CrossCover Issues

1
Cross-Cover Issues

• Jose Mata

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General Principles

• YOU ARE NEVER ALONE! The senior resident is
  there to help you.
• With every call, ask yourself if this is truly
  something that has to be dealt with now.
• You have the primary responsibility for dealing
  with all of these issues.

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General Principles (cont)

• 5. Always remember your ABCs first
• 6. Always remember to ask about code status
• 7. Communicate with your co-residents
• 8. Be nice to the nurses.

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Bradycardia

• Immediate
• 1. Atropine and Zoll pads to bedside
• 2. Symptomatic or unstable? If so, call a code
  (ACLS), place patient in Trendelenberg, call the
  senior resident, and go examine the patient
• 3. Order an EKG
• 4. Get a full set of vital signs, start
  continuous monitoring

5
Bradycardia (cont)

• Assessment
• 1. Review the chart (PMH, cumulative vitals,
  meds, admitting Dx, labs, EKGs, cardiac
  studies, recent interventions)
• 2. Take a focused history
• 3. Perform a focused physical exam
• 4. If stable and not symptomatic, consider
  deferring any further interventions

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Bradycardia (cont)

• Plan
• 1. If type II 2nd degree or 3rd degree block,
  consider transcutaneous pacing and call
  cardiology
• 2. Consider short-acting analgesics or
  sedatives prior to transcutaneous pacing
• 3. Avoid medication changes

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Tachycardia

• Immediate
• 1. Symptomatic or unstable? If so, call a code
  (ACLS), call your senior resident, and go
  examine the patient
• 2. EKG
• 3. Full set of vital signs
• 4. Start continuous monitoring

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Tachycardia (cont)

• Differential
• Narrow QRS, regular ST, AVNRT, AVRT, A flutter
  w/ regular block
• Narrow QRS, irregular A fib, A flutter w/
  variable block, MAT, frequent PACs
• Wide QRS, regular VT, SVT w/ aberancy
• Wide QRS, irregular VT, A fib w/ aberancy

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Tachycardia (cont)

• Assessment
• 1. Review the chart
• 2. Take a focused history
• 3. Perform a focused physical exam
• 4. If wide QRS and regular, remember the
  Brugada criteria

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Tachycardia (cont)

• Plan
• 1. Vagal maneuvers
• 2. Adenosine (6mg IV X2, if no response, then
  12mg IV)
• 3. Consider calling the senior resident
• 4. Treat the underlying cause
• 5. Consider beta or Ca channel blockers
• 6. Consider cardioversion

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Hypotension

• Immediate
• 1. Symptomatic or unstable? If so, call a code,
  call your senior resident, and go examine the
  patient
• 2. Get a full set of vital signs, consider
  continuous monitoring
• 3. Order an EKG
• 4. Put the patient in Trendelenberg

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Hypotension (cont)

• Assessment
• 1. Repeat BP yourself
• 2. Review BP trends
• 3. Review the chart
• 4. Perform a focused cardiopulmonary exam
  (breath and hearts sounds, neck veins, murmurs
  or arrhythmias, distant heart sounds, peripheral
  perfusion)
• 5. Consider an arterial line

13
Hypotension (cont)

• Differential
• Abnormal heart rate bradycardia, tachycardia,
  arrythmia
• Decreased preload hypovolemia, PTX, PE,
  tamponade, MI, pulmonary HTN
• Decreased contractility MI, valve disease,
  aortic dissection, medications
• Decreased SVR sepsis, anaphylaxis, adrenal
  insufficiency, medications

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Hypotension (cont)

• Plan
• 1. Isotonic fluid bolus (NS or LR)
• 2. Send labs (CBC, ABG, CMP at least)
• 3. Consider sepsis work-up (CXR, blood
  cultures, urine culture, LP)
• 4. Consider vasoactive medications
• 5. Consider antibiotics
• 6. Consider transfusion

15
Hypotension (cont)

• Diagnosis-specific plan
• Tamponade ECHO, call cardiologist
• Tension PTX immediate decompression
• Anaphylaxis epinephrine (0.2-0.5mL of 11000
  SC/IM Q 20), diphenhydramine (50mg IV),
  hydrocortisone (250mg IV)
• Sepsis antibiotics and pressors
• MI MONA Rx, consider thrombolytics/cath

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Chest Pain

• Immediate
• 1. Get a full set of vitals
• 2. Ask if patient is unstable
• 3. EKG
• 4. Consider calling your senior or cardiologist
• 5. Go and examine the patient

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Chest Pain (cont)

• Assessment
• 1. Review EKG
• 2. Get specific details regarding the chest
  pain from the patient
• 3. Perform a focused cardiopulmonary exam
  (breath and hearts sounds, new murmurs or
  arrhythmias, rubs, neck, peripheral perfusion)
• 4. Review the chart

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Chest Pain (cont)

• Differential
• Cardiac MI, angina, pericarditis
• Vascular Aortic dissection
• Pulmonary PE, PNA, pleuritis, PTX
• GI GERD, PUD, esophageal rupture, esophageal
  spasm
• Musculoskeletal Shingles, costochondritis
• Psychiatric Anxiety

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Chest Pain (cont)

• Plan
• 1. If ischemia suspected, MONA Rx
• 2. If tension PTX, decompress
• 3. Consider CXR
• 4. Send labs (CBC, CMP, ABG, coags, cardiac
  enzymes etc.)
• 5. Consider transfer to ICU
• 6. Consider CT or V/Q scan if PE suspected
• 7. Repeat EKG if initially positive and then
  pain relieved

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Dyspnea

• Differential
• Pulmonary COPD, PNA, aspiration, PE, PTX,
  obstruction, ARDS
• Cardiac MI, CHF, tamponade, arrythmia
• Metabolic sepsis, acidosis
• Hematologic anemia, methhemoglobinemia
• Psychiatric anxiety

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Dyspnea (cont)

• Assessment
• 1. Determine acuity
• 2. Assess for associated symptoms
• 3. Review medications and the chart
• 4. Obtain full set of vitals and review
  cumulative vital signs
• 5. Perform targeted physical exam (cardiac,
  neck, lungs, extremities, mental status)

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Dyspnea (cont)

• Plan
• 1. Provide oxygen (NC, then simple mask, then
  NRB mask, then high-humidity mask, then
  intubation) goal is pCO2gt60, O2satgt92
• 2. Consider CBC, CXR, ABG, EKG, BNP, and cardiac
  enzymes
• 3. Consider beta-agonists and steroids
• 4. Consider furosemide
• 5. Consider antibiotics

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Fever

• Definition gt38oC (100.4oF)
• Differential
• Infection (esp noscomial if gt3 days in hospital)
• Inflammation CVD, CA
• Drug fever
• Neuro Sz, SDH, ICH, hypothalamic injury
• Endocrine thyrotoxicosis, adrenal disease
• Other aspiration, blood product reaction, ATX,
  MI, pancreatitis, hematoma

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Fever (cont)

• Assessment
• 1. Review all vitals, especially BP
• 2. Review medications
• 3. Find out when blood cultures were last drawn
• 4. Perform a focused history and physical exam
• 5. Find out when all IVs, central lines, and
  Foleys were placed

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Fever (cont)

• Plan
• 1. Consider sending blood cultures, urine
  cultures, CBC, and CXR
• 2. Consider acetaminophen (650mg PO/PR) if
  patient uncomfortable
• 3. Consider antibiotics if a source is found
• 4. Consider empiric antibiotics if unstable
• 5. Consider pulling all lines and Foley

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Hypertension

• Rarely requires acute intervention from a
  cross-cover unless there is a hypertensive
  urgency or emergency
• Assessment
• 1. Re-check the BP yourself
• 2. Review BP trends
• 3. Having symptoms? HA, visual changes, chest
  pain, AMS
• 4. Is there an acute CNS process?

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Hypertension (cont)

• Plan Consider treating only if the patient is
  having symptoms or for BP gt220/110
• 1. Consider increasing current medications
• 2. hydralazine (10-40mg IV)
• 3. labetalol (20-80mg IV)
• 4. captopril (6.25-25mg PO)
• 6. If HTN emergency, give labetalol and
  transfer to ICU to start a nitro drip

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Low Urine Output

• Definitions
• Normal output 0.5 cc/kg/hr
• Oliguria lt400 cc/day
• Anuria lt100 cc/day

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Low Urine Output (cont)

• Assessment
• 1. If Foley, flush tubing first
• 2. If no Foley, review past urine output and
  check the daily weights
• 3. Examine the patient volume status,
  prostate exam, palpable bladder
• 4. Review the chart

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Low Urine Output (cont)

• Differential
• 1. Decreased renal perfusion (intravascular
  volume depletion, arrhythmias, infection,
  bleeding)
• 2. Obstructive uropathy
• 3. Intrinsic renal disease
• 4. Contrast nephropathy
• 5. Drug toxicity

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Low Urine Output (cont)

• Plan
• 1. Consider post-void residual (gt200 cc)
• 2. Consider fluid bolus (250-500 cc NS)
• - caution if CHF
• 3. If volume overloaded and getting IVF,
  consider decreasing the IV rate
• 4. Consider furosemide, 20-80mg IV
• 5. Consider dialysis

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Insomnia

• Start with a brief history assessing whether
  there is a treatable underlying cause (eg. pain,
  drug reaction/toxicity)
• Get specific history as to whether the patient
  has liver disease or is elderly (extreme caution
  with benzodiazepines and caution with zolpidem if
  positive)

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Insomnia (cont)

• Plan
• 1. Consider antihistamines first
  diphenhydramine (25-50mg PO) or hydroxyzine
  (50-100mg PO)
• 2. Consider zolpidem (5-10mg PO)
• 3. Consider trazadone (25-50mg PO)
• 4. Consider benzodiazepines temazepam (15-30mg
  PO) or lorazepam (0.5-1mg PO)

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Falls

• Start with physical exam
• 1. Complete acute trauma survey
• 2. Complete neurological exam
• 3. Mental status exam
• History circumstances, LOC, syncope, associated
  symptoms, PMH, coagulation history

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Falls (cont)

• Differential (incredibly broad)
• Neuro Sz, CVA/TIA, vertigo, AMS, etc.
• Cardiac MI, arrhythmia, vasovagal,
  orthostasis, decreased cardiac output
• Meds concomittant alpha/beta blockade,
  sedatives, psychotropics, vasodilators
• MS arthritis, weakness, deconditioning
• Other wet floor, poor eyesight, non-compliance

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Falls (cont)

• Plan
• 1. Consider head CT
• 2. Consider X-rays
• 3. Consider serial neurological exams
• 4. Institute fall precautions
• 5. Consider restraints
• 6. Make sure incident report gets done

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Combative or Confused

• Assessment
• 1. Is there a chance for physical injury?
• If so, call security or a CODE 55
• 2. Is the patient upset or altered mentally?
  Perform mental status exam.
• 3. Could medications be the etiology?
• 4. Review vital signs and recent labs?
  Agitation could be a harbinger of a serious
  underlying medical condition.

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Combative/Confused (cont)

• Differential
• Sundowning/disorientation
• Angry/upset
• Delirium (esp. if EtOH or drug abuse)
• Sepsis
• Medications
• Psychiatric
• Metabolic

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Combative/Confused (cont)

• Plan
• 1. Talk to the patient
• 2. Consider medications haloperidol (1-10mg
  IV/IM/PO) or droperidol (2.5-10mg IV/IM)
• 3. Benzodiazepines only if EtOH withdrawal
  suspected lorazepam (1-4mg IV/IM/PO) or
  chlordiazepoxide (25-100mg PO)
• 4. Consider physical restraints

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Hypothermia

• Theyre not dead until they are warm and dead
• Classification
• Mild (34o to 36oC)
• Moderate (30o to 33.9oC)
• Severe (lt 30oC)
• Get full vitals immediately and institute ACLS as
  needed

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Hypothermia (cont)

• Risk Factors
• Extremes of age
• Cold water submersion
• Alcohol intoxication
• Sepsis
• Head injury
• Endocrine disorders
• Drug ingestions

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Hypothermia (cont)

• Plan
• 1. Get a core temperature (esophageal probe is
  the gold standard)
• 2. Apply continuous monitors
• 3. Remove wet clothing
• 4. Rapid core rewarming warm IV fluids, warm
  humidified O2, heat lamps, peritoneal lavage,
  dialysis, hot water bottles
• 5. DO NOT WARM EXTREMITIES