Post on 02-Jun-2015
HOW TO SURVIVE YOUR FIRST NIGHT ON CALL
Objectives
Have a few tools for common on-call issues
Give appropriate checkout Prevent disasters
Your first night on call
The pager goes off…
Potential news on the other end of the phone
“You have (another) direct admission on F8.”
“Your patient in F 605 is crashing.” “The lady in H 613 would like something
to help her sleep.”
When it is scenario #3
Many calls you receive will be for non-urgent patient complaints
When called for such complaints, you have several options: Ignore them Be careless Be overly cautious Respond appropriately
It NEVER hurts to go say hi to the patient
Cross-Cover
When on call, many (if not most) of the patients for whom you are responsible will not be YOUR patients.
You must depend upon your colleagues to tell you what you need to know about these patients when they check out
Once your colleagues leave, it’s all YOU
CHECK OUTWhere 102% of all medical errors occur
Check Out List
List of patients on a service Used by on-call person (usually intern)
when called about a patient Often the only information the person on
call will know about the patient Usually includes patient names,
locations, principal diagnoses, and any issues that need to be followed up overnight.
Check Out List
Should also include any other information someone might reasonably need on call Diabetes Renal dysfunction Hepatic dysfunction (cirrhosis) Unstable psychiatric conditions Any medications you want or don’t want
given Known potential for instability/overnight
issues
Check Out
Unless not possible, should also include a face-to-face discussion of
major issues
Check Out- If then statements Crappy checkout: “BMP at 1900” Good checkout:
“BMP at 1700, K was 2.5 and we replaced, if still less than 4.0 give 40 more mEq PO”
Crappy checkout: “Watch this guy’s BP” Good checkout:
“He was hypotensive, responded to 1L NS, I think it was just dehydration but we’ve got abx on board for pneumonia. If he drops again you can give another 1-2L, but if that doesn’t cut it move him to MICU”
Check Out- If then statements Crappy checkout: “This guy is totally
crazy” Good checkout:
“He’s been delirious, probably from this UTI. He responded to haloperidol 1mg IM earlier, no QTc issues, can try this again if need be. Definitely avoid opiates/benzos”
Specific issues on Call
Pain Nausea/Vomiting Insomnia Anxiety Agitation Constipation
Heartburn Pruritus A couple of more
urgent issues Electrolytes
Obviously, for any new, unexpected change in a patient, the first thing to
do is to GO SEE THE PATIENT.
THE “SIMPLE,” “MUNDANE,” AND OFTEN ANNOYING…
Pain-Opiates
Morphine 2.5-5 mg IV May repeat q 4 hrs prn
Oxycodone 5-10mg PO May repeat q 4 hrs prn
Avoid Demerol Increased euphoria, risk of seizures
Conversions of Opiates
Morphine 5mg IV = Morphine 15mg PO = hydrocodone 15mg PO The IV is 3x the PO form
Oxycodone is about twice as potent as PO morphine/hydrocodone
You will get a card that has these details, and if you google “opioid conversion” you get good calculators
Pain-Opiates
Opioids (cont) Dose adjustments
Start with ½ dose in elderly or in renal/hepatic dysfunction
Use caution in patients with respiratory illness May have to use more in patients on chronic
opiates PO:IV conversion for morphine is 3:1
If you give too much, remember: Narcan 0.4mg IV
Pain-Acetaminophen
Acetaminophen The SAFEST for most patients Also good for fever 650mg PO/PR Very safe as long as you give less than 4gm
per day in most people and <2gm/day in cirrhotic patients Probably should avoid in active alcoholics
and certainly for patients w acute alcoholic hepatitis
Pain-Combo drugs
Opioid/acetaminophen combinations Percocet
Oxycodone 5mg/APAP 325mg Vicodin
Hydrocodone 5-10mg/APAP 325mg Many other dose combinations available
Quick rule of thumb: most patients can have 1 percocet 5/325 q4h prn pain and be fine
Pain
NSAIDs AVOID in kidney injury, CKD, cirrhosis, CHF,
ACS and UGIB So avoid them in most of our patients
Naproxen 500mg PO q 12 hrs Ibuprofen 800mg PO q 8 hrs Ketorolac (Toradol) 60mg IM/IV once, then
30mg IV/PO q 6 hrs Cannot use for > 5 days
Nausea/Vomiting
Ondansetron (Zofran) 8mg po or IV q 8 hrs prn Safest side effect profile for elderly Not that expensive anymore, and very
cheap PO now. Should be first line PO nausea medicine
Nausea/Vomiting
Promethazine (Phenergan) 25mg IV/IM q 4 hrs prn 50mg PO/PR q 4 hrs prn Causes sedation, agitation, delirium
NauseaphenergandeliriumbenzofallSDHMICUdeathM and M conference presentation +/- lawsuit
Use lower doses (try half) in elderly due to increased side effects (or just avoid in the elderly)
Nausea/Vomiting
Metoclopramide (Reglan) 10mg IV/PO q 6 hrs prn Remember it stimulates gut motility
Avoid in suspected bowel obstruction or diarrhea
Sedating in some patients Use half dose in dialysis patients or elderly Dystonic reaction
Treat with Benadryl 25-50mg IV
Insomnia
Diphenhydramine (Benadryl) 50mg PO 25mg IV Avoid in elderly (anticholinergic), and
certainly in elderly patients with dementia InsomniabenadryldeliriumbenzofallS
DHMICUdeathM and M conference presentation +/- lawsuit
Insomnia
Trazodone 50-100mg qHS Safe in elderly Side effects
Hypotension Priapism falls
Insomnia
Zolpidem (Ambien) 10mg qHS 5mg in elderly (if at all) InsomniazolpidemdeliriumbenzofallSD
HMICUdeathM and M conference presentation +/- lawsuit
Dickey Stephens Park
Acute Anxiety
Why is the patient anxious? Actively dying always makes me anxious too.
Keep in mind a common scenario Anxious pt anxious nurse intern gives benzos
code blue anxious program director Short-acting benzodiazepines (very
dangerous) Lorazepam (Ativan)
1-2mg PO/IV q 4-6 hrs prn Alprazolam (Xanax) do not use it Can try trazodone in elderly first, or can try
hydroxyzine if drug-seeking
Anxiety can be from bad things Anxiety + tachypnea = PE, pneumonia,
sepsis, or MI Anxiety + disorientation =
hypoglycemia, delirium, shock, sepsis Anxiety + fever = sepsis Anxiety + fever + tachycardia +
hypotension = severe sepsis nearing death
Anxiety in 25 yo healthy person w normal vitals except heart rate 96 = anxiety
Agitation
This is not a “nuisance call.” Probably is delirium 9 times out of 10 in inpatients 30% of delirium is caused by our drugs. Other
causes include dehydration, shock, hypoglycemia, hyponatremia, and alcohol withdrawal
Worst thing you can do: “Ok, Ms. Jones is a little agitiated, give her ativan 2mg IV now and let me know how she does” If you do that, the code pager will go off before your
personal pager 1 time in 4 Get on the computer and read the notes, check
the vitals, ask yourself if she is a withdrawing alcoholic, if she is hypoglycemic, if she is septic
Agitation
Haloperidol (Haldol) 2mg-5mg PO/IM/IV In elderly, use 0.5-1mg PO/IM/IV Watch for dystonic reaction
Ativan 2mg PO/IV Avoid in confused elderly patients If delirious, then give haldol without benzo.
May need higher dose if patient uses medication chronically
Constipation
Constipation = miralax deficiency
Constipation Miralax
17 gm 1- ∞ x/day Milk of Magnesia
30 mL PO Magnesium Citrate
8 oz (240mL) bottle PO Fleet’s enema
One enema PR
AVOID THESE IN DIALYSIS PATIENTSRisk of hyperMg/hyperPO4
Constipation
Lactulose 30mL PO Can cause bloating/gas Unless they have hepatic enceph, use
miralax instead Bisacodyl (Dulcolax)
10mg PO/PR Can cause cramping
Combinations also work well
Heartburn
MgOH/AlOH (Maalox) 30mL PO Avoid in dialysis patients
CaCO3 (Tums) 2 tablets PO Safe in dialysis patients
Ranitidine (Zantac) 150mg po BID prn Dose once daily in dialysis patients
Heartburn
GI cocktail Usually combination of Maalox, viscous
lidocaine, and another medication (Benadryl or Donnatal)
Usually complicated to order and is delayed by Pharmacy
Some studies say no better than Maalox alone
Do not give PPI alone for acute heartburn Onset of action is delayed by several hours
Pruritus
Benadryl 25-50mg PO/IV q 4 hrs Avoid or reduce dose in elderly
Hydroxyzine (Atarax, Vistaril) 25-100mg PO/IM q 6 hrs Avoid in elderly Cannot be given IV
Itchingbenadryl or hydroxyzinedeliriumbenzofallSDHMICUdeathM and M conference presentation +/- lawsuit
If one does not work, try the other
MORE URGENT ISSUES
Chest Pain
“What are his vitals? … Ok, Give him SLNG 0.4mg and call for a stat ECG, troponin now and in 4-6 hours, I’m on the way”
Give nitroglycerin 0.4mg sublingual Response does not predict cardiac source, but
may give the patient relief. Will decrease BP every time
EKG Troponin/cardiac enzymes If no response to NTG x 3 and EKG is negative,
can try Maalox or GI cocktail
Chest Pain
7 lethal causes Acute MI Pulmonary embolus Pericarditis with tamponade Tension pneumothorax Aortic dissection Boerhaave’s syndrome (esophageal
rupture) Severe pneumonia
Fever
2 Rules: 1) Get blood cultures before starting any
antibiotics 2) Get blood cultures before starting any
antibiotics
Fever
Obtain blood cultures before starting antibiotics
Causes in hospitalized patients: UTI (foley) Pneumonia Wounds (surgical, trauma, decubiti) Plastic (IV’s, CVL’s, drainage catheters, etc.) DVT C. difficile colitis (if diarrhea present) Sinusitis (if NG tube has been used)
ELECTROLYTES: SOME QUICK REMINDERS
But first more of my favorite city
Electrolytes
Potassium 10mEq for every 0.1mEq above 3.0 20mEq for every 0.1mEq below 3.0
K 2.8, want to correct to 4.0 (20x2)+(10x10) = 140mEq
Electrolytes
Potassium (cont.) For urgent replacement, give PO powder or
tablets and IV IV rates
10mEq/hr through peripheral 20mEq/hr through CVL
Use caution when replacing patients with chronic kidney disease (but still replace if they need it!)
Be even more careful in dialysis patients, but they still need it.
Electrolytes
Magnesium Safe to give in large amounts
“Symptomatic patients, such as those with tetany, arrhythmias, or seizures should receive intravenous magnesium. Such patients should have continuous cardiac monitoring.”
Can be given quickly Give 2-4g MgSO4 IV, and schedule some PO
(like MgOx 400mg BID or TID) 1gm of Mg sulfate IV = 8 mEq Mg Sulfate IV
Only replace if absolutely necessary in dialysis patients
Electrolytes
Calcium Very dangerous to replace IV. In asymptomatic
patients, should be replaced PO. Calcium carbonate (tums) 1250 PO 4x/day
If low, first check serum albumin: [Measured Ca] + [(4.0 – albumin) x 0.8] = corrected Ca
If replacing, know PO4 first Replacement IV for long QT, Vtach, seizure
Ca gluconate 1 amp (10mL of 10% solution) = 1g 1g Ca gluconate = 4.65 mEq Usual replacement is with 1-2g Ca gluconate IV
Electrolytes
Phosphorus If mildly low (>1.5), replace PO
Neutra-Phos 2 packets BID-TID Milk
If very low or symptomatic, pt needs IV as well Ask for help
Do not replace in dialysis patients unless absolutely necessary
(tired of hearing this yet?)
Sodium
2 rules: All hyponatremic patients should have
serum and urine osmolality drawn Get help to make sure all corrections are
slow
Questions