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InternSurvivalGuide

High – Yield Intern Survival Guide

 

Opening pointers:

1.        It’s never inappropriate to call an upper level for any reason, at any time.  Remember to always follow the chain of command.  Get upper-level involvement sooner rather than later if you think a patient is really sick…

2.        When in doubt, do more rather than less…

3.        Early on it is good advice to always go and see the patient if there is any doubt/hesitation about stability, what is going on or what you should do.

 

VITAL PROBLEMS

 

HYPOTHERMIA  =  Temp < 95

                                                                                               

Rectal temps are the most accurate, when in doubt obtain one

What not to miss: 

Sepsis - check for hypotension, tachycardia, etc and treat accordingly

    If otherwise hemodynamically stable, order a warming blanket

 

 

HYPERTHERMIA =  Temp > 100.4

What not to miss: 

Sepsis, Febrile Neutropenia – (always calculate the ANC).  If fever is new onset, obtain blood cultures x 2, RUA and/or urine cx’s, and attempt to determine etiology.  If you can ascertain the source, initiate appropriate antibiotic coverage.  If the patient has been febrile previously, order blood cultures x 2.

If you have a febrile neutropenic, initiate immediate broad spectrum antibiotics (Levaquin/Maxipime or Zosyn/Fortaz).  If they are already on ABX, consider expansion of coverage (ie, Vanc, antifungals, etc.)

 

 


HYPERTENSION

What not to miss: 

Hypertensive Emergency – noted by end organ damage – ie: MS changes, papilledema, angina, pulm edema, renal insufficiency.  If present, pt will need ICU transfer for management. 

If pt is hypertensive but asymptomatic, can treat w nitropaste 1 or 2 inches applied to chest wall PRN, Clonidine 0.1 mg PO PRN, order next dose of scheduled med earlier, additional dose of scheduled med, etc

IV Meds: Hydralazine 10-20 mg IV q4h PRN, Labetalol 10-20 mg slow IV push followed by 40-80 mg q10min

 

HYPOTENSION = MAP < 65 ~ Systolic BP < 90

What not to miss: 

Septic Shock, Acute GI bleed, Pulmonary Embolus, Arrythmia

    Over the phone: obtain vitals, sats, consider EKG – request manual recheck.

    Almost always requires bedside exam, be sure to check the pressure manually (many times a large cuff was used or the machine was inaccurate).  Assess for signs of end-organ hypoperfusion (altered MS, UOP < 30 cc/hr). If truly hypotensive, bolus NS.  The treatment of hypotension is usually fluids, fluids, fluids.  However, if pt has CHF, ESRD or ARF, try 250cc or 500cc boluses initially and watch for fluid overload (if not hypoxic, tachypnic, and lungs are clear, fluids will likely not hurt – and if profoundly hypotensive fluids are likely your only option on the floor – can run peripheral dopamine at 10 mcg/kg/min while arranging ICU transfer, and pt in this situation will likely require intubation).  REMEMBER: If pt does not immediately stabilize, call your upper level for help.

 

TACHYCARDIA

Unstable tachyarrythmias often require help from upper levels, below are some more common arrythmias with typical treatments:

    Afib with RVR:: if unstable, D/C Cardioversion;  If stable, Diltiazem              10-20 mg IV, Digoxin oral load, Lopressor 5 mg IV, etc

    Sinus Tachycardia: Treat underlying cause

    VTach/VFib: D/C Cardioversion

    PSVT: Carotid massage, Adenosine (6mg, 12mg, 12mg) – have   an upper level present, pacing pads intact, and a rhythm                strip recording the event


 

TACHYPNEA / BRADYPNEA / HYPOXEMIA

For any of the above disturbances, over the phone obtain vitals and sats.  These usually require a bedside examination, especially if Sats are low or RR is high/low. 

Pt is hypoxemic (sats <90%) – obtain CXR and ABG, then initiate O2 as appropriate.  If pt is wheezing, try increasing FiO2 ( ie 40% Facemask, 100% non-rebreather), give albuterol/atrovent nebs (usually 2 back-to-back then q4h and PRN) and consider dose of Solumedrol.  Remember that if FiO2 is increased you must obtain an ABG later (1h) to rule/out CO2 retention.  If pt sounds wet, try increasing FiO2, give IV Lasix, sit pt upright.  If the ABG looks poor or pt seems unstable call your upper level.

 

LAB DERANGEMENTS

 

HYPOKALEMIA

PO replacement is preferable to IV, but either or both can be given as appropriate.  If hypokalemia is mild (>3.0) can give 40 mEq PO x 1 or 40 mEq in 400cc NS and infuse IV over 4 hours.  If hypokalemia is mod-severe (<3.0), may give both PO and IV as above.  K should be rechecked after infusion and additional replacement can be given as needed.  Remember to check Mg. Expect an approximate increase of 0.1 per each 10 mEq supplemented. Consider a lower dose for repletion if pt has CKD or ESRD.

 

HYPERKALEMIA

Consider EKG, especially if >6.5.  If EKG changes are noted or K is very high (>8), give 1 amp CaGluconate (to stabilize myocardium), 10U reg insulin, 2 amps bicarb, and 1 amp D50 in 500cc NS and infuse over 8h. You should also give Kayexalate (15-30 g PO/PR) to get rid of the K – the other interventions only cause intracellular shift.

If no EKG changes noted and the K is not critically elevated, you can omit the CaGluconate and give only the Insulin/Glucose/Bicarb, or you can simply give Kayexalate.  Remember that Kayexalate only works if the GI tract works.  Also, remember to recheck the K in a few hours to ensure that the tx worked.

EKG Changes: peaked T waves, PR prolongation, P wave loss, widened QRS, Sine wave, V Fib


 

HYPOCALCEMIA

Usually not an urgent problem, don’t forget to correct for albumin level.  If corrected Ca is <8, give 4g (1 amp=1 g) CaGluconate in 100 mL NS/D5W over 2h

For ionized Ca:

    1-1.1                     give 4g CaGluconate

    0.85-0.99               give 6g CaGluconate

    0.75-0.84               give 8g CaGluconate

CaChloride is usually given via central line

 

HYPERCALCEMIA

Fluids, fluids, fluids (NS).  If this does not result in adequate diuresis, Lasix 20-40mg IV can be given.  This should only be attempted after adequate volume expansion.  Drugs such as Pamidronate or Zometa are often used to tx hypercalcemia in cancer pts.  Discuss this with your upper level or fellow before starting.

 

HYPOMAGNESEMIA

If IV replacement is needed (severe or can’t take PO)

    give 2-3 grams Magnesium Sulfate IV or more as appropriate

For oral replacement, give 400-800mg MgOxide PO BID-TID

 

HYPOPHOSPHATEMIA

If IV replacement is needed (severe or can’t take PO)

replete w sodium phos or potassium phos usually 2 to 4 mmol over 4-6 hrs depending on severity

Possible estimation of repletion:

    2.3-3     give 0.16 mmol/kg

    1.5-2.3  give 0.32 mmol/kg

    < 1.5     give 0.64 mmol/kg

Mix in NS/D5W (max 15 mmol/100cc) and infuse over 4-8 h (to avoid arrhythmias and hypotension)

For oral replacement, give Neutral-Phos (potassium phosphate) 1-2 packets PO QID

 

 


 

 

COMMON COMPLAINTS / NURSE CALLS

 

 

NAUSEA / VOMITING

Look for underlying cause.  If cause is unknown, treat symptoms and ensure proper hydration.

Try Phenergan 12.5mg, 25mg PO/PR/IV; Compazine 5mg, 10mg PO/IV; or Reglan 10 mg PO/IV; or Zofran 4-8mg IV/PO/SL.  Ativan 1-2 mg or Dexamethasone 4mg IV is used in onc/chemo pts occasionally.

 

 

CONSTIPATION

If you don’t know the pt well, it is often better to avoid aggressive PO meds as these can cause cramping/pain/perforation if pt is obstructed.  If you suspect obstruction, obtain KUB.

Any of the following are appropriate to try

    Enemas – fleets or tap water

    Dulcolax 10mg PO/PR (stimulant)

    Milk of Magnesia 30cc Q6h

    Colace 100mg BID (stool softener)

    If not obstructed, consider Lactulose 30cc Q4h, MagCitrate, or  other concoctions

 

 

DIARRHEA

Usually not a problem that requires emergent intervention.  Make sure that the pt is not dehydrated.  If this is a new symptom, obtain Cdiff, stool Cx’s, fecal WBC

Do not treat diarrhea in Heme pts unless otherwise instructed (may be infectious and tx would be harmful)

If appropriate, consider Loperamide 4mg PO now and 2mg PO with each loose BM (max 16 mg/day).  Use caution when using with pts at risk for Cdiff colitis.

 


 

ALTERED MENTAL STATUS / AGITATION

Obtain vitals over the phone, especially Sats

May check glucose level; evaluate electrolytes,  R/O Sepsis/SIRS

Sundowning is common and responds best to reorienting the pt.  Sedatives often worsen confusion in the elderly.  Look for meds that may be contributing to the delirium (Benadryl, Benzos, etc)

If necessary, try Ativan 0.5 – 2mg PO/IM, Haldol 0.5 – 5mg PO/IM, Geodon 10 mg IM, Risperdal, Seroquel, etc

 

COUGH

Try to identify the etiology and make sure massive hemoptysis is not present

Treat symptomatically with Guaifinosen/Dextromethorphan (Robitussin DM) 10mL PO Q4h PRN.  Can also use formulations with Codeine or Tessalon Perles (100-200mg PO TID)

 

CHEST PAIN

Ask for vitals with sats over the phone.  CP usually requires bedside examination.

Seven deadly causes of chest pain: MI, tension pneumothorax,  PTE, Boorehave’s, Dissecting aortic aneurysm, pericarditis with tamponade, and pneumonia.

If the history is worrisome for a Cardiac source (substernal, radiating to the arm or neck, nausea, vomiting, etc) obtain EKG.  Compare with an old EKG if possible

If cardiac cause is suspected, try SL 0.4mg NTG q5min x 3 or NTP.  Also, consider O2, ASA, Morphine if indicated.  If pain is not relieved with NTG or EKG changes are noted, call upper level.  If possible identify historical risk factors (HTN, smoking, CAD, DM, lipids) prior to calling as this will help guide further decision making.  Cardiac markers do not need to be ordered on all CP pts, but are appropriate if a cardiac cause seems very likely.

If the pt is hypoxemic, order ABG and CXR as above.  Think about PTE/Pneumonia and get help if necessary.

If pain seems musculoskeletal (reproducible by pressing, localized) try pain meds as discussed later.

For GI pain, try Maalox 30 mL PO or a GI Cocktail (viscous lidocaine, Donnatol, Maalox). Elevate Head of bed.

 

 


 

INSOMNIA

Ambien 5 mg PO QHS PRN if elderly, 10 mg PO QHS PRN otherwise

Trazodone 25-50 mg PO QHS PRN

Benadryl 25 mg PO – may want to avoid in elderly pts

 

TRANSFUSION REACTIONS

Pt’s are often premedicated with Tylenol 650 mg PO/PR and Benadryl 25 mg PO/IV

If pt has a contraindication to these meds, it is appropriate to use only one or neither of them.

If a pt experiences hypotension, CP, back pain, tachypnea, acute increase in temp > 2F etc during a transfusion, stop the transfusion and assess the pt.  If anaphylaxis or hemolytic reaction is suspected, notify your upper level.  Fevers or hives do not necessarily require you to D/C the transfusion (these are why you premedicate).  If the pt looks comfortable, you may proceed with the transfusion.  SOB may be a sign of a transfusion reaction, but it may also be secondary to volume overload.  If the pt sounds wet, give Lasix 40mg IV and stop/slow the transfusion (depending on how bad the pt needs blood).

 

 

GI BLEEDS

Obtain vitals over the phone

At bedside, ensure that 2 large bore peripheral IV’s are in place.

Obtain stat CBC, Coags, Type and Screen/Match.

If pt is hypotensive, start fluid boluses (NS) and notify upper level for any significant bleed

In the meantime, place NG tube for lavage if upper source of bleeding is suspected.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FEVER  (temp > 100.5)

Obtain vitals over phone, determine if this is new finding or persistent (if so, is temp trending up or down and are any changes in vitals associated).  If pt has not been recently worked up, order BCx’s x2, UCx, Urinalysis and CXR.  If pt not on antibiotics, consider starting broad spectrum coverage if pt seems unstable/declining.  Consider broadening coverage if already on abx’s but in same scenario.  Typically, broad spectrum agent such as Zosyn or Cefepime plus coverage for MRSA w Vanc is used.  In heme pts, calculate ANC and treat for febrile neutropenia if appropriate.

Draw cultures before abx’s if at all possible.  Treat fever with cooling blanket, Tylenol 650mg q4hrs and/or Ibuprofen 400mg.  If pt remains febrile, can alternate above regimen.  Toradol is also effective if above is unsuccessful.

 

 

 

 

Decreased Urine Output (Oliguria)

Oliguria = < 30cc/hr UOP

In middle of night, consider other vitals, and R/O obstruction.  Have nurse place and/or flush foley or straight cath.  Consider ordering a spot urine Na and creatinine to eval FENa.  If pt is volume contracted (if unsure can check weight and/or orthostatics) , consider IVF’s as appropriate.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAIN

 

Mild Pain

Ø   Acetaminophen 650mg Q4-6h PRN

Ø   Ibuprofen 400-800mg Q6-8h PRN

Ø   Neurontin (neuropathic pain) Start 300mg PO TID

 

Moderate Pain

Ø   Percocet (Oxycodone/Acetaminophen) 1-2 tabs Q4-6h PRN

Ø   Lortab (Hydrocodone/Acetaminophen) 1-2 tabs Q 4-6h PRN

Ø   Tramadol 50-100mg PO Q4-6h PRN

Ø   Toradol 30-60mg IV/IM x 1

 

Severe Pain

Ø         Morphine 2-10mg IV Q4h PRN (May require more if sickle cell pt)

Ø         Dilaudid 2-10mg IV (more potent than morphine)

Ø         Fentanyl Patch 25-100mcg/h patch Q72h

Ø         Oxycontin 10-160mg PO Q12h (High dose only for tolerance – ie cancer pt)

Ø         OxylR 5-30mg PO Q4h PRN

Ø         Demerol 25-50mg IV/IM Q4-6h (Caution using this drug due to seizures and high-abuse potential.  Pts will often request this drug, but it should be used sparingly.  Beware of pts who are “allergic to everything but Demerol”).

 

All doses are “usual” doses, higher doses are sometimes needed, but watch for respiratory depression and use Narcan (0.4-2mg SC/IV) if necessary.


PRONOUNCING DEATH

Example death note:

    Called by nursing staff to see pt.  Upon arrival, pt noted to be apneic and unresponsive.  Heart sounds absent to auscultation, breath sounds absent in all four quadrants.  Bilateral Carotid, Brachial, Radial, Femoral, and DP/PT pulses absent to palpation.  Pupils fixed and dilated, corneal reflex absent bilaterally.  Pt was pronounced dead at ______, family notified.

Nursing staff is usually aware of the protocol and paperwork that must be performed.  In most situations you will only be responsible for assessing the pt and completing the death certificate; however, make sure that the family has been contacted and be available for them if necessary.  Fill out death certificate (AL form requires you to fill out #’s 37-39,41-43,46-50 on death certificate in black ink without mistake/marked out words/white-out) and D/C pt to the morgue.  If you have time, dictate the death summary (like a D/C summary except you read the death note at the end).  This is above and beyond but will be much appreciated by the responsible team.

 

TRANSFUSION TIPS

Example transfusion orders:  Type and match __ units of ___, transfuse when ready.  Premedicate with Tylenol 650mg PO/PR and Benadryl 25mg PO/IV.

ANEMIA

In general, pts are given PRBC’s if HCT is less than 21.  Pts are usually transfused for HCT below 30 if a GI procedure is planned.  The rule of transfusing below 21 is not set in stone (e.g. a pt with severe CAD would likely be transfused sooner often with a Hct of 30), ask your upper level if you’re unsure. M Some Heme pts should receive irradiated, leukocyte reduced RBC’s.

THROMBOCYTOPENIA

Unless otherwise instructed, platelets are transfused if less than 10; or if less than 25 and signs of active bleeding are noted (nose bleeds, etc).  If the pt does not respond appropriately (should increase by 30-50 but its probably OK if the pt is above target number).  Remember, platelets DO NOT have to be type matched (though it is preferable). Rarely, heme pts should receive irradiated blood products (ie, h/o fludarabine, marrow txplt, etc).


COAGULOPATHY

FFP is given to temporarily reverse coagulopathy (preprocedure or in a pt with abnormal coags who is actively bleeding).  Give 10-20mL of FFP per kilo.  One unit of FFP is 200mL (so a 70kg pt would need approx 1000mL, or 5 units FFP).  Most people give 4-6 Units.

Vitamin K is also given, recommend 5-10 mg PO/Sub-Q (PO is safest), avoid IV administration if at all possible.

 

 

Cross Cover Pearls

 

1.        If you are called by the nursing staff regarding a pt “who needs a central line because IV access cannot be obtained”, the appropriate response is to politely ask the nurses to keep trying for peripheral access.  If they cannot obtain access, ask them to call a nurse on another floor to attempt peripheral access (ER, MICU, etc).  If access is still an issue, go evaluate the pt for a possible External Jugular line or attempt peripheral access yourself.  It is very appropriate to place a central line on the floor if necessary, but these situations are seldom.  Of course, if the pt is unstable, skip the above steps and put in a central line.

 

2.        On your admission orders, try to provide necessary PRN medications if appropriate (ie Tylenol, MOM, Ambien, pain meds, etc).  This will make a HUGE difference in the number of calls your colleagues will field during the night.

 

3.        Cross Cover:  Minimize what you sign out, have a complete and accurate sign out list, always verbally sign out your pts, and give recommended course of action for potential problems.  Order f/u labs at reasonable times and together if necessary.  Consider times that night float intern will be present and that labs often take 1-2 hours between time of lab draw and results.  Always make the on-call team aware of potentially unstable pts and DO NOT leave an unstable pt to the on-call team without an appropriate plan of action.  Cosign your fellow intern’s verbal orders (if you agree with what they did).  Write on call notes for any major developments – notes are not necessary for every call.  Make sure the primary team is aware of overnight events.  If called to discuss pt with family, it is appropriate to refer the family’s main questions to the primary team – however, it is often very helpful to obtain contact information for the team.  Issues of immediate concern should be addressed with family as appropriate.

 

 

 

 

4.        Your job as the cross cover intern is to keep the pt alive and stable overnight and help the primary team in their management of their pt.  It is unlikely that you will solve all the pt’s chronic medical conditions or even presenting complaints during the middle of the night.  Do what needs to be done for the pt and then let the primary team do their job of treating/managing the pt.  The fact that the nurse calls you about a concern does not mean it is necessary to address over night; however, just because the nurse does not notify you does not mean you should not assist a pt if you are aware of a serious problem.  It is occasionally appropriate to politely inform the nursing staff that you will inform the primary team of the problem in the morning.

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