Nadia Habal, MD

1
X-COVER?!?

• Nadia Habal, MD
• Presbyterian Hospital of Dallas

2
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???

3
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

4
Example

• 69 y/o with PCKD and transplant kidney p/w
  painless hematuria
• 1. Renal pt continues to have hematuria likely
  ruptured renal cysts 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.

5
Example, continued

• Cross Cover To Do
• F/u ERCP results
• ALL NKDA
• RX allopurinol, aspirin, atenolol, Lipitor
• You get the idea!

6
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!!!

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What do I do when Im called?

• We will go through some basics by organ systems
  today
• Future subjects to be covered during Internship
  101
• lecture series
• ID      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

8
NEUROLOGY

• Altered Mental Status
• Seizures
• Cord Compression
• Falls
• Delirium Tremens

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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

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Move Stupid

• Metabolic B12 or thiamine deficiency
• Oxygen hypoxemia 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
  and 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
• 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 gt30min, pt is in statuscall
  Neuro (they can order bedside EEG)
• Get Head CT if appropriate and if pt stabilized

12
Cord Compression

• Suspect in patients with new weakness or change
  in sensation (especially if they have a
  demonstrable level), new bowel/bladder retention
  or incontinence.
• Prognosis is dismal for pts w/no function for
  gt24h.
• 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.

13
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 INRconsider head CT to
  r/o bleed

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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

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PULMONARY

• Shortness of Breath
• Oxygen De-saturations

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Shortness of Breath

• Go to the bedside!!!
• Check an oxygen saturation and ABG if indicated
• Check CXR if indicated

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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
• 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

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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 force lt
  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 4cm above the carina)
• Check ABG 30 min after pt 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
• Give SL nitroglycerin if pain still present
  (except if low blood pressure, give morphine
  instead)
• Supplemental oxygen
• Aspirin 325 mg

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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

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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 sepsisneed for empiric
  antibiotics
• If hives and wheezing, consider anaphylaxistx
  with oxygen, epinephrine, Benadryl
• Need for pressors? Transfer to ICU!

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Commonly Used Pressors
Name Receptor Affected Dose Action
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 having pain, anxiety, headache, SOB?
• Confirm patient is not post-stroke ptBP
  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 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/allergie
  s

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Hypertension (continued)

• URGENCY
• SBPgt210 or DBPgt120
• No end organ damage
• OK to treat with PO agents

• EMERGENCY
• SBPgt210 or DBPgt120
• Acute end organ damage
• Treat with IV agents
• Decrease MAP by 25 in one hour then decrease to
  goal of lt160/100 over 2-6 hrs.

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GI

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

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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)

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GI Bleed (to be discussed in detail at a later
date)

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

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

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Constipation

• Very common call!
• Check electrolytes, pain meds, bowel regimen
• Check KUB if suspect ileus/obstruction
• Rectal exam to check for fecal impaction/mechanica
  l obstruction
• Treatment
• If not acute process, can order laxative of
  choice
• Fleets enema for immediate relief (unless renal
  failure b/c high phosthen can order water/soap
  suds enema)
• Lactulose/mag citrate PO if no mechanical
  obstruction

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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 dont suspect infection loperamide initially
  4mg then 2mg after each unformed stool up to 16mg
  daily

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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
  sparingly in elderly, ensure pt on adequate bowel
  regimen

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RENAL/ELECTROLYTES

• Decreased urine output
• Hyperkalemia
• Foley catheter problems

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Decreased Urine Output

• Oliguria lt20 cc/hour (lt400 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

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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

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

40
Hyperkalemia

• Ensure correct valuenot 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

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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

42
ENDOCRINOLOGY

• DKA
• HONC
• (Will be covered in detail at later time)

43
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

44
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)

45
ID

• 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 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

47
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 gt24 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

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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
  adjust for renal fxn
• If need to turn on/off quickly (e.g., pt going
  for procedure) use heparin dripthere 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 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 lt10-20K in nonbleeding
  patient.
• use when platelets lt50K 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

51
RADIOLOGY

• What test do I order for what problem?
• Plain Films
• CT scans
• MRI

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Plain Films

• CXR
• Portable if pt in unit or bed bound
• PA/Lat is best for looking for effusions/infiltrat
  es
• Decubitus to see if an 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

53
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 wont do CT until contrast is
  gonehave to check KUB to see if contrast has
  passed first

54
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

55
DEATH

• Pronouncing a patient
• Notify the patients family
• Request an autopsy
• How to write a death note

56
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

57
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

58
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

59
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.

60
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!