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Welcome to the online Housestaff Survival Guide. The purpose of this website is

Welcome to the online Housestaff Survival Guide. The purpose of this website is to provide residents with quick online access to the all the information in their housestaff survival manuals, and beyond. How to use this site: Use the links on the left to navigate. You can find most of this information in your copy of the Housestaff Survival Guide. This website combines this guide with links to useful online resources. Here’s what you will find: Crosscover: common overnight issues, such as chest pain/sob Specialty: common overnight issues for specialty services, such as heme/onc and sickle cell Procedures + Calculators: information on interventions such as procedures, O2 and ECGs Electrolytes: a quick reference for daily electrolyte repletion Call survival tips: a collection of on-call tips, and more Phone Numbers: a collection of phone numbers, pagers, tips, and more Other important sites: Online ICU Guidebook UIH Clinical Care Guidelines New-Innovations AMION [cards] HOME Housestaff Survival Guide Housestaff HOME Survival Guide Home Crosscover Specialty Procedures + Calcs Electrolytes Call Survival Tips Phone Numbers Sign-out CV Chest pain Hypotension / HTN Tachycardia / Bradycardia Pulm Shortness of breath GI Abdominal pain Nausea and Vomiting Constipation / Diarrhea GI Bleeds Neuro Etoh withdrawal Seizures AMS / Sundowning ID Fever Antibiotics Vancomycin dosing Renal Oliguria Hyperkalemia Other Hypo and Hyperglycemia Pruritus / Rash Pain Decision making capacity Death pronouncement Housestaff Crosscover Survival Guide Crosscover Housestaff Survival Guide Home Crosscover Specialty Procedures + Calcs Electrolytes Call Survival Tips Phone Numbers Sign-out Housestaff Survival Guide | Crosscover | Chest pain On the phone: Complete set of vitals. Try to get a good history on the phone. Generally: Onset (gradual = ischemia, pneumonia v sudden = PE, aortic dissection, PTX) Crushing, squeezing, pressure (MI), severe tearing with sudden onset (dissection) Dull/sharp/pleuritic; radiation; location; alleviating factors; assoc’d sx (nausea, vomiting, cough, hemoptysis); cardiac risk factors Based on your first impression, order immediate tests. Consider EKG, CXR, cardiac enzymes. Coags required unless clear musculoskeletal pain. Always go see the patient, to assess for stability, eliminate doubts and help you figure out what is going on. PE: all vital signs; BP in each arm and pulses in both arms and legs (aortic dissection) CV: new murmurs, extra heart sounds, JVP, carotid pulses, sternum/chest wall pain with palpation Lungs: crackles, decreased breath sounds, hyper-resonant percussion, friction rub, trachea deviation Abd: tenderness, BS Ext: Leg edema (CHF, DVT) Based on your history and physical, continue with further workup. Diifferential includes: CV (Angina, MI, pericarditis, dissection), Pulm (PE, PTX, PNA, Effusion) GI (Esophageal spasm, rupture, GERD, PUD, Pancreatitis) MSK (costochondritis, zoster, etc) Pulmonary If you suspect a PE What to think/risk stratification What type of chest pain is it (typical v atypical)? Risk factors? What are his O2 requirements and vital signs? What is the patients Well’s Score? What to order immediately Diagnostics: CT w/PE protocol, VQ ABG. R heart strain? (EKG, troponin, BNP) Therapeutics: empiric anticoagulation until you can r/o supplemental O2 If you suspect a PTX CXR upright with inspiration and expiration If present, and is > 20% of lung: call surgery for chest tube 100% oxygen non-rebreather: improves reabsorption If tension PTX: 16g IV catheter in 2nd intercostal space, then chest tube GI Al hydroxide (Maalox) 30mL po q4hrs, famotidine 20mg po BID or IV Elevate HOB Viscous lidocaine Other: Write a note; avoid morphine until dx and tx are established Re-assess as needed CV If concern for coronary etiology What to think/risk stratification What type of chest pain is it (typical v atypical)? What are his risk factors? What is his TIMI score? What to order immediately Cardiac enzymes + EKG: compare to prior EKG. 3 sets q6hrs Call senior for ST elevations, LBBB, TWI or any questions ABG if pulse ox <95% , tachypneic and to calculate A-a gradient; CXR: look for infiltrate, wide mediastinum, pleural effusion Aspirin 324mg chewable if no contraindication If confirmed to be cardiac Call your senior! ABCs/ACLS, O2 ASA + nitro + morphine + telemetry (nitro 0.5mg SL up to 3 doses 5m apart or 1inch topical paste) (morphine: low dose, can repeat if awake and SBP>90) If ACS: call cardiology fellow to discuss heparin + plavix, consider CCU If concerned for aortic dissection: Check BP on both arms, review mediastinum on CXR, consider CT Angio If confirmed to be dissection Call senior! Call CT surgery & vascular surgery! Transfer to CCU/MICU Control BP w/labetalol or nitroprusside drips for BP • TIMI • Shortness of breath • ECG Guide Quick Links Crosscover Housestaff Survival Guide Home Crosscover Specialty Procedures + Calcs Electrolytes Call Survival Tips Phone Numbers Sign-out Housestaff Survival Guide | Crosscover | Hypotension Recall that BP = CO x SVR, Low cardiac output: cardiogenic (acute MI, worsening CHF, tamponade) hypovolemia, PE, tension PTX, tense ascites Low vascular resistance: sepsis, anaphylaxis, medications, adrenal insufficiency First: Full set of vitals over the phone. Go to patient. Assess for SHOCK: decreased organ perfusion: brain (mental status), heart (chest pain), kidneys (urine output <20ml/hr), skin (cold, clammy), absent bowel sounds. Initially, if there are any concerns for shock, ask RN for 2 large IVs, pt in Trendelenburg, start bolus NS, and get ABG kit to bedside to evaluate acidosis Hx: compare to pt’s baseline BP and make sure cuff is appropriately sized. Is the pt confused or disoriented? Chest pain? Bleeding? h/o infection, allergy, cardiac event? Trauma/surgery/procedure/GI bleed? Sudden onset? Consider massive PE, tension PTX, major cardiac event Recent medications? (IV contrast or antibiotics) PE: Manually re-check vitals Gen: how sick? Cold/clammy, sweaty, obtunded? Neck: JVP, tracheal deviation (PTX?) CV: HR, new murmurs, pulse volume Lungs: crackles, decreased breath sounds Abd: tenderness, GI bleeding Ext: skin temp, cyanosis, cap refill (normal is <2s) Neuro: Mental status Crosscover Housestaff Survival Guide Management If pt is asymptomatic and SBP > 90 (and close to patient’s baseline), let it be. If concerned about shock, get 2 large IVs, give oxygen, consider foley to monitor UOP, intubation if obtunded. Cardiogenic Shock: - arrhythmias – VT, complete heart block, SVT, VF, Afib w/ RVR - ischemia – ST elevation or new LBBB - Post cath, consider tamponade (Triad: JVD, diminished heart sounds, hypotension; also tachycardia, narrow pulse pressure and pulsus paradoxus) - cautious with fluids (except in tamponade – fluids needed until pericardiocentesis) - transfer to CCU or MICU (if any concern for non-cardiology etiology) Sepsis/anaphylaxis/hypovolemia: -bolus fluids (e.g. 500ml normal saline) or wide open and assess immediate response -access: minimum 2 large bore IVs -anaphylaxis: fluids, epipen (from arrest cart if necessary), then q10-15min PRN; hydrocortisone 250mg IV, diphenhydramine 50mg IV, famotidine 20mg IV (ranitidine at VA) -sepsis: IV fluids and antibiotics Other considerations: Acute adrenal insufficiency (esp. in pt with h/o Addison’s, hypopituitarism, long-term steroids): give dexamethasone 10mg IV q6hrs, or hydrocortisone 100mg IV q8hrs If pt is symptomatic or in shock, call your senior, and consider transfer to MICU/CCU for pressors. Dx algorithm: (oversimplified) cool skin & normal JVD -> hypovolemia or septic shock cool skin & increased JVD: -> cardiogenic warm skin & fever -> sepsis warm skin, rash, wheeze, stridor -> anaphylaxis Potential tests: orthostatics, ECG, CXR cardiac enzymes, ABG, CBC, type&cross, lytes (anion gap?), lactate, LFTs, coags, blood cultures Echo if concern for cardiogenic shock Home Crosscover Specialty Procedures + Calcs Electrolytes Call Survival Tips Phone Numbers Sign-out Housestaff Survival Guide | Crosscover | Hypertension First: Full set of vitals over the phone. Repeat manual BP yourself (use larger cuff if needed) Hx: Review baseline BP: Acute increases in BP are more dangerous. Assess for chest pain, back pain (dissection), change in MS, change in vision, unilateral weakness or decreased sensation (stroke), SOB (pulmonary edema). If there is any evidence of end-organ damage (myocardial ischemia, hematuria, proteinuria, CNS symptoms), this is Hypertensive Emergency PE: BP in both arms (aortic dissection); HR (bradycardia may = increased ICP) Gen: mentation; how sick is the pt? HEENT: papilledema, retinal hemorrhages or exudates, arteriolar narrowing CV: elevated JVP, S3 Lungs: crackles (pulmonary edema), decreased sounds (effusion) Neuro: mental status, lethargy(encephalopathy), focal deficits (CVA) Tests: If concern for urgency/emergency consider UA (for blood/protein), EKG, CXR (widened mediastinum for aortic dissection), non-conCT(subarachnoid hemorrhage, hemorrhagic CVA) DDX: pain, anxiety, nausea, alcohol withdrawal are common, but Do Not Miss: hypertensive emergency associated with hypertensive encephalopathy, aortic dissection, pulm edema, MI, subarachnoid or cerebral hemorrhage Management: Treat pain and anxiety. Review boxes on the right side of this page. Consider stopping IVF. Aim for slow decrease in BP if it’s chronic. . . . or see below . . . (avoid reflexively ordering hydralazine and other meds that are difficult for the pt to take at home) **Blood pressure for post-stroke/neurology patient is DIFFERENT -> usually BP >180/100 to maintain adequate cerebral perfusion (CPP = MAP – intracranial pressure)** Crosscover Housestaff Survival Guide Hypertensive Urgency: asymptomatic; SBP >220, DBP >120 Treatment: PO antihypertensives, decrease MAP by 25% or to 160/110 over several hours First try to increase doses of meds pt is already taking; or consider Labetalol 50mg po, Nitropaste 1 inch topical (also uploads/Sante/ intern-survival-guide-uic 1 .pdf