Nina Zatikyan

1
A Day in the life and Cross-Cover

• Nina Zatikyan
• Ann Malbas
• Chief Residents

2
Overview- cross cover

• Making your Cross-cover list
• Emergency vs. non-emergency
• When should I go and see the patient?
• Common calls/questions
• When do I need to call my resident???

3
How to make your cross cover list

• Log on to www.caregate.net
• Go to your Patient lists
• Click on to Sign out Rpt button

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Cross-Cover notes

• Always check-out FACE-TO-FACE!!
• Write down in My Report all the instructions
  for your Cross-Cover.
• If you are cross-covering and something happened
  and/or you performed any diagnostic/therapeutic
  interventions write it in My Report for the
  primary team to see.
• Inform the primary team in AM about overnight
  events.

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What do I do when Im called?

• Review basics by organ systems today

• Infectious Disease
• Heme
• Radiology
• Death

• Neuro
• Pulmonary
• Cardiology
• Gastrointestinal
• Renal

• -Ask yourself, does this patient sound stable or
  unstable?
• -Ask for vitals
• -Is this a new change?

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NEUROLOGY

• Altered Mental Status
• Seizures
• Falls
• Delirium Tremens

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Altered Mental Status

• Try naloxone (Narcan), usually 0.4-1.2 mg IV, if
  there is any possibility of opiate OD
• If elderly person is agitated/sundowning 
• Family member at bedside- the best
• Medications
• Haloperidol 2mg IV/IM
• Ziprasidone (Geodon) 10-20mg IM
• Quetiapine (Seroquel) 25mg po qhs
• Restraints (last resort) non-violent/non-behavior
  al

• Always go to the bedside!!!
• Is this a new change?
• Duration?
• Recent/new medications
• Check VITALS, Neuro Exam
• Review Labs cardiac enzymes, electrolytes,
  cultures
• Check stat Accucheck,02 sat, ABG, NH3, TSH
• Consider checking non-contrast head CT
•  
•  
•  

Caution with Benzos/ambien in the elderly
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Move Stupid

• Metabolic B12 or thiamine deficiency
• Oxygen hypoxemia/hypercapnea is a common cause
  of confusion 
• Others - including anemia, decreased cerebral
  blood flow (e.g., low cardiac output),
•        CO poisoning
• Vascular CVA, intracerebral hemorrhage,
  vasculitis, TTP, DIC, hyperviscosity,
•         hypertensive encephalopathy
• Endocrine hyper/hypoglycemia,
  hyper/hypothyroidism, high /low cortisol states
• Electrolytes particularly sodium or calcium
• Seizures postictal 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

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Seizures

• Go to bedside to determine if patient still
  actively seizing
• Call your resident
• Assess ABCs
• give 02, intubate if necessary
• Place patient in left lateral decubitus position
• Labs
• electrolytes (Ca), glucose, CBC, renal/liver
  fxn, tox screen, anticonvulsant drug levels,
  check Accucheck
• Treatment
• Give thiamine 100 mg IV first, then 1 amp D50
• Antipyretics for fever or cooling blankets
• Lorazepam 0.1mg/kg IV at 2mg/min
• If seizures continue
• Load phenytoin 15-20 mg/kg IV in 3 divided doses
  at 50 mg/min (usually 1 g total) or fosphenytoin
  20mg/kg IV at 150mg/min
• Phenytoin is not compatible with
  glucose-containing solutions or benzos if you
  have given these meds earlier, you need a second
  IV!
• If still seizing gt30min, pt is in statuscall
  Neuro (they can order bedside EEG)

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Falls

• Go to the bedside!!!
• Check mental status/Neuro exam
• Check vital signs including pulse ox
• Review med list (benzos, pain meds etc)
• Accucheck!
• Examine for fractures/hematomas/hemarthromas
• Check orthostatics if appropriate
• If on coumadin/elevated INR or alteredconsider
  non-contrast head CT to r/o subdural hematoma
• Order fall precautions

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Delirium Tremens (DTs)

• See if patient has alcohol history
• Give thiamine 100mg, folate 1mg, MVI
• Check blood alcohol level
• DTs usually occur 3 days after last ingestion
• Make sure airway is protected (vomiting risk)
• Use Lorazepam (Ativan) 2-4mg IV 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
• NO HALOPERIDOL increases seizure threshold !

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PULMONARY

• Shortness of Breath
• Hypoxia

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Shortness of Breath

• Go to the bedside!!!
• History of heart failure? Recent surgery? COPD?
• Look at I/Os
• Physical Exam (heart and lungs especially)
• Check an oxygen saturation and ABG if indicated
• Check CXR if indicated
• Lasix 40mg IV x1 if volume overloaded
• Increase supplemental 02, if no improvement start
  on BiPAP, call resident
• Move to ICU/intubate if necessary

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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!

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Oxygen Desaturations

• Supplemental Oxygen
• Nasal cannula for mild desats. Use humidified if
  giving more than gt2L
• 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, FiO2 100
  .
• IPAP helps overcome work of breathing and helps
  to change PCO2
• EPAP helps change pO2
•  

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Indications for Intubation

• Uncorrectable hypoxemia (pO2 lt 70 on 100 O2 NRB)
• Hypercapnea (pCO2 gt 55) with acidosis (remember
  that people with COPD often live with pCO2 5070)
• Ineffective respiration (max inspiratory forcelt
  25 cm H2O)
• Fatigue (RRgt35 with increasing pCO2)
• Airway protection
• Upper airway obstruction

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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 2-4 cm above the carina)
• Check ABG 30 min after patient intubated and
  adjust settings accordingly

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CARDIOLOGY

• Chest pain
• Hypotension
• Hypertension
• Arrhythmias

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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 HP
• Vital signs BP, pulse, SpO2
• If you think its cardiac MONA
• Give SL nitroglycerin if pain still present
  (except if low blood pressure, give morphine
  instead)
• Supplemental oxygen
• Aspirin 325 mg
• Cycle enzymes
• Call Cardiology if there is new ST elevation,
  LBBB, or if there is an elevation in cardiac
  enzymes

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Hypotension

• Go and see the patient!!!
• Repeat BP and HR, manually
• Compare 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

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Management of Hypotension

• Anaphylaxis sob/wheezing
• epinephrine 
• benadryl 
• supplemental 02
•  Adrenal Insufficiency
• check, cortisol/ACTH level
• ACTH stim test
• replace volume rapidly
• Hydrocortisone 50-100mg IV q6-8h
•  

• Hypovolemia
• volume resuscitation
• if CHF,bolus 500ml NS
• transfuse blood
• Cardiogenic
• fluids
• inotropic agents
• Sepsis febrile gt101.5
• blood cultures x 2
• empiric antibiotics

Stop BP meds!   Don't forget about tamponade,
PE and pneumothorax!!
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Commonly Used Pressors
Phenylephrine (Neosynephrine)
Alpha 1
10200 mcg/min
Pure vasoconstrictor causes ischemia in
extremities
Norepinephrine (Levophed)
A1, B1
264 mcg/min
Vasoconstriction, positive inotropy causes
arrhythmias
Dopamine
Dopa
12 mcg/kg/min
Splanchnic vasodilation ("renal dose dopamine"
even though many doubt such effect exists)
B1
210 mcg/kg/min
Positive inotropy Causes Arrhythmias
A1
1020 mcg/kg/min
Vasoconstriction Causes Arrhythmias
Dobutamine
B1, B2
120 mcg/kg/min
Positive inotropy and chronotropy Causes
Hypotension
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Hypertension

• Is there history of HTN?
• Check BP trends
• Is patient symptomatic?
• ie chest pain, anxiety, headache, SOB?
• Confirm patient is not post-strokeBP parameters
  are different initial goal is BPgt180/100 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

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Management of HTN

• 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
• PRN meds
• hydralazine 10-20mg IV
• enalapril (vasotec) 1.25-5mg IV q6h
• labetalol 10-20mg IV
•  
•  Remember, no need to acutely reduce BP unless
  emergency

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Hypertension (continued)

• URGENCY
• SBPgt210 or DBPgt120 with no end organ damage
• OK to treat with PO agents (decr BP in hours)
• hydralazine 10-25mg
• captopril 25-50mg
• labetolol 200-1200mg
• clonidine 0.2mg

• EMERGENCY
• SBPgt210 or DBPgt120 with acute end organ damage
• Treat with IV agents (Decrease MAP by 25 in min
  to 2hrs then decrease to goal of lt160/100 over
  2-6 hrs)
• nitroprusside 0.25-10ug/kg/min
• nitroglycerin 17-1000ug/min
• Labetolol 20-80mg bolus
• Hydralazine 10-20mg 
• Phentolamine 5-15mg bolus

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Arrhythmias

• Bradycardia
• Assess ABCs
• give 02
• monitor BP
• Sinus block 1st, 2nd or 3rd degree
• Hold BB meds
• Prepare for transcutaneous pacing
• Atropine 0.5mg IV  x3
• Consider low dose
• Epi (2-10mcg/min) 
• dopamine(2-10mcg/kg/min)

• Tachyarrhythmias
• Afib/flutter RVR 
• rate control (BB/diltiazem/digoxin if BP low)
• consider anti-arrhythmic (amiodarone)
• SVT/SVT with aberrancy
• vagal maneuver
• adenosine 6-12mg IV
• Ventricular fib/flutter 
• check Mg level, replace if needed (gt3.0)
• amiodarone drip

Remember, if unstable shock!!
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Gastrointestinal

• Nausea/Vomiting
• GI Bleed
• Acute Abdominal Pain
• Diarrhea/Constipation

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Nausea/Vomiting

• Vital signs, blood sugar, recent meds (pain
  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)

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GI Bleed

• UPPER
• Hematemesis, melena
• Check vitals
• Place NG tube
• NPO
• Wide open fluids, typecross for blood
• Check H/H serially
• If suspect 
• PUD Protonix gtt
• varices octreotide gtt
• Call Resident and GI

• LOWER
• BRBPR, hematochezia
• Check vitals
• NPO
• Rectal exam
• Wide open fluids if low BP
• Check H/H serially
• Transfuse if appropriate
• Pain out of proportion? Dont forget ischemic
  colitis!

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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

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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 managementmay use morphine if no
  contraindication
• Remember, if any narcotics are started, use
  carefully in elderly, ensure pt on adequate
  bowel regimen

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Diarrhea           Constipation

• Is this new?
• check stool studies
• c.diff
• culture
• op
• wbc
• FOBT x 3
• Do not treat with loperamide if you think it
  might be C.diff!!!

• Is this new?
• check KUB
• Ileus/bowel obstruction
• place NPO
• Treat
• Laxative of choice
• MOM
• Miralax
• enema
• tap water
• soap
• Bowel regimen
• colace 100mg bid
• dulcolax 5-15mg

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RENAL/ELECTROLYTES

• Decreased urine output
• Hyperkalemia
• Foley catheter problems

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Decreased Urine Output

• Oliguria lt20 ml/hour (lt400 ml/day)
• Check for volume status, renal failure, accurate
  I/O, meds
• Consider bladder scan (place foley if residual
  gt300ml)
• Labs
• UA WBC (UTI) elevated specific gravity
  (dehydration) RBC (UTI/urolithiasis) tubular
  epithelial cells (ATN) WBC casts (interstitial
  nephritis) Eosinophils (AIN)
• Chemistries BUN/Cr, K, Na

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Treatment of Decreased UOP

• Decreased Volume Status
• Bolus 500ml NS
• Repeat if no effect

• Normal/Increased Volume
• May ask nursing to check bladder scan for
  residual urine
• Check Foley placement
• Lasix 20-40 mg IV

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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 resistance call
  Urology
• Nursing may flush out Foley if it must stay in
• The sooner its out, the better (when
  appropriate)

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Hyperkalemia

• Ensure correct valuenot hemolysis in lab
• Check for renal insufficiency, medications
  (ACEI/ARBs, heparin, NSAIDs, cyclosporine,
  trimethoprim, pentamidine, K-sparing diuretics,
  BBs, KCl, etc)
• Check EKG for acute changes
• peaked T-waves 
• flattened P waves
• PR prolongation followed by loss of P waves
• QRS widening

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Treatment of Hyperkalemia

• Severe (gt7mEq/L) or EKG changes
•         Protect myocardium
• Calcium gluconate 1-2amps IV over 2-5min
•  

• Mild (lt6.0 mEq/L)
•         Decrease total body stores
• Lasix 40-80mg IV
• Kayexalate 30-90g PO/PR
• Moderate (6-7mEq/L)
•         Shift K in cells
• NaHCO3 50mEq (1-3amps)
• D5010units insulin IV
• albuterol 10-20mg neb

Emergent dialysis should be considered in
life-threatening situations. Remember this is
a progressive treatment plan, so if your patient
has EKG changes you need to treat for
severe/mod/mild!!!
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Infectious Disease

• Positive Blood Culture
• Fever

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Positive Blood Culture

• You get called by the lab because a blood culture
  has become Positive.
• Check if primary team had been waiting on blood
  culture.
• Is the patient very sick/ ICU?
• Is the culture 1 out of 2 and/or coag negative
  staph? 
• This is likely a contaminant.
• If ½ Blood Cx are positive, consider repeating
  another set
• 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

42
Fever

• Has the patient been having fevers?
• DDX infection, inflammation/stress rxn, ETOH
  withdrawal, PE, drug rxn, transfusion rxn
• If the last time cultures were checked gt24 hrs
  ago 
• order blood cultures x 2 from different IV sites 
• 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

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HEME

• Anticoagulation
• Blood replacement products

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Anticoagulation

• Appropriate for
• DVT/PE 
• Acute Coronary Syndrome
• Usually start with low molecular weight heparin 
• Lovenox 1 mg/kg every 12 hours and renally
  adjust 
• If need to turn on/off quickly (e.g., pt going
  for procedure)
• heparin dripprotocol in EPIC
• Risk factors for bleeding on heparin
• Surgery, trauma, or stroke within the previous 14
  days
• H/o PUD or GIB
• Pltslt150K
• Age gt 70 yrs
• Hepatic failure, uremia, bleeding diathesis,
  brain mets

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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 lt10K in non bleeding patient.
• use when platelets lt50K in bleeding pt, pre-op
  pt, or before a procedure
• FFP contains all factors
• DIC or liver failure with elevated coags and
  concomitant bleeding
• Reversal of INR (ie for procedure)

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RADIOLOGY

• Which test should I order?
• Plain Films
• CT scans
• MRI

47
Plain Films

• CXR
• Portable if pt in unit or bed bound
• PA/Lateral is best for looking for
  effusions/infiltrates
• Decubitus to see if the effusion layers.
• Needs to layer gt1cm in order to be safe to tap
• Abdominal X-ray
• Acute abdominal series includes PA CXR, upright
  KUB and flat KUB

48
CT

• Head CT
• Non-contrast best for bleeding, CVA, trauma
• Contrast best for anything that effects the blood
  brain barrier (ie 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 wont do CT until contrast is
  gonehave to check KUB to see if contrast has
  passed first
• If you are going to give contrast, check your
  Cr!!!

49
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

50
DEATH

• Pronouncing a patient
• Patient may be pronounced by 2 RNs
• Notify the patients family
• Request an autopsy
• How to write a death note

51
Pronouncing a Patient

• Check for
• Spontaneous movement
• If on telemetryany 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

52
Notify the Patients 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

53
Request an Autopsy

• Ask family if they would like an autopsy
• Medical Examiner will be called if
• Patient hospitalized lt24 hours
• Death associated with unusual circumstances
• Death associated with trauma

54
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.

55
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 funits gonna be a great year!!