Common Calls From The Floor

Bradycardia

Evaluation

Management

Tachycardia

Narrow complex tachycardia

Evaluation

Management

Wide Complex Tachycardia

Evaluation

Management

 

Hypotension

Evaluation

Decreased SVR: Exam = warm extremities, sometimes flushing

Decreased preload: Exam= cold extremities

Decreased contractility

Management

  1. Is the patient stable?
  2. Have low threshold to transfer a hypotensive patient to the ICU for better nursing support, pressors and/or intubation
  3. Treatment is aimed at the underlying cause but almost all cases call for fluid resuscitation. If suspicion of CHF is low then give rapid isotonic fluid resuscitation
  4. If there is concern for mixed cardiogenic and septic shock, let your volume exam guide treatment. Keep fluid boluses small (i.e 200ml and reassess). Trend lactate.
  5. In general, start O2, additional large bore peripheral IVs, put patient in trendelenburg, draw basic STAT labs (CBC, lytes, BUN, creatinine, glucose, LFTs blood/urine culture), STAT EKG, CXR, ABG/lactate

If the patient stable then ask this question

  1. Is this BP real?
  2. Is the BP different from prior values? if the patient usually has a BP 80/40 then the acuity may be decreased somewhat
  3. Is there associated hypoxemia, AMS, or increased RR (reasons for intubation)?
  4. Is the MAP <60? MAP less than 60 results in significant risk of hypoperfusion to vital organs

Hypertension

Evaluation

Physical examination

Lab: not always required. Use selectively to determine cause and whether patient meets criteria for hypertensive emergency.

Management

For hypertensive urgencies: Majority of patient with HTN have no acute end organ damage and their BP can be lowered over days with oral medications. Consider rechecking BP after 30 minutes of quiet rest. Restarting a patient's home med is a good first step. Alternatively, consider starting one or more long acting oral med that can be continued on discharged.

In cases where more rapid lowering and closer tritration of BP is desired, consider shorter acting med

For Hypertensive emergencies

Fever

Differential

- Infection (lung, heart, brain, urine, sinuses, prostate, abdomen, skin, joints, lines, etc) 
- Infammation (Collagen vascular disorder, neoplastic disorder) 
- Mucositis
- Atelectasis
- Blood product reaction
- Drug fever (beta lactam antibiotics and amphotericin common causes)
- PE vs DVT 

Is it a true temperature?

-  Is it greater than >100.4 F?
- Quickly chart check and determine if patient is stable vs unstable (look at vitals, etc).  If unstable go to bedside immediately! 

 If unstable:

First:  Brief yet thorough chart check

 Go assess bedside.

Get as much hx as you can - drug allergies, recent infections, blood transfusions, etc. Targeted exam (skin, lungs, extremities, etc). If patient is not responsive or sudden change in mentation, address those first.  
- If you have an idea where the infection is coming from, start targeted antibiotics.   
- If no idea where infection is coming from,  repeat blood culture if > 48 hours since last blood culture. If blood culture performed less than 48 hours ago, usually no need to repeat blood culture.
-Consider pan culture - UA, Urine Clx, line clx, CXR, and EKG on top of repeat blood cultures. 
- Labs to order (based on presentation/suspicion): CBC, CMP, Lactate, Trop, BNP, D-dimer, PT/PTT, etc.
- Also start broad-spectrum antibiotics (Vancomycin/Zosyn) (unless antibiotic allergies)
- ICU consult, Stat. 

If stable:

- Assess where the nurse took temperature, is it in the correct location?
- Have RN recheck temperature in 30 mins and dochalo/ call you. You do not have to act on one temperature, first confirm it. (Exceptions might be if the patient is neutropenic, then consider neutropenic fever). 
- Do a thorough chart check while you wait for a call back:
         - Why was the patient admitted?
         - What was the WBC?
         - What was the urine output?
         - Any recent meds/blood transfusions/surguries?
- If after 30 minutes temperature is confirmed, go assess patient bedside. 
- Get a detailed history from patient. 
- Do a thorough PE, looking for skin infections (including decubitus ulcers), and looking at all lines. 
- If worried about an infectious cause, start appropriate antibiotics. 



Low urine output

Normal urine output

- typically at least 0.5 cc/kg/hr. 
- Oliguria: urine output < 400cc/day
- Anuria : urine output < 100cc/day 

Do you believe the numbers? 

- If patient has foley, flush tubing to make sure it is not clogged. 
- If no foley, ask about urine output, look at daily weights, etc. 

 Examine patient bedside.

- Assess volume status: mucous membranes, skin pallor/dryness, edema, complaints of thirst, neck veins (assess CVP), crackles in lungs (pulmonary edema), bladder palpable on exam, prostate exam, etc. 

Check a post-void residual by bladder scan. 

- If volume > 300cc, then insert foley (In and out). If consistent > 300cc, keep foley in. 

 Causes of urinary retention: 

- BPH, anticholiergic medication, side effect of medication:narcotics/benadryl/anestetics

Assess for renal failure (AKI) 

- Prerenal, renal, postrenal causes. 
- Look for fluid overload (CHF), and obstruction (renal US). 
- If both negative, then fluid challenge is acceptable: 500cc L bolus. (Go to AKI for further management). 

CHF/Volume overloaded? Initiate diuresis:

- Working kidneys: lower IVF rate and self-diuresis
- CHF/symptomatic: use lasix 20mg - 80mg IV 
- Renal failure: Dialysis? If kidneys still working, can try high dose lasix - 160mg- 240mg IV Lasix. 

Dyspnea

DDx (5 major categories of disease to consider)

Pulmonary

Cardiac

Metabolic

Hematologic

Psychiatric

Evaluation of Patient

History

Physical exam

Labs/Studies

Initial Management

A. Oxygen

B. Diuretics

C. β-Agonists

D. Intubation

E. Other

Chest pain


I. DDx (Biggest killers)

Evaluation of Patient

History:

- Learn about acuity of onset of chest pain
- Associated symptoms? (cough, dyspnea, palpitations, fever)
- Review recent events or meds given at time of symptoms onset
- Review relevant PMHx and admitting diagnosis
- Look at initial EKG (from chart if available)
- Focus on ruling out the major killers rather than definite diagnosis

Physical exam:

- Start by asking nurse for vital signs (HR, RR, BP, O2 sat). Ask for second set 15-30 minutes later.
- Ask nurses to get immediate EKG as you walk to patient’s room.
- Lung/cardiac exam 

Initial Labs/Studies to Order

- Ask nurses to get immediate EKG as you walk to patient’s room.
- Crisis panel
- CBC, CMP, troponin x3 q6h, CXR, ABG
- CHF = echo

Management


Suspected Angina/MI 

- Start O2 by NC and give sublingual NTG 0.4mg q5 min x3; hold for SBP < 100
- Remember, if chest pain responds to NTG it does not automatically rule in angina.
- If ineffective, try other antianginals
- Metoprolol 5mg IV q5 min x 3 (avoid in COPD/asthma)
- Nitropaste
- If not already on aspirin/Plavix and has no contraindications, order ASA 325mg and Plavix 300mg x 1
- Further meds = high-dose statin, consider ACE inhibitors

Suspected Dissection

- Call and transfer to ICU to reduce BP and inotropy with beta-blocker
- Order CT scan or echo and call surgery
- EKG may show evidence of ischemia in RCA distribution if dissection is proximal 

Suspected Pneumothorax

- Call surgery for chest tube placement
- If tension pneumothorax, immediate needle decompression at 2nd intercostal space at midclavicular line. Don’t wait for CXR. 

Suspected PE

- ABG confirms hypoxia
- Consider CTPA or V/Q scan and start anticoagulation

Suspected Pericarditis

- NSAIDS and colchicine

Wrap up: 

- Obtain post-pain EKG and document event 

 

Combative or Confused patients

  1. Does the patient have altered mental status or is he/she upset over something?
  2. If there is any question of physical injury, call security (0). No matter how many years of commando training you have, it is not your responsibility to restrain patients in a safe manner. Also, patients generally tend to calm down when they are confronted by overwhelming numbers of people who are responsive to their needs or anxieties.
  3. Try to do as much of an altered mental status workup as you can. If you suspect an underlying reason for the agitation (pain, sundowning, hypoxia, medication), then obviously treat the underlying reason. 

Management

Non-pharmacologic

Pharmacologic

Falls

Evaluation/Management

Differential diagnosis. 

Insomnia

  1. Trial non pharmacological measures first: sleep hygiene, noise reduction (ear plugs/muffs), reduce lighting, avoid night time interruptions if able, turn off TV/radio/etc. In room
  2. Before using pharmacotherapy, check patient allergies
  3. Melatonin is generally a safe starting point for medications, with 1-3mg PO scheduled at 9 to 10pm
  4. If not effective, can consider trazodone 50mg PO at bedtime (caution with orthostatic hypotension, atrial/ventricular arrhythmias) 
  5. Can also consider benadryl 25-50mg or hydroxyzine 50-100mg PO nightly PRN (safer for elderly) insomnia. Watch for anticholinergic side effects (dry mouth, blurry vision, urinary retention) and use with caution if impaired cognition.
  6. If still ineffective can consider ambien 5-10mg PO nightly
  7. If above measures not effective, evaluate the patient before considering any strong sedatives.