Intern Basics- Part II

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Intern Basics- Part II

• Jacobi medical Center

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Falls

• Assess the patient after the fall
• Witnessed or not
• Ask the patient about the fall and any injury
• Examine the patient with special attention to the
  area of injury examine the head to rule out any
  injury to the head
• Imaging studies to rule out any fractures
• If any change in the mental status from the
  baseline is noted, get a head CT
• Complete the incident report
• Restrains as needed

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Altered Mental Status

• Confusion, delirium, drowsiness, stupor
• Look for the possible (and obvious) causes
• -medications (opiates, benzodiazepines, other
  sedatives)
• -metabolic (hypoglycemia, hyponatremia,
  hypernatremia, uremia, hypercapnia, hypoxia)
• -trauma to the head
• -Stroke
• -Seizures
• -Infections
• -Others hyperthyroidism, liver failure,
  Hypertensive encephalopathy

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AMS (contd.)

• Work up
• -Any acute change in mental status (stupor),
  call an RRT (rapid response team), stabilize the
  patient first. Always check ABC. Make sure the
  patient has a working IV line
• -Check finger stick glucose to r/o
  hypoglycemia
• -If patient seems unable to protect his
  airway, then he probably needs intubation (call
  RRT if not already called ask the nurse to call
  anesthesia and respiratory therapist)
• -labs CBC, serum electrolytes, BUN/Cr, ABG
• -If any suspicion of infection, check UA and
  CXR
• -Head CT

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AMS (contd.)

• Management
• -Delirium Haldol 2-5mg IM can be given
• -Underlying cause should be treated. If
  patient has been intubated, then will need to be
  transferred to the ICU/CCU. Contact SMR for the
  transfer.

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Insomnia

• Antihistamines (benadryl) may cause daytime
  sleepiness the next day, avoid in patients with
  angina, cardiac arrythmias, BPH, COPD
• Benzodiazepine (restoril, ativan) daytime
  sleepiness, cause respiratory depression, avoid
  in COPD or any underlying lung problems
• Newer hypnotics (ambien) fewer side effects,
  better tolerated consider trazodone

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Constipation

• Causes functional (most common in the
  hospitals), obstruction, medications (most
  commonly opioids), neurogenic
• Abdominal x-ray if needed
• Treatment colace, senna, dulcolax (bisacodyl),
  lactulose, enema (tap water, fleets),
  disimpaction of stool

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Diarrhea

• Acute onset rule out infection
• Check fecal leucocytes, occult blood in stool,
  stool culture, C. diff toxin
• Check CBC for leucocytosis
• If any reason to suspect C. Diff infection and
  patient appears acutely sick, should start
  metronidazole empirically

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Heparin drip adjustments

• Initial dose
• PTT lt35
• PTT 35-45
• PTT 46-70
• PTT 70-90
• PTTgt90

• 80 U/Kg bolus, then 18U/Kg/hr
• 80 U/kg bolus, increase drip by 4 U/kg/hr
• 40 U/kg bolus, increase drip by 2 U/kg/hr
• No change in rate
• Decrease drip by 2 U/kg/hr
• Hold infusion for 1hr, decrease the rate of drip
  by 3 U/kg/hr

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Death notification

• Confirm death pupils, heart, breathing
• Note the official time of death (when you
  pronounce the patient)
• Notify the family
• Call organ donation (If they reject the case,
  they will give a case number also get the name
  of the person you speak to)
• Write a death note in the EMR and complete the
  discharge summary
• When the death certificate is ready, the
  admitting will call you to get your signature/
  finger print (please do that promptly and do not
  sign that out)

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Sample death note

• Called to the bedside by the nurse. Patient found
  unresponsive, pupils unreactive, no spontaneous
  breathing, no heart sounds. Pt pronounced dead at
  1100am on 07/24/2010. Pts son (name) notified.
  Called organ donation and spoke with Ms. X. The
  case was rejected and the case number is XXXXX.

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Questions??