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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: