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X-COVER?!?
Nadia Habal, MD
Presbyterian Hospital of Dallas
What is going on?
 Goals of Lecture:
 How do I make my X-cover list?
 How do I identify emergency from non-emergency?
 How do I know when I need to go and see the patient?
 How do I handle common calls/questions?
 When do I need to call my resident???
How to make your CareGate list:
 Log on to CareGate
 Go to Cross Cover
 Under “problems”, put one liner about the patient
 Then list all important problems and what has been done
about them
 Under “to do” section put MR number, pt allergies,
important meds, anything for X-cover to follow up on
Example:
 69 y/o with PCKD and transplant kidney p/w painless hematuria
 1. Renal: pt continues to have hematuria: likely ruptured renal cysts
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2/2 PCKD, considering CT abd and MRI results. Also worrying about
infx, CA, etc. Continue immunosuppression with Cellcept,
prednisone. CMV/EBV by PCR neg. Urology following - possible
cystoscopy to r/o bladder source.
2.Htn: BP well controlled.
3.Paroxysmal AF: atenolol and Cardizem. Short episode of afib with
RVR overnight, with rates of 120s. Continue ASA for prophylaxis.
4.Hypothyroidism - continue replacement.
5.Anxiety - continue Ativan.
6.RA-pain relief.
7.Insomnia: Ambien.
8.Wt loss: cancer w/u.
9.Choledocholithiasis and pancreatic duct stones: ERCP today.
Example, continued:
 Cross Cover To Do
 F/u ERCP results
 ALL: NKDA
 RX: allopurinol, aspirin, atenolol, Lipitor
 … You get the idea!
Not Acceptable:
 “Patient intubated, sedated, in 1 ICU”… when the pt has
been extubated and on the floor for 4 days
 Must update room numbers on x-cover list
 Must update DNR status
 Must put pertinent changes in status (e.g., if a patient
went into afib or had GI bleed or is having a procedure)
 Must put all pending tests on the list
 If someone is really sick, include family contact info in the
event of a code or critical change in medical status
 YOU MUST UPDATE THE WHOLE LIST EVERYDAY!!!
What do I do when I’m called?
 We will go through some basics by organ systems today
 Future subjects to be covered during Internship 101
lecture series:
 ID:
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June 30: Pneumonia
CV:
July 3: Arrhythmias
GI:
July 7: GI bleeding
Pulm: July 10: Sepsis/SIRS
Endo: July 17: Hyperglycemic states (DKA and HONC)
Neuro: July 31: Altered mental status and “Brain Code”
NEUROLOGY
 Altered Mental Status
 Seizures
 Cord Compression
 Falls
 Delirium Tremens
Altered Mental Status
 Always go to the bedside!!!
 Try to redirect patient: drowsy, stuporous, making
inappropriate comments?
 Is this a new change? How long?
 Check for any recent/new medications administered
 Check VITALS, alertness/orientation, pupils, nuchal
rigidity, heart/lungs/abdomen, strength
 Scan recent labs in chart including: cardiac enzymes,
electrolytes, +cultures
 If labs unavailable, get stat Accucheck, oxygen saturation
 Try naloxone (Narcan), usually 0.4-1.2 mg IV, if there is any
possibility of opiate OD
“Move Stupid”
 Metabolic – B12 or thiamine deficiency
 Oxygen – hypoxemia is a common cause of confusion
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Others - including anemia, decreased cerebral blood flow (e.g., low cardiac output),
CO poisoning
Vascular – CVA, intracerebral hemorrhage, vasculitis, TTP, DIC, hyperviscosity,
hypertensive encephalopathy
Endocrine – hyper/hypoglycemia, hyper/hypothyroidism, high /low cortisol states and
Electrolytes – particularly sodium or calcium
Seizures –post–ictal confusion, unresponsive in status epilepticus; also consider
Structural problems – lesions with mass effect, hydrocephalus
Tumor, Trauma, or Temperature (either fever or hypothermia)
Uremia – and another disorder, hepatic encephalopathy
Psychiatric – diagnosis of exclusion; ICU psychosis and "sundowning" are common
Infection – any sort, including CNS, systemic, or simple UTI in an elderly patient
Drugs – including intoxication or withdrawal from alcohol, illicit or prescribed drugs
Seizures
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Go to bedside to determine if patient still actively seizing
Call your resident
Check your ABCs
Place patient in left lateral decubitus position
Immediate Accucheck
If still seizing, give diazepam 2mg/min IV until seizure stops or
max of 20mg (alternative: lorazepam 2-4mg IV over 2-5min)
 Give thiamine 100 mg IV first, then 1 amp D50
 Load phenytoin 15-20 mg/kg in 3 divided doses at 50 mg/min
(usually 1 g total)
 Remember, phenytoin is not compatible with glucose-containing
solutions or with diazepam; if you have given these meds earlier, you
need a second IV!
 If still seizing >30min, pt is in status—call Neuro (they can order
bedside EEG)
 Get Head CT if appropriate and if pt stabilized
Cord Compression
 Suspect in patients with new weakness or change in sensation
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(especially if they have a demonstrable level), new bowel/bladder
retention or incontinence.
Prognosis is dismal for pts w/no function for >24h.
Prognosis is best for pts with new, incomplete loss (i.e. weakness).
Surgical emergency: call Neurosurgery.
Stabilize the spine: collars for C-spine, Turtle shells (TLSO) for
T/L-spine.
Dexamethasone not always indicated (in case of traumatic
fracture, for instance).
If tumor, needs immediate radiotherapy.
Falls
 Go to the bedside!!!
 Check mental status
 Check vital signs including pulse ox
 Check med list
 Check blood glucose
 Examine pt to ensure no fractures
 Thorough neuro check
 Check tilt blood pressures if appropriate
 If on coumadin/elevated INR—consider head CT to r/o
bleed
Delirium Tremens (DTs)
 Give thiamine 100mg, folate 1mg, MVI
 See if patient has alcohol history
 Check blood alcohol level
 DTs usually occur ~ 3 days after last ingestion
 Make sure airway is protected (vomiting risk)
 Use Ativan 2mg at a time until pt calm, may need Ativan
drip, make sure you do not cause respiratory depression
 Monitor in ICU for seizure activity
 Always keep electrolytes replaced
PULMONARY
 Shortness of Breath
 Oxygen De-saturations
Shortness of Breath
 Go to the bedside!!!
 Check an oxygen saturation and ABG if indicated
 Check CXR if indicated
Causes of SOB
 Pulmonary:
 Pneumonia, pneumothorax, PE, aspiration, bronchospasm, upper
airway obstruction, ARDS
 Cardiac:
 MI/ischemia, CHF, arrhythmia, tamponade
 Metabolic:
 Acidosis, sepsis
 Hematologic:
 Anemia, methemoglobinemia
 Psychiatric:
 Anxiety – common, but a diagnosis of exclusion!
Oxygen Desaturations
Supplemental Oxygen
 Nasal cannula: for mild desats
 Face mask/Ventimask: offers up to 55% FIO2
 Non-rebreather: offers up to 100% FIO2
 BIPAP: good for COPD
 Start settings at: IPAP 10 and EPAP 5
 IPAP helps overcome work of breathing and helps to change
PCO2
 EPAP helps change pO2
 CPAP: good for pulmonary edema, hypercapnea, OSA
 Start at 5-7
Indications for Intubation
 Uncorrectable hypoxemia (pO2 < 70 on 100% O2 NRB)
 Hypercapnea (pCO2 > 55) with acidosis (remember
that people with COPD often live with pCO2 50–70 +)
 Ineffective respiration (max inspiratory force < 25 cm
H2O)
 Fatigue (RR>35 with increasing pCO2)
 Airway protection
 Upper airway obstruction
Mechanical Ventilation
 If patient needs to be intubated, start with mask-
ventilation until help from upper level Arrives
 Initial settings for Vent:
 A/C FIO2 100 Vt 700 Peep 5 (unless increased ICP,
then no peep) RR 12
 Check CXR to ensure proper ETT placement (should
be around 4cm above the carina)
 Check ABG 30 min after pt intubated and adjust
settings accordingly
CARDIOLOGY
 Chest pain
 Hypotension
 Hypertension
 Arrhythmias
Chest Pain
 Go and see the patient!!!
 Why is the patient in house?
 Recent procedure?
 STAT EKG and compare to old ones
 Is the pain cardiac/pulmonary/GI?—from H+P
 Vital signs: BP, pulse, SpO2
 If you think it’s cardiac:
 Give SL nitroglycerin if pain still present (except if low
blood pressure, give morphine instead)
 Supplemental oxygen
 Aspirin 325 mg
Hypotension
 Go and see the patient!!!
 Repeat Manual BP and HR
 Look at recent vitals trends
 Look for recent ECHO/ meds pt has been given.
 EXAM:
 Vitals: orthostatic? tachycardic?
 Neuro: AMS
 HEENT: dry mucosa?
 Neck: flat vs. JVD (=CHF)
 Chest: dyspnea, wheezes (?anaphylaxis), crackles (=CHF)
 Heart: manual pulse, S3 (CHF)
 Ext: cool, clammy, edema
Management of Hypotension
 If offending med, stop the med!
 If volume down/bleeding: give wide open IV NS
 Correct hypoxia
 Recent steroid use? Adrenal insufficiency
 Is there a neuro cause for hypotension?
 If appropriate, consider: PE, tamponade, pneumothorax
 If fever, consider sepsis—need for empiric antibiotics
 If hives and wheezing, consider anaphylaxis—tx with
oxygen, epinephrine, Benadryl
 Need for pressors? Transfer to ICU!
Commonly Used Pressors
Name
Receptor Affected Dose
Action
Phenylephrine
(Neosynephrine)
Alpha 1
10–200 mcg/min
Pure vasoconstrictor;
causes ischemia in
extremities
Norepinephrine
(Levophed)
A1, B1
2–64 mcg/min
Vasoconstriction, positive
inotropy; causes
arrhythmias
Dopamine
Dopa
1–2 mcg/kg/min
Splanchnic vasodilation
("renal dose dopamine"
even though many doubt
such effect exists)
B1
2–10 mcg/kg/min
Positive inotropy;
Causes Arrhythmias
A1
10–20
mcg/kg/min
Vasoconstriction;
Causes Arrhythmias
B1, B2
1–20 mcg/kg/min
Positive inotropy and
chronotropy;
Causes Hypotension
Dobutamine
Hypertension
 Is there history of HTN?
 Check BP trends
 Is patient having pain, anxiety, headache, SOB?
 Confirm patient is not post-stroke pt—BP parameters are
different: initial goal is BP>180/100 to maintain adequate
cerebral perfusion
 EXAM:
 Manual BP in both arms
 Fundoscopic exam: look for papilledema and hemorrhages
 Neuro: AMS, focal weakness or paresis
 Neck: JVD, stiffness
 Lungs: crackles
 Cardiac: S3
Management of Hypertension
 If patient is asymptomatic and exam is WNL:
 See if any doses of BP meds were missed; if so, give now
 If no doses missed, may give an early dose of current med
 Remember, no need to acutely reduce BP unless
emergency
 So, start a medication that you would have normally
picked in this patient as the next agent of choice
according to JNC/co-morbidities/allergies
Hypertension (continued)
URGENCY
 SBP>210 or DBP>120
 No end organ damage
EMERGENCY
 SBP>210 or DBP>120
 Acute end organ damage
 OK to treat with PO
 Treat with IV agents
agents
 Decrease MAP by 25% in
one hour; then decrease
to goal of <160/100 over
2-6 hrs.
GI
 Nausea/Vomiting
 GI Bleed
 Constipation
 Diarrhea
 Acute Abdominal Pain
Nausea/Vomiting
 Vital signs, blood sugar, recent meds?
 Make sure airway is protected
 EXAM: abdominal exam, rectal (considering obstruction,
pancreatitis, cholecystitis),neuro exam (increased ICP?)
 May check KUB
 Treatment:
 Phenergan 12.5-25mg IV/PR (lower in elderly)
 Zofran 4-8mg IV
 Reglan 10-20 mg IV (especially if suspect gastroparesis)
 If no relief, consider NG tube (especially if suspect bowel
obstruction)
GI Bleed (to be discussed in detail at a later date):
UPPER
LOWER
 Hematemesis, melena
 BRBPR, hematochezia
 Check vitals
 Check vitals
 Place NG tube
 Rectal exam
 NPO
 Wide open fluids if low BP
 Wide open fluids vs. blood
 NPO
 Check H/H serially
 Check H/H serially
 If suspect PUD: Protonix
 Transfuse if appropriate
drip
 Pain out of proportion? Don’t
 If suspect varices: octreotide
forget ischemic colitis!
 Call Resident and GI
Constipation
 Very common call!
 Check: electrolytes, pain meds, bowel regimen
 Check KUB if suspect ileus/obstruction
 Rectal exam to check for fecal impaction/mechanical
obstruction
 Treatment:
 If not acute process, can order “laxative of choice”
 Fleets enema for immediate relief (unless renal failure b/c
high phos—then can order water/soap suds enema)
 Lactulose/mag citrate PO if no mechanical obstruction
Diarrhea
 Check: electrolytes, vitals, meds
 Quantify volume, number, description of stools
 Labs: fecal leukocytes, stool culture, guaiac, C.diff toxin if
recent antibiotic or nursing home resident
 Treatment:
 Colitis: flagyl 500mg po tid
 GI bleed: per GI section
 If don’t suspect infection: loperamide initially 4mg then 2mg
after each unformed stool up to 16mg daily
Acute Abdominal Pain
 Go to the bedside!!!
 Assess vitals, rapidity of onset, location, quality and severity
of pain
LOCATION:
 Epigastric: gastritis, PUD, pancreatitis, AAA, ischemia
 RUQ: gallbladder, hepatitis, hepatic tumor, pneumonia
 LUQ: spleen, pneumonia
 Peri-umbilical: gastroenteritis, ischemia, infarction, appendix
 RLQ: appendix, nephrolithiasis
 LLQ: diverticulitis, colitis, nephrolithiasis, IBD
 Suprapubic: PID, UTI, ovarian cyst/torsion
Acute Abdomen?
 Assess severity of pain, rapidity of onset
 If acute abdomen suspected, call Surgery
 Do you need to do a DRE?
 KUB vs. Abdominal Ultrasound vs. CT
 Treatment:
 Pain management—may use morphine if no
contraindication
 Remember, if any narcotics are started, use sparingly in
elderly, ensure pt on adequate bowel regimen
RENAL/ELECTROLYTES
 Decreased urine output
 Hyperkalemia
 Foley catheter problems
Decreased Urine Output
 Oliguria: <20 cc/hour (<400 cc/day)
 Check for volume status, renal failure, accurate I/O, meds
 Consider bladder scan
 Labs:
 UA: WBC (UTI); elevated specific gravity (dehydration);
RBC (UTI/urolithiasis); tubular epithelial cells (ATN); WBC
casts (interstitial nephritis); Eosinophils (interstitial casts)
 Chemistries: BUN/Cr, K, Na
Treatment of Decreased UOP
Decreased Volume Status:
 Bolus 500 cc NS
 Repeat if no effect
Normal/Increased Volume:
 May ask nursing to check
bladder scan for residual
urine
 Check Foley placement
 Lasix 20 mg IV
Foley Catheter Problems:
 Why/when was it placed?
 Does the patient still need it?
 Confirm no kinks or clamps
 Confirm bag is not full
 Examine output for blood clots or sediment
 Do not force Foley in if giving resistanc: call Urology
 Nursing may flush out Foley if it must stay in
 The sooner it’s out, the better (when appropriate)
Hyperkalemia
 Ensure correct value—not hemolysis in lab
 Check for renal insufficiency, meds
 Check EKG for acute changes, peaked T-waves, PR
prolongation followed by loss of P waves, QRS
widening
Treatment of Hyperkalemia
 Immediate Rx (works in minutes): for EKG changes,
stabilize myocardium with 1-2 amps calcium gluconate
 Temporary Rx (shift K into cells):
 2 amps D50 plus 10 units regular insulin IV: decreases K by
0.5-1.5 mEq/L and lasts several hours
 2 amps NaHCO3: best reserved for non-ESRD patients with
severe hyperkalemia and acidosis
 B2-agonists: effects similar to insulin/D50
 Long-lasting Elimination:
 Kayexalate 30g po (repeat if no BM) or retention enema
 NS and Lasix
 Dialysis
ENDOCRINOLOGY
 DKA
 HONC
(Will be covered in detail at later time)
DKA
 Identify precipitating factor (e.g., infection, MI,
noncompliance with meds)
 Check for anion gap
 Check for ketones in urine or serum
 Give bolus 1 Liter NS, then run IVF at 200 ml/hour if no
contraindication
 Start insulin drip DKA protocol in ICU (EPIC order)
 Check electrolytes every 4 hours and replace as appropriate
HONC
 Similar to DKA but for Type II diabetes and no ketones
 There is also an insulin drip NON-DKA protocol in ICU
(EPIC order)
ID
 Positive Blood Culture
 Fever
Positive Blood Culture
 You get called by the lab because a blood culture has become
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Positive.
Check if primary team had been waiting on blood culture.
Is the patient very sick/ ICU?
Is the culture “1 out of 2” and/or “coag negative staph”? This is
likely a contaminant.
If pt is on abx, make sure appropriate coverage based on
culture and sensitivity
If you believe it to be true Positive then give appropriate
empiric treatment for organism and likely source of
infection/co-morbidities of patient and discuss with primary
team in the AM
Fever
 Has the patient been having fevers?
 DDX: infection, inflammation/stress rxn, ETOH
withdrawal, drug rxn, transfusion rxn
 If the last time cultures were checked >24 hrs ago, then
order blood cultures x 2, UA/culture, CXR, respiratory
culture if appropriate
 If cultures are all negative to date, likely no need to
empirically start abx unless a source is apparent and you
are treating a specific etiology
HEME
 Anticoagulation
 Blood replacement products
Anticoagulation
 Appropriate for DVT, PE, Acute Coronary Syndrome
 Usually start with low molecular weight heparin—(Lovenox)
1 mg/kg every 12 hours and adjust for renal fxn
 If need to turn on/off quickly (e.g., pt going for procedure)
use heparin drip—there is a protocol in EPIC
 Risk factors for bleeding on heparin:
 Surgery, trauma, or stroke within the previous 14 days
 History of peptic ulcer disease, GI bleeding or GU bleeding
 Platelet count less than 150K
 Age > 70 yrs
 Hepatic failure, uremia, bleeding diathesis, brain mets
Blood Replacement Products
 PRBC: One unit should raise Hct 3 points or Hgb 1 g/dl
 Platelets: One unit should raise platelet count by 10K;
there are usually 6 units per bag ("six-pack")
 use when platelets <10-20K in nonbleeding patient.
 use when platelets <50K in bleeding pt, pre-op pt, or before
a procedure
 FFP: contains all factors
 use when patient in DIC or liver failure with elevated coags
and concomitant bleeding or for needed reversal of INR
RADIOLOGY
What test do I order for what problem?
 Plain Films
 CT scans
 MRI
Plain Films
CXR:
 Portable if pt in unit or bed bound
 PA/Lat is best for looking for effusions/infiltrates
 Decubitus to see if an effusion layers; needs to layer >1cm
in order to be safe to tap
Abdominal X-ray:
 Acute abdominal series: includes PA CXR, upright KUB
and flat KUB
CT
 Head CT
 Non-contrast best for bleeding, CVA, trauma
 Contrast best for anything that effects the blood brain
barrier, tumors, infection
 CT Angiogram
 If suspect PE and no contraindication to contrast (e.g.,
elevated creatinine)
 Abdominal CT
 Always a good idea to call the radiologist if unsure whether contrast is
needed/depending on what you are looking for
 Renal stone protocol to look for nephrolithiasis
 If you have a pt who has had upper GI study with contrast, radiology won’t
do CT until contrast is gone—have to check KUB to see if contrast has
passed first
MRI
 Increased sensitivity for soft tissue pathology
 Best choice for:
 Brain: neoplasms, abscesses, cysts, plaques, atrophy,
infarcts, white matter disease
 Spine: myelopathy, disk herniation, spinal stenosis
 Contraindications: pacemaker, defibrillator, aneurysm
clips, neurostimulator, insulin/infusion pump, implanted
drug infusion device, cochlear implant, any metallic
foreign body
DEATH
 Pronouncing a patient
 Notify the patient’s family
 Request an autopsy
 How to write a death note
Pronouncing a Patient
Check for:
 Spontaneous movement
 If on telemetry—any meaningful activity
 Response to verbal stimuli
 Response to tactile stimuli (nipple pinch or sternal rub)
 Pupillary light reflex (should be dilated and fixed)
 Respirations over all lung fields
 Heart sounds over entire precordium
 Carotid, femoral pulses
Notify the Patient’s Family
 Call family if not present and ask to come in, or if family is
present:
 Explain to them what happened
 Ask if they have any questions
 Ask if they would like someone from pastoral care to be
called
 Let them know they may have time with the deceased
 Nursing will put ribbon over the door to give family
privacy
Request an Autopsy
 Ask family if they would like an autopsy
 Medical Examiner will be called if:
 Patient hospitalized <24 hours
 Death associated with unusual circumstances
 Death associated with trauma
How to Write a Death Note
DOCUMENTATION:
 “Called to bedside by nurse to pronounce (name of pt).”
 Chart all findings previously discussed:
 “No spontaneous movements were present, pupils were
dilated and fixed, no breath sounds were appreciated, etc.”
 “Patient pronounced dead at (date and time).”
 “Family and attending physician were notified.”
 “Family accepts/declines autopsy.”
 Document if patient was DNR/DNI vs. Full Code.
Bottom Line:
 When in doubt, call your Resident
 It is OK to call your attending if over your head
 You are Never All Alone 
 Write a NOTE about what has happened for the
primary team
 Call primary team in the AM about important events.
 Have fun…it’s gonna be a great year!