Internal Medicine Residency Program
William
Rifkin M.D.
A.
Medical issue, not psychiatric
C
Very common among: inpatients, baseline demented, elderly (25% of delirious are
demented, 40% of
Demented inpatients are delirious)
D.
Common Causes: (especially in patients
with the above noted: ‘substrate’)
1. Translocation Delirium
(sundowning in new environment)
2. Drugs: anticholenergics,
narcotics, benzodiazepines, steroids
3. Infection of any kind (think
common first)
4. Metabolic: renal, liver,
thyroid, hyper/hypoglycemia, electrolytes
5. Hypoxia
Treatment:
1. Do not ignore, can be
important
2. Search for proximal cause
and remove or treat
3. Reorientation, mobilize,
Close follow-up, reassess often
4. If severe: consider Haldol
.5mg IM and/or posey vest. Avoid wrist/leg restraints; benzos
Acute GI Bleed: (hematemesis
and/or melena)
Mortality
10%
Asses hemodynamic status by
BP and HR
SBP <100: severe blood loss
HR>100 and SBP >100: moderate blood loss
HCT not reliable initially
·
Two large bore IV’s
·
Type and Cross 2-4 units, CBC,
PT/PTT, Chem 8, LFT’s
·
NG Tube Placement and aspiration (clear aspirate = lower risk)
·
IF moderate-severe blood loss:
IVF: NS wide open
Transfuse PRBC’s
FFP for platelets less than 50K or on ASA and for
each 5 units of PRBC’s transfused
DDAVP IV (0.3 micrograms/kg) for uremic patients
IV Octreotide (100 mcg
bolus, then 50-100 mcg/hr) for those with suspected liver disease or portal
hypertension and active upper GI bleeding
·
D/C all NSAIDS and obtain GI and Surgical evaluations
Acute Respiratory Failure:
A. Definition
B. Signs and Symptoms
C. Causes (history is
paramount)
COPD
Asthma
Pulmonary Embolism
Pulmonary Edema
Pneumothorax
Pneumonia
Pickwician (obesity)
Neuro-muscular
Drug Effects (respiratory
suppression)
Narcotics
Benzodiazepines (in those
with COPD, ETOH or barbiturates)
Brain Stem Disease or
Herniation
D. Treatment
Specific Therapy directed
towards underlying cause
Reparatory Support as per
ABG
Supplemental oxygen is only needed is patient is hypoxic (PO2 <60,
Sat <88%)
Supplemental oxygen can suppress respiration in those with hypoxic
drive to breathe
PCO2 elevated at baseline: “CO2 retainers” (normal or near normal pH
with high PCO2)
Use minimum oxygen to raise PO2 to 60 (sat to 90%), above this amount
may be harmful
Do not withhold needed supplemental oxygen in retainers, use CPAP,
BIPAP or intubation
Check patient status often: RR, pulse ox, ABG, adjust oxygen as needed
If cannot balance oxygen needs and pH or PCO2 consider CPAP, BIPAP or
Intubation
If cannot oxygenate adequately by non-invasive means consider CPAP,
BIPAP or Intubation
If patient cannot maintain
adequate ventilation (rising PCO2, falling pH): intubate
Hypercalcemia:
·
Adjust for albumin level or measure ionized calcium level
·
Signs/Symptoms: “Bones, stones, groans and psychic overtones”
(fractures, renal stones, abdominal pain, depression, change in mental status,
constipation, polyuria, stupor and coma)
·
Primary hyperparathyroidism and malignancy account for 90% of all cases
Treatment:
(if marked or symptomatic)
IVF (1/2 NS or NS at 250-500
ml/hr) and furosemide (20-40 mg IV every 2 hours)
If severe or malignancy:
bisphosphonates (Pamidronate 90mg IV over two hours), but takes days to work
If severe: Calcitonin 4
IU/kg IM/SC/intranasal every 12 hours (works rapidly), skin test before 1st
dose
Hypocalcemia:
Correct
for albumin level. No treatment if due to low albumin
Most
commonly due to renal failure (low Ca++, high PO4++)
Signs
and Symptoms: muscle spasm, cramps,
tetany, convulsions, parathesias, Chvostek’s sign, long QT
Treatment:
1. Severe, Symptomatic: IV
calcium gluconate (10%) 10-20 ml over 10 minutes, then IV infusion (6-8 10ml
vials of 10% calcium gluconate in 1 liter of D5W over 4- hours). Monitor and
maintain serum calcium at 7-8.5 mg/dL
2. Asymptomatic: oral calcium (1-2 g) and Vitamin D. Replace
Mg++ if low
POTASSIUM
Hyperkalemia:
Causes:
spurious (hemolyzed), renal failure, over-supplementation, acidosis,
hypoaldosteronism
Signs/Symptoms: muscle weakness, abdominal distention,
diarrhea, VT/VF, death
Note: ˝ of patients with K+> 6.5
Meq/L will have normal ECG’s. (No peaked T waves, widened QRS)
Treatment:
1. Confirm elevation is
genuine, D/C supplementation
2. If no ECG changes: Kayexalate 40-80 mg PO/PR/day divided BID/TID
and/or furosemide IV/PO (effects over 1-3 hours) (0.5-1 meq of K+ removed per 1
g of Kayexalate)
3. If symptomatic, ECG changes or K+> 6.5 meq/L
(acutely): options:
4.
Frequent monitoring of serum K+
Hypokalemia:
Signs/Symptoms:
muscular weakness/cramps, fatigue, hyporeflexia, tetany, broad T, prominent U
waves, ST depressions on ECG
Treatment:
1. Mild-Moderate: oral K+
supplementation (40 meq
2. Severe (< 3.0 meq/L) or
unable to take
3. If resistant to correction
consider and supplement low Mg++ levels
SODIUM:
Hyponatremia: (<130
meq/L)
A. Normal (280-295 mosm/kg) defining
isotonic hyponatremia: (psuedohyponatremia)
1. Hyperproteinemia:
2. Hyperlipidemia
Rx: none (treat underlying problem)
B. High (>295 mosm/kg) defining
hypertonic hyponatremia
1. Hyperglycemia
2. Mannitol, sorbitol,
glycerol, maltose
3. Radiocontrast agents
Rx: treat reversible causes (high glucose)
C. Low (< 280 mosm/kg) defining
hypotonic hyponatremia (most common, true hyponatremia)
Determine
Volume Status: (JVP, orthostatic changes, skin turgor, dry axilla)
If
urine Na+ < 10 meq/L If urine
Na+ > 20 meq/L
Extra-renal
salt loss: Renal Salt
Loss:
Dehydration 1. Diuretics
Diarrhea 2. ACE
Inhibitors
Vomiting 3.
Nephropathies
4. Mineralcorticoid Deficiency
5. Renal Na+ Wasting
Rx:
IVF with NS or ˝ NS, add mineralcorticoid if deficiency suspected
SIADH (some causes: any CNS
process, pulmonary TB, pneumonia or neoplasm, other neoplasms, some drugs:
antidepressants, antineoplastics, carbamazepine, neuroleptics)
Postoperative hyponatremia
Hypothyroidism
Psychogenic Polydipsia
Beer Potomania (or Tea and
Toast diet, leading to loss of intra-renal solute and urine concentration)
Idiosyncratic drug reaction
(thiazides, ACE-I)
Rx:
Symptomatic
(seizures, MS changes)
Correct Na+ no
faster than 1 meq/L/hr (but no more than 12 meq/L on first day to avoid central
pontine myelinolysis. Slow rate of correction to 0.5 meq/L/hr once symptoms
improve. Initial goal: serum Na+ of 125-130 meq/L.
Saline
plus furosemide: 3% saline (1-2 mL/kg/hr) plus furosemide (0.5-1 mg/kg IV).
Measure serum Na+ every four hours and re-adjust accordingly.
Asymptomatic
hyponatremia:
1. Correct Na+ no faster than 0.5 meq/L/hr, no more than 12 meq/L in first
24 hours Improvement should occur over days
2. Water restriction:
500-1000cc/day
3.
4. Demeclocycline (300-600 mg
5. Fludrocortisione:
if cerebral salt-wasting syndrome
III. Hypervolemic (edematous
states)
CHF
Liver Disease
Nephrotic Syndrome
Advanced Renal Failure
Rx:
1. Treatment of underlying
condition
2. Water restriction (1-2
L/day)
3. Diuretics: used cautiously,
w/o increase in free water intake
4. 3% Saline (200cc plus
furosemide) vs. emergent dialysis: only if severe (<110 meq/L) and CNS
symptoms
5.
Hypernatremia: (Na+ > 145
meq/L)
1.
An intact thirst drive (or access to water) prevents, only seen when
appropriate water intake is not possible
2.
Signs/Symptoms: orthostatic changes,
oliguria, hyperthermia, delirium to coma
Evaluation:
A. Urine Osmolality > 400 mosm/kg: renal
water-conserving ability intact
i.
Nonrenal losses: sweating (fever), respiration, stool
ii.
Renal losses: Osmotic diuresis (hyperglycemia, mannitol)
B.
Urine Osmolality < 250 mosm/kg:
Diabetes Insipidis
i.
Central
ii.
Nephrogenic (lithium, demclocycline, s/p obstruction, interstitial
nephritis)
Treatment: Fluid
therapy should be administered over a 48-72 hour period, aiming for a decrease
in serum Na+ of no more than 1meq/L/hour. If corrected too rapidly: cerebral
edema, coma, death.
A. Calculate water deficit: Volume in L = Total Body Water X (measured Na+ - 140)/140
TBW =
weight in Kg X (50% for men over 60 and women under 60)
(60% for men under 60, 40% for women over
60)
B. Add maintenance needs (usually about 1 L/day if
minimal extra renal losses)
C. Use ˝ NS IV to replete ˝ of calculated deficit
over first 24 hours, the other half over the next 48 hours.
i.
half the volume of ˝ NS infused is ‘free water’, thus 2 L of ˝ NS (84
cc/hr) provides 1 L of free water
ii.
add glucose and potassium as needed to the solution (if NPO or
hypokalemic)
iii.
if severely hypovolemic and hyperosmotic, can begin repletion with NS
D. Measure serum Na+ at least every 6
hours to assure proper rate of correction and to re-calculate deficit
GLUCOSE:
Hyperglycemia: (serum glucose > 200)
A. Usually due to DM and/or
steroid use. Check for glucose in IVF.
B. If not critically ill and
taking
1. Be aware that concurrent
illness can lead to higher glucose levels, may need short term modification
2. Discontinue metformin if any
likelihood of contrast administration
3. Best to simulate home eating
patterns (if not on
C. If acutely ill, worse
control or not
1. Common error: admit with
‘sliding scale’ coverage and FS QID, but never checking results and need to
adjust coverage. For most diabetics, the initial sliding scale is not
sufficient for adequate control. Should assess “prn” sliding scales needs for
previous 24 hours and fold into standing doses (see below)
2. Common error: discontinuing
standing insulin used at home. May need to reduce if less
3. Goal: usually less strict
control than desired for stable outpatient. However, some evidence that
inpatient course can be improved with reasonable control (<200).
Specifically post MI or infected.
D.
Determination of NPH insulin dosage:
1. Measure FS QID (before meals
and QHS)
2. Control with sliding-scale
regular insulin: example: (those on high
doses of insulin at home may need a scale with higher dosages)
3. Determine the previous days’
total amount of regular insulin given and give 2/3 of this dosage as NPH before
breakfast and continue sliding scale coverage, with further adjustment each day.
If giving more than 2/3 of calculated needs as NPH, then discontinue sliding
scale coverage to avoid hypoglycemia. Continue regular FS to determine adequacy
of control.
4. For more fine-tuned control,
can divide the AM and PM dosage into NPH and Regular, as follows: 2/3 of total
needs in AM (2/3 as NPH, 1/3 regular), one-sixth as regular with dinner,
one-sixth at bedtime as NPH.
For example:
if total daily needs in 36 u
24
u before breakfast (16 u NPH, 8 u Regular)
6
u regular with dinner
6
u NPH at bedtime
5. Be aware that changes in
oral intake and overall condition can necessitate downward adjustment of
dosages.
6. Once fairly stable FS
achieved can reduce FS orders to BID
7. No usual role for lispro
(super-short acting) or ultralente (super-long acting) unless part of home
regimen.
Insulin
Kinetics:
Onset Peak Duration
Regular 30-60 min 2-4 hrs 6-8
hrs
NPH 1-2 hrs 6-12 hrs 18-24 hrs
ANTICOAGULATION:
Guidelines for the
Initiation, Monitoring and Clinical Use of Anticoagulant Therapy
(from
the Anticoagulant Consensus Panel, Chest, 2003)
Unfractionated IV Heparin
for
Initiation
1. Check baseline PT/PTT, CBC
2. Give bolus: 80 units/kg IV
3. Begin infusion at 18
units/kg/hr IV
4. Target PTT: 60-110
(institution specific)
Monitoring:
1. PTT six hours after bolus
2. PTT every six hours after
dose change
3. When two consecutive PTT’s
are therapeutic can check PTT every 24 hours
4. Order CBC with platelet
count every three days during treatment (if platelet count falls consider
heparin-induced thrombocytopenia or HIT)
Low Molecular Weight Heparin
(LMWH)
Lovenox
(enoxaparin) is on formulary, routine monitoring of PTT is not necessary,
platelet counts are.
Indication: Dose
DVT
prophylaxis 30mg SC q 12 hours
DVT
treatment 1mg/kg SC q 12 hours
(or 1.5 mg/kg SC QD), decrease dose if CrCl < 30 ml/min
ACS 1 mg/kg SC q 12
hours (for at least 2 days)
Coumadin (Warfarin)
Can initiate concurrently
with heparin unless patient suspected of having a hyper-coagulable state
Day
1: baseline INR, dose 5 mg
Day
2 : Check INR: If INR < 1.5 give same dose
If
INR > 1.5 give lower dose
Day
3: Check INR: If INR <
1.5 patient will likely need higher 5mg
maintenance dose
IF
INR 1.5-2.0 patient will likely need 5
mg maintenance dose
IF
INR > 2.0 patient will likely need
less than 5mg maintenance dose
Heparin and Coumadin therapy
should overlap for 4-5 days and a therapeutic INR on 2 consecutive days should
be obtained before heparin is discontinued
Coumadin
is contraindicated in:
Ř Patients where the risk of
hemorrhage outweighs the potential benefits of therapy
Ř Pregnancy
Ř Alcoholism/drug abuse
(active)
Ř Unsupervised dementia/psychosis
Therapeutic Goals:
Indication INR Target
(range) Duration of Therapy
DVT
prophylaxis 2.5 (2-3) post-operative
(weeks)
Treatment
of DVT/PE 2.5 (2-3) at least 6
months
Tissue
Heart Valves 2.5 (2-3) variable
number of months post operatively
A-fib 2.5
(2-3) lifelong
or until contraindicated
Recurrent
DVT/PE 2.5 (2-3) lifelong or
until contraindicated
Mechanical
heart valves 3.5
(3-4) lifelong
Managing excessive
prolongation of the INR or bleeding while on Coumadin:
Minor/No Bleeding
INR Recommendations
Above
therapeutic, but < 5 Hold
dose; restart at same or lower dose when INR is therapeutic
5.0-9.0
Hold dose; recheck in 24 hours; restart at lower dose when INR is
therapeutic
Oral vitamin K (1.0-2.5 mg) if high risk of bleeding
(e.g. recent surgery)
9.1-20.0
Hold dose; restart at lower dose when INR is therapeutic
Oral vitamin K (2.5-5.0 mg)
can be given
>
20.0 Hold
dose; restart at lower dose when INR is therapeutic
Vitamin
K (5-10 mg) can be given IV/SC
Check
H/H
FFP
can be given if high risk of bleeding (e.g. recent surgery)
Serious Bleeding (e.g. fall in H/H, GI, CNS)
INR
therapeutic or elevated Hold
dose;
Vitamin
K (5-10mg) IV
FFP
(15 ml/kg)
Manage
source of bleeding
AUTOPSY POLICY:
Ask
for autopsy from family in all inpatient deaths. If necessary chaplains can
help explain different religion’s precepts and prohibitions. Autopsy is
important source of medical education. It is estimated that about 20% of
autopsies reveal new information on presumed diagnosis or cause of death.
Autopsy should be especially encouraged in cases of:
1. Unexpected or unanticipated
deaths
2. Deaths due to unknown cause
3. Family (genetic or family
history issues) or public concern (high-risk infectious diseases)
4. Unexpected or unexplained
deaths during or following dental, medical or surgical procedures
5. Deaths of patients who have
participated in clinical trials or protocols
6. Deaths known or suspected to
have resulted from environmental or occupational hazards
Deaths occurring under the following
circumstances must be
reported to the medical examiner (who will rule on exact follow-up):
1. All forms of criminal
violence or from an unlawful act or criminal neglect
2. All accidents (MVA,
industrial, home, etc.)
3. All suicides
4. All deaths that are caused
or contributed to by drug and/or chemical overdose or poisoning
5. Sudden death of a person in
apparent good health
6. Deaths which occur
unattended by a physician and where no physician can be found to certify the
cause of death. Unattended shall mean not treated by a physician within 31 days
preceding death.
7. Deaths of all persons in
legal detention, jails or police custody. This category also includes any
prisoner who is a patent in a hospital, regardless of the duration of hospital
confinement.
8. Deaths which occur during
diagnostic or therapeutic procedures or from complications of such procedures
9. Deaths due to disease,
injury or toxic agent resulting from employment
10. When there is an intent to
cremate or dispose of a body in any fashion other than interment in a cemetery
11. Deaths which occur in any
suspicious or unusual manner
ACUTE CHANGE IN SERUM
CREATININE: (Acute Renal Failure)
·
Marker for GFR
·
If absent renal function, can increase by 1-1.5 mg/dL per day
·
2-5% of hospitalized patients develop ARF
·
Fractional excretion of Na+ is very helpful in differentiating
pre-renal from renal causes (if oliguric):
FeNa+ = Urine
Na+/Plasma Na+ X 100%
Urine Cr/Plasma Cr
For all
causes: watch fluid status and electrolytes carefully and adjust medication
dosages
Consider
acetylcysteine (Mucomyst) when using IV contrast, especially in diabetics
(dosing as order set in MACS)
Classification and
differential:
Etiology Prerenal Postrenal Intrinsic (usually ATN)
BUN/Cr > 20:1 > 20:1 <20:1
FeNa
(%) <1 varies >1
Sediment benign RBC’s
or WBC’s renal tubular casts (ATN)
red
cell casts (glomerular disease)
white
cell casts (interstitial nephritis)
Causes dehydration BPH ischemia
over diuresis blocked Foley contrast (especially
Diabetics)
heart failure medications
(nephrotoxic or allergic)
Treatment maximize volume status Foley (or replace) maybe IVF and furosemide hastens
recovery
Remove
inciting agent
Recovery,
if at all, is over weeks
PAIN:
1. Consider as fifth vital sign
2. Frequently undertreated
3. From ACHQ Guideline:
A: Ask about pain regularly (quality, description,
location, intensity, duration)
B: Believe the patient
C: Choose appropriate options, dosage, frequency
D: Deliver interventions in a timely, logical manner
E. Empower the patients, (PCA if appropriate)
F: Follow up and reassess often
4. Start with acetaminophen and
NSAIDS, use narcotics if needed
5. Determination of source of
pain is crucial, it is a symptom, not a diagnosis
6. For narcotics:
Use short acting to titrate
(fentanyl patch takes 24-36 hours to kick in), then convert to longer acting
formulations
Try to use one medication at
a time, to ease titration
Morphine is cheapest and has
most flexible dosing options (SL, PR,
Assure equianalgesic dosing
when converting from IV to
Always prescribe a standing
dose with breakthrough dosing
Prescribe with laxatives to
avoid constipation
Toxicity usually from the
combined drug (ASA, acetaminophen), no upper dose of narcotic, based on pain
and side effects (sedation, nausea, vomiting, constipation, delirium)
7. Common Errors
·
Undertreat due to fear of addiction:
Addiction very unlikely unless h/o substance abuse
·
Fear of narcotic respiratory suppression: titrate carefully, hold for
sedation. Patient will not go directly from pain to respiratory sedation, will
have sedated state in-between (if emergency, can reverse with naltrexone
0.1-0.2 mg IVP, may need to repeat if reversing a long-acting narcotic)
·
Prescribe incorrectly: frequency of meds should correspond to half-life
(IV= 3 hours,
·
Demerol: do not use, neurotoxic
metabolites, IM hematomas, no evidence that increases biliary tree pressures
·
PRN: in most patients “PRN” is
not a good idea as pain is harder to treat once established, nurse may think
patient is drug seeking, delays administration, language barriers
·
Benefit of Cox-2 inhibitors is over long term treatment, not acutely.
No added analgesic effects.
·
Renally adjust all medications, watch NSAIDS carefully in CRF
·
Codeine is a very weak analgesic, usually more side effects than others
·
Whenever standing dose prescribed, should add breakthrough dosing
Acetaminophen/NSAIDS
Drug Usual
Dose Frequency Comments
Acetaminophen 650-1000 mg
Ibuprofen
(Advil, Motrin) 400-800 mg
Ketorolac
(Toradol) 10 mg
60
mg IM Once
30
mg IM Max
5 day use
Narcotics
Drug Usual
Dose Frequency Comments
Morphine
30 mg
PO/PR q4 h
10
mg SC/IV q3 h
MS
Contin 90-120
mg
Hydrocodone/acetaminophen 1-2 tabs q4
h Max 4g/day
acetaminophen
(5/500,
7.5/750,10/660)
Oxycodone/acetaminophen 1-2 tabs q4 h Max 4g/day
acetaminophen
(5/325,
7.5/500, 10/650)
Tramadol
(Ultram) 50-100 mg
Cautions:
Adjust
dosage in renal failure and elderly
See a
separate prescribing guide for details
Effects
are very individual, adjust according to response (use lower dose if sedated,
higher dose if pain not controlled)
Use MMC
Pain Management Guide (green card) for more details
HYPERTENSIVE URGENCIES AND
EMERGENCIES:
Urgency:
·
Asymptomatic
·
SBP >220 mmHg or DBP > 125 mmHg and
1. Optic disk edema or
2. Progressive target end organ
complications or
3. Periooperative
·
BP must be reduced within a few hours
·
High BP alone rarely requires urgent/emergent therapy (can control with
Emergency:
·
Require substantial reduction of BP within 1 hour to avoid serious
morbidity or death
·
Not defied by specific BP reading (although usually very high)
·
Defined by end organ damage:
Hypertensive encephalopathy
(HA, irritability, confusion and altered mental status) or
Hypertensive nephropathy
(hematuria, proteinuria or progressive renal dysfunction) or
Intracranial hemorrhage or
Aortic dissection or
Preeclampsia-eclampsia or
Pulmonary edema or
Unstable angina/MI
·
Parenteral therapy is indicated
·
Goal: reduce BP by no more than 25% in first minutes to 2 hours, then
towards 160/100 within 2-6 hours
·
Do not use sublingual or oral short-acting nifedipine (Procardia)
(drops BP too quickly)
Pharmacologic
Management:
IV
Agent Dose Onset Duration Comments
Nitroprusside
0.25-10 mcg/kg/min seconds 3-5
min Most
titratible, fastest, CN toxicity
Need
a-line,
Nitroglycerin 0.25-5 mcg/kg /min 2-5
min 3-5 min Used in acute coronary
syndromes
Labetalol 20-40 mg q 10 min 5-10 min 3-6
hrs Good in pregnancy, can
covert to
Or 2 mg/min
infusion
Enalaprilat 1.25 mg q 6 hrs 15 min >6 hrs Can convert to
Furosemide 10-80 mg 15 min 4 hrs Unpredictable onset, good for CHF
Oral
Agent (less acute) Dose Onset Duration Comments
Clonidine 0.2 mg initially, 30-60 min 6-8 hrs sedation,
rebound
Then 0.1 mg
q 1 hr
To total of
0.8 mg
Captopril 12.5-25 mg 15-30 min 4-6 hrs variable-excessive
response
Inpatient Prevention:
A. Infections
5% of those hospitalized w/o
infection acquire a nocosomial infection
a. UTI from Foleys (most common
cause)
i. Only use Foleys when medically necessary, not to
prevent/treat decubiti (Rx is good nursing care)
ii. Remove foleys when placed w/o rationale
iii. Foley
must be removed to clear a UTI
b. Bloodstream infections from
IV lines
i. Check lines frequently, remove at first sign of
infection (red, tender, warm, indurated)
ii. Remove all lines when no longer medically needed
(off IV meds or fluids)
iii. Femoral Lines are for emergencies only. Change
to less infection-prone site ASAP
c. Not all fever indicates
infection
i. unless clinically septic (shock-like picture) can
usually ‘round up usual suspects’ (blood/urine cultures, U/A, check lines,
chest x-ray) and assess results before starting antibiotics
ii. Indiscriminant use of antimicrobials makes further
assessment of infectious source difficult
d. Wash your hands (use purgell dispensers) after
every patient contact. This is not only mandatory, it is good medicine.
Contact Precautions
a. Patients on contact precautions: all persons
entering the patients’ room must wear gloves (whether or not they plan to touch
the patient) and remove gloves/wash hands upon leaving the room. If patient has
open wounds or the examiner expects possible blood/fluid exposure gowns must be
worn and removed upon leaving the room.
B. DVT Prophylaxis
options
a. unfractionated heparin 5000
u SC TID
b. Lovenox 30mg SC BID (ortho),
40mg SC QD (non-ortho)
c. Intermittent compression
device (especially if bleed risk, CNS surgery); inferior to heparins
C.
GI prophylaxis
1. Indications to prevent upper
GI bleeding in inpatients:
a. patients with coagulopathy
b. patients with respiratory
failure (on vents)
c. strong history of upper GI
bleeding (recent)
d. maybe if on: steroids or
high-dose NSAIDS
2. Should usually use a
proton-pump inhibitor (PPI)
a.
b. Most can be discontinued
upon discharge
D. Radiology Issues
Do not order a MRI or MRA on any patient with ANY metal in them. For example, pacemakers,
brain aneurysm clips, implanted drug infusion device, metal in eye, stents,
heart valve, Cava filter, etc. If at all
unsure, ask the radiologist. Do Not order a MRI or MRA on a patient you do not
know without carefully reading the chart, x-rays AND examining the patient. (Each
year a couple of patients with pacemakers are sent for MRI)
All necessary sedation for radiology
procedures should be performed on the inpatient unit, under observation. In any
event any use or preparation of sedatives requires an order in the computer and
a explanatory note in the chart detailing the reasons for sedation, monitoring,
follow-up etc.
E. Restraints
Only to be used when needed
to promote patient safety
Use alternative means
(reorientation, address pain or metabolic issues, medications) whenever
possible
Use least restrictive means
possible (poesy vest better than wrist/leg restraints to prevent falls)
Reassess need often, be sure
to address underlying issues
Indication for restraints is
considered “medical” if behavior disturbance (for example delirium, dementia)
is due to a medical, infectious, metabolic (or the like) issues. “Behavioral”
indications include acute psychiatric disturbances such as suicidality.
Avoiding iatrogenica:
·
Never assume
·
D/C IVF
·
D/C Foleys
·
DVT PPX
·
GI PPX
·
Bowel regimens
·
Trend: VS and Labs
·
Think before daily labs
·
Examine skin and wounds
·
Review Med lists daily
·
Adjust for renal failure
·
Confirm admission med doses
·
Question admission dx
·
Follow up on official radiology report
Sign-Out:
·
Critically important
·
Go over with resident
·
Brief history and updated active issues
·
Code Status
·
“To do list”
·
Culture if spike
·
Access
·
Only sign out issues that affect overnight care
·
Do not sign out procedures or post procedure films
·
Anticipate and have a plan
·
T and C if appropriate
·
If sign out lab/radiology: “what looking for and then what”
Presentations and Progress
Notes:
·
Brief ID of patient
·
Events of last 24 hours
·
Vitals, I/Os, lines, vent settings
·
Meds: including day of abx
·
Focused PE
·
Labs/cultures
·
Recent imaging
·
Problem based plan
Definition of SIRS/Sepsis
SIRS
requires two of:
·
Temp >38 or < 36
·
HR >90
·
RR >20
·
WBC >12K or <4K or >10% bands (if band count reliable)
Sepsis:
SIRS with source of infection
Septic
Shock: Sepsis with hypotension and e/o organ hypo-perfusion despite IVF
resuscitation
Cross Coverage:
·
If called: GO SEE THE PATIENT
o
Assess
o
No phone orders
§ Rare exceptions, but still
need to see
·
ALWAYS LEAVE A NOTE:
o
Why you were called
o
VS and focused exam
o
A/P and F/U
Blood:
·
Products
o
PRBC: RBCs, for symptomatic anemia, fluid resuscitation; 1 u is
300-400cc and = about 1 gm Hg
o
FFP: All plasma coagulation factors; for clotting factor deficiencies,
reversal of PT/PTT, TTP; 220cc
o
Cryo: Factor 8, VWF, Fibrinogen, Factor 13, Fibronectin: for hemophilia
A, vWF disease, 15cc
o
Platelets: for bleeding from plt deficiency, poor function, inhibition,
save this bullet: autoimmunization 50cc, should see about 10K rise if not auto
immunized
·
Transfusion Reactions:
o
All but mild: stop transfusion,
Type Signs/Symps Mechanism Mgmt
Mild
allergic pruritis, urticaria Ab
to plasma proteins benedryl and may re try transfusion
Severe
allergy SOB, abd pain, Abs to plasma
proteins as for
all, benedryl, sc epi, steroids,
low bp, anaphylaxis use
washed rbc’s in future
Fever
chills, rigors, SOB, anxiety
abs to wbc antigens as for all; antipyretics;
premedicate
TRALI
Fever, chills,
sob, ARDS abs from donor plasma
to pt wbc as for all, supportive
Acute hemolytic CP, flank pain, shock, ABO incompatible
as for all, steroids,
induce diuresis,
Monitor
for ARF, DIC, Low BP
Septic
Fever, chills, low bp bacteria in product as for all, culture pt and
product
Resources
‘at the speed of care’ for background questions: online via computer (AECOM Library Website)
·
Up to Date
·
·
Current Medical Diagnosis and Treatment
·
Merck Manual
·
Many others
A stepwise approach to assessing an acid-base
problems.
Look at the pH. Is it
acidemic, normal, or alkaline?
When you have made the
decision about pH look at the carbon dioxide concentration. It is
<40, 40, or > 40? This
will allow you to determine if the pH change is due to respiratory or
metabolic disturbance
Look at the plasma
bicarbonate concentration. Is it < 24, 24, or > 24?
Look at the plasma anion gap.
This is particularly of used in assessing metabolic acidosis.
Look at the plasma chloride
concentration, and look at it in relation to the plasma bicarbonate
concentration. Note that
normal anion gap metabolic acidosis is associated with hyperchloremia,
a normal anion gap, and a low
plasma bicarbonate.
In contrast, increased anion
gap metabolic acidosis has a normal plasma chloride, a reduced plasma
bicarbonate, and increased unmeasured anions (increased plasma anion gap). In
metabolic alkalosis, particularly those associated with chloride depletion,
such as nausea and vomiting or diuretics, the plasma chloride concentration is
low in association with an increased plasma bicarbonate concentration.
Golden rules of determining if an acid-base disorder
is a simple or mixed disorder:
1. In a simple acid-base
disturbance the plasma bicarbonate and CO2 concentrations change in
the same direction. If they
don't, it is a mixed disorder.
2. In a simple acid-base
disorder, the appropriate secondary response must be present. If they
are not present, it is a
mixed disorder.
3. In a simple acid-base
disorder, the secondary response never fully corrects the pH. They
bring pH back toward normal.
If they fully correct the pH or overshoot, it is a mixed acid-base
disorder.
Clinical description in pointing toward specific acid-base
disorders:
1. Tachypnea suggests hyperventilation and, therefore,
respiratory alkalosis.
2. Obstruction to airway flow or inability to breathe, such
as oversedation, suggest impaired gas
exchange by the lung; therefore, increased carbon dioxide
concentration which is respiratory
acidosis.
3. Nausea and vomiting, chloride depletion metabolic
alkalosis
4. Diuretics, chloride depletion metabolic alkalosis
5. Diarrhea results in direct bicarbonate loss from the gut,
resulting in normal anion gap
metabolic acidosis.
6. Chronic renal insufficiency when mild to moderate
typically results in normal anion gap
metabolic acidosis. More advanced renal failure results in
the retention of acid anions, such as
phosphate and urates, and has an increased anion gap
metabolic acidosis.
7. Type I diabetic, off insulin, suggests ketoacidosis, which
is a cause of increased anion gap
metabolic acidosis.
8. Circulatory shock from any cause will tend to result in
anaerobic metabolism leading to lactic
acidosis with an increased plasma anion gap.