses q5mins). It’s important that if a patient is having ACS, that you get them chest pain free (chest pain = ischemic myocardium). AVOID if patients are having an inferior MI because these patients are pre-load dependent. - Morphine: You can use this if a patient is still having pain after NTG SL, or if their BP drops from NTG. - Beta Blocker: Metoprolol 5mg IV q5min x3 or 25mg PO q6hrs (as their BP and HR permits). You ideally don’t want someone who’s having an MI to be tachycardic and hypertensive. - Heparin drip: Per the heparin drip protocol. Will require the patient’s weight. Some people give an initial bolus, some don’t. - Plavix 600mg PO x1 load; then 75mg PO QDAY. Double check with Cardiology (some do 300mg, some do 600mg, some say no Plavix at all). - Order a formal 2D echo for the next day. - Notify at minimum the NF resident. Aortic dissection Vitals: They may be hypertensive (will need to treat) or hypotensive (not good….). History and physical: Do they have tearing or knife like chest pain that radiates to their back or up/down their back? Are there asymmetric radial pulses or asymmetric pressures between the arms (difference of >20mmHg). New aortic regurgitation murmur? What to order: - D-dimer: If you have a low suspicion, you can order a D-dimer, which if negative (<500ng/mL), is highly predictive in ruling out a dissection. - CT chest angiogram, rule out dissection (main mode of imaging that we use). - TEE: Not available at night. If your suspicion is very high and the patient absolutely cannot get a CT angio (maybe because of severe CKD or contrast allergy), Cardiology may come in to perform a TEE. Treatment: - Transfer to the ICU. - Control the blood pressure and HR (goal SBP~110, HR~60) with IV beta blocker. This helps prevent any further shear force on the dissection. May use labetalol (20mg IV bolus, then 20-80mg q10 mins; max dose 300mg qday; or IV drip 0.5 to 2mg/min), propranolol IV drip (1 to 10mg load, followed by 3mg/hr), or an esmolol drip (advantage is that given its short half-life, it is easier to titrate). - If it’s an ascending dissection (Type A), you need to call MAC for an emergent transfer for CT surgery. A descending dissection (Type B) is usually medical management, but would still transfer to the ICU and talk to MAC. Consider calling surgery while the MAC transfer is pending. - Notify the NF resident and the Hospitalist attending (if still inhouse). Notify the Back-up wards attending. P a g e | 13 Cardiac tamponade Caused by pericardial fluid that exerts pressure on the heart and leads to hemodynamic compromise. The development of tamponade depends on how rapid the pericardial fluid accumulates. If it is rapid, then as little as 150cc can cause tamponade, whereas with a very slow accumulation, patients can probably tolerate 1000cc and not develop tamponade. When is it tamponade? It’s when you have evidence of hemodynamic compromise, such as on echo (diastolic collapse of the RA, +/- RV, septal shift with inspiration), hypotension, and pulses paradoxus. Vitals: They may be tachycardic, hypotensive. History and physical: Look for underlying diseases that increase the risk for pericardial effusions, such as cancer, uremia, trauma, recent cardiac procedures (such as cath). On exam, can assess for Beck’s triad (hypotension, JVD, distant heart sounds). Listen for a pericardial friction rub. Assess for pulses paradoxus. What to order: - EKG: May see tachycardia with low QRS voltages, electrical alternans (QRS size alternates beat to beat). - CXR: May see a globular shaped heart. - 2d echo: If you have a high suspicion, consult Cardiology to see if they can come in to do an echo. Treatment: - Pericardiocentesis: Some ER attendings know how to do this emergently with a large gauge needle so you can try asking them. Cardiology is the one who usually does this via catheter and echo, so if you highly suspect or diagnose this, call Cardiology. - IVF as a temporizing measure if hypotensive. Pulmonary embolism Vitals: tachycardic, tachypneic, hypoxic; if very severe, then hypotensive History and physical: Assess for any risk factors, such as prolong immobility, malignancy, history of DVT, not on DVT prophylaxis, post-operative state, or recent travel. Do they have calf pain or pleuritic type chest pain? What to order: - D-dimer: If a low suspicion, can use this to rule it out. - CT angiogram chest: Specify “rule out PE”. - VQ scan: If a patient cannot get a CTA chest (because of CKD or a contrast allergy). - EKG: May show S1Q3T3, RV strain, or a new incomplete RBBB. Treatment: - Patient will need anticoagulation with LMWH (enoxaparin, 1mg/kg subcut q12hrs) or heparin drip (titrate q6hrs with PTT). Cannot use LMWH in patients on HD. Avoid with severe CKD if possible. - If an already diagnosed patient becomes hypotensive, they may require thrombolytics (call an RRT). Pneumothorax / tension pneumothorax Vitals: Hypoxia. May be tachycardic and hypotensive if a tension pneumothorax is present. History and physical: Sudden onset sharp chest pain or pleuritic chest pain. Risk factors such as recent trauma, recent procedures (central line, bronchoscopy, or thoracentesis), COPD or asthma. On exam, they may have decreased breath sounds on one side. What to order: - Chest xray: Look for a pleural line or a mediastinal shift (tension pneumothorax). Acute treatment: - Oxygen - Notify the NF resident and attending to help with the management. - If unstable vitals or a large pneumothorax, will probably need an emergent chest tube placement. People who can place chest tubes at night include ER attendings, ICU fellow/attending, or General Surgery. Esophageal perforation / Boerhaave’s syndrome History and physical: Largest risk is a recent esophageal procedure or surgery. Boerhaave’s is when there is increased intra-esophageal pressure from straining or vomiting, leading to spontaneous perforation. Patients can present with a lot of vomiting/retching, and then severe sternal or epigastric pain. They can decompensate very quickly. What to order: - CXR: can show free air - CT neck/chest to look for the rupture Treatment: - Call General Surgery. Start broad-spectrum antibiotics such as Ceftriaxone/Metronidazole. P a g e | 14 SHORTNESS OF BREATH The differential for shortness of breath can be very large, but at night, there are only a few select things you need to keep in mind. It is a subjective symptom and can be due to an actual pulmonary process, or be a manifestation of a cardiac or other systemic problem. What to do when patients complain of SOB: 1. What are the vitals? Many times they will also have issues with their O2 saturation and tachypnea. 2. What is the patient’s PMH and why were they admitted. Make sure the last set of labs are stable. This helps you to formulate a possible differential. Are there any recent chest procedures noted on the signout? (such as a thoracentesis) 3. Assess the patient. If the patient is de-sating, place on oxygen. The emergent things to assess for include: Upper airway: - Foreign body: Did they swallow something? - Anaphylaxis: Were there any new medications or transfusions? - Angioedema: Any new ACEI or NSAIDs? Any history of this (such as familial angioedema)? Is there any swelling to the face and lips? Pulmonary: - PE: Is it pleuritic chest pain? Do they have calf pain/swelling to indicate DVT? Any thrombosis risks? - Asthma/COPD exacerbation: Do they have a history of this? Any wheezing on exam? - Pneumothorax: Any recent procedures like a thoracentesis? Any absent breath sounds on one side? - PNA: Any cough or fevers? - Non CHF pulmonary edema: Have they been on maintenance IVF? Are ins/outs net positive since admission? Are there crackles? Cardiac: - ACS: Any associated chest pain? Do they have CAD or risk factors? Is the SOB their anginal equivalent? - CHF exacerbation: Are they admitted for this already and are they not at ins/out goal for the night? Any crackles on exam, JVD or BLE edema? - Arrhythmia: Are they tachycardic on vitals? Are they in SVT/VT on telemetry? Others: - Sepsis: Are they admitted for an infection or look infected? - DKA: Do they have DM? They may be tachypneic (thus SOB) as a respiratory response to ketoacidosis. - Anemia: Are they admitted for this or have signs/symptoms of bleeding? (obvious would be GIB or vaginal bleeding). If it is an internal bleed, such as a hemothorax or intra-abdominal, you may see other signs, such as decrease breath sounds (hemothorax) or increase pain/distension (intra-abdominal). 4. What to order: If the etiology is still unclear, then at minimum, you should order a CXR. CXR: Should rule in/out edema, pneumothorax, and PNA. Troponins/EKG if you are concerned for an anginal equivalent or there are CAD risk factors. If suspicious, CT chest angiogram to rule out PE. Consider ABG/VBG to assess the CO2 if tachypneic (if normal to high CO2, you worry they are tiring out). 5. Appropriate treatment 6. Follow up and make sure they are still doing okay. 7. If you are very concerned that the patient may have (or actually does have) one of these diagnosis you should let the NF resident or Hospitalist attending know. SOB in a bolus 1. Make sure the vitals are okay. If the patient looks unstable, ask for help or call an RRT. 2. Look at the PMH, what they are admitted for, and make sure the last set of labs are stable. 3. Assess the patient: At minimum, major things to assess are upper airway (any kind of obstruction), lungs (PE, PNA, edema, asthma/COPD/wheezing), and heart (ACS). 4. At minimum, order a CXR, and possibly troponin/EKG if it doesn’t sound like a pulmonary etiology. 5. Treat as needed. 6. Follow up with the patient to make sure they are doing okay. P a g e | 15 Top SOB emergencies/issues to rule out at night UPPER AIRWAY Foreign body Not a common cause for dyspnea in adults, but can happen (for example, a psych patient swallowing an EKG lead pad). If the patient is actively choking, then Heimlich maneuver. If the respiratory status is stable, then order a portable CXR to see if you can visualize where the object is. Call Pulmonary to see if they will come in and do a bronchoscopy or wait until morning. Consider transferring the patient to the SDU for closer monitoring if the object was described as large. Anaphylaxis Vitals: Make sure the O2 saturation and BP are okay. H/P: Were there any new antibiotics or transfusions? Any facial or neck swelling? What to order: Nothing. Treatment: Call an RRT. Stop any offending infusion/medication. While the ICU team is coming, place the patient on oxygen and start a NS bolus. Treatment includes Epinephrine IM (0.3mg of 1:1000 solution) to the thigh, Benadryl 25-50mg IV, Solumedrol 125mg IV; if wheezing, Albuterol 2.5mg nebs. Angioedema This can be hereditary (deficiency of C1 esterase inhibitor; this is rare) or precipitated by something (such as ACEI, NSAID, or allergen). Vitals: Make sure the O2 saturation and BP are okay. H/P: Is there face swelling, especially the lips and tongue? Any recent medication such as NSAID or ACEI? Any exposure to potential allergens? Is there a history of this suggesting familial angioedema? What to order: Nothing. Treatment: - If there is airway compromise, they may need an emergent intubation (call ICU/anesthesia). - If hemodynamically stable and with anaphylaxis, give IM Epinephrine, oxygen, NS IVF if hypotensive. - If due to an allergy or medication, stop the agent and may give Benadryl and steroids (Solumedrol 60mg IV or Prednisone 20-40mg PO). - If the patient has a history of hereditary angioedema, treatment is C1 esterase inhibitor replacement protein (C1INHRP). Of note, Olive View does not carry C1NHRP. Alternative treatment is FFP (two units q2-4hrs until clinical improvement). - Transfer to the SDU for closer monitoring (if the patient does not warrant ICU). PULMONARY Asthma/COPD exacerbation Vitals: Is their O2 sat okay? H/P: Is there a history of asthma or COPD? Do they smoke? Is there wheezing on exam? Any signs of pulmonary infection that could have precipitated the exacerbation? What to order: - CXR: To assess for PNA. If there are hyper-inflated lungs, may also point towards undiagnosed COPD. - ABG/VBG: You want to assess their CO2 level. If it is near normal or high, then you need to worry that they are tiring out and may need BIPAP/intubation (because if they are tachypneic, you would expect a low CO2 because they are blowing it off). - PFTs: As an outpatient. Treatment: - Oxygen: If they are de-sating, place on NC. If they are requiring facemask to maintain oxygenation, then they should be transferred to the SDU. If they look like they may be tiring out, you can do trial of BIBAP. - Nebs treatment: Albuterol 2.5mg/Atrovent 0.5mg inhaled nebs q4hrs around the clock. - May also start prednisone (40 to 60mg PO QDAY) for severe wheezing/sob. Nebs should be okay for mild symptoms until morning. P a g e | 16 Pulmonary Embolism Vitals: Tachycardic, tachypneic, hypoxic. Hypotensive if very severe. H/P: Assess for any risk factors, such as prolonged immobility, malignancy, history of DVT, not on DVT prophylaxis, post-operative state, or recent travel. Do they have calf pain/swelling or pleuritic chest pain? What to order: - D-dimer: If a low suspicion, can use this to rule it out. - CTA chest: Rule out PE. - VQ scan: If the patient cannot get a CTA chest (because of severe CKD or contrast allergy). - EKG: May show S1Q3T3 (large S wave lead I, large Q wave lead III, inverted T wave lead III), RV strain, or new incomplete RBBB. Treatment: - Patient will need anticoagulation with LMWH (enoxaparin, 1mg/kg subcut q12hrs) or heparin drip (titrate q6hrs with PTT). Cannot use LMWH in patients on HD. Avoid with severe CKD if possible. As nightfloat, it’s okay to start the Heparin/LMWH and let the primary team start Coumadin. - TPA: If the patient is hypotensive (SBP<90). May be an RRT/code blue situation with ICU monitoring afterwards. Pneumonia Vitals: Is their O2 sat okay? Is their blood pressure okay? If their blood pressure is low, be sure to give them IV fluids. You may have to go down the sepsis route. H/P: Do they have a fever or cough? Any risk for aspiration? What to order: - CXR: Look for consolidation or infiltrates. - Lactic acid and CBC if they are looking sick. This gives you an idea if they are heading towards sepsis. Treatment: - Location, location, location: If they are looking sick and borderline vitals, transfer to the SDU vs ICU (if looks like septic shock). - IVF: Start with NS boluses. - Antibiotics: If their symptoms started after admission, you can treat as HCAP with Vancomycin and Zosyn (or Cefepime). If you suspect an aspiration pneumonia, you will need anaerobic coverage as well (ie Metronidazole if not using Zosyn). Pulmonary edema Vitals: They may have hypoxia or be tachypneic. H/P: Are they on maintenance IVF and have they been ins/outs net positive since they were admitted? Are there crackles on exam? Sometimes they can have so much edema that you only end up hearing decrease breathe sounds/poor airway movement. Do they have a history of CHF? What to order: - CXR: Look for pulmonary edema. Treatment: - Trial of IV Lasix (10-20mg x1 if they are Lasix naïve). - If currently in a CHF exacerbation, you can give an extra dose of their usual inhouse Lasix dose. - If they are septic and in pulmonary edema, they may need to go to the ICU and be intubated while they are getting their fluid resuscitation. Pneumothorax Vitals: Hypoxia. May be tachycardic and hypotensive if a tension pneumothorax is present. H/P: Sudden onset sharp chest pain or pleuritic chest pain. Risk factors such as recent trauma, recent procedures such as a central line or thoracentesis; COPD, asthma. On exam, they may have decrease breath sounds on one side. What to order: - Chest xray: Look for a pleural line or any mediastinal shift. Acute treatment: - Oxygen - If a pneumothorax is present, notify at minimum the NF resident for assistance with the management. - If unstable vitals, or a large pneumothorax, a chest tube will be needed. People who can place chest tubes at night include ER attendings, ICU fellow/attending (can drive in), or General Surgery. P a g e | 17 CARDIAC ACS: SOB can be an anginal equivalent. Do they have a history of CAD or risks factors? If troponin and EKG are positive or you have a high suspicion, notify Cardiology and treat for ACS. Refer to the chest pain section. CHF exacerbation: If they are admitted for a CHF exacerbation, they should already be getting diuresed. Check the night time ins/outs and if it looks like they are not meeting their I/O’s goal, give an extra dose of IV Lasix. Arrhythmia: Sometimes when patients are very tachycardic (such as with Afib with RVR or SVT), they can experience SOB. Check vitals to make sure they are not tachycardic or if on Tele/SDU, check the tele monitor. Refer to the abnormal vitals section (tachycardia). OTHERS Sepsis: If they are SOB and with sepsis, it is either because they have sepsis from PNA (PNA causing SOB), or they are tachypneic from a respiratory compensation to an underlying lactic acidosis. DKA: Similar principle to sepsis, where patients are breathing fast to compensate for the ketoacidosis. Anemia: Check their last CBC and then see if they have other signs/symptoms of bleeding, such as hematemesis/BRBPR/melena or vaginal bleeding. If they are a cancer patient, consider DIC/hemolysis (leading to anemia and SOB). Alveolar Hemorrhage: Depending on their comorbidities (such as SLE), they may be at risk for diffuse alveolar hemorrhage. This is usually associated with hemoptysis, but can sometimes present as just SOB or hypoxia. P a g e | 18 ABNORMAL VITAL SIGNS TEMPERATURE Hyper/hypothermia is semi-relative among patients. When patients are inhouse, you need to look at what their baseline temps are. If a patient tends to run in the low 36’s, then having a temp of 37.5 (while not qualifying as a fever), could mean a developing fever/infection. The same applies to hypothermia. Fever: Many consider ≥ 38.0 (100.4°F) a fever. Most of the time, it’s due to an infection. If it is a new fever, you need to do a full fever work up. Tylenol may be given if they are febrile. If they are ≥ 40.0 (104°), would do cooling measures as well (such as a cooling blanket or cold packs). If there are no contraindications, would give an IVF bolus to head off any sepsis. Hypothermia: Defined as a core temperature <35.0 (95°F). While many associate being febrile with an infection, severe sepsis can also present with hypothermia as well. The differential for hypothermia include: - Sepsis: Assess the patient, full fever, and escalate care if needed. - Myxedema coma/hypothyroidism. Other symptoms include hyponatremia, hypoglycemia, and AMS. - Adrenal insufficiency, hypoglycemia HYPERTENSION 1. Ask the nurse: What are the rest of the vitals? Did the nurse repeat the BP to confirm? Did the patient receive his BP meds and at what time? Does the patient complain of anything? 2. What is the patient’s baseline BP while inhouse? Someone who has been running SBP 160-170’s who then has a BP reading of 180/90, you will most likely not be worried about, as compared to the same reading in a person who has had mostly SBP’s in the 120-130’s. 3. Does the patient have any symptoms? If they do, such as HA, blurry vision, chest pain, or decrease UOP, you should order the appropriate labs/imaging to evaluate, as this can change the rate of the BP correction. These include a CT head, troponins/EKG, CXR (look for possible CHF), Chem panel, and RUA. 4. Why is the patient hypertensive? Common reasons at night would include… Most of the time, it’s because of essential hypertension and the BP medications need titration. Recent CVA (where hypertension is a normal response). In this case, the primary team may want permissive hypertension with SBP goals of when to treat. Patient is fluid overloaded and awaiting dialysis. Patient is in acute pain. 5. Define what you’re dealing with: Hypertensive Urgency: (BP>180/120 with little to no symptoms and no evidence of end organ damage) If patients do not have any symptoms, there is no rush to bring them down to normotensive (this may cause more problems such as cerebral hypoperfusion). Patients who run high at baseline usually need to reach a higher BP to have symptoms as compared to patients who are normotensive at baseline. Sometimes patients with a headache or mild chest pain will still be treated as hypertensive urgency. Always look at trends. A single BP bump may not need treatment other than observation. Treatment: Goal BP would be around 160/100 over the next several hours to even days. If the nurse tells you the patient has an SBP>200, you can follow the decrease in MAP of 25% rule, or a goal of around SBP 170-180 should be okay. If you are dealing with a patient who is already running high at baseline, but is a little higher than usual, you can either give an extra dose of their usual PM blood pressure medication, or give a one-time dose of a PO agent. Agents: - Extra dose of their usual afternoon BP medication (if there is still room in the overall dose). - Hydralazine: 10-25mg PO x1 (most of the time, you can get away with 25mg PO). Sometimes people use 10mg IV x1 (can only be done in the SDU or ICU). Hydralazine is used by most people. - Captopril: 12.5-50mg PO x1. To be honest, not used as much by housestaff. - Clonidine: 0.1mg PO x1. Not favored by housestaff due to potential rebound hypertension. Example: Patient has been running SBPs 150-160’s but the nurse calls you because the last BP check was 190/95, HR 85, without any symptoms. Patient is on Norvasc 5mg, Metoprolol 50mg bid and has already received the PM dose. You can either do nothing and have the nurse recheck the BP later OR medicate with an extra dose of Metoprolol 50mg PO x1 or try Hydralazine 25mg PO x1 and recheck BP. P a g e | 19 Hypertensive Emergency: (Elevated BP with evidence of end organ damage). Symptoms: Headache with AMS/encephalopathy, blurry vision, chest pain, or decrease urine output. Evidence of end organ damage: - Neuro: encephalopathy (altered/somnolent), CVA (ischemic or bleed), papilledema - CV: ACS, heart failure (by exam or CXR), dissection, troponin leak - Renal: AKI, proteinuria, hematuria Treatment: If a patient has any evidence of end organ damage, you need to promptly bring down the blood pressure by 25% of MAP over minutes to hours with IV agents. This will require the patient to be transferred to the ICU. These are the more commonly used agents. - Nitroprusside drip: Initial dose is 0.25-0.5 µg/kg/min, titrate until symptoms resolve and BP goal is met. Max dose is 8-10µg/kg/min (patients should not stay at this high dose chronically because Nitroprusside is metabolized to cyanide in the body). The onset of effect is within one minute and wears off in one to ten minutes. Veno/vasodilates. - Nitroglycerin drip: Initial dose is 5 µg/min. Increase by 5 µg/min every 3-5 minutes until a response or to 20 µg/min. If no response at 20 µg/min, may increase by 10-20 µg/min. Max dose is 100 µg/min. The onset of effect is two to five minutes and wears off in five to ten minutes. Side effects are mainly headache and tachycardia. Does not have the cyanide effect like Nitroprusside. Venodilation >>arterial dilation. - Labetalol: Alpha and beta blocker. The onset of effect is within five minutes. Avoid in CHF, asthma/COPD, greater than first degree heart block, pheochromocytoma and meth overdose. IV bolus: Initial bolus 20mg IV x1. Then 20-80mg q10 minutes, up to 300mg. Drip: 0.5 – 2mg/min. - Hydralazine IV bolus: Initial dose is 10mg IV x1. Then 10-20mg IV q20-30minutes. The onset of effect is 10-30 minutes and wears off in two to four hours. Vasodilates. Drug of choice in certain HTN emergency situations: - Encephalopathy: First choice is Nitroprusside drip. Alternative is Labetalol. - Angina, myocardial ischemia/infarct: First choice is a nitroglycerin drip; may use SL, paste, or patch while awaiting IV access. Labetalol IV is the next choice. If you still cannot control the BP, then you can try a Nitroprusside drip. - Intracranial hemorrhage: Management of these cases are usually initiated in the ER. If a bleed is diagnosed upstairs, then ICU, Neurology, and MAC need to be notified and the patient should be transferred to the ICU while awaiting Neurosurgery consult. Overall, BP control is tricky because you control the BP to prevent further bleeding, but run the risk of cerebral hypoperfusion. If SBP>200 or MAP>150, would treat with Nicardapine or Labetalol drip. - Ischemic CVA: Usually permissive HTN is warranted in the first 24 hours of an acute CVA. In conjunction with Neurology consult, BP medication would only be given if the patient is very hypertensive (such as SBP>220/120 if no thrombolytics are given). Most of the time, Neurology will have given their BP threshold and choice of BP medication. - Aortic dissection: First choice is Labetalol IV. May also use an Esmolol drip (short acting, can titrate). May add on a Nitroprusside drip after beta blockade to achieve an SBP goal of 100-120 (within 20 minutes of the diagnosis). Hypertension treatment in a bolus Route PO hypertensive urgency Agent Hydralazine Captopril Clonidine Nitroprusside drip IV hypertensive emergency Nitroglycerin drip Labetalol bolus Labetalol drip Hydralazine bolus Dose 10 - 25mg PO x1 12.5 - 50mg PO x1 0.1mg PO x1 Initial dose 0.25-0.5 µg/kg/min Max dose is 8-10µg/kg/min Initial dose 5 µg/min Max dose 100 µg/min Initial bolus 20mg IV x1. Then 20-80mg q10 mins, max 300mg 0.5 – 2mg/min Initial dose 10mg IV x1 Then 10-20mg IV q20-30 mins Notes Caution cyanide poisoning at high doses SE: Headaches, tachycardia P a g e | 20 HYPOTENSION Why is the patient hypotensive? This requires a little more attention and investigating. You want to make sure you catch anything that can potentially cause mortality. Hypotension/shock can be categorized as: Hypovolemic shock: As the name implies, it is due to a decrease in the intravascular volume. Causes include: Blood loss: trauma, GI bleed, ruptured aneurysm, internal bleeding (especially if after a procedure) Fluid loss: emesis, diarrhea, poor PO intake, third spacing Cardiogenic shock: Something is wrong with the pump. Causes to think about include: Cardiomyopathy: Patients with a very poor EF (<20%) will often have baseline low BP’s to begin with. ACS: They may have had a large infarct or possibly an RV/inferior infarct. Arrhythmias: Afib/flutter with RVR, Vtach, Vfib, SVT, and complete heart block. Distributive shock: Also known as vasodilatory shock. Common causes you may encounter include: Sepsis: Probably a little easier to spot because they will usually have some infectious symptoms. Anaphylactic: Any new meds or foods? Transfusion reaction: This encompasses primary hypotension with transfusions (drop of >30mm Hg in systolic, diastolic, or both within minutes of starting the transfusion, and return to BP baseline after ceasing transfusion) or anaphylactic reaction. Obstructive shock: Relatively rare (2%). Massive PE (right side of the heart can’t pump against the high pressures in the lungs), tension pneumothorax, and tamponade. What to do when you get the call. 1. Ask the nurse: Did you repeat the blood pressure? Sometimes it’s a random reading and the recheck will be normal. What are the rest of the vitals? If the patient is tachycardic, it may either be compensation for the low BP or a possible arrhythmia, such as Afib or VT. Did the patient receive any BP meds, which ones and at what time? Sometimes patients receive all their PM doses at once and this can cause transient hypotension. Does the patient complain of any symptoms (dizzy, lightheaded, CP)? 2. Ask yourself: What is the patient’s baseline BP? If someone has been running SBP 90-100’s, then a BP of 85/65 may not be as worrisome, as compared to someone who is baseline hypertensive. Why is the patient hospitalized and what is the PMH? If the patient is admitted because of an infection, hypotension will be more worrisome. If the patient has a cardiomyopathy and an EF of <20%, may not be so worrisome (may be their baseline). 3. How low can you go: If a patient’s SBP < 80’s (confirmed on repeat BP check) and this is not their baseline, consider calling an RRT. This way, there is back up during the assessment in case the patient decompensates. If a patient’s SBP >80’s, stable, no symptoms, and you believe it is due to a little dehydration or quickly reversible with IVF, you may start with a trial of 1L NS bolus. If a patient looks unstable, regardless of what the BP is, call an RRT. 4. Assessing the patient and what to do: If the BP happens to be just a tiny bit lower than their baseline (let’s say they are known to go as low as SBP 90 but then now they’re SBP 85 without symptoms), you can probably just order half to one liter NS bolus (if they are not a CMY patient), and ask the nurse to recheck the BP in one hour. If they are on telemetry or SDU, check the tele to make sure they are in sinus (and not Afib/VT/SVT leading to hypotension). History and physical: Keep in mind the DDx for hypotension and patient’s medical issues. 5. Treat as needed. 6. Follow up with the patient to make sure they are doing okay. P a g e | 21 Causes of hypotension to worry about at night HYPOVOLEMIC Blood loss: Do they have risk factors for bleeding, such as cirrhosis (GI bleed), or recent procedure (such as liver/renal biopsy, thoracentesis, paracentesis). Are there physical signs of bleeding (emesis, BRBPR, melena, hematuria, vaginal). - Treatment: If they are actively bleeding and hypotensive, call an RRT. While the ICU team is on their way, have the nurse place large bore IV’s and start a NS bolus. Check the patient’s baseline labs. Order stat labs (at minimum, Chem 10, CBC, coags, lactate, type and screen/cross). Order PRBC and any other appropriate blood products (such as FFP if the INR is elevated; platelets if platelets are low or patient is on Plavix or ASA). Fluid loss: Do they have a lot of nausea/vomiting/diarrhea? Are they getting too much diuresis? - Treatment: If they are hypotensive because they are having a lot of N/V or diarrhea, you can give 1L NS boluses at a time and reassess (if they don’t have CHF). If it’s because of over diuresis, you can hold the diuretic, and give 250-500cc of NS back. If they are ESLD and intravascularly dry (let’s say from too much diuresis or from a large volume paracentesis) you can use albumin to fluid resuscitate (albumin 25g of 25%, IV q6 hrs do set doses such as x2-4). CARDIOGENIC Cardiomyopathy: What is their EF? Do they have signs of fluid overload? They are either at their baseline BP or they are so fluid overloaded, that their cardiac muscles are overstretched and do not contract as optimally to produce a normal BP. In the case of fluid overload, many times once they start to diurese and get fluid off, their BP will improve. - Treatment: If they look euvolemic and their BP is lower than usual, may give small NS bolus (start with 250cc). If they are very fluid overloaded, giving Lasix and diuresing should help. May transfer to the SDU from Telemetry for closer monitoring. Usually you will have been signed out that they are in the process of diuresis. ACS: Do they have CP, risk factors, or CAD? Are they admitted for an ACS evaluation? - Treatment: If you suspect this, you need to order troponins and EKG stat. Usually if they are hypotensive and with ACS, you need to make sure they are not having an inferior infarct. If there are ischemic changes in the inferior leads (II, III, AVF), then ask the nurse to do a right sided EKG. If V4R has an ST elevation, then it strongly indicates involvement of the RV. If you see this, AVOID nitroglycerin (will make them more hypotensive because they are preload dependent). Give IVF, call Cardiology, (and RRT if the patient is looking unstable). Arrhythmia: Are they tachy? What was their tele? What does the 12 lead EKG show? Do they sound regular or irregular on auscultation? Is there a history of arrhythmia or risk for it (such as a very low EF)? - Treatment: If Afib/flutter with RVR, with stable BPs or slightly lower BP (90’s), you probably have time to order Metoprolol 5mg IVP or Diltiazem 20mg IVP (nursing in the SDU can administer this). If they are lower than SBP 90’s, you are probably better off calling an RRT because sometimes it is faster getting the meds from the RRT cart than by ordering them. If it looks like SVT on 12 lead EKG and the BP is low, call an RRT. If the BP is stable, you can give adenosine 6mg IVP, may repeat with 12mg IVP x1. If sustained VT or VF (>30 seconds), call a code blue. P a g e | 22 DISTRIBUTIVE Sepsis: This is the first thing that comes to everyone’s minds. Any documented infection or new infectious symptoms? Is the skin warm (decrease systemic vascular resistance)? - Treatment: Consider starting or broadening antibiotics, first dose stat. If the patient is in a med/surg bed and their blood pressure is borderline (ie <100), would give IVF and transfer to the SDU. If the patient’s BP continues to drop, or does not improve after 2-3L boluses, the patient may need ICU level of care for pressors. Anaphylaxis, transfusion reaction: Any new medications? Any SOB, itch, or a rash? Are they swollen? - Treatment: Call an RRT. Stop any offending infusion/medication. While the ICU team is coming, place the patient on oxygen and start a NS bolus. Medication treatment includes Epinephrine IM (0.3mg of 1:1000 solution) to the thigh, Benadryl 25-50mg IV, Solumedrol 125mg IV; if wheezing, Albuterol 2.5mg nebs. OBSTRUCTIVE PE: Sudden tachypnea, hypoxic or tachycardic? Any calf tenderness/swelling? Any SOB or pleuritic CP? - Treatment: Usually you would order a CTA chest to diagnose and treat with Heparin/Coumadin, but if their PE is already causing hypotension, then you need to call an RRT because it’s most likely a large PE (that may require thrombolytics). Tension pneumothorax: Were there any recent procedures, such as thoracentesis or central line? Do they have absent or decrease breath sounds on one side? - Treatment: If hypotensive or unstable, call an RRT. For emergent treatment, a decompression with a nd 16g needle at the 2 mid-intercostal space can be done on the affected side (would probably wait for the RRT to assess). If there is time, order a portable chest xray to confirm the pneumothorax. Then a chest tube is placed. Tamponade: Do they have chest pain or sob? A history of a pericardial effusion? Are there distended neck veins or distant heart sounds? - Treatment: If they are very hypotensive or looking unstable, call an RRT. Patients will need a pericardiocentesis. Emergently, it can be done with a needle (at night ER attendings may help). Definitively, Cardiology needs to place a catheter. If the BP is stable, notify Cardiology consult for recs. Hypotension in a bolus 1. 2. 3. 4. Ask the nurse if they repeated the vitals and did the patient receive any BP meds? What is the patient’s baseline BP? What is the patient’s underlying issues that can contribute to the hypotension? Assess the patient: You want to see if you… Need to call an RRT now. Can give IVF (in most cases you can) and reassess. Give IVF and order things in the meantime for work up. 5. Depending on the situation or if the blood pressure is persistently low, you are probably better off transferring the patient to at least the SDU for closer monitoring. P a g e | 23 Blank P a g e | 24 TACHYCARDIA How tachycardic the patient is dictates how emergent the situation is. If they are only mildly tachycardic (100’s to 120’s) without any blood pressure compromise, you have to time to figure out the etiology. This is in contrast to someone who suddenly jumps to a HR 150’s, then you need to worry. What to do when you get the call. 1. Ask the nurse for the rest of the vitals if unstable, call an RRT/code blue. 2. What is the patient’s baseline heart rate? 3. What is the rhythm (narrow complex versus wide complex QRS)? Check the telemetry or order an EKG. Most tachycardias that you will encounter will be sinus tachycardia, Afib/flutter, or SVT (AVNRT/AVRT). Every now and then it will be VT/VF. If it’s a wide complex, you are likely dealing with VT or Torsades. Call an RRT/code blue. If it’s a narrow complex tachycardia then assess the P waves. This helps you to diagnose what kind of SVT this is. If the patient’s HR is too fast (such as >140) and you can’t identify the P waves, you can try vagal maneuvers, carotid sinus massage (contraindicated in patients with carotid bruits, history of CVA/TIA, recent MI), or adenosine to slow the HR down to see the P waves. 4. What are the patient’s medical issues that can contribute to the tachycardia? Aside from sinus tachycardia causes, other things to consider include severe CMY, valvular abnormalities, and hyperthyroidism. 5. Assess and treat the patient. Narrow Complex Tachycardia Regular Rhythm Sinus tachycardia SVT (AVNRT/AVRT) Atrial tachycardia Regular or Irregular Irregular Rhythm Aflutter Afib Multifocal atrial tachycardia P waves before every QRS. P waves either buried or retrograde P after QRS. HR usually >150. There is a single ectopic atrial pacemaker that has a different P wave morphology from the sinus P wave. Look for flutter waves (saw tooth pattern) in the inferior leads. Atrial rate 250-350, ventricular rate usually 150 (if 2:1 block). If variable block then irregular rhythm. No distinct P waves. Irregularly irregular R-R interval. Multiple ectopic atrial foci as pacemaker. Should see at least three different P wave morphologies in the same 12 lead EKG. SINUS TACHYCARDIA Volume depletion: - Dehydration: Does the patient have nausea/vomiting/diarrhea? You can give a 1L NS bolus and reassess. Are they being over diuresed? You can hold the diuretics and give a small amount of fluids back (such as 250-500cc). Are they intravascularly dry (such as ESLD)? You can give albumin as fluid resuscitation. - Blood loss/anemia: Any signs of bleeding? Will need to type and cross and transfuse PRBC. Consider transfer to the SDU/ICU for closer monitoring if actively bleeding. Fever: This is a very common cause and it’s not uncommon to see a patient’s HR go up to 120-130’s. Once you’ve determined that they are stable from an infectious standpoint (meaning not hypotensive), you can give IVF (1-2L and reassess). Pain: Another common cause. Make sure the patient has adequate PRN pain meds. Sepsis: They are tachycardic in part to maintain their BP. It’s important that they get fluids, fluids, fluids. Anxiety: If they are feeling anxious, try to reassure them. If this fails, you can try a small dose of Ativan (0.5 mg to 1 mg PO), or Benadryl to help them sleep, Hyperthyroidism: Unless they are in Afib with RVR, you just wait for the Methimazole/Propranolol to kick in. PE: If there are other signs such as tachypnea/hypoxia and risk factors, evaluate with a CTA chest and if positive, treat with heparin drip (or LMWH)/Coumadin. ACS: If they are having chest pain, look at the EKG for ischemic changes and order troponins. If ACS is diagnosed, tachycardia should be treated with beta blockers (ie Metoprolol) if the BP allows. Hypoxia: Place the patient on O2 and fix the hypoxia. Meds: Albuterol nebs (for asthma) commonly cause tachycardia. Aside from making sure they are fluid resuscitated, you can just monitor. P a g e | 25 SVT (AVNRT/AVRT) What is it? Technically, SVT refers to any tachycardia originating above the ventricle, but many people refer to AVNRT/AVRT as SVT. AVNRT is due to two pathways in the AV node. AVRT is due to an AV nodal pathway and an outside accessory pathway. With AVRT, it can be orthodromic (antegrade conduction down AV node and up accessory pathway) or antidromic (antegrade conduction down the accessory pathway and up the AV node). EKG: AVNRT rate is usually between 120-220 bpm. P waves are inverted in the inferior leads and often buried in the QRS. In AVRT, P’s are retrograde in the inferior leads (meaning the atrias were stimulated to contract from the AV node towards the SA node, leading to an inverted P wave). With orthodromic AVRT, the QRS is narrow while with antidromic AVRT, the QRS is wide. Vitals: Make sure they are not hypotensive if unstable, call an RRT or code blue. Acute rate control for AVNRT and AVRT: - Vagal maneuvers such as carotid massage or valsalva. Avoid carotid massage in patients with a history of CVA/TIA and recent MI. - Adenosine: 6mg IVP; if no response may repeat with 12mg IVP x1 (on floor/tele, you do the IV push). There is a risk that in patients who have AVRT, adenosine may slow the AV node and lead to rapid conduction through the bypass pathway leading to VT/VF. - If adenosine fails, second line is Metoprolol 5mg IVP q5mins x3 doses or Diltiazem 15-20mg IVP. - If patients are in AVNRT/AVRT, you really don’t want to just sit there and wait for the patient to break on their own; you need to do something. - Unless you know they have a history of antidromic AVRT or pre-excitation such as WPW, you can still nodal block them. Acute rate control of known history of WPW or antidromic AVRT: - DO NOT give anything that will slow down the AV node, such as vagal maneuvers or adenosine, Metoprolol, or Diltiazem (this may lead to AF that can lead to VF). - Use procainamide infusion (20-50mg/min) with close BP monitoring until the arrhythmia terminates or the BP drops. If you cannot tell if the wide complex tachycardia is from AVRT or VT, assume and treat as if VT. AVNRT: (from Up to Date) Many times the atrial and ventricular activation occurs at the same time, so P’s become buried in the QRS and become difficult to see (cannot see in this one). ATRIAL TACHYCARDIA: What is it? An atrial focus is the pacemaker (not the SA node). EKG: Upright P wave before every QRS (the P wave will look different than the baseline sinus P because the atrial tachycardic P wave is from an atrial foci, not the SA node). Acute rate control: - Same as with Afib/flutter. Treat with a beta blocker or calcium channel blocker. If stable and not tachycardic, you can try PO medications, but if the HR >130-140’s, would try IV medication. P a g e | 26 ATRIAL FIBRILLATION/FLUTTER: What is it? Afib is caused by random firing in the atria. Atrial flutter is caused by a reentrant rhythm that originates in the left or right atrium. This leads to the electrical activity going around in a continuous loop in the atria (leading to the high atrial rate and saw tooth look on EKG). EKG: Afib has no distinct P waves and irregularly irregular QRS rhythm. Atrial flutter has saw tooth like P waves in the inferior leads. Because the AV node limits the rate of the atrial impulses that can pass through, you often see a 2:1 block for atrial flutter (meaning if the atrial rate ~300, ventricular rate will be around 150). Vitals: If hypotensive, call an RRT. Is this new or old? If it’s new Afib, to help out the primary team, order a 2D echo to evaluate for any thrombus or structural abnormalities. Acute rate control: If the BP is stable, you can choose to either control with PO or IV medications. - If the HR is 100’s - 120’s, it may be reasonable to try an extra dose of their PO medication. Also make sure they are on telemetry, if not so already. - If the HR >140’s, you should probably use IV meds to rate control with goal HR<110. Make sure the patient is hooked up to a vitals machine with baseline a BP checked prior to pushing meds. Common options include: Metoprolol: 5mg IVP over 2 minutes, may repeat every five minutes up to three doses total. Of note, unless the patient is in the SDU, you will have to push this. Avoid in bad asthma/COPD. Diltiazem: 20mg IVP over 2 minutes. May repeat after 15 minutes. Avoid if CHF. Digoxin: Loading dose 0.75-1.5 mg PO or 0.5-1 mg IV, divided into three doses and given as 50% initially then 25% x2 q6-8hrs. Try this if you can’t use Metoprolol or Diltiazem. Often used in patients who have heart failure or if their BP is baseline low. Not that great for outpatient treatment for younger patients because it doesn’t work well with exertional increases in HR. Can be used in addition to Metoprolol or Diltiazem if these alone have not controlled the HR. Avoid Amiodarone. This is also a rhythm control agent, which you want to avoid with newly diagnosed Afib (because an undiagnosed atrial thrombus may embolize and cause a stroke if they convert to sinus rhythm). If these do not work, call the NF resident or Hospitalist for assistance and consider calling Cardiology. Atrial fibrillation (from Up to Date) Atrial Flutter (from Up to Date) MULTIFOCAL ATRIAL TACHYCARDIA: What is it? Multiple atrial pacemaker foci are contributing to the ventricular rate. Etiologies include COPD or other causes of hypoxemia, CAD, hypomagnesemia, and hypokalemia. EKG: You will see three different P waves (meaning different pacemaker foci) with different PR intervals. Acute rate control: - If tachycardic, you may use AV nodal blocking agents, such as Diltiazem or Metoprolol. - Treat hypomagnesemia and hypokalemia. Consider underlying etiologies and treat the cause (ie hypoxemia, electrolyte disturbances). P a g e | 27 WIDE COMPLEX TACHYCARDIA: Most wide complex tachycardias are going to be due to VTach. VTach: Considered to be three beats or more in a row. Called sustained VT if it lasts >30 seconds. - If it is unsustained, make sure the vitals are okay and check the electrolytes (make sure Mg>2, K>4). If this is new and getting near sustained, notify the NF resident. If it’s getting close to 30 seconds in length, notify Cardiology and make sure the patient is at minimum, on telemetry or SDU. - If it is sustained and monomorphic call a code blue. Torsades de Pointe: Polymorphic VT where the QRS can look sinusoidal. Associated with prolonged QT. - Call a code blue. Once the ICU team is there, and if vitals are stable, can sometimes try to give Mg 1-2g IV first, but if it doesn’t work or the patient is unstable, then electrical cardioversion. - Treat any hypomagnesemia, hypokalemia, and hypocalcemia. Remove any agents that can cause prolonged QT. SVT: Can be seen with aberrancy (widened QRS) or pre-excitation rhythm like WPW. If the patient does not carry a diagnosis of these already and you can’t tell by EKG, it is VT until proven otherwise. Artifact: The patient faked you out! Many artifacts can look like VT (like tremors, brushing your teeth). If you look at the tele strip and you can march out the QRS complexes through the “VT”, then you are most likely dealing with artifact. Ventricular tachycardia (from Up to Date) Torsades (from Up to Date). Notice the sinusoidal look. Tachycardia in a bolus 1. Ask the nurse what are the rest of the vitals? If very hypotensive (SBP <80’s, call an RRT). 2. Ask the nurse if the patient is mentating. If not, call a code blue/RRT. 3. If the patient’s BP is stable, ask the nurse over the phone for a stat 12 lead EKG or tele strip. If they say tele looks like VF or VT, call a code blue. 4. What is the patient’s PMH and reason for admission? 5. Patient’s bedside: If the 12 lead EKG shows: VF or a wide complex tachycardia (which is likely VT) Call a code blue. Narrow complex tachycardia, then figure out what it is. Most of the time, it is: - Sinus tachycardia: Treat accordingly. - Afib with RVR: Treat with IV BB or CCB. - If the HR is too fast and you can’t see P waves, try vagal maneuvers or Adenosine 6mg12mg. The vagal maneuvers or Adenosine broke it likely SVT (AVNRT/AVRT). HR slowed down and you see P’s sinus tachycardia. You don’t see distinct P’s (looks like Afib with RVR): treat the RVR. 6. If the patient is in a med/surg bed, upgrade to at least Telemetry or SDU. P a g e | 28 BRADYCARDIA Defined as HR < 60. This can occur in many people, young and old, with a structurally normal heart. Often seen when people are asleep (can go as low as 30’s with pause up to 2 seconds and still be normal). Most of the time when you are paged, it will be for patients with bradycardia who are asleep. Symptoms that you would expect to see with bradycardia include dizziness, lightheadedness, or syncope. When you get called: 1. Ask the nurse: What are the rest of the vitals. Make sure the patient is not hypotensive. 2. Is it sinus rhythm? Aside from sick sinus syndrome, sinus bradycardia can be benign, whereas anything else may need urgent attention. 3. Is the patient asleep? If it’s sinus brady and the patient is asleep, there is not much to worry about. If they are bradycardic to <40’s and still awake and walking around, you will need to go evaluate. 4. What are the patient’s medical issues? If it is a patient with an underlying cardiac issue, bradycardia may be a little worrisome. In ACS, it could mean ischemia to the SA node, AV node, or RV infarct. For cardiomyopathy, it could mean too much beta blockers, or impending cardiac arrest (ie a CMY patient going from sinus to slow junctional rhythm to cardiac arrest). In severe sepsis (such as ICU), it could mean impending code/death. For terminal patients who are comfort care, could also mean impending passing. 5. Assessment and treatment: Depends on whether they are sinus brady or everything else. Most of the time, it will just be sinus brady. SINUS BRADYCARDIA: Normal variation with sleep: HR can go as low as 30’s. Most of the time, it will be this scenario at night. Just make sure it’s sinus and rest of the vitals are stable. Just make a note of it for the primary team. Medication (such as beta blockers, CCB, Amiodarone): If it’s medication induced, you will probably see the bradycardia during waking hours as well. If you are cross cover, and the HR is dipping into the 40’s with symptoms, would hold any PM doses unless contraindicated or noted otherwise by the primary team. Athletes, elderly: Can be normal in these populations (granted so long as there are no symptoms). Sick sinus syndrome: Seen mostly in older people. Due to dysfunction of the SA node. Increase ICP: This is part of Cushing’s triad where you see bradycardia, HTN, and respiratory depression. If you are dealing with a neuro patient and you start to see this, would run this by a resident because depending on the patient’s situation, they may need emergent intervention. ACS (if it affects the SA node): Treat the ACS. Increase vagal tone OSA (thought to be from increased vagal tone) AV NODE BLOCK First degree AV block: - EKG: Prolonged PR interval (>200ms), but all QRS’ are conducted. - Signs/symptoms: Probably don’t see as much bradycardia with this one. - Treatment: No intervention needed. If patients have symptoms, they may qualify for pacemaker (but this is rarely seen). Second degree AV block Mobitz Type 1 (Wenckebach): - EKG: Progressively prolonged PR until a QRS is dropped. - Etiology: Due to an abnormal AV node (hence prolongation of PR). Can be found in normal people like elderly or athletes (increase vagal tone), AV nodal blocking agents (beta blockers, CCB, digoxin), myocarditis, and myocardial infarct. - Treatment: Usually does not require any treatment but if they have symptomatic bradycardia, may place a pacemaker. dropped QRS Second degree AVB Mobitz Type I (from Up to Date) P a g e | 29 Second degree AV block Mobitz Type 2: - EKG: Consistent PR interval, but occasionally dropped QRS. - Etiology: Due to an abnormal Purkinje-His fibers (which is why the PR interval stays the same, because the AV node is working; it is the conduction through the His to provide a QRS that is affected). Seen mostly in older patients with degeneration of the conducting system, MI, or AV nodal slowing medication (such as digoxin, BB, or CCB). - Signs/symptoms: If the patient has a normal sinus rate, they may have little symptoms versus someone who is running at a baseline lower heart rate. - Treatment: Immediate treatment is to look for reversible causes such as medications. In these rd cases, there is a high risk of progressing to 3 degree AV block (complete heart block), so almost all patients will need a pacemaker. They should be monitored on Telemetry. dropped QRS dropped QRS Second degree AVB Mobitz Type II (from Up to Date) Third degree AV block (complete heart block): - EKG: Dissociation between P and QRS complexes. The P waves and QRS will march out independent of each other. Where the escape rhythm originates from (which is somewhere below the block) will dictate the QRS morphology and ventricular rate. - Etiology: There is a block either in the AV node or anywhere in the conduction system below it. In adults, it may be due to an increase in vagal tone, AV nodal slowing medications, or ischemic heart disease. - Symptoms: The lower the escape pacemaker location, the lower the HR (remember that the inherent ventricular rate is 15-40 bpm), which means higher risk of symptoms such as dizziness and syncope. The slower the rate, the higher risk for asystole, VT, or VF. - Treatment: If bradycardic, hypotensive, chest pain, SOB, or loss of consciousness, call an RRT/code blue (going down ACLS route). If available and ready, use atropine 0.5mg IV q3-5 mins (not to exceed 3mg). If this does not work, pace with pacer pads or use drips such as dopamine 210mcg/kg/min or epinephrine 2-10mcg/min. If the HR ≥ 30’s, patient’s BP is stable and they are awake and alert, you can observe. You can also preemptively have pacer pads on the patient. If this is a new diagnosis at night, call Cardiology to let them know about the patient (for potential pacemaker the next day) and see if there are any other recommendations. These patients should at minimum be in the SDU with pacer pads on. Remove any reversible causes, such as AV nodal slowing medications (digoxin, BB, CCB) or treat the ACS. Long term treatment is a pacemaker. Third degree AVB (from Up to Date): P’s and QRS’ march out independently. P a g e | 30 LOW O2 SATURATION Many times this goes hand in hand with tachypnea and SOB. Many people use hypoxia and hypoxemia interchangeably when referring to low oxygen saturation on pulse oximetry. Technically, hypoxia refers to inadequate blood supply to the body or tissue, whereas hypoxemia refers to a decrease in the partial pressure of oxygen in the blood. While an ABG is best at assessing hypoxemia, we mostly use the O2 saturation on the pulse ox as a surrogate for hypoxemia. Normal O2 sat is 95-100%. Anyone <90% you should worry about. There are five major things that lead to hypoxemia: 1. Hypoventilation: You see normal A-a gradient and usually increase PaCO2 on ABG. Causes include CNS depression (from primary CNS issue or from medications such as narcotics and benzodiazepines) and chest muscle impairment (such as muscular dystrophy or GBS). 2. V/Q mismatch: There is already a physiologic baseline V/Q mismatch. Things that increase the mismatch (altered ventilation or perfusion) include airway obstruction (asthma/COPD), alveolar issues (pulmonary edema, CHF), and vascular issues (PE). 3. Right to left shunt: Blood has traveled from the right to left side of the heart and failed to become oxygenated in-between. It can be an anatomic shunt (such as an ASD or pulmonary AVM) or physiologic (atelectasis, PNA, CHF perfusion to that part of the lung is “blocked” so as blood passes through this area, it does not get ventilated). 4. Diffusion issues: Such as interstitial lung disease. 5. Low inspired oxygen: Such as high altitude. What to do: 1. Ask for the rest of the vitals. What was patient’s baseline O2 sat and their baseline oxygen need (room air versus nasal cannula versus facemask). Make sure the nurse puts some oxygen on the patient. 2. What is the PMH and reason for admission? Are they on IVF? What is their last EF? 3. If the patient looks stable and this is a new desaturation, recheck the pulse ox yourself. Have them take deep breaths and see if this changes anything. Common things that can alter a pulse ox reading include: - Improper placement: Try placing it on another finger or try a new pulse ox detector. - Check the nails: Nail polish can alter the absorption of the pulse ox red light and reading. - Blood flow: Check the cap refill to make sure it’s okay. - Hypothermia: Try to warm up the fingers/hands and recheck the pulse ox. 4. Assess and treat the patient (refer to SOB section for details). Things to worry about at night include: Pulmonary embolism: Are they tachypneic and/or tachycardic? Do they have chest pain? Any risk for clots (immobilization, not on DVT prophylaxis) or history of clots? - Treatment: Obtain a CT chest angiogram if there is a high suspicion and if positive, anticoagulate. Pulmonary edema: Do they have CHF? Are they on maintenance IVF? Any crackles on exam? Are they ins/outs positive? - Treatment: Check a CXR. Treat with Lasix (if Lasix naïve, can give 10-20mg IV x1) and reassess. PNA: Were they admitted for this? Any risk of aspiration? Any cough or fever? - Treatment: Check a CXR. If it’s a worsening PNA, consider broadening the antibiotic coverage, giving IVF, and transferring to the SDU. If it’s a new PNA, give IVF and start antibiotics. If concerning for aspiration (recently vomited or pulled an NGT), also start Metronidazole for anaerobes. Pneumothorax: Any recent chest procedures, like a thoracentesis? Any chest pain? Decrease breath sounds on one side? - Treatment: Check a CXR. Place on oxygen and notify the NF resident to help with the management. If it’s a tension pneumothorax and unstable, call an RRT. Asthma/COPD: Do they smoke or have a history of this? Any wheezing on exam or no air movement? - Treatment: Check a CXR. Can do trial of nebs (Albuterol 2.5mg/Atrovent 0.5mg inhaled nebs x1) to see if it helps the symptoms. If it looks like PNA on CXR, start antibiotics. Hypoventilation: Do they have OSA or risks for it, such as obesity or a big neck? Did they get narcotics or benzodiazepines? Do they have chest wall pain and are they taking shallow breaths? - Treatment: If it looks like OSA, you can place the patient on oxygen and defer to the primary team in the morning to start CPAP. If it’s from narcotics or benzodiazepines, they are also usually somnolent as well at this point. Would notify the NF resident. If the patient is somewhat arousable and their breathing is not to the point of apnea, you can place them on oxygen and wait for the meds to wear off. If they are unarousable and becoming apneic, then consider Narcan (naloxone) to reverse the narcotic, or flumazenil to reverse the benzodiazepine. P a g e | 31 Chronic trach +/- vented patient: They may have mucous/secretions in their tracheostomy or airway. - Treatment: Suction at the trach opening. May try deep suctioning as well. Chest PT may help break up any mucous. 5. What to order: - Stat portable CXR: Everyone who desats gets one. It can rule in or out many pulmonary issues. - ABG/VBG: You already know that they are not getting enough oxygen to their blood via the low O2 sat, so ABG/VBG really only buys you the CO2. If it’s elevated, it may tell you it is hypoventilation (like OSA or narcotics), acute asthma, or chronic COPD. - CT chest angio: Consider PE if you cannot find a reason for their sudden hypoxia. 6. Oxygen: Anyone who develops hypoxemia should be placed on supplemental oxygen. The general progression goes from room air nasal cannula face mask non-rebreather BIPAP intubation. High flow NC may be used in place of a FM/NRB if a patient feels claustrophobic with the face mask. 7. If they are requiring facemask but do not look to the point of intubation yet, transfer to the SDU. Also notify the NF resident about this patient if you had to progress from room air to face mask. 8. Reassess the patient to make sure they are still doing okay. Modes of delivering oxygen: (* used most often here at Olive View) Mode Room air *Nasal cannula (NC) *Simple face mask (FM) Liters/min Venturi Mask 4-12 L/min High flow NC Partial rebreather mask *Non-rebreather mask (NRB) *BIPAP 1-6 L/min (start w/2L) 6-10 or 12 L/min FiO2 21% 24 - 44% 40 - 60% Notes For every 1 L/min, add ~ 4% to 21% (RA) Gives more precise FiO2; Not used very often, but when used, mostly for COPD. Gives more precise FiO2. Alternative for 15-40 L/min Up to 100% patients who can’t tolerate a mask or wants to eat. 10-12 L/min 70 - 80% RT will do this if they feel it’s indicated. 10-15 L/min Up to 100% We usually go from FM to NRB. Should only be used for a few hours to no longer than overnight. Good for quickly reversible causes (fluid overload, COPD/asthma, hypercarbia). 30 - 50% *Intubation In practice: - Someone on room air desats. Place him on 2L NC and see how he responds. If there is no improvement, titrate up to 6L/min with goal O2 sat >93%. If this doesn’t work, then proceed to FM (up to 10L/min). If the patient had to go from RA to FM, notify the NF resident. If FM doesn’t work, then place a NRB mask. If the patient can’t tolerate any kind of FM, you can try a high flow NC. If the patient progresses to NRB/high flow NC, then you may be close to intubation (because they are now nearing FiO2 100%). At this point, you may need to call an RRT if the patient is still desating/in distress. - If they are having a lot of work of breathing, you can try BIPAP, which works almost like intubation, but without the actual ET tube. With quickly reversible causes, such as CO2 retention or pulmonary edema, patients can be on BIPAP for a few hours while reversible causes are being treated. This route can avoid an intubation. - Relative contraindications to BIPAP: In these situations, BIPAP may not work effectively or cause more harm. Cardiac/respiratory arrest; patient can’t control secretions; patient can’t protect their airway; impaired consciousness (except for instances due to hypercarbia); facial trauma/deformities; high aspiration risk (ie active nausea/emesis); recent esophageal anastomosis. Desaturation in a bolus 1. Check the rest of vitals. If unstable, call an RRT. 2. What is the PMH and reason for admission? 3. Assess the patient. If this is new, recheck the O2 sat on a different finger to confirm. Look for pulmonary etiologies for the hypoxemia and meds that may cause hypoventilation. 4. Order at minimum a CXR. +/- ABG/VBG. 5. Treat as needed. If the etiology for hypoxia is still uncertain, consider a CTA to rule out PE. 6. Follow up with the patient and make sure they are doing okay. P a g e | 32 TACHYPNEA Tachypnea often goes hand in hand with shortness of breath. A normal respiratory rate is about 12-20. Tachypneic will be >20 breaths per minute. Many times I don’t trust what the documented respiratory rate is. If you are evaluating someone who is tachypneic, you should count it out yourself. You can count the breaths in 15 seconds and multiply by four. Or you can listen with a stethoscope for 15 seconds and then multiply by four (I find this easier). What to do: 1. Are the rest of the vitals okay? What’s the O2 sat? 2. What is the patient’s PMH and reason for admission? 3. Assess and treat the patient. Some things to look out for at night when someone is tachypneic: - Worsening or new PNA - Worsening or new asthma/COPD exacerbation - Worsening or new pulmonary edema - New PE - Respiratory compensation for a metabolic issue (patient needs to blow off CO2), such as a metabolic acidosis from DKA or lactate (sepsis). - They are anxious or in DT’s 4. What to order: - Stat portable CXR: This is quick and easy and can tell you many things about the lungs (PNA, pneumothorax, edema, pleural effusion). You should always order this for new or worsening tachypnea. - ABG/VBG: If they look like they are tiring out, a VBG to look at the CO2 can help tell you if they are impending intubation (you would expect low a CO2 if tachypneic, but if close to normal or high CO2, then worry). If they are acidotic, it may suggest an underlying metabolic acidosis and the tachypnea is the respiratory compensation. - Chem 10: If the CXR is negative and still tachypneic, order a chem 10 to look at their metabolic status (bicarb). - CT chest angio: If they are tachypneic, new hypoxia, and +/- tachycardia and you have no other good reason why (even after consulting NF resident/attending), then no one will fault you for ordering a CT to rule out a PE. 5. What to do: - If their respiratory status is borderline, would transfer to the SDU for closer monitoring. - If you can’t figure out the etiology after talking to the patient and CXR, call the NF resident or Hospitalist attending to help out. P a g e | 33 Blank P a g e | 34 FEVER (full fever work up / FFWU) A full fever work up entails assessing a patient and making sure that any new infection (or worsening infection) is caught early to prevent mortality. It’s part of your job as cross cover to ensure that the appropriate work up is initiated and any necessary antibiotics are started. Everyone who spikes a new fever should get a full fever work up (unless the primary team directs you otherwise). You will never be faulted for doing too much. So the nurse tells you that a patient has spiked a fever: 1. What are the vitals? First and foremost you should ask the nurse this when they initially call you. Even more importantly with patients who are admitted because of an infection. Fever/hypothermic: Most of the time, it means there’s an infection. Tachycardia: May either be related to being febrile, or is a cardiac response to maintain the BP (even if the BP is normal at this point). Would still give IVF (start off with 1L NS bolus) because tachycardia may be signaling impending hypotension. Hypotension: - Need to give IVF, usually in the form of NS boluses. This is part of early goal direct therapy in sepsis. Consider transferring the patient to the SDU for closer monitoring. - If a patient becomes very hypotensive (such as SBP <80) would call an RRT. - If a patient’s BP does not respond after 2-3L bolus or continues to drop even during the bolus, the patient may need transfer to the ICU for pressors. - Hold any BP meds/diuretics (because they may end up getting their PM and next AM doses). Tachypnea: If possible, obtain a CXR to evaluate. Tops things to think about: - This may either be respiratory compensation because the patient has a metabolic acidosis from an elevated lactate (from their infection). - They are developing pulmonary edema from the fluid resuscitation. IVF takes precedence over pulmonary edema in most cases of sepsis. If patients are becoming septic, they need the IVF boluses because pressors don’t work well unless they are fluid resuscitated. You can always intubate patients if you put them in pulmonary edema. Would notify the ICU if it is heading in this direction. - Worsening pulmonary infection. Sometimes you can try BIPAP as a temporizing measure, but if they look like they are tiring out or in distress, may need to call the ICU for intubation. Hypoxia: If possible, obtain a CXR to evaluate. - Causes to consider from an infection standpoint: Pulmonary infection developing/progressing; developing pulmonary edema from fluid resuscitation, developing ARDS. - The usual progression of oxygen need is NC (1-6L) FM (6-12L) NRB (10-15L) BIPAP (only a temporary measure for a few hours to overnight for quickly reversible causes such as pulmonary edema) intubation. If patients are escalated to FM/NRB, they should be transferred to the SDU. If they are still looking very tachypneic, you need to call the ICU to assess for possible intubation. 2. What are the patient’s PMH and reason for admission that can play a part in the fever? Think of patients in three groups (admitted for an infection already, admitted for a non-infectious reason, and neutropenic). 3. Assess the patient: Since worst case scenario a fever can lead to septic shock, you should assess everyone. Check to see if they have anything indwelling that can be a nidus of infection (such as a foley catheter, central line, PICC line, permacath, g-tube, recent ortho hardware). Ask questions: This will have to entail doing a quick review of systems. - Headache/confusion/nuchal rigidity - URI symptoms, chest pain/sob - GI symptoms like nausea/emesis/diarrhea/pain - Urinary symptoms like dysuria/frequency, urgency; scrotal or vaginal complaints - Skin complaints (like new decub ulcers, skin boils) Physical Exam: Be sure to also check indwelling lines for redness or tenderness. 4. What to order: If you cannot identify a source of infection, the minimum that should be ordered are: Blood cultures x2 sets (each set includes an aerobic and anaerobic bottle): One set should be from an indwelling line if present (ie PICC). Of note, permacath Bcx can only be drawn by a dialysis nurse or MD. RUA, urine culture Chest xray (pa/lat if possible, otherwise stat portable is fine) Lactate (all Bcx’s come with a lactate), coags (incase they need a central line), (+/- Chem 10, CBC) *Cdiff and stool cultures: You can consider this if diarrhea is present. P a g e | 35 5. If you DO find a potential source of infection, you should still pan culture (#4), order any appropriate labs/ imaging (such as CT scans, xrays) and perform any needed procedures (such as an LP or paracentesis) and start the appropriate antibiotics. 6. If patients are unstable, call an RRT and the ICU team will come and evaluate. NOTE: IV fluids and CHF patients: This becomes tricky. If they are only febrile, with stable vitals and you can’t find an infective source, you can do smaller volume IVF (such as 250-500cc). If they have unstable vitals and are infected/suspected infection, you need to bite the bullet and give IVFs. In these cases, they should go to at minimum the SDU and a resident should be called to run the case by. Already documented infection: You may not necessarily need to perform a FFWU if the patient already has a documented infection and spikes again. Many times if their vitals are stable, you only need to repeat blood cultures every 48 hours +/- IVF’s, unless otherwise noted by the primary team. If the primary team asks for a FFWU on a known infected patient, verify if they want everything or just Bcx’s. Sepsis Screening and Management bundle: This is an order set in ORCHID that you will use if you are initiating a sepsis work up (in order to meet Sepsis Core Measures). As part of the bundle, for Severe Sepsis, you will need Bcx’s (with lactate) and antibiotics within three hours of the diagnosis, and a repeat lactate within six hours (if the initial lactate was elevated). If Septic Shock, they will need IVF’s within the first three hours and a reassessment for possible pressors in six hours. NEUTROPENIC FEVER This is a special category of patients, mostly seen with cancer patients during/after chemo. Neutropenia is defined as ANC <1500 (severe if ANC<500). When neutropenic patients develop a fever/infection, they have the potential to become very ill, very fast. Many times, they auto-infect themselves (such as from the GI tract). 1. Ask for vitals. (refer to above) 2. ALWAYS go see the patient. Again, check for indwelling lines (many times they will have PICC lines), and run through a ROS. Extra things to ask for are sore throat (look for HSV esophagitis or esophageal candidiasis) and any rectal pain (such as HSV lesions). 3. Physical exam: Keep in mind to look at indwelling lines, inside their mouth/throats, and peri-anal area (if they have any complaints). For neutropenic patients, DO NOT PERFORM DRE’s. This can lead to micro-tears and introduction of bacteria into the blood stream. 4. What to order: At minimum: Blood culture x2, RUA, UCx, CXR, lactate, CBC, +/- stool cx and cdiff 5. Antibiotics: Even if you don’t find a potential source of infection, ALL neutropenic fever patients need to be started on Cefepime: Cefepime 2g IV q8, first dose stat. Covers gram pos/negs and pseudomonas. Start in all febrile neutropenic patients. Vancomycin 1g IV q12. Can add this if there is a central line, concern for MRSA, or the patient looks ill. Metronidazole 500mg PO q8. Can add this if they have diarrhea to cover cdiff, or if you are concerned about an intra-abdominal process (will cover anaerobes that Cefepime does not). Fluconazole 400mg loading, then 200-400mg PO or IV daily (if you suspect esophageal candidiasis). Acyclovir 400mg PO 5x/day (if you see any oral/peri-anal ulcers concerning for HSV). 6. Reassess patients to make sure they are doing okay. Full fever in a bolus 1. Ask for vitals. 2. Assess the patient for any potential source of infection (including indwelling lines) or worsening of a current infection. 3. Order at minimum: Blood cultures x2 sets, RUA, Ucx, CXR, lactate (+/- stool culture, Cdiff) 4. Give IVF. If no contraindication, you can start off with a 1L NS bolus. 5. Perform any needed procedures such as LP’s, paracentesis (but this should not delay antibiotics if the patient is very ill or the procedure cannot be done that night). 6. Start any appropriate antibiotics. Always start Cefepime for neutropenic fever patients. 7. Transfer to the SDU or ICU if needed. P a g e | 36 ALTERED MENTAL STATUS (AMS) What is AMS? It usually means a change from the patient’s baseline mental status. If the patient has a neurologic issue (such as a stroke or dementia), or is elderly, it’s important to ask the primary team during signout for the patient’s baseline mental status. Ask for the level of orientation (AOx 0-4) and how alert the patient is (awake and alert, sleepy but arousable, awake but doesn’t track, etc, etc). This will help you greatly at night. Definitions: It’s important to understand the different levels of consciousness, but if all else fails, it’s best to just describe what you see. Confusion (encephalopathy): reduced comprehension, coherence, or capacity to reason; they can’t maintain a coherent thought process Delirium: waxing and waning confusional state; can also include hallucinations, altered sleep/wake cycle, HR and BP instability Drowsiness: quickly arousable to stimuli Stupor: arousable to pain stimuli; makes some purposeful movements Coma: unresponsiveness to any stimuli; does not make any movements Differential diagnosis by systems: There are SO MANY THINGS that can cause AMS. It’s important to know what the differential is so that you know what to look for. Keep in mind, for younger patients, you may see more drug ingestions, seizures, or meningitis/encephalitis; while as for older patients, you may see more infections (even the smallest UTI), delirium, constipation, and medications causing AMS. Etiologies (adapted from Pocket Medicine) Neurologic Systemic Bleed Stroke Mass/midline shift Seizure Infection: meningitis, encephalitis, abscess CNS vasculitis Hydrocephalus Concussion/trauma Dementia Cardiac: ACS, hypertensive encephalopathy Pulmonary: hypercarbia, hypoxia GI: hepatic encephalopathy, constipation (especially elderly) Renal: uremia, hyper/hyponatremia Endocrine: hypoglycemia, hyperglycemia (HHS, DKA), hypercalcemia, hypo/hyperthyroid, Addison crisis ID: any infection (especially elderly), meningitis, encephalitis Heme/Onc: TTP, neurologic malignancy or metastasis Psych: delirium Hypo/hyperthermia Medications: opiates, sedatives Ingestions: toxins; alcohol withdrawal/DT’s What to do: 1. Ask the nurse for vitals. Is the patient hypoxic or hypertensive (HTN encephalopathy)? 2. Ask the nurse what is the patient’s baseline mental status or how they were before this change. 3. Ask the nurse what they meant by “altered”? This makes a big difference because “altered” can mean many things to many people. This gives a sense of how emergent and how quickly you need to act. Are they just more sleepy but arousable? Are they somnolent and not arousable? Are they totally unconscious and not responding to stimuli? (If this is the case and patient had been awake and alert prior, would probably call an RRT). 4. While still on the phone, ask for an accucheck (so it’s ready when you get there). 5. What is the patient’s PMH and why are they admitted? Did the primary team tell you the patient’s baseline mental status? Are they on narcotics or benzodiazepines? Do they have conditions that can predispose to AMS, such as cancer (brain metastasis), stroke, or dementia? 6. Assess the patient: How oriented is the patient? Name, place, date (year, month), and why they are in the hospital. What’s their level of consciousness? Are they arousable and can carry a conversation or no matter what you do, they won’t wake up for you (not good…) Any medications? When was the last time the patient received anything (such as narcotics or benzodiazepines) and how much/often? You can have cancer patients on a lot of pain meds or PCA’s that maybe have underlying liver/renal disease that alter the clearance of the opiate and lead to AMS. P a g e | 37 7. 8. 9. 10. Run through a review of systems: Things to focus on include: - Any pain (such as HA to suggest meningitis/encephalitis)? - Any history of seizure or seizure like activity (such as tongue biting, incontinence, muscle aches)? - Any infectious symptoms (especially in the elderly; even small infections can cause AMS)? - Do they drink alcohol (leading to DT’s) or take drugs (especially if patient was just admitted)? Focused physical exam: Neuro: Focal deficits to suggest CVA, bleed, mass effect. HEENT: - Pinpoint pupils narcotics - Fixed and dilated anoxic or herniation - Papilledema increase ICP - Nuchal rigidity meningitis/encephalitis Abd: Distended or ascites to suggest liver disease and hepatic encephalopathy Skin: Rash to suggest meningitis What to order: Depends on your clinical suspicion. If the patient is obtunded and cannot provide a history, you may have to be broad and order everything. Accucheck (for everyone) to rule out hypoglycemia, if not done so already. Labs: Review the most recent labs and order as needed. If in doubt, order more, not less. - VBG (for most everyone) to rule out hypercarbia, especially if drowsy or obtunded and at risk for hypercarbia (such as a respiratory patient, COPD, OSA, obese). - Chem 10, CBC, LFT’s, ammonia (hepatic encephalopathy), UTOX, ETOH, TSH, Troponin EKG to evaluate for ACS Head CT (rule out bleed or mass). Especially if there is an alteration in consciousness that cannot be explained by medications or anything else. This helps to rule in/out major neurological etiologies, such as bleed, stroke (acute CVA may not show up on CT in first 24 hours), or mass. CXR to rule out PNA (especially in the elderly) +/- LP (depends on your suspicion for meningitis/encephalitis) Treatment as needed. Things to keep in mind: If a patient is somnolent but arousable, consider upgrading to the SDU for closer monitoring. Hypercarbia: You can try BIPAP and repeat the VBG in one hour to reassess the PCO2. If the PCO2 does not improve with readjustment of the BIPAP settings, the patient may need intubation/ICU. Intracranial bleed or midline shift: Notify the NF resident because the patient needs to be emergently MAC’d (transferred) for Neurosurgery. Call Neurology (+/- Heme/Onc if it is a malignancy related mass) for recommendations, and transfer to the ICU. Hepatic encephalopathy: If acute, you can try lactulose 30cc PO q1-2 hrs until the patient has his first bowel movement, then change to q6-8hrs. If obtunded, you can give lactulose via an NGT or per rectum. Alcohol withdrawal or DT’s: Transfer to the SDU for a CIWA protocol (cannot be done on the floor). Delirium/sundowning: Try redirecting the patient before going to sedatives (ie Haldol) or soft restraints. CVA: If there is a high suspicion for this and the patient is still in the window for TPA (~4hrs), call an RRT and page the Stroke pager (notifies essential people such as Neurology on call, Stroke fellow, MRI tech). Reassess the patient. AMS in a bolus (RRT situation) 1. 2. 3. 4. 5. What are the vitals? What does the nurse mean by altered? What is the patient’s baseline mental status? What is the patient’s PMH and reason for admission? What’s the last set of labs? Assess the patient: - Give Narcan if he received recent narcotics. - Give Flumazenil if he received recent benzodiazepines. 6. Things to order: - Get an accucheck to rule out hypoglycemia. - Check an ABG/VBG to rule out hypercarbia. - Check an EKG to r/o ACS. - If none of the above pans out, order labs and head CT (rule out bleed, CVA, mass). 7. Treat as needed. P a g e | 38 BLEEDING GI Bleeding Either patients came in with a diagnosis of a GIB or they may have a new one at night. Upper GIB sources include varices, Mallory Weiss tears, mass, or gastric ulcers. These can manifest as coffee ground emesis, frank hematemesis, melena or hematochezia (if it’s a very brisk UGIB). Lower GIB’s can be from hemorrhoids (internal or external), diverticulosis, masses/polyps, or AVM’s. These can manifest as melena or BRBPR. Risks for GIB include cirrhosis, NSAID/ASA use, history of GI masses or polyps, and PUD. What to do: 1. Where was the bleeding and how much? Is the patient still actively bleeding? Sometimes patients endorse bleeding but it’s never witnessed by the nurse. If they are actively vomiting a substantial amount of blood (more than just tiny streaks), call an RRT. 2. Ask for vitals. If they are tachycardic, this is worrisome because they may be mounting a response to maintain their blood pressure. Also, be careful about false reassurances if the HR is normal in patients who are on propranolol and bleeding. Orthostasis is seen with a blood loss of about 15%. Supine hypotension is seen with a blood loss of about 40%. 3. What is the PMH and reason for admission? Do they have risks for GIB (such as cirrhosis, history of PUD or GI masses)? If they are cirrhotic, have they had an EGD/colonoscopy documenting varices? What is their baseline CBC and coags? 4. Assess the patient: Cirrhotic: These are the scariest patients to have when bleeding, because they can go downhill very fast. Find out if they have a history of varices and what their current bleeding complaints are. If it is a first time bleed for a cirrhotic, it’s most likely from a varice. If they are bleeding from esophageal varices, they will most likely be having hematemesis or coffee ground emesis (blood in the stomach is irritating). They may also be having melena (but this may not appear yet if the bleed is acute). First time bleed: It can be hard to tell where the source is, but you can at least narrow it down by history. A lot of preceding nausea and emesis may indicate Mallory Weiss tear (especially if it’s just scant blood). History of NSAID use with epigastric pain may indicate gastric ulcers. Anyone who is cirrhotic I assume it’s a variceal bleed and treat as such. Do a DRE to see if there is gross blood or melena. 5. What to order: At minimum: Stat CBC (can obtain a CBC through an ABG if there is no venous access), coags, type and screen (would type and cross if the last Hb was low and the patient is still actively bleeding). If this is an acute bleed, you may not see an initial Hb drop until 24 hours later. Consider a Chem 10 and LFT’s. NG lavage: To be honest, most housestaff only do this when GI asks for it. This is helpful in seeing if the UGI is the source of the bleeding and if it’s still actively bleeding. Do not place an NGT if a patient had a recent esophageal banding (can potentially knock off the bands). 6. How to initially treat: Oxygen. Make NPO. Place two large bore IV’s. These are better for large volume resuscitation as compared to triple lumen central lines (unless the central line is a cordis). If hypotensive, give NS boluses. Transfusion: If there is a drop in the Hb, would transfuse to keep the Hb >7-8. Keep the platelets >50 (transfuse one unit at a time). Keep the INR close to 1.0 (lowest INR you can achieve with FFP is 1.5 if there is already a baseline coagulopathy). Depending on the INR level, start with two to four units of FFP. Hold any anticoagulation or anti-platelet therapy (including prophylactic anticoagulation). IV Protonix drip: 80mg IV bolus, followed by 8mg/hr. Mainly for PUD bleed. IV Octreotide drip: 50mcg IV bolus, followed by 50mcg/hr. Mainly used for varices. - NOTE: If you are unsure of the UGIB source, you can start both Protonix and Octreotide until GI evaluates with an endoscopy. If cirrhotic and UGIB, consider ceftriaxone 2g IV q24 (because of the risk of bacterial translocation). Notify GI (even if it’s in the middle of the night) and NF resident. If patients are having new or recurring GIB, even if stable, you still need to call GI, obtain the consult’s name, and document their recs. If the patient had a true episode of GIB, would transfer to the SDU. Consider the ICU if they are still actively bleeding and/or hemodynamic unstable. 7. Patients will eventually get an endoscopy to assess where the bleed is coming from. P a g e | 39 After cardiac catheterization (groin access) Cardiac cath is either through the radial artery or through the femoral artery. For a radial access, a radial clamp is usually placed after the cath is done and removed a couple hours later. For a groin access, mechanical clamps or sometimes sandbags are used to apply pressure and then removed about six hours after the cath. Patients are instructed to lay supine for at least six hours after a groin access to prevent any bleeding or hematoma formation. What to do: 1. Patient will usually complain of pain in the groin, swelling, or a bulge is noticed during a groin check. 2. Make sure vitals are stable. 3. Check the last CBC and coags (to see if the INR or platelets need to be corrected). 4. Make sure the leg is neuro-vascularly intact (check for a pedal pulse and sensation). 5. Assess the groin. Common local vascular complications from a groin access include: Hematoma: This is more common than you think. - On exam: Groin mass or swelling - What to order: CBC (make sure the Hb is stable). Groin u/s with doppler to rule out pseudoaneurysm. - Treatment: Hold any ppx heparin/LMWH. Retroperitoneal bleed: This can occur if a puncture site is above the inguinal ligament and a hematoma forms and bleeds, sometimes extending into the retroperitoneal area. - On exam: Hypotension and flank pain. - What to order: CT a/p with IV contrast to look for the bleed. If they have kidney disease, may try an ultrasound. Also check a stat CBC and type and screen (in case you need to give blood). - Treatment: Notify Cardiology and the NF resident. Most of the time, treatment is to watch and transfuse PRBC as needed. If hypotensive, give IVF and transfer to the SDU for closer monitoring. Hold ppx heparin/LMWH. Pseudoaneurysm: This is when a hematoma still remains connected to the arterial lumen, so that blood flow still goes from the artery to the hematoma. - On exam: You can sometimes feel a pulsatile mass or hear a bruit over the area. - What to order: To confirm, order a groin ultrasound WITH doppler/duplex to assess for any blood flow. Be sure to specify that this is what you are looking for (rule out pseudoaneurysm). Check a stat CBC to make sure the Hb is stable. - Treatment: Notify Cardiology, as well as the NF resident. Then consult General Surgery to make sure nothing surgical needs to be done. In most cases, treatment is applying external pressure. Another option is for IR to inject thrombin (which may be an option if the pseudoaneurysm doesn’t improve in the next few days). Be sure to hold any ppx heparin/LMWH. Avoid having the patient get up/sit up. AV fistula formation: - On exam: You may hear a bruit or feel a thrill over the area (like over an AVF for dialysis). - What to order: Ultrasound of the area with dopplers may pick this up. - Treatment: Consult General Surgery. Permacath oozing What to do: 1. Ask the nurse how much has bled. 2. Check the last CBC (to get a baseline Hb, see where the platelets are) and coags. 3. Assess the amount of bleeding. If it’s just a soaked dressing, change it. If there is oozing, you can try placing a 1L saline bag over it as pressure. Hold any prophylactic heparin. P a g e | 40 Nosebleed Where is it from? Anterior bleed: 90% of anterior bleeds originate from the Kiesselbach's plexus of the nasal septum and are relatively self-limiting. These can be self-treated. Posterior bleed: This is usually from a branch of the sphenopalantine artery or sometimes, the carotid artery. Since these originate from larger arteries, they can be brisk and actually require an ER evaluation (if the patient is from home) and ENT to treat it. What to do: 1. Check the last CBC (to get a baseline Hb and platelets) and coags. 2. Anterior bleeds: The patient can apply pressure and lean forward (to prevent swallowing post nasal blood). Gauze or cotton can be used as packing in the bleeding nostril. Some people will also place packing in the non-affected nose as well (to provide counter pressure and help with tamponade). If the bleed is soaking through the packing, you can try placing a rhino-rocket. This is essentially a tampon for the nose. ICU or floors may carry this but definitely the ER will have them. You can ask a resident or ER resident to help you place one. If this does not stop it, then you are more likely dealing with a posterior bleed. 3. Posterior bleed. Posterior bleeds need posterior packing which ENT usually does. If you are concerned that this is what you are dealing with, let your resident know and call ENT. After renal biopsy Renal biopsies are usually done from a posterior approach under guided ultrasound. Patients are monitored afterwards for any bleeding (primary complication). This can occur either: 1. Into the urinary collecting system (hematuria) 2. Underneath the renal capsule (leading to pain) 3. Perinephric space (leading to a hematoma) What to do: 1. If a post renal biopsy patient complains of flank pain, pain at the biopsy site, hematuria, or has hypotension, then assess the patient. 2. Make sure vitals are stable. If hypertensive, this may need to be controlled because it puts an increased risk of bleeding or worsening bleeding. 3. Check the last CBC and coags. Correct any coagulopathy or low platelets if bleeding is suspected. 4. What to order: - CT a/p to assess for any bleeding (into the renal capsule or retroperitoneal space). - Stat CBC and type and screen (in case you need to transfuse PRBC). 5. Notify the Renal consult and the NF resident. After a line is pulled Most patients who have lines removed (ie central lines, groin lines) do not experience much bleeding afterwards. Those with a baseline coagulopathy are at a higher risk of bleeding if adequate hemostasis is not achieved. What to do: 1. What are the vitals? If they are unstable, call an RRT. 2. Is the patient on therapeutic anticoagulation or have a baseline coagulopathy? 3. What kind of line was pulled? (the larger the line, the more bleeding there may be). How long ago was the line pulled? (the longer the time, the more time to bleed). How much blood is there? 4. Assess the patient. - If vitals are unstable, call an RRT. - If the area is still bleeding, apply pressure. Sometimes you may need to apply pressure from 5-20 minutes. Hemostasis is achieved if you remove pressure and do not notice ANY blood (even a drop) after about 10-15 seconds. 1. If there was a significant amount of bleeding (ie blood soaked sheets), order a stat CBC and transfuse if needed. P a g e | 41 CONSTIPATION / NAUSEA CONSTIPATION If patients complain of constipation, easy things to ask to help dictate what to give are: 1. Do you have BM's every day? (tells you if they need pro-motility agents) 2. Are your stools hard or soft? (tells you if they need stool softeners) 3. Do you take pain medication? (tells you if their bowels have slowed down due to opioids) Fiber: Yes, we all need more fiber in our diet. When taken with adequate water (important), it increases bulk and stimulates GI motility. However, actually contraindicated in constipation from opioids be caus e motility is paralyzed…can create a big mushy obstruction! Psyllium powder (Metamucil): powder form: 3.4g PO QDAY to TID PRN constipation Methylcellulose powder (Citrucel): one scoop PO QDAY to TID PRN constipation Stool softeners: Used often as first line. docusate sodium (Colace): 100mg PO BID PRN constipation (the small red pill) Osmotic agents: Causes intestines to secrete more water and leads to increase stool frequency. Lactulose: 15-30cc PO QDAY-BID (max 60cc/day). Can also wr ite a x1 dose now, and repeat in about 1-2 hrs if no bowel movement yet. Magnesium citrate: 150-300cc/day (divided QDAY to BID). Of note, each bottle is 300cc, so you can do 150cc PO BID PRN constipation. Avoid in renal patients (can cause hypermagnesemia). Milk of magnesia: 30cc PO BID PRN. Avoid in renal patients (can cause hypermagnesemia). MiraLax: One capful mixed in water PO QDAY PRN constipation (max one cap/day). Stimulants/motility: Senna: 1-2 tabs PO QDAY/QHS (QHS because when they wake up in the morning, they are ready to go) Bisacodyl (Dulcolax): 1-3 tabs PO QDAY PRN; 1 tab PR QDAY PRN Per rectum: Fortunately inhouse, nursing will do this. Bisacodyl (Dulcolax): 1 tab PR QDAY PRN tap water enema: Most prefer to do this over fleets. Fleets enema (Na phos): One bottle (about 133cc) PR x1. Avoid in renal patients because it can increase the serum phos. Lactulose: 30cc PR x1 (yes, can sometimes be PR as well, especially in hepatic encephalopathy patients who are very somnolent and an aspiration risk.) NOTE: There is a risk of bowel perforation if a patient who is SEVERELY constipated receives several laxatives orally (as the bowels try to move the stool along, it increases pressure against the backed up stool, leading to perforation). In these cases, you would give laxatives per rectum. NAUSEA Nausea can be a common complaint during cross cover. It can be due to a patient’s underlying illness or represent a new complaint/illness. Nausea can either represent a primary GI pathology (such as gastroenteritis, GERD, UGIB, bowel obstruction, pancreatitis), intracranial pathology (such as head bleed, stroke, vertigo, migraine), or from other things such as ACS, drugs, or chemo. If it is not due to the patient’s underlying illness, but sure to do your diligence and rule out any emergent pathology before treating the nausea. Common anti-emetics used: Metoclopramide (Reglan): 8-10mg IV or PO q8hrs PRN; caution in prolong QTc; may cause EPS Ondansetron (Zofran): 4-8mg IV or PO q8hrs PRN; caution in prolong QTc Prochlorperazine (Compazine): 5-10mg PO q4-6hrs PRN; max 40mg/day Lorazepam (Ativan): 0.5-2mg IV, PO, or SL q6hrs PRN (mostly seen with chemo induced nausea); would not use this unless the primary team has directed you to. P a g e | 42 PAIN MEDICATION Remember to write for analgesics if patients have pain, or PRN pain medications just in case (save your cross cover unnecessary pages). For inpatient, cannot order "ranges" (such as 1-2 tabs or 4-6 hrs). Must be definitive numbers or else pharmacy will page you! Also, try to specify the type of pain the PRN is written for (such as mild/mod/severe pain). These are commonly used pain medications (but by no means a complete list). Acetaminophen: Mild pain. Liver disease may still receive this (but lower dose), but withhold if decompensated liver disease. Tylenol 325mg, 650mg, or 1g PO q4-6 hrs (no more than 3-4g/day) NSAIDS: Moderate to severe pain. Caution in renal patients, elderly, severe HTN, and those with PUD/gastritis. Ibuprofen 200mg, 400mg, 600mg or 800mg PO q4-6 hrs prn pain (max 3.2g/day). - Average dose: 400mg PO q4-6 hrs prn pain Toradol/ketorolac: Severe pain. Used often for renal colic. - IM: 60mg IM x1 or 30mg IM q6hrs (max 120mg/day) - IV: 30mg IV x1 or 30mg IV q6hrs (max 120mg/day) - PO: 10mg PO q6 hrs (max 40mg/day; no more than 5 days); mainly as continuation of IM/IV therapy Tramadol (Ultram): A weak opioid (partial agonist). Good alternative if you don't want to give patients more addicting narcotics but they need something stronger than NSAIDS. It can decrease the seizure threshold if given with SSRI's or TCA's, or if a patient has a seizure disorder. Tramadol 50-100mg PO q4-6 hrs PRN pain (max 400mg per day). Good starting point: 50mg PO q6 PRN pain. Hepatic dosing: 50mg PO q12 PRN pain. Renal dosing (CrCl<30): 50-100mg PO q12 PRN pain (max 200mg/day) Opioids: Those who are overweight, on chronic pain meds, or drug users can probably tolerate higher starting doses. There are a lot of different PO formulations, but every MD develops their own regimen. Norco (hydrocodone/acetaminophen): More narcotic, less Tylenol. Can start with 5/325 dose. - Norco 5/325mg, 7.5/325mg, 10/325mg 1-2 tabs PO q4-6 hrs PRN pain. Vicodin (hydrocodone/acetaminophen): (non-formulary at OVMC but a typical PO narcotic to know). - Vicodin 5/500mg 1-2 tabs PO q4-6 hrs PRN pain (not to exceed 8 tabs in 24 hrs) . Morphine: Most commonly used if you want to get quicker relief. Dose depends on the patient's opioid tolerance level and weight. If unsure, better to start off low (you can always add more, but you can’t take back). Average weight patient: - IV: Moderate pain 2-4mg q4 hrs PRN / Severe pain 4-6mg q4 hrs PRN Elderly, small person, renal failure, or opioid naive: 2 mg IV q4hrs PRN pain to start Dilaudid (Hydromorphone): Much more potent than morphine (5-7x more) and used often for breakthrough pain. Subcutaneous: - if opioid naïve: 0.5-1mg subcut q4-6 hrs PRN - if non opioid naïve: 1-2mg subcut q4-6 hrs PRN Oral: if opioid naïve, 2-4mg PO q3-4 hrs PRN Fentanyl, MsContin: Would only go to these once you've tried patients on short acting opioids such as morphine and you know that they have chronic pain (such as cancer, chronic LBP, etc). You should do a conversion from short acting to long-acting to get a sense of starting dose. MsContin: 15, 30, 60, 100mg PO q8-12 hrs Fentanyl: Needs a fentanyl patch form (attending or resident with DEA and privileges to sign the form). - Patch 25, 50, 75, 100mcg/hr q72 hrs (so patch stays on for 72 hrs before changing) - You can only prescribe this if the patient is on a stable dose of an opioid equivalent for at least 7 days. - NOTE: If the patient uses the patch at home and you write to continue, be sure the patient isn’t wearing his old patch from home AND gets a new patch inhouse. Fentanyl 25mcg patch ~ Morphine 60mg PO in 24 hours P a g e | 43 PAIN MEDICATION TID BITS HOW TO TITRATE PAIN MEDICATION: 1. Ask the patient two things: Does the current dose bring the pain down to zero? How long does it help you before you have to ask for it again? 2. How to titrate pain meds: If the current dose doesn’t help alleviate the pain, you can increase the dose (ie 4mg to 6mg) If the current dose doesn’t give relief long enough you can shorten the interval (ie Q4hrs to Q3hrs) If it doesn't do both, can consider increasing dose and shortening interval at the same time. HOW TO CONVERT PAIN MEDICATIONS BETWEEN ROUTES/TYPES: Conversion of Morphine/Dilaudid (between routes and between meds) x3 x4 PO 20mg 5mg Morphine Dilaudid / Hydromorphone IV / SQ 6mg 1mg x6-7 x5 PCA PUMP: This is mostly used for surgical and oncology patients. If all else fails, you can place patients on a PCA pump. Patients usually cannot overdose on this because they will fall asleep first and can't press the button anymore. For oncology patients, this is helpful because you can calculate the 24 hour IV need and convert it to an oral regimen (such as PCA morphine to oral MsContin). The main components of a PCA are (there is a morphine or dilaudid option): Bolus: If you want to give an initial bolus when you start or change a PCA dose. Basal rate: How much they will always receive per hour. Demand dose: How much they will get each time they press the button. Lockout: The interval in which they can receive pain meds if they press the button (such as q10 mins). If they press the button again before the time interval has elapsed, they will not receive any additional pain meds for that click. Knowing how often they press the button can help you to adjust the dose or the lockout interval. ABDOMINAL PAIN / DYSPEPSIA: This is more so for patients who have epigastric pain that may be due to gastritis, PUD, outpatient dyspepsia diagnosis, or plain ol’ abdominal pain that you are still working up. Mylanta 30cc PO q4hrs prn dyspepsia (avoid in renal patients). H2 blocker (such as Pepcid 20mg PO BID); more so if it sounds like chronic dyspepsia. PPI (such as Prilosec) 20mg PO QDAY; more so if it sounds like chronic dyspepsia. GI cocktail: Useful for quick relief of epigastric pain that you don’t want to use (and has not responded to) narcotics. - GI cocktail 30cc PO q6 hrs PRN abd pain (supposedly you can just write this and pharmacy will accept) - Mylanta 10-30cc, Lidocaine 5cc, Donnatal 10cc: of this mixture 30cc PO q6hrs PRN abd pain P a g e | 44 SLEEP Commonly used sleep agents inhouse. If the primary team has not written for anything, as a cross cover, you should only write a one time dose. Diphenhydramine (Benadryl): Avoid in the elderly as it may cause delirium. Used for its sedation side effect. Benadryl 25mg PO QHS PRN insomnia Benzodiazepines: Avoid in the elderly patients and liver/renal patients. Reduces the time to onset of sleep and prolongs sleep time. Temazepam (Restoril): 15mg PO QHS PRN insomnia Lorazepam (Ativan): This is sometimes used as well, but only if the primary team said it’s okay to. If going the benzodiazepine route, use Temazepam. Non-benzodiazepines: Okay to use with elderly patients. Zolpidem (Ambien): 5-10mg PO QHS PRN insomnia. In liver disease limit to 5mg. A rare side effect is complex sleep walking behavior without any recollection afterwards. Still okay to use, but just an FYI if the nurse tells you your cross cover patient is doing something funny. AGITATION Patient population: Elderly/demented: Delirium can be a very big problem with the elderly (especially demented) because the hospital is an unfamiliar place. Can be a big problem at night when they sundown. Psych: Many times it is just part of the psych disease process (such as schizophrenia). Alcohol withdrawal/DT’s: The good thing is that they are already on the CIWA protocol. Treatment: Behavioral: More so with the elderly/dementia. Try to talk to the patient and redirect them. For elderly patients, it is helpful to have family members there so they see something familiar or maintain day/night-time cycle as much as possible. Restraints: For when negotiations fail. You will need to sign a restraint order that needs renewal q24hrs. - Posey vest: This is a soft netted vest that patients wear with straps/ties that hold them to a chair or bed. Used mostly for elderly patients (who don’t follow directions) to prevent them from getting up and falling or for patients who can’t follow directions and will not be forcefully tugging at things. - Soft restraints: Fabric restraints for wrists/ankles. I prefer these over leather for elderly patients. - Leather restraints: For wrists/ankles/waist. Used for very strong patients or alcohol withdrawals who do not follow directions. - Mittens: Can be used in patients who try to pull IV lines out, but you don’t want to use wrist restraints. Medications: Common ones used by Medicine for acute agitation. - Ativan/Lorazepam: Normal size patient: 2mg IV/IM x1 (can titrate up/repeat doses as needed; avoid in the elderly). For smaller people, try 1mg first. On the floors can only be given IM by nursing. If the patient is not climbing up the walls, you can give as an IV piggy back. - Haldol: 5mg IV/IM x1 (caution in patients with prolong QT; preferred over Ativan in the elderly) Elderly: The best treatment would be to redirect them or have a one to one sitter. If these do not work and you need to give medications, Haldol is preferred (give a smaller dose, such as 1-2mg to start). AVOID BENZODIAZEPINES because this can actually make them worse/more delirious. Anxiety: If someone is just anxious and never had Ativan before, you can give 0.5 to 1mg PO x1. If on the smaller side, try 0.5mg first. Liver disease: Try and avoid benzodiazepines in patients with liver disease, because it can hang around in their system and cause a prolonged effect. Note: Benzodiazepines (such as Ativan) can sometimes cause confusion and paradoxically agitation. P a g e | 45 DECREASE UOP When you get called about this, many times it will be from nursing at the end of a shift when they’ve tabulated the patient’s ins/outs. Or, it will be at 7am when the night nurse has noticed that the patient has not urinated at all (because the patient was asleep…). If a normal patient can urinate from 20-30cc/hr, then they’re okay. Decrease UOP fits into a larger picture of possible AKI/CKD. From a nightfloat/cross cover perspective, there are a few select things to keep in mind. Definitions: Oliguria: UOP 100 - 400ml/24hr Anuria: UOP <100ml/24hr Common causes to think about while on cross cover: Pre-renal: volume depletion; poor blood flow Renal: ATN, AIN Post renal: outflow obstruction from BPH, renal stones, strictures What to do when you get called: 1. Make sure the vitals are okay. 2. What is the patient’s PMH/reason for admission/current state? 3. Assess and treat: If they have a foley already: If the nurse reports zero urine output, ask the nurse to flush the foley, sometimes it’s just clogged, especially if they have hematuria. If they are possibly dehydrated: You can give a small bolus of 500-1000cc and see if they urinate. You can try this even if they are not dehydrated (barring that they don’t have CHF or are ESRD and make little to no urine). If they have BPH, then there would be concern for post-renal obstruction. Even if the patient doesn’t endorse feeling bladder fullness, you can ask for a PVR (with a foley or the RN can do a bedside bladder scan) and if it is high, such as >150cc, then keep the foley in. If they have CHF, then they can be fluid overloaded with poor forward blood flow to the kidneys, leading to decrease UOP. In these cases, you need to diurese them until their cardiac contractility is good enough to create adequate blood flow to the kidneys. If this doesn’t work in the first 24-36hrs of admission, you may have to resort to inotropes, such as Dobutamine or Dopamine (would need to call Cardiology at this point). If they are infected, it may herald impending severe sepsis/shock. In this case, give them fluids and make sure the patient is being resuscitated/triaged properly. If they are CKD or a dialysis patient: They may make very little urine to begin with. Or if the patient is stable/asleep, you can wait and see if the patient urinates later. 4. Reassess: If you have tried IVF and they have not urinated, you may ask the nurse to place a foley. - If a lot urine comes back (150-200ml), then they were either obstructed (ie BPH), or had urinary retention. Keep the foley in place. If this was an acute retention (versus chronic retention), they are less likely to develop post obstructive diuresis. If they do happen to develop this, you can give back about one half of what their urine output is as IVF. - If a little bit of urine came back, then they could still be dehydrated and may need more IVF in order to produce more urine. - If minimal to no urine comes back (and they are not a renal patient), order a Chem panel (to check the Cr). Also order a renal ultrasound to assess for any renal stones or stricture (worse case would be bilateral obstructive ureteral stones) or hydronephrosis suggesting an obstruction. (You would most likely not encounter this particular scenario). P a g e | 46 SEIZURE Primary seizures are those where no cause can be found, whereas secondary seizures are due to an identifiable cause, such as a metabolic disturbance, ingestions, or anatomic abnormality. Status epilepticus is when a seizure lasts more than 5-10 minutes, or there is a series of seizures where the patient never returns to baseline. Seizures can be classified as either generalized or partial. Generalized: Diffuse brain involved with loss of consciousness. - Tonic clonic (grand mal): What we usually imagine when we think of seizures. There may be urine/bowel incontinence and tongue biting. Post-ictal confusion can last for several hours. - Absence (petit mal): There is a loss of consciousness but they don’t lose postural tone. This is the one where it looks like they are staring off into space. Usually no postictal confusion. Usually seen in kids. - Others (myoclonic, tonic, clonic, or atonic seizures) Partial: Focal part of the brain is involved. Consciousness is maintained, for the most part. - Simple partial: Since a focal part of the brain is involved, patients have focal symptoms related to that focus, such as unilateral tonic or clonic extremity movement, or visual symptoms. - Complex partial: Still a focal seizure but some part of the consciousness or mentation is affected as well. Symptoms may be misinterpreted as psychiatric symptoms, such as hallucinations, repetitive behaviors, or affective symptoms such as depression or paranoia. - Partial seizure with secondary generalization: Starts off in one focus that moves over to the other hemisphere. Causes of secondary seizures: These are important things to keep in mind when you encounter a patient who has a new seizure at night: Intracranial: trauma, bleed, mass, CVA Infection: meningitis, encephalitis Metabolic issues (hyper/hyponatremia, hyper/hypoglycemia, hypocalcemia, hypomagnesemia, uremia, hyperosmolar state, liver failure) Withdrawal: alcohol, benzodiazepine Hypertensive encephalopathy Eclampsia Anoxic brain injury What to do: 1. You get called by a nurse that a patient is having a seizure. Either call an RRT or if the patient is already in the SDU, have the nurse get vitals and get Ativan ready while you are on your way to the patient. 2. What is the patient’s history? Does the patient have a history of seizures and are they on meds for it (if so, are the medication serum levels appropriate)? This tells you how much of a work up you will need to do. 3. What to do when you get there. Make sure vitals are stable. Sometimes during a tonic-clonic seizure, patients may be apneic, so it’s a good idea to place them on oxygen. Protect the airway. Try to roll patient to one side to make sure they don’t aspirate. Have the suction ready if they have a lot of secretions. IV access: This is for medication. Accucheck: You want to make sure it’s not hypoglycemia that’s causing the seizure. If you do not know the patient’s alcohol history (maybe this is DT’s), give thiamine 100mg IV prior to the amp of D50. This prevents any exacerbation of possible Wernicke’s encephalopathy. + Labs: Make sure the patient’s labs are okay (such as Na and Ca ). How to break the seizure: Many times seizures self-resolve before the medication is given. Goal is to stop the seizure however possible. - To break a seizure that is lasting more than five minutes: First line are benzodiazepines: Lorazepam (Ativan) 2-4mg IVP (no faster than 2mg/min). May repeat up to 8mg total. Ativan is most commonly used. May also use diazepam (Valium) 5-10mg IVP (no faster than 5mg/min) if Ativan not available. May repeat up to 30mg total. If no IV access, may use midazolam (Versed) 10mg IM (if >40kg/88lbs) or 5mg IM (if <40kg). P a g e | 47 - If a seizure has not broken with benzodiazepines: Load phenytoin (Dilantin) 20mg/kg IV at 50mg/min (about 1-1.5g IV over 20-30mins IV). Caution: Do not run Dilantin and a benzodiazepine in the same IV line (my precipitate Dilantin). - Notify Neurology consult. - If still seizing beyond the Dilantin load, may either: Try an additional Dilantin infusion of 10mg/kg or Call the ICU because the patient needs to be intubated and placed on a drip such as phenobarbital, pentobarbital, midazolam, or Propofol. Hopefully at this point, Neurology has been notified and they would have given their recs. 4. Once the seizure is broken (self-resolved or with meds): Call Neurology to get their recs as to what they would want to do next. They may either adjust a preexisting antiepileptic drug or start a different one (if it’s a patient with a new first time seizure). Figure out why the patient had a seizure. This is important because you want to fix any reversible causes (especially if this is a first time seizure). - Is the patient’s existing seizure disorder controlled on current medications? Check appropriate antiepileptic drug levels. - Is there something intracranial going on? CT head non-contrast can rule out many things such as mass, bleed, subacute CVA. If you suspect an acute CVA, page the stroke pager. At minimum, the patient will need a CT head and if possible, an MRI/MRA head/neck with stroke protocol. - Is there an infection? This not only pertains to intracranial infections such as meningitis/encephalitis, but also systemic things, such as PNA or UTI. LP if exam and history warrants it. Would also pan culture (Bcx x2, RUA, Ucx, CXR). + - Is there a metabolic issue? Check the last set of labs or do stat labs (Chem 10) to evaluate Na, Ca , Mg, glucose, renal function. - Are they going through withdrawal, such as alcohol/DT’s or benzodiazepine (make sure the patient is admitted to the SDU with a CIWA protocol). - Are they having hypertensive encephalopathy? If this is the case, then the patient needs to go to the ICU to get an anti-hypertensive drip. Seizure in a bolus 1. What are the vitals? 2. Does the patient have a history of seizures (on meds) or risks for seizures? 3. Assess the patient: (if you feel uncomfortable, you can call an RRT). Make sure vitals are stable Protect the airway Ensure IV access Accucheck 4. Break the seizure with Ativan 2mg IVP, repeat up to 8mg. 5. If the seizure does not break, try a Dilantin load. 6. If Dilantin does not work, call the ICU for intubation and drip to control the seizure. Notify Neurology. 7. If the patient does not need the ICU, look for causes for the seizure (non med compliance, infection, something intracranial, DT’s). P a g e | 48 HYPERGLYCEMIA Fortunately, unless patients are in DKA/HHS, they will most likely not decompensate from just hyperglycemia alone. Per sliding scale protocol, nurses are supposed to notify an MD if the accucheck is greater than 400. A little primer: While patients are in the hospital, there are many variations as to what is being used to control their sugars. Sometimes patients are on all, some, or none of their home oral medications in addition to an ISS (insulin sliding scale—regular or lispro). All patients with DM inhouse should at least be on an ISS (unless the primary team notes otherwise). Accuchecks should be done QAC (before meals) and QHS (before bedtime) for most DM patients, unless they are on TPN or in DKA/HHS, where then timing of the accuchecks may be different. Many times metformin will be held in case patients need a CT with IV contrast inhouse (incase patients gets contrast nephropathy Cr elevates and concomitant metformin use leads to lactic acidosis side effect). Ideally, if oral DM meds are going to be held, adding on a little basal NPH in addition to the ISS usually helps control the blood sugar better than the ISS alone. Insulin Insulin commonly used at Olive View Onset Peak Duration Notes Lispro (rapid acting) 5-15 mins 1-1.5 hrs 3-4 hrs Right before or with B/L/D Regular (fast acting) 30-60 mins 2 hrs 6-8 hrs 30-60 mins before B/L/D NPH (intermediate acting) 2-4 hrs 6-7 hrs 10-20 hrs If alone, dosed BID (before breakfast and before dinner or QHS). If with reg insulin, before breakfast and dinner. Lantus (long acting) 1.5 hrs Flat 24 hrs In AM or QHS What to do when the sugar is high: Per protocol, MD is to be notified if sugars are >400. 1. Double check to make sure they are on an ISS. Sometimes people forget to order this. 2. If it’s the pre-dinner sugar, and the patient is going to eat, just say “MD notified” and let the nurse give insulin per the sliding scale. If it is the QHS accucheck, it’s most likely ok for the patient to get the QHS insulin dose. 3. Unless the primary team specifically told you to give extra insulin or the patient is in DKA/HHS, I would refrain from giving extra in addition to the ISS at night because patients can’t tell you if they become hypoglycemic while asleep. 4. If there is no contraindication, you can give NS IVF if their sugar is >400 to help bring down their sugar. 5. If you have time, would double check the morning labs, just to make sure the Chem 10 was okay and there wasn’t an anion gap (to be honest, you will probably be okay if you don’t check it). 6. If they were admitted for DKA (and the AG was just closed) and the sugars are a lot higher than daytimes sugars, would have a lower threshold to give extra insulin/IVF and check a Chem 10 (to assess for a reopened AG). NOTE: - Patient’s with ESRD or worsening Cr inhouse. Be careful about giving extra short acting insulin, because they don’t excrete insulin as well, so they are more prone to becoming hypoglycemic. - Nothing will happen to a patient if they are a little hyperglycemic overnight, but they will get into trouble if more insulin beyond the ISS is given and they become hypoglycemic. - For every one unit of regular insulin, it roughly decreases the glucose by 50mg/dL (at least per formulas used by Type 1 diabetics to correct pre-prandial sugars; this is an estimate because every patient has their own sensitivity to insulin). - In ORCHID, NPH is listed as “isophone”. P a g e | 49 HYPOGLYCEMIA Most of the time, calls about hypoglycemia are for diabetic patients on insulin. Signs/Symptoms: Tremors, diaphoresis, palpitations, anxiety, AMS, somnolence, and if severe, seizure and coma. What to do: 1. The nurse calls you and tells you the patient is hypoglycemic. If the patient is awake and with it and the accucheck is not horribly low (at least >70), then you can tell the nurse to give some juice. If the accucheck is <70, you can have the nurse give an amp of D50 (which contains 25g of sugar). If for whatever reason the patient cannot take orals, give one amp D50. Then have the nurse repeat an accucheck. 2. What is the patient on? Most of the time, patients are on DM medications. If they have not received their nighttime insulin yet, would hold it. It’s okay if the patient’s blood sugar runs a little high, but it’s a lot worse if they become hypoglycemic. 3. If the patient already received their insulin. Have them drink extra juice for good measure. You can have the nurse repeat an accucheck in a couple of hours, to make sure it’s stable. You can also give the patient a snack if available. 4. If the patient is NPO: Usually, long acting insulin (such as Lantus or NPH) should be okay to give because it mimics our basal insulin. Per insulin orders, usually if patients are NPO, the long acting dose is cut in half and all short acting should be held. If this didn’t happen, you can try to monitor with frequent accuchecks to make sure the patient will be okay. 5. If the patient is persistently hypoglycemic: Then you will need to place them on IV dextrose, D5 ½ NS at 100150cc per hour should get them to morning. At times, an IV of D10 (10% dextrose) is required. 6. If the patient is not diabetic or on insulin: Would still try juice, amp D50 or dextrose drip if needed. Other etiologies to consider in this case are severe ESLD, cortisol deficiency, insulinoma, patient is sneaking insulin, and sepsis (although hopefully these patients are already in the ICU). P a g e | 50 MISCELLANEOUS “I FELL DOWN” When a nurse tells you the patient fell down, try to get as much information about how the patient fell and how they were found on the ground. If it was witnessed, ask what was the mechanism of the fall, if the patient hit their head (or what other body part), and if they lost any consciousness. If it was un-witnessed, then ask how the nurse found the patient and if she heard anything (like a thump). What to do: 1. Go assess the patient. Ask them what happened and how they fell down. Was there LOC or any trauma? 2. Assess for orientation (person, place, time, purpose) and do a neurological exam. 3. What to order (or not): No head CT: If it sounded like a mechanical fall, no head trauma, no LOC, and neuro exam is normal. You can just document your assessment in ORCHID. Yes head CT NON CONTRAST rule out bleed: If there was head trauma + elevated INR, headache, dizziness, nausea, abnormal neuro exam, AMS, LOC, or this was syncope (and not a mechanical fall). Maybe head CT: If they cannot tell you if they hit their head (maybe demented), or they hit their head but normal neuro exam. Most people will still get a CT with head trauma even if the neuro exam is normal. Targeted imaging: As pertains to their trauma (ie elderly+hip painXray or CT of the hip r/o fracture). 4. If the patient is elderly or a fall risk, place the patient on fall precautions. 5. If they did hit their head, try to reassess the patient in a couple of hours to make sure they are still doing okay. “I WANT TO LEAVE AMA” This can be a difficult situation because it’s hard to convince someone to stay if you’re not their primary doctor. What to do: 1. Read the signout and look up the H/P and latest progress note to have a better idea of why the patient is in the hospital and what their current treatment is. 2. Go talk to the patient. Explain to the patient that you are the night doctor, but the primary team has told you about him and why he is in the hospital. 3. Ask the patient why he wants to leave. Try to see if some of his concerns can be remedied, such as no more blood draws or vitals check for the rest of the night, or listening to his concern about a health care staff that he doesn’t like. Compassionate listening can often help by itself. 4. Explain to him that if he leaves now, he won’t get his full treatment, and that this, this and this can happen (+/risk of morbidity or death depending on the diagnosis). Make sure the patient can verbalize back to you the risks/benefits that you have just mentioned. 5. See if he can at least stay until morning and talk to the primary team. 6. If in the end, he still wants to leave AMA, you can have a NF resident talk to him as well (some housestaff prefer to have two MD’s talk to a patient who wants to leave AMA). If the decision is final for AMA, then notify the NF resident (and Hospitalist attending if before 12am). They can help you with sending the patient out with any follow up or antibiotics/other medications (just because a patient is leaving AMA does not preclude them from getting prescriptions or follow up). 7. Have the patient sign the AMA form and clearly document all risks, including death if appropriate. 8. DOCUMENT your discussion with the patient, the actual risk and benefits that you discussed with him, that he understood, return precautions, and any follow-up/prescriptions given. 9. If the patient is demented or in withdrawal (such as alcohol), then they do not have the capacity to make the decision to leave AMA. If you think a patient does not have the capacity to make an AMA decision, then let a NF resident know to help you out, because then this gets a little tricky. It may involve asking Psych to evaluate the patient for competency (there is always a Psych person on call at night in the Psych ER). 10. In the end, it is the patient’s own right and decision about how they want to be medically treated. I do not believe in exhausting yourself to convince patients to stay (unless it is something active such as ACS or unstable vital signs). Forcing patients to stay is in fact illegal and I will let patients know this from the beginning of the conversation, so they don’t feel that you are against them. If they do leave, then let them know that they can and should come back to the ER (or any ER) if anything gets worse. Being compassionate and “on their side” is usually the most productive. P a g e | 51 “I NEED A TRANSFUSION” How to transfuse blood products at Olive View: 1. Obtain the patient’s consent. Tell the patient the risks/benefits of the transfusion. If they are unable to sign, you can have the next of kin sign it or obtain a verbal consent over the phone. If you can’t find anyone to sign and it’s an emergency, you can do a two physician consent. 2. Type and screen: Will check the patient’s blood for ABO, Rh, and routine antibodies. This is a good thing to order if you think the patient may need a transfusion. Once typed and screened, it only takes about 15 minutes to find the matching units for transfusion. 3. Type and cross: Same as a type and screen except that now they find a match to actual units of blood. You usually will order this as “type and cross X-units of blood” (however much you want to transfuse). 4. Premedication: This helps to prevent any reaction to the blood products. - Tylenol 325mg to 650mg PO x1 prior to transfusion - Benadryl 25mg PO x1 prior to transfusion PRBC: For every one unit of PRBC, you would expect the serum Hb to increase by 1g/dL. Goal Hb: - For normal people, keep the Hb > 7-8 g/dL (unless they are symptomatic). - For CAD patients, keep the Hb > 8 g/dL. Post transfusion CBC usually about one hour after the transfusion is complete. Note: - Fluid overload: If you are concerned about fluid overload (such as CMY patients or ESRD patients), you may give Lasix 20mg IV after the transfusion. - Hyperkalemia: If you are transfusing PRBC in an ESRD patient, check the serum K afterwards. Transfusing blood may cause a slight hemolysis and raise the serum K (which in ESRD patients is already an issue). You should also monitor the serum K if you are doing a massive transfusion (for lets say a hemorrhaging patient), but for a normal patient, 1-2 units of PRBC should not cause an issue. - Autoimmune hemolytic anemia: Be careful in transfusing patients with AIHA, because transfusions can make the hemolysis worse. Double check with Heme/Onc first (who were likely consulted already). - Dialysis: Patients with ESRD will often have blood transfusions during their dialysis. Platelets: For every one apheresis unit of platelets, it should raise a patient’s platelet count by 30-50,000 within 10-60 minutes. This is why we only transfuse one unit at a time. Goal platelets: - For normal patients, keep the platelets >10,000 (because there is risk of spontaneous bleeding at platelets<10,000). - For febrile patients or DIC, keep the platelets >20,000. - For patients who are bleeding or planned procedures, keep the platelets >50,000. If you suspect TTP/HUS, do not transfuse! It can make it worse. If you suspect TTP, notify Heme/Onc so they can review the peripheral smear, and if confirmed, order plasmapharesis. FFP (fresh frozen plasma): This is used to correct the INR or treatment of hereditary angioedema. FFP contains coagulation factors and some fibrinogen. One unit of FFP has about 250ml of volume and inherently has an INR of about 1.3-1.5. This is why at best, transfusing FFP can only bring a person’s INR down to about 1.5. Effect on the INR lasts for about four hours, so recheck the coags! Dose: Initial dose for adults is about 10-15mL/kg (about three to five units). If you are transfusing because a patient has a bleed, then would start off with transfusing three to four units and rechecking the coags after the transfusion. Cryoprecipitate: Derived from FFP packets. Contains fibrinogen (what we mainly use it for), factor VIII, and vWF. For every one unit of cryo, it raises the fibrinogen by about 8 mg/dL. Dose: Initial dosing is 10 units of cryo. Goal fibrinogen (mainly for DIC patients): Keep fibrinogen >100-150. P a g e | 52 DEATH NOTE If this is your first time pronouncing a death, have a resident help you. What to do: 1. For comfort care patients, nurses will likely call you letting you know the time is near (patient may be bradying down if still on tele; or becoming apneic). If the patient is on comfort care/withdrawal of care and the family is at bedside, you should let them know that this may be signaling the end. If the family is not at bedside, please call them to let them know that they should come in. 2. The nurse will then notify you when the patient has passed away. Try to remember what time the nurse called you so you can note it in the death note. 3. Let the family know that you will need to perform the exam to confirm the time of death. If the family is grieving, it’s okay to give them some time before you approach them for the exam. 4. Exam: You can give the family the option of staying if they want. A shortcut way to remember the exam are the four P’s (pupils, pulse, pain, (p)breathing). - Check for a pupillary reflex - Look and listen for spontaneous breathing - Listen for heart sounds - Feel for a pulse - Assess for a response to pain stimuli (I usually do nail bed pressure discretely because sternal rub may be a lot for family members to see, but can be used as well) 5. Offer family members an autopsy (you will need this for the death packet). 6. If the death is unexpected (ie not a comfort care patient), notify the back-up wards attending if after 12am (and the primary attending if the signout has specified that). 7. Death note example. Time of death is the time you finish the exam. I was notified by nursing at 8:30pm that the patient was becoming more apneic. I notified family members at bedside that the patient may pass away soon. At 9:45pm, nurse notified me that patient had stopped breathing. I came to bedside at 9:50pm. I offered my condolences to family members and examined the patient in their presence. There was no pupillary response to light. I did not observe spontaneous breathing or appreciate heart sounds on auscultation. There was no palpable radial pulse. Patient did not respond to nail bed stimuli. Patient was pronounced deceased at 9:55pm on 7/15/12. Family was offered autopsy, but they declined. Dr. Nguyen was also present during the death exam. 8. Fill out the death packet: The important things include the worksheet to see if this is a coroner’s case, if family wanted an autopsy, and the death certificate worksheet (this is not a final document, only a worksheet). - Death certificate worksheet will ask for (1) cause of death (most of the time it is cardiac arrest, respiratory arrest, or combination of both), (2) which is secondary to (process that led to the cardiac +/- respiratory arrest, such as cancer, pneumonia, etc, etc). - If possible, note the time frame for the cause of death (seconds, minutes, hours). For example, the nurse may have called you at 6pm saying the patient was having agonal breathing and then the patient had respiratory arrest at 8pm. This gives a time span of two hours. The final death certificate needs this and the primary attending will not know because he was not there. - It’s okay if you are uncertain about the secondary diagnosis. 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