Being a Super Intern - University of Washingtondepts.washington.edu/uwmedres/program/itc/16-17/ITC N.V.C lecture 2016_no TP.pdf · Being a Super Intern: Making people poop and other

BeingaSuperIntern:MakingpeoplepoopandotherimportantthingsatnightGabrielleBerger,MDJuly2016

RoadMap•  Triage common cross-cover calls

with a focus on prac6cal skills for assessment and treatment

1.  Altered mental status 2.  Nausea/vomi6ng 3.  Cons6pa6on 4.  Insomnia

It’s 9pm… And the pager goes off…

Doctor, your pa6ent is ALTERED!

Case1•  85 yo M with COPD, cirrhosis, and Afib admiVed for new PE

•  Started on heparin gV, nebs, and oxycodone with IV morphine for breakthrough pain

•  Nurse pages you that he’s holding the evening meds, including coumadin, because he doesn’t think pt is safe to swallow

Whatisyournextstep?A.  Call the nurse aZer finishing your new admit in the ED B.  Call the nurse for more info now

C.  Order a swallow eval D.  Order a stat EKG and trop and see the pa6ent NOW

E.  Head to the caf for another cup of coffee, you have a feeling it’s going to be a long night

Whatisyournextstep?A.  Call the nurse aZer finishing your new admit in the ED B.  Call the nurse for more info now

C.  Order a swallow eval D.  Order a stat EKG and trop and see the pa6ent NOW

E.  Head to the caf for another cup of coffee, you have a feeling it’s going to be a long night

Case1

•  GREAT! The RN tells you: –  Pt seemed 6red at dinner 6me but ate 50% of meal

–  When RN tried to give evening meds pt was difficult to arouse, opens eyes on command but quickly falls back asleep

Case1:AMS

WATCHER •  INR 1.7, Cr 2.1, Na 127, other labs normal

•  HR 100s, BP 100/60, RR 16, O2 sat 90-92% on 4L –  CV: Irreg irreg, II/VI SEM at RUSB, no LE edema

–  PULM: scaVered wheezes, no crackles –  NEURO: somnolent, arouses to voice but falls back asleep,

withdraws from pain symmetrically, no clonus

Whatisthebestnextstep?

A.  Narcan 0.4mg IV x 1 B.  Stat CTA of the head, stroke protocol

C.  Stat chem 7 and ABG D.  Start 2% saline at 30 cc/hr

E.  Send ammonia level and start lactulose 30g po q4h

F.  Neuro consult

Whatisthebestnextstep?

A.  Narcan 0.4mg IV x 1 B.  Stat CTA of the head, stroke protocol

C.  Stat chem 7 and ABG D.  Start 2% saline at 30 cc/hr

E.  Send ammonia level and start lactulose 30g po q4h

F.  Neuro consult

M

Metabolic /Toxic

I

Infec6ous

S

Stroke (hemorrhagic,

ischemic)

Seizure

T

Trauma

O

Hypoxia Hypercarbia

WhohasanapproachtoAMS?

HypoNa, hypoglycemia, uremia, hepa6c enceph, steroids, EtOH/drugs, etc

Metabolic

Labs (chem 7, Utox)

Check for asterixis

Review med list à check

EMR

Infec6ous

VS, ini6ate infec6ous work up

Rarely need to do an LP

Stroke/

Seizure

Head CT (non-con) à CTA head if

neuro deficit

Treat seizures empirically

Trauma

Non-con head CT

Oxygen (hypoxia or

hypercarbia)

ABG

Case1:AMS•  Labs return:

–  Na 128, Cr 2.3, Glc 123

–  ABG 7.2/78/74 on 4L NC •  eMAR reviewed

–  Morphine 4mg IV x1 at 6pm for breakthrough pain

•  Treatment –  Txfr’d to MICU, placed on NIPPV

–  Morphine d/c’d, switched to dilaudid

Case2:AMS

•  87 yo F admiVed for severe sepsis, found to have a UTI

•  Treated with ceZriaxone, VS stabilized, awai6ng SNF

•  It’s 9:15pm, RN pages you asking for a sleeping pill

•  You call back for more details and find out that pt “seems off”

Case2:AMSYou go to see the pa6ent …

•  VS: T 36.9, HR 80, BP 126/86, 98% RA

•  GEN: awake, picking at blankets, constantly shiZing in bed, trying to sit up

•  NEURO: follows commands, thinks she is at home and the year is 1925, then starts telling someone to get off the ceiling

Case2:AMS

Now what?!?

Case2:AMS

•  Delirium=acute,fluctuaIngsyndromeofalteredaKenIon,awareness,andcogniIon

•  COMMONinelderly,hospitalizedpaIents

•  HyperacIvev.hypoacIve

•  Benign?

Case2:AMSàdelirium

Kalish, et al. Delirium in Older Persons: Evalua6on and Management. Am Fam Phys 2014; 90(3):150-8.

Case2:Deliriummanagment

1.  ManageunderlyingmedicalcondiIons•  Pain,urinaryretenIon,consIpaIon,meds

2.  PreventcomplicaIons•  Removelines,tubes,restraints•  Bedsidecommode,safetymat

3.  ReinforcepreventaIveintervenIons•  Sleephygiene,avoidopioidsandsedaIngmeds•  FrequentreorientaIon

Case2:Deliriummanagement

Kalish, et al. Delirium in Older Persons: Evalua6on and Management. Am Fam Phys 2014; 90(3):150-8.

2 op6ons 1.  Haloperidol 0.5-1mg po/IV qHS (or BID) 2.  Que6apine 25-50mg po qHS (or BID)

ü  Start low, go slow ü  Check QTc!!!

Case2:AMS•  87 yo F with UTI awai6ng placement…

•  On exam, pt has fullness and tenderness in the suprapubic region

•  You note that she is receiving oxycodone 5-10mg q6h prn for low back pain

•  You also note that UOP is low

Case2:AMS

•  You order an I/O cath which drains 1L of clear yellow urine

•  She feels SO much beVer (and promptly goes to sleep)!

QuickTake#1

•  78 yo M with metasta6c lung CA admiVed for bony pain •  You’re called for new onset seizure

•  L arm started jerking 5 min ago, then developed GTC seizure that lasted ~60 sec, pt now unresponsive

•  O2 sat dropped to 70s, now low 90s on 2L

Whatisthebestnextstep?

A.  Lorazepam 2mg IV x 1 now B.  Phenytoin load 20mg/kg IV x 1 now

C.  Leve6racetam 1g IV x 1 now D.  Observe, order MRI brain w/ contrast

E.  Stat ABG

Whatisthebestnextstep?

A.  Lorazepam 2mg IV x 1 now B.  Phenytoin load 20mg/kg IV x 1 now

C.  Leve6racetam 1g IV x 1 now D.  Observe, order MRI brain w/ contrast

E.  Stat ABG

QuickTake#1–Cont’d

•  Pt pos6ctal but protec6ng his airway, awai6ng MRI

•  RN pages again that pt having another GTC

Whatisthenextstepnow?

A.  Lorazepam 2mg IV x 1 now B.  Phenytoin load 20mg/kg IV x 1 now

C.  Leve6racetam 1g IV x 1 now D.  MRI brain with contrast

E.  Stat ABG

Whatisthenextstepnow?

A.  Lorazepam 2mg IV x 1 now B.  Phenytoin load 20mg/kg IV x 1 now

C.  Leve6racetam 1g IV x 1 now D.  MRI brain with contrast

E.  Stat ABG

QuickTake#1–Cont’d

•  Pt gets lorazepam 2mg IV x 1 and seizure breaks

•  MRI shows a new enhancing lesion in the L temporal lobe

•  It’s 6:59am and you’re about to sign out when you get paged the pa6ent is seizing again

InaddiIontomoreaIvananddexamethasone10mgIVx1,whatisthebestnextstep?

A.  Lorazepam gV at 2mg/hr B.  Phenytoin load 20mg/kg IV x 1 now

C.  Leve6racetam 1g IV x 1 now D.  MRI brain with contrast

E.  Stat ABG

InaddiIontomoreaIvananddexamethasone10mgIVx1,whatisthebestnextstep?

A.  Lorazepam gV at 2mg/hr B.  Phenytoin load 20mg/kg IV x 1 now

C.  Leve6racetam 1g IV x 1 now D.  MRI brain with contrast

E.  Stat ABG

Acuteseizuremanagement•  If the seizure is brief (< 1-2 min) and breaks

spontaneously, no need for benzos

•  If seizure lasts > 1-2 min or is recurrent, give lorazepam 2mg IV x 1

•  If ongoing seizures, give phenytoin load and start oral phenytoin

•  If pt becomes hypotensive during phenytoin administra6on à switch to fosphenytoin

AlteredMentalStatusTakeHomePoints

1.  Use a framework (MISTO) to organize the DDx

2.  Check QTc before trea6ng delirium: •  Haloperidol 0.5-1mg po/IV qHS or BID

•  Que6apine 25-50mg po qHS or BID

3.  Use lorazepam for ac6ve seizure, phenytoin load for recurrent seizure

Doctor,yourpa9entisCONSTIPATED

Case3

•  66 yo M admiVed with LLE celluli6s and volume overload

•  On HD4, you’re called at 11 pm because he hasn’t had a BM since admission, having mild abdominal discomfort

•  You’re admiDng 2 pa6ents in the ED…

Whatnext?

A.  Docusate 200mg po BID B.  Bisacodyl 10mg PR x 1

C.  Senna 17mg po qHS D.  Tap water enema

E.  Let the team deal with it in the morning

F.  Get more informa6on

Whatnext?

A.  Docusate 200mg po BID B.  Bisacodyl 10mg PR x 1

C.  Senna 17mg po qHS D.  Tap water enema

E.  Let the team deal with it in the morning

F.  Get more informa6on

Case3

•  Do you really need more informa6on?

•  What’s the minimum amount of informa6on you need over the phone to evaluate cons6pa6on?

Last night…

AdmitinER

AdmitinER

Code

FOOD

Sleep?

Signout

6pm

“Teaching”

12am

Writenotes

6am

PaIentwantstoleaveAMA

CHESTPAINSurgeryrecs

FoleyfelloutNausea

HeadachePharmacy—clarifydose

NGtubefelloutPaIents"llwantstoleaveAMA

Can’tsleepCanyousigntheseorders?

ConsIpaIonIVfellout

Can’twakeup

PaIentdidleaveAMA“What’stheplan?”

DeliriumLowK Ptfelloutof

bed

Abdominalpain

S9llcan’tsleep

Case3:consIpaIon1.  Symptoms of a more serious

condi6on? –  New fever or other VS

changes

–  Risk factors for obstruc6on

2. If not, usually ok to treat empirically –  Start from above or below?

Case3:consIpaIonWhat’syourgoal?

•  BM now! •  By morning

•  Some6me this month

Case3:consIpaIonSlow Days

Stool soZeners: docusate

Bulking agents: metamucil

Moderate 24 hrs

Osmo6c: PEG (miralax, GoLytely), lactulose

S6mulant: senna, bisacodyl po

Fast Min-hrs

S6mulant: bisacodyl suppository, enemas

Saline laxa6ve: Mg citrate

Case4

•  38 yo M with sickle cell disease is admiVed for vasoocclusive crisis

•  He is started on a dilaudid PCA with scheduled colace, senna, and daily bisacodyl po

•  PMH includes ventral hernia with intermiVent SBO

•  On HD6 complains of abdominal discomfort and cons6pa6on, no improvement with bisacodyl PR or tap water enema

Whatisthebestnextstep?

A.  Methylnaltrexone 12mg SC x 1 B.  Naloxone 5mg po x 1

C.  Place NG tube, give GoLytely gV at 50cc/hr D.  Gastrograffin enema x 1, repeat x 1 if no BM

Whatisthebestnextstep?

A.  Methylnaltrexone 12mg SC x 1 B.  Naloxone 5mg po x 1

C.  Place NG tube, give GoLytely gV at 50cc/hr D.  Gastrograffin enema x 1, repeat x 1 if no BM

Treatment Indica9on ClinicalPearls

Methylnaltrexone

SevereconsIpaIoninpaIentsonhigh-doseopioids(cancer,sicklecell)

•  Opioidantagonist•  Doesnotcrossblood-

brainbarrieràNOwithdrawal

PEG(GoLytely)gK

DIOSinCFpaIents

•  NeedtoplaceNGtube

Gastrograffinenema ImpacIon

•  Cancauseselectrolyteshiis(Mg,Phos)

•  ChecklytesBID

OpIonsforreallybadconsIpaIon…

Docusateforeveryone?

•  Canadian policy statement

–  Based on Lit Review on the effec6veness of docusate

–  Conclusion: “the available evidence suggests that docusate is no more effec6ve than placebo in the preven6on or management of cons6pa6on”

ConsIpaIonTakehomePoints

1.  You do NOT need to do a bedside evalua6on for every pa6ent with cons6pa6on

2.  Choose a therapy based on how quickly you want the treatment to work

3.  Consider advanced therapies for certain pa6ent popula6ons (eg, methylnaltrexone)

Doctor,yourpa9entisNAUSEATED

Your27thpageofthenight

RE:PtKS–he’svomiIng.Again.From:Imoverit,RN

Case5:PtKS

•  52 yo M with pancrea66s

•  AdmiVed 3 days ago to the MICU à treated with IVF resuscita6on and bowel rest

•  Transferred to floor today

•  S6ll NPO, VS stable, but nauseated

Whatdoyoudonext?A.  Evaluate the pa6ent B.  Zofran 8mg po x1 as you finish your ED admission

C.  Zofran 8mg IV q8h prn nausea D.  A6van 1mg IV q6h prn nausea

E.  Phenergan 5-10mg IV q6h prn nausea

F.  Find a bathroom and hide, cross-cover is making you sick

Whatdoyoudonext?A.  Evaluate the pa6ent B.  Zofran 8mg po x1 as you finish your ED admission

C.  Zofran 8mg IV q8h prn nausea D.  A6van 1mg IV q6h prn nausea

E.  Phenergan 5-10mg IV q6h prn nausea

F.  Find a bathroom and hide, cross-cover is making you sick

Theemesisladder

Zofran8mgIVq8h

Reglan5-10mgIVq6h

Compazine5-10mgIVq6h

Phenergan6.25-25mgIV/poq6h

AvoidIVifpossible;startlow!

Transi9ontopobefored/

c

Case1:nauseaAwordofcauIonaboutsideeffects…

IVBenedryl,Phenergan

An6histamine

Seda6ng effect, can

cause a high

CombiningReglan+

Compazine

An6dopamine

Dystonic rxns, treat with IV

benedryl

Zofran

An6serotonin

QTc prolonga6on

Case5•  84 yo F admiVed for inability to care for self

•  PMH includes HTN, HLD, DM, CVA, chronic venous stasis

•  Overnight on HD3, she develops new onset nausea and vomi6ng

Case5:onthephone

•  RN tells you: –  Volume of emesis is low, no blood or coffee grounds

–  Pa6ent seems 6red –  Afebrile, BP 90/54, HR 108, O2 sat 95% RA

–  Oriented, complains of epigastric discomfort

Whatisyournextstep?A.  Zofran 8mg IV x1, go to the bedside now B.  Zofran 4mg IV x1 then evaluate in person when you’re

done in the ED C.  Zofran 4mg IV now, ask the RN to call back if no beVer

in 30 min D.  Place NGT and order a stat Hct

E.  Head CT without contrast

Whatisyournextstep?A.  Zofran 8mg IV x1, go to the bedside now B.  Zofran 4mg IV x1 then evaluate in person when you’re

done in the ED C.  Zofran 4mg IV now, ask the RN to call back if no beVer

in 30 min D.  Place NGT and order a stat Hct

E.  Head CT without contrast

Case5:Nextsteps•  On evalua6on à 6red appearing, mildly diaphore6c •  Afebrile, BP 88/54, HR 108, O2 sat 95% RA on 2L

Case5:nauseaàwhentoevaluateinperson?

•  CAD risk factors •  Atypical

presenta6on? •  Ass’d symptoms

MI

•  Mental status changes

•  Headache, blurry vision

CNS

•  Coffee ground emesis

•  Hematemesis •  New onset abd pain

GI

Case5:nausea

•  AZer seeing the EKG, you appropriately call you senior and ac6vate the STEMI pager

•  The pt goes for emergent PCI and is transferred to the CCU

•  Everyone thinks you’re the best intern EVER!

NauseaTakehomePoints

1.  You do not need to do a bedside evalua6on for every pa6ent with nausea

2.  HOWEVER, always consider the possibility of a more serious illness (MI, CNS disease, GIB)

3.  Avoid IV benedryl and phenergan

QuickTake#2•  29 yo F, G2P1, 13w gesta6on, presents with 2 months

of severe N/V, found to have Ca 15

•  AdmiVed for primary hyperparathyroidism à treated with IVFs and cinacalcet

•  Remains nauseated

•  Receives zofran, reglan, and compazine

•  HD 3 she complains of severe headache, Ca 12.5

Whatisthemostlikelycauseofheadache?

A.  Hypercalcemia B.  Zofran

C.  Reglan D.  Compazine

E.  Cinacalcet

Whatisthemostlikelycauseofheadache?

A.  Hypercalcemia B.  Zofran

C.  Reglan D.  Compazine

E.  Cinacalcet

Doctor,yourpa9entCAN’TSLEEP

Case6•  It’s 2am, you get your 67th page of the

night

•  49 yo M with LLE celluli6s

•  H/o anxiety, depression •  Pt hasn’t slept since admission

•  Reques6ng home zolpidem 10mg qHS

RE:PtTD–can’tsleep.Plsorderzolpidem.From:Marla,RN.

Whatnext?

A.  Give the pa6ent a backrub B.  Order trazodone 50mg po qHS

C.  Order diphenhydramine 25mg po x1 D.  Order temazepam 15mg po qHS

E.  Order zolpidem 10mg po qHS, first dose now

F.  Evaluate the pa6ent

Whatnext?

A.  Give the pa6ent a backrub B.  Order trazodone 50mg po qHS

C.  Order diphenhydramine 25mg po x1 D.  Order temazepam 15mg po qHS

E.  Order zolpidem 10mg po qHS, first dose now

F.  Evaluate the pa6ent

Case3:ApproachtoinsomniaAretheremodifiableenvironmentalfactors?•  Turnofflights,treatpain/consIpaIon,minimizeVSovernight,reschedulemedsforday

Isthereconcernfordelirium?•  Needsfurtherassessmentandworkup

Isthisachronicproblem•  Orderhomemeds!

Case3:treaInginsomnia

•  Trazodone 25-50mg po qHS –  An6depressant at higher doses, minimal side effects –  Safe for elderly pa6ents

•  If delirious, use haloperidol or que6apine –  *Always check QTc before ordering an6psycho6c for

sleeplessness

•  Avoid benzos and diphenhydramine, esp in the elderly! –  High risk for side effects and paradoxical reac6ons

Case3:awordaboutzolpidem

Don’t prescribe ambien (zolpidem) for hospitalized pa6ents UNLESS they take it regularly at home

z

TakeHomePointsInsomnia

•  Trazodone 25-50mg po qHS is your friend

•  AVOID zolpidem (ambien) UNLESS pa6ent takes it at home

•  Reschedule meds and VS during the day

Conclusions

•  You are all super interns! •  Use a framework for AMS

•  Cons6pa6on can oZen be triaged over the phone

•  Consider risk factors for MI or GIB when assessing nausea

•  Trazodone is a great sleep aid!

QuickTake#3•  52 yo F with cirrhosis admiVed for UTI

•  Started on CTX, transi6oned to cipro, con6nues on lactulose, rifaximin, propranolol, zofran, oxycodone

•  On HD3, pt complains of chest discomfort, BP 75/50 with HR 140

•  You order an EKG

QuickTake#3

Youcallacodeandordermagnesium2gIVstat,thepaIentstabilizesintheICU.Youdecidetheculpritwas:

A.  Combina6on oxycodone + cipro B.  Combina6on zofran + cipro

C.  Combina6on lactulose + oxycodone + cipro D.  Combina6on rifaximin + oxycodone + zofran

Youcallacodeandordermagnesium2gIVstat,thepaIentstabilizesintheICU.Youdecidetheculpritwas:

A.  Combina6on oxycodone + cipro B.  Combina6on zofran + cipro

C.  Combina6on lactulose + oxycodone + cipro D.  Combina6on rifaximin + oxycodone + zofran

It’sneverwrongtoevaluatethept…butsomeImesyoucanjusttreat!

Treatment Meds Clinical Indica6on

An6eme6c agents

Ondansetron (Zofran) Prochlorperazine (Compazine) Promethazine (Phenergan)

Med/toxin induced emesis Chemo-related emesis Func6onal vomi6ng

Prokine6c agents

Metoclopramide (Reglan)

Gastroparesis Pseudoobstruc6on Dysmo6lity

Special se{ngs Lorazepam (A6van) An6cipatory nausea ass’d with chemo

Benedryl?

Pa6ent Factors

•  Delirium •  Pain •  Anxiety •  Preexis6ng illness (OSA,

depression)

Environmental Factors

•  Noise •  Lights •  Meds à Lasix 10pm •  Nursing interrup6ons (meds,

vitals)

Case6:insomnia•  Insomnia is VERY COMMON in the hospital

ConsIpaIon

Suppositories and enemas work FAST

• Great if pa6ent is uncomfortable

• Preferred route if there is concern for impac6on

Avoid products with Mg in renal

failure

• Cramping • Delirium

Opioids worsen cons6pa6on

• Be aggressive with your bowel regimen!

• (Docusate usually won’t cut it!)

•  A few 6ps: