Common Internal Medicine issues and emergencies for psychiatric patients may occur. It is important for any psychiatrist to have a good approach to these issues and to direct the right work up and medical care and not confound psychiatric symptoms with acute medical issues.
Never forget the vital signs because they are vital. Always remember the A-B-C-Ds:
CODE BLUE
and start CPR.Management | Pearls | |
---|---|---|
STEMI | Call a code STEMI. Give ASA 160mg, clopidogrel 300-600mg or ticagrelor 180mg loading dose, and unfractionated heparin or low molecular weight heparin (consider bleeding risk, can choose fondaparinux). Pain can be managed with morphine. Oxygen should also be given. | Less likely to be MI if the pain is reproduced on palpation |
NSTEMI | Can use the same medications as above for STEMI | Less likely to be MI if the pain is reproduced on palpation |
Pulmonary Embolism (PE) | PEs are notoriously difficult to detect, but you must be aware of when it could happen! CTPE can be ordered (The risk of contrast-induced nephropathy is negligible if the patient does not have an AKI or CKD (roughly as long as Cr < 100 you are OK), else you have to think twice about it). Anticoagulation is the first-line treatment (see side-bar for more details). | If the pain is pleuritic with respiration, consider a pulmonary embolism. Any new or worsening tachycardia plus hypoxia with no ECG changes should make you suspect a possible PE. In conjunction with a normal CXR, this would be enough to treat empirically with anticoagulation |
GERD | Should be a diagnosis of exclusion in new-onset chest pain. Treat with Almagel (magnesium hydroxide) or ranitidine |
CODE BLUE
or activate Rapid ResponseA HR <110 is acceptable. Don’t need to be aggressive unless there are ischemic symptoms (angina, troponin bump, ECG changes, etc).
History and Physical | Investigations | |
---|---|---|
Pneumothorax | Hyperresonance, poor a/e, tracheal deviation | CXR (if hypotensive, aspirate immediately) |
Myocardial Infarction | Rapid onset, cardiac RFs, Hx CAD, chest pain | ECG, serial troponin |
Pulmonary Embolus | Wells Criteria for PE | D-dimer, CT-PA |
Heart failure | Hx HF, ↑ JVP, crackles, edema | BNP, CXR, ECG |
Severe asthma | Hx asthma, wheezing | Trial of B-agonist |
COD exacerbation | Hx COPD, wheezing | CXR, ABGs, peak flow |
Anaphylaxis | New meds or exposures, angioedema, ↓ BP | N/A |
Severe anemia | Pallor, tachycardia | CBC, Crossmatch |
Septic pneumonia | Fever, tachycardia, ↓ BP | CXR, blood cultures |
Metabolic acidosis | Ingestions, renal pt, T1DM | ABG, lytes, Cr, glucose |
When managing issues around blood pressure, there are only four possible scenarios:
History and Physical | Investigations | |
---|---|---|
Hypovolemia | Tachycardia < 150, ↓ urine output, ↓ JVP | Cr, BUN, lactate, Group&Sc, Xmatch |
Anaphylaxis | Exposure to agent, SOB, wheezing, angioedema | Clinical Dx (act quickly), give 0.3 mg IM epinephrine |
Sepsis | Fever, source of infection (skin, resp, abdo, urine) | CBC, U/A, CXR, U/S, blood and urine, C&S |
Arrythmia/cardiogenic shock | Palpitations, pulse irregular, dyspnea, ECG | ECG |
Cardiac tamponade | Beck's triad - muffled heart sounds, ↑ JVP, hypotension | ECG, CXR, Echo |
Pulmonary embolus | PERC, Wells criteria for PE | D-dimer, CT-PA |
General Management of Hypotension
Easy to Stop | • Calcium channel blockers (amlodipine) • ACE inhibitors (-prils) • ARBS (-sartans) • Hydrochlorothiazides |
---|---|
Harder to Stop | • Beta blockers (generally do not cause that much hypotension and may be important in avoiding tachyarrythmias such as atrial fibrillation which may worsen heart failure) • Furosemide (may be needed in ongoing treatment of heart failure) |
Hypertensive Urgency | Hypertensive Emergency/Crisis | |
---|---|---|
BP | SBP > 180 DBP > 120 | SBP > 180 DBP > 120 |
Presentation | • Asymptomatic or no evidence of end-organ damage • Use PO meds to decrease by 25-30% Outpatient management | Evidence of end organ damage: CNS (altered LOC, asterixis), cardiac, renal, papilledema. |
Treatment | Outpatient management. Use PO meds to decrease BP by 25-30%. | Inpatient management. Use IV meds to decrease BP by 25-30%. |
Medications | In a patient with HTN pick hydrochlorothiazide over furosemide. But for patients with acute congestive heart failure, Lasix (furosemide) is superior to HCT | Hydralazine, captopril, labetalol IV (continuous infusion), nitroglycerin patch |
Example | Will want to lower BP to 160/100 using PO meds | Nitropatch 0.8mg + labetalol 20mg IV (0.5mg/min infusion) |
I's
can be used to remember the I’s of DKA and HHS:I
- Insulin deficiency (New onset T1DM, failure to take enough insulin)I
- Infection is the most common precipitating factor (Pneumonia, UTI) I
- Ischemia or Infarction (MI, CVA, Acute Mesenteric Ischemia) I
- Inflammation (Pancreatitis, Cholecystitis) I
- Intoxication (Alcohol, Drugs) I
- Iatrogenesis (Glucocorticoids, Thiazides)Class | Examples | Onset | Peak | Duration | Uses |
---|---|---|---|---|---|
Rapid Acting | Lispro/Humalog Aspart/Novorapid Glulisine/Apidra | 15 minutes | 1 to 2 hours | 4 hours | “Bolus” insulin: for glucose elevations related to meals/carb intake, or to correct high BG |
Short Acting | Regular or Toronto (Humulin R or Novolin R) | 30 minutes | 2 to 4 hours | 6 to 8 hours | “Bolus” insulin: for glucose elevations related to meals/carb intake, or to correct high BG *Used for insulin infusions |
Intermediate Acting | NPH (Humulin N or Novolin N) | 1 to 2 hours | 8 hours | 12 to 18 hours | “Basal” insulin: for glucose elevations related to hepatic glucose production in fasting state *Peak can cover lunch |
Long Acting | Detemir/Levemir Glargine (Lantus, Toujeo) | 1 to 2 hours | None | 12 to 24> hours | “Basal” insulin: for glucose elevations related to hepatic glucose production in fasting state |