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When Things Go Bump in the Night Surviving Surgical Night Call in the age of Cross-Cover Robert O. Carpenter, MD, MPH General Surgery Resident General Tips When in doubt, which should be often, go see the patient! When in doubt, which should be often, call your upper level resident Never transfuse, order expensive tests, admit a patient, or transfer a patient to the ICU without telling the resident & attending If the ship is sinking--LOAD THE BOAT! That’s right boys and girls … it can be a tough world on call! You 7/1/07 Topics Abdominal Pain Nausea/Vomiting Constipation Diarrhea Bleeding Hypotension Hematemesis Hematochezia Post-op Pain Abdominal Pain Acute vs. chronic If acute – always examine the patient Multiple causes - need to rule out life threatening ones – Perforated viscous / dead bowel – Ruptured aneurysm Abdominal Pain History Physical exam » Abdomen » Lungs, rectal--guiac, hernias, testicles » Pelvic exam in female Labs—CBC, CMP, Amylase/Lipase, lactate X-rays—CXR, KUB with flat/upright or left lateral decubitus to rule out free air Doh! Free Air! Abdominal pain CT scan if indicated—talk to attending first – Consider contrast … PO, IV, BOTH? Consider surgical consult early Don’t forget chest etiology in upper abdominal pain – pneumonia, cardiac angina Nausea & Vomiting Causes: Systemic illness, CNS, GI diseases, Medications, Viral Illness, Obstruction, Pregnancy Don’t forget cardiac angina equivalent Promethazine (Phenergan) – Careful in elderly » 12.5-25 mg po/iv q4-6 h prn Metoclopramide (Reglan) » 5-10 mg po/iv q3-4 h prn Serotonin antagonists$$$ (Anzemet, Kytril, Zofran) No longer at VUMC!!! Nausea & Vomiting (cont) If does not resolve – think of obstructive causes Initial work up similar to abdominal pain Limit oral intake NGT / IVF if persistent … – EARLY! Avoid aspiration!!! Watch for electrolyte abnormalities » Hypokalemia, metabolic alkalosis Then – Fall 2002 Constipation Laxatives – Biscodyl (Dulcolax) » 5 mg po or 10 mg pr (suppository) » Motility agent – Docusate Sodium (Colace) » 50-100 mg qd or bid » Stool softener » Prevention (narcotics) Constipation (cont) – Milk of Magnesia (MgOH) » 30-60 ml po » Osmotic » Bean Alert – Docusate/Casanthranol (Peri-Colace) 1-2 caps bid (100/30 mg) – Psyllium (Metamucil) 1 tsp in liquid bid/tid Bulk Agent Prophylactic vs Treatment Constipation (cont) Lactulose 15-30 ml (10-20 grams) -osmotic agent Magnesium Citrate (300 cc bottle) - Osmotic - Bean Alert Enemas -Fleet’s Enema (caution CHF/Renal failure) -Tap water/Soap Suds if necessary -Don’t give in patient with rectal anastamosis Constipation (last one) Glove up: patient may need manual disimpaction Avoid Mg/PO4 products in renal failure Avoid PR meds or enemas in patients with rectal anastamoses (ex. s/p LAR) Evaluate medication list for culprits Prevention = Sleep NOW – February 2007 Diarrhea (acute) Associated with fever? – C Diff, hemorrhagic colitis, chemo/XRT Diarrhea vs. loose stools Leakage around impaction Send C. Diff Ag if recent Abx Stool O&P, fecal leukocytes and Cx if clinically indicated Diarrhea (treatment) Avoid anti-diarrheals acutely … – toxic megacolon – Use only if diarrhea is non infectious Watch for dehydration Lomotil (Diphenoxylate hydrochloride) – 5mg po qid --respiratory side effects with OD Imodium (Loperamide hydrochloride) – 2-4mg after loose stools (max 8mg/day) Bleeding Surgical vs Medical Check pcv, plts, and coags –correct coagulopathy; physical exam/hemocult Hold pressure if at a certain site Get help and gather supplies – NGH case & TICU Case Get good light Expose the area … find bleeder, & Press!!! Hypotension Assess quickly and recheck manual pressure Does patient look ill? – Use your senses!!! ABC’s first—call for help if necessary – Trauma case Reverse Trendelenburg position Need good IV access--at least 16g IV’s x 2! » Triple lumen catheter = 3 22g IV’s » Introducer Hypotension (cont) Look for causes Preload, Contractility, Afterload – Hypovolemia, Cardiogenic causes, Sepsis, Anaphylaxis Give fluid unless cardiac failure Check pcv, ABG, bmp Consider transfer to ICU Best Advice I Can Give You Eat When You Can Sleep When You Can GO When You Can! Call Loved Ones When On Call and … Don’t F … Mess With the Pancrease!!! Hematemesis ABC’s first – MICU case Good IV access Abnormal vital signs? – Hypotensive, tachycardic, tachypnic – Patients can bleed to death Coffee ground vs. bright red blood History of esophageal varices or ulcers Send CBC/plt, PT/PTT, T&C 2-4 units – Correct any coagulopathy (No clot … no stop!) Hematemesis (cont) Consult GI for therapeutic endoscopy ?NGT If known varices and unstable may need Minnesota tube (Sengstaken-Blakemore) Pharmacologic therapy – – H2 Blocker PPI (IV form or continuous infusion) Sengstaken-Blakemore Hematochezia ABC’s first Good IV access … at least 16g IV’s x 2!!! Abnormal vital signs? – Hypotensive, tachycardic, tachypnic – Patients can bleed to death » VA patient, Saint T patient BRB, Melena Send CBC/plt, PT/PTT, T&C 2-4 units – Correct any coagulopathy (No clot … no stop!) Hematochezia Most common cause melena – UGI source NGT aspirate, Posterior nose bleed Lower GI source – Diverticulosis, cancer, hemorrhoids If actively bleeding … tagged RBC scan / Angiography may be able to localize Bowel prep / colonoscopy /upper endoscopy Transfuse > 6 units – means OR TIME!!! – PLEASE … get surgeons involved before then Post-op Pain IV pain meds if unable to take PO PO usually lasts longer Give patient control with PCA Frequent IV Meds (Frequency variable) – – – – Morphine 2-10mg IV/IM Demerol 25-100mg IV/IM Dilaudid 0.5-2mg IV/IM Fentanyl 50-100 mcg IV Post-op Pain PO Narcotics » Lortab, Percocet, Tylenol #3, Darvocet, Oxycontin » Most contain Tylenol, watch for OD Toradol 30 mg iv q6h (NSAID) » Bean alert!!! » Slight increase risk of bleeding » GI –ulcer complications No One Parting Shot!!! EXCUSES … just do it! They taught you … Take the TIME… Make the EFFORT… Remember … of the Five edicts … FAMILY is the KEY!!! Thank You