- Last edited on February 4, 2024
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on-call:approach-to-im-on-call-emergencies-issues [on February 19, 2023] psychdb [Seizures] |
on-call:approach-to-im-on-call-emergencies-issues [on February 4, 2024] psychdb [Table] |
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| {{INLINETOC}} | {{INLINETOC}} | ||
| ===== Primer ===== | ===== Primer ===== | ||
| - | **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. | + | **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. |
| + | ===== Physical Exam ===== | ||
| + | <alert type="info" icon="fa fa-book fa-lg fa-fw"> | ||
| + | See also: **[[https://meded.ucsd.edu/clinicalmed/introduction.html|UCSD School of Medicine: Practical Guide to Clinical Medicine]]** | ||
| + | </alert> | ||
| + | * Never forget that a good physical exam is critical, so brush up on your general exam skills! | ||
| ===== Vital Signs ===== | ===== Vital Signs ===== | ||
| Never forget the vital signs because they are //vital//. Always remember the A-B-C-Ds: | Never forget the vital signs because they are //vital//. Always remember the A-B-C-Ds: | ||
| - | |||
| * **Airway**: Threatened airway, stridor, excessive secretions | * **Airway**: Threatened airway, stridor, excessive secretions | ||
| * **Breathing**: RR ≤ 8 or ≥ 30, distressed breathing, saturations < 90% on ≥50% 02 or 6L/min | * **Breathing**: RR ≤ 8 or ≥ 30, distressed breathing, saturations < 90% on ≥50% 02 or 6L/min | ||
| Line 12: | Line 16: | ||
| * **Disability**: Decreased level of consciousness (GCS decrease ≥2 points) | * **Disability**: Decreased level of consciousness (GCS decrease ≥2 points) | ||
| * **Other**: Urine output ≤100 cc over 4 hours (except dialysis patients) | * **Other**: Urine output ≤100 cc over 4 hours (except dialysis patients) | ||
| + | |||
| + | ==== The Unresponsive Patient ==== | ||
| + | * **Look** at the chest | ||
| + | * **Listen** for breath sounds | ||
| + | * **Feel** for carotid pulse (no longer than 10 seconds) | ||
| + | * No respiratory effort, no pulse → Call ''CODE BLUE'' and start CPR. | ||
| + | * Respirations and pulse present → Take vitals to assess for airway compromise, breathing insufficiency, and hypotension | ||
| + | ===== Neurologic ===== | ||
| + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> | ||
| + | See main article: **[[neurology:1-approach-neuro-emergencies|]]** | ||
| + | </alert> | ||
| + | ==== Altered Level of Consciousness or Delirum ===== | ||
| + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> | ||
| + | See main article: **[[neurology:1-approach-neuro-emergencies#altered-level-of-consciousness|Approach to Neurologic Emergencies: Altered Level of Consciousness]]** | ||
| + | </alert> | ||
| + | |||
| + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> | ||
| + | See main article: **[[cl:1-delirium|]]** | ||
| + | </alert> | ||
| + | |||
| + | ==== Stroke ==== | ||
| + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> | ||
| + | See main article: **[[neurology:approach-stroke|]]** | ||
| + | </alert> | ||
| + | |||
| + | ==== Seizures ==== | ||
| + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> | ||
| + | See main article: **[[neurology:approach-seizures#treatment|Approach to Seizures: Treatment]]** | ||
| + | </alert> | ||
| + | |||
| + | * If you witness a seizure, call for help, as the patient will likely have decreased LOC following the event. It is appropriate to call a code blue (“Medical Emergency”) if you need medications or more support. | ||
| + | * The first line treatment is with benzodiazepines either IV (preferred or IM). Give lorazepam 2mg, or midazolam 2mg, or diazepam 5mg q2-5minutes PRN until seizures are controlled. | ||
| + | * If not already on antiepileptics, it is reasonable to load them with dilantin (20mg/kg) to prevent further seizures. | ||
| + | |||
| ===== Chest Pain ===== | ===== Chest Pain ===== | ||
| - | <WRAP group> | ||
| - | <WRAP half column> | ||
| == Initial == | == Initial == | ||
| * Assess the patient | * Assess the patient | ||
| Line 28: | Line 64: | ||
| * What is the quality of the pain? (Sharp and stabbing?) | * What is the quality of the pain? (Sharp and stabbing?) | ||
| - | </WRAP> | ||
| - | <WRAP half column> | ||
| == Differential Diagnosis == | == Differential Diagnosis == | ||
| * Differential diagnosis should include non-cardiac causes! The top two serious causes to rule out on a medical ward are pulmonary embolism and MI, while the most common causes of chest are costochondritis (musculoskeletal chest pain) and GERD. | * Differential diagnosis should include non-cardiac causes! The top two serious causes to rule out on a medical ward are pulmonary embolism and MI, while the most common causes of chest are costochondritis (musculoskeletal chest pain) and GERD. | ||
| Line 35: | Line 69: | ||
| * This includes myocardial infarction, pulmonary embolism, aortic dissection, pericarditis, tension pneumothorax, esophageal rupture | * This includes myocardial infarction, pulmonary embolism, aortic dissection, pericarditis, tension pneumothorax, esophageal rupture | ||
| * These are important things to not miss! A severe presentation of any of the above (except for a pulmonary embolism) will also come with other signs and symptoms (the patient will look very unwell or also have other abnormalities on their vital signs) | * These are important things to not miss! A severe presentation of any of the above (except for a pulmonary embolism) will also come with other signs and symptoms (the patient will look very unwell or also have other abnormalities on their vital signs) | ||
| - | </WRAP> | ||
| - | </WRAP> | ||
| == Investigations == | == Investigations == | ||
| Line 86: | Line 118: | ||
| ===== Tachycardia ===== | ===== Tachycardia ===== | ||
| - | ==== Stable or Unstable ==== | ||
| * First question is always "is the patient stable?" | * First question is always "is the patient stable?" | ||
| * If unstable: | * If unstable: | ||
| Line 109: | Line 140: | ||
| </callout> | </callout> | ||
| - | == Atrial Fibrillation Management == | + | ==== Atrial Fibrillation ==== |
| A HR <110 is acceptable. Don’t need to be aggressive unless there are ischemic symptoms (angina, troponin bump, ECG changes, etc). | A HR <110 is acceptable. Don’t need to be aggressive unless there are ischemic symptoms (angina, troponin bump, ECG changes, etc). | ||
| + | ===== Respiratory Distress ===== | ||
| + | * Check vital signs (O2 saturation, respiratory rate) | ||
| + | * Raise the head of the bed | ||
| + | * Call the respiratory therapist! | ||
| + | * If patient requires 50% of more FiO2 and you expect it to stay as is or deteriorate, then call the rapid response team and consider transfer to ICU | ||
| + | * Verify what kind of supplemental oxygen is being given: | ||
| + | * Nasal prongs (low flow -- change) | ||
| + | * Face mask (low flow -- change) | ||
| + | * Venturi mask (higher flow, color coded, 50% FiO2 is orange color) | ||
| + | * Non-rebreather “100% - although really is not” | ||
| + | * Optiflow -- high flow nasal cannula with FiO2 up to ‘100%’ though with air entraining it is much less. | ||
| + | * ABGs are useless in an acute respiratory emergency | ||
| + | * If the patient is already desaturating or having low normal saturation on high FiO2, then they are hypoxic | ||
| + | * Doing an ABG will NOT help you in this acute situation. | ||
| + | * You may send a VBG if a RN is taking blood work, and this would be to rule out a hypercapnic component to the respiratory failure | ||
| + | * Common, non-serious causes of dyspnea or desaturation includes heart failure, COPD, asthma, atelectasis, or anxiety | ||
| + | |||
| + | <panel type="info" title="Urgent and Emergent Causes of Dyspnea or Desaturation" subtitle="" no-body="true" footer=""> | ||
| + | <mobiletable 1> | ||
| + | ^ ^ 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 | | ||
| + | </mobiletable> | ||
| + | </panel> | ||
| ===== Hypotension/Hypertension ===== | ===== Hypotension/Hypertension ===== | ||
| When managing issues around blood pressure, there are only four possible scenarios: | When managing issues around blood pressure, there are only four possible scenarios: | ||
| Line 119: | Line 182: | ||
| - **Hypertensive Bad**: BP is //high//, and patient is having associated symptoms | - **Hypertensive Bad**: BP is //high//, and patient is having associated symptoms | ||
| ==== Hypotension ==== | ==== Hypotension ==== | ||
| - | <WRAP group> | ||
| - | <WRAP half column> | ||
| - | When there is low blood pressure, everyone manages the use of antihypertensives differently. Always treat the patient, not the number. Consider why they are on the antihypertensive to evaluate the risk/benefit to the patient of holding the medication. If you are not familiar with the patient, take the time to go over the trend of vitals in their chart prior to deciding. | ||
| - | |||
| - | <panel type="info" title="Stopping Antihypertensives" subtitle="" no-body="true" footer=""> | ||
| - | ^ 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) | | ||
| - | </panel> | ||
| - | |||
| - | </WRAP> | ||
| - | <WRAP half column> | ||
| <callout type="warning" title="Red Flags for Acute/Critical Care Involvement" icon="true"> | <callout type="warning" title="Red Flags for Acute/Critical Care Involvement" icon="true"> | ||
| * 4 Red Flags: | * 4 Red Flags: | ||
| Line 141: | Line 193: | ||
| * If due to heart failure (especially if patient is hypoxic from heart failure), do not give more IV fluids | * If due to heart failure (especially if patient is hypoxic from heart failure), do not give more IV fluids | ||
| </callout> | </callout> | ||
| - | </WRAP> | + | <panel type="info" title="Urgent and Emergent Causes of Hypotension" subtitle="" no-body="true" footer=""> |
| - | </WRAP> | + | <mobiletable 1> |
| + | ^ ^ 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 | | ||
| + | </mobiletable> | ||
| + | </panel> | ||
| + | **General Management of Hypotension** | ||
| + | * When there is low blood pressure, everyone manages the use of antihypertensives differently. | ||
| + | * Always treat the patient, not the number. | ||
| + | * Consider why they are on the antihypertensive to evaluate the risk/benefit to the patient of holding the medication. | ||
| + | * If you are not familiar with the patient, take the time to go over the trend of vitals in their chart prior to deciding. | ||
| + | |||
| + | <panel type="info" title="Stopping Antihypertensives" subtitle="" no-body="true" footer=""> | ||
| + | ^ 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) | | ||
| + | </panel> | ||
| ==== Hypertension ==== | ==== Hypertension ==== | ||
| <WRAP group> | <WRAP group> | ||
| Line 149: | Line 220: | ||
| <panel type="info" title="Hypertensive Urgency vs. Emergency" subtitle="" no-body="true" footer=""> | <panel type="info" title="Hypertensive Urgency vs. Emergency" subtitle="" no-body="true" footer=""> | ||
| | ^ Hypertensive Urgency ^ Hypertensive Emergency/Crisis ^ | | ^ Hypertensive Urgency ^ Hypertensive Emergency/Crisis ^ | ||
| - | ^ BP | SBP > 210, or \\ DBP > 120 | SBP > 180 \\ DBP > 120 | | + | ^ 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. | | ^ 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%. | | ^ Treatment | Outpatient management. Use PO meds to decrease BP by 25-30%. | Inpatient management. Use IV meds to decrease BP by 25-30%. | | ||
| Line 204: | Line 275: | ||
| * ''**I**'' - **Iatrogenesis** (Glucocorticoids, Thiazides) | * ''**I**'' - **Iatrogenesis** (Glucocorticoids, Thiazides) | ||
| </callout> | </callout> | ||
| + | |||
| </WRAP> | </WRAP> | ||
| </WRAP> | </WRAP> | ||
| + | <WRAP group> | ||
| + | <WRAP half column> | ||
| * **Correcting Hyperglycemia** | * **Correcting Hyperglycemia** | ||
| * You will likely be paged for blood glucose >20 because that’s how the default sliding scale orders are written | * You will likely be paged for blood glucose >20 because that’s how the default sliding scale orders are written | ||
| + | * Consider calling the hospital pharmacist if available to help with insulin dosing as well. | ||
| * **Easy version**: just give the maximum dose according to the sliding scale, or just give 2 units of insulin and ride it out | * **Easy version**: just give the maximum dose according to the sliding scale, or just give 2 units of insulin and ride it out | ||
| + | * Most sliding scales will have insulin Lispro (fast-acting insulin) | ||
| * Before administration of insulin, always ask: | * Before administration of insulin, always ask: | ||
| * When was the last meal or snacks? | * When was the last meal or snacks? | ||
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| * Marked tachycardia (in patients with marked acidemia or severe hyperglycemia, extracellular potassium shifts may result in ECG manifestations of hyperkalemia despite total body losses) | * Marked tachycardia (in patients with marked acidemia or severe hyperglycemia, extracellular potassium shifts may result in ECG manifestations of hyperkalemia despite total body losses) | ||
| * Neurologic symptoms (seizures, focal weakness, lethargy, coma, death) | * Neurologic symptoms (seizures, focal weakness, lethargy, coma, death) | ||
| + | </WRAP> | ||
| + | <WRAP half column> | ||
| + | <callout type="info" title="General Blood Sugar Targets" icon="true"> | ||
| * **General Blood Sugar Targets** | * **General Blood Sugar Targets** | ||
| * Pre-prandial goal: 5-8 | * Pre-prandial goal: 5-8 | ||
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| * Start correcting if the BG > 10 | * Start correcting if the BG > 10 | ||
| * **Wait about 2 hours after eating or insulin administration to check the blood glucose again** | * **Wait about 2 hours after eating or insulin administration to check the blood glucose again** | ||
| + | </callout> | ||
| + | </WRAP> | ||
| + | </WRAP> | ||
| + | |||
| + | <panel type="info" title="Insulin Types" subtitle="" no-body="true" footer=""> | ||
| + | <mobiletable 1> | ||
| + | ^ 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 | | ||
| + | </mobiletable> | ||
| + | </panel> | ||
| ==== Hypoglycemia ==== | ==== Hypoglycemia ==== | ||
| * Hypoglycemia is much more concerning than hyperglycemia because there is a risk for seizures, decreased LOC, and cardiac events | * Hypoglycemia is much more concerning than hyperglycemia because there is a risk for seizures, decreased LOC, and cardiac events | ||
| * Immediate treatment is to ask the nurse to give juice/sugars | * Immediate treatment is to ask the nurse to give juice/sugars | ||
| + | * Stop all sulfonylureas | ||
| + | * Reassess the patient's insulin orders | ||
| * Otherwise, you need to know how to push D50W (also for shifting hyperkalemia) to resolve this as it doesn’t come with a fluid load like running D5W or D10W does and it works the fastest | * Otherwise, you need to know how to push D50W (also for shifting hyperkalemia) to resolve this as it doesn’t come with a fluid load like running D5W or D10W does and it works the fastest | ||
| * Ask for an amp of D50W (50mL), the amp comes with both a needle as well as a Luer Lock tip | * Ask for an amp of D50W (50mL), the amp comes with both a needle as well as a Luer Lock tip | ||
| Line 243: | Line 336: | ||
| * Blood glucose should go up by about 5-10 points after an amp of D50W | * Blood glucose should go up by about 5-10 points after an amp of D50W | ||
| - | * Causes of Hypoglycemia | + | * **Causes of Hypoglycemia** |
| * In hospital, it will almost always be due to excess insulin administration so you should come down on any insulin dose they are on; remember Type 1 diabetics cannot have their basal insulin fully stopped | * In hospital, it will almost always be due to excess insulin administration so you should come down on any insulin dose they are on; remember Type 1 diabetics cannot have their basal insulin fully stopped | ||
| * Other causes include sulfonylureas, liver failure, renal failure, adrenal insufficiency, sepsis. | * Other causes include sulfonylureas, liver failure, renal failure, adrenal insufficiency, sepsis. | ||
| Line 249: | Line 342: | ||
| ===== Electrolyte Abnormalities ===== | ===== Electrolyte Abnormalities ===== | ||
| <callout type="success">{{fa>arrow-circle-right?color=green}} See also main articles on: **[[cl:hypocalcemia|]], [[cl:hypercalcemia-hyperparathyroidism|]], [[cl:hypokalemia|]], [[cl:hypomagnesemia|]], and [[cl:hyponatremia|]]**</callout> | <callout type="success">{{fa>arrow-circle-right?color=green}} See also main articles on: **[[cl:hypocalcemia|]], [[cl:hypercalcemia-hyperparathyroidism|]], [[cl:hypokalemia|]], [[cl:hypomagnesemia|]], and [[cl:hyponatremia|]]**</callout> | ||
| - | ==== Potassium (Hyperkalemia/Hypokalemia) ==== | + | ==== Hyperkalemia ==== |
| - | <WRAP group> | + | * Check first, was the sample hemolyzed (i.e., falsely elevated potassium)? |
| - | <WRAP half column> | + | |
| - | **Hyperkalemia** | + | |
| * In hyperkalemia, you usually need to shift potassium. But this depends on the urgency; remember, the question is which way do you think the potassium is going to go? Is it going to stabilize, improve, or get worse without your intervention? | * In hyperkalemia, you usually need to shift potassium. But this depends on the urgency; remember, the question is which way do you think the potassium is going to go? Is it going to stabilize, improve, or get worse without your intervention? | ||
| * If K = 6 or greater, order an ECG and consider calcium gluconate 1g IV for myocardial protection | * If K = 6 or greater, order an ECG and consider calcium gluconate 1g IV for myocardial protection | ||
| * Check other electrolytes and glucose | * Check other electrolytes and glucose | ||
| - | * Remove offending meds (ACE/ARB/spinronolactone/septra/tacro) | + | * Remove or hold offending medications (ACE, ARB, spironolactone, Septra, tacrolimus) |
| - | * Think of precipitating conditions (renal failure/volume depletion/TLS) | + | * Think of precipitating conditions (renal failure, volume depletion, TLS) |
| * Consider whether this could be a hemolyzed sample -- in doubt can always send a STAT repeat. | * Consider whether this could be a hemolyzed sample -- in doubt can always send a STAT repeat. | ||
| * If they have urine output and you’ve removed potassium sparing medications, put them on a low potassium diet, and their potassium is <5.5, you can just repeat potassium in 4 hours | * If they have urine output and you’ve removed potassium sparing medications, put them on a low potassium diet, and their potassium is <5.5, you can just repeat potassium in 4 hours | ||
| Line 269: | Line 360: | ||
| * If renal failure and refractory HyperK in the acute setting, nephrology should be involved for dialysis. | * If renal failure and refractory HyperK in the acute setting, nephrology should be involved for dialysis. | ||
| - | </WRAP> | + | ====Hypokalemia==== |
| - | <WRAP half column> | + | |
| - | **Hypokalemia** | + | |
| * If K < 2.5, then order an ECG and pay attention to QT segment | * If K < 2.5, then order an ECG and pay attention to QT segment | ||
| * Always order extended electrolytes and replace magnesium if low | * Always order extended electrolytes and replace magnesium if low | ||
| Line 282: | Line 371: | ||
| * NS with 20-40mEq/L -- identify rate and specific duration of therapy | * NS with 20-40mEq/L -- identify rate and specific duration of therapy | ||
| * You will need to give a whole liter of fluid before you can administer the equivalent of one dose of Kdur -- prioritize the oral route!! | * You will need to give a whole liter of fluid before you can administer the equivalent of one dose of Kdur -- prioritize the oral route!! | ||
| - | </WRAP> | + | * Consider holding any diuretics |
| - | </WRAP> | + | |
| ==== Hypomagnesemia ==== | ==== Hypomagnesemia ==== | ||
| - | * If critically low (<0.5): order an ECG to assess QT segment | + | <alert type="info" icon="fa fa-book fa-lg fa-fw"> |
| - | * Treat with MgSO4 2-4g IV in 200-400cc D5W over 2-4hours (all respectively). The nurses will often know the protocol and ordering MgSO4 2g IV should be sufficient | + | See also: **[[cl:hypomagnesemia|]]** |
| + | </alert> | ||
| + | * Can also be due to [[addictions:alcohol:1-use-disorder|alcohol intake]], proton pump inhibitor use, or diarrhea. | ||
| + | * Consider replacing: | ||
| + | * If critically low (<0.5): order an ECG to assess QT segment | ||
| + | * Treat with MgSO4 2-4g IV in 200-400cc D5W over 2-4hours (all respectively). The nurses will often know the protocol and ordering MgSO4 2g IV should be sufficient | ||
| + | * Note that oral Mg can also cause diarrhea! | ||
| ==== Hypophosphatemia ==== | ==== Hypophosphatemia ==== | ||
| - | * If critically low: check K, then replace IV with KPhos 15mmol in 500cc D5W if K < 3.5, OR use NaPhos 15mmol in 500cc D5W if K > 3.5 | + | * Common causes include [[addictions:alcohol:1-use-disorder|alcohol use]] or minimal oral intake |
| - | * If non critical: replace with phosphate novartis 500mg PO | + | * Replace as needed |
| + | * If non-critical: replace with phosphate Novartis 500mg PO | ||
| + | * If critically low: check K, then replace IV with KPhos 15mmol in 500cc D5W if K < 3.5, OR use NaPhos 15mmol in 500cc D5W if K > 3.5 | ||
| - | <WRAP group> | + | ====Hypernatremia==== |
| - | ==== Sodium (Hyponatremia/Hypernatremia) ==== | + | |
| - | <WRAP half column> | + | |
| - | **Hyponatremia** | + | |
| - | * Not the same principle of replacement as in other electrolytes! Sodium imbalances are a problem of water imbalance | + | |
| - | * If acutely hyponatremic (<120), and there are complications such as seizure or mental status change, the patient needs hypertonic saline and ICU/neprhology involvement | + | |
| - | * Most issues of hyponatremia overnight will be chronic and best managed with a fluid replacement or restriction strategy | + | |
| - | * Avoid rapid correction 6-8/24h for risk of osmotic demyelination syndrome | + | |
| - | * Safest action overnight is to do nothing unless there are acute signs and symptoms of deterioration | + | |
| - | + | ||
| - | </WRAP> | + | |
| - | <WRAP half column> | + | |
| - | **Hypernatremia** | + | |
| * This is a problem of water balance (too little), can be common in dementia patients | * This is a problem of water balance (too little), can be common in dementia patients | ||
| + | * Give them water to drink by mouth | ||
| * Again, unlikely to be acute issue overnight | * Again, unlikely to be acute issue overnight | ||
| - | * Slow infusion of D5W if within goals of care is appropriate (in the event that patients are unable to take by mouth) | + | * If NPO give them IV D5W. Stop normal saline. |
| + | * Slow infusion of D5W if within goals of care is appropriate (in the event that patients are unable to take water by mouth) | ||
| * Avoid rapid correction due to risk of cerebral edema | * Avoid rapid correction due to risk of cerebral edema | ||
| - | </WRAP> | + | |
| - | </WRAP> | + | ==== Hyponatremia ==== |
| - | ===== Respiratory Distress ===== | + | <alert type="info" icon="fa fa-book fa-lg fa-fw"> |
| - | == Management == | + | See also: **[[cl:hyponatremia|]]** |
| - | * Check vital signs (O2 saturation, respiratory rate | + | </alert> |
| - | * Call the respiratory therapist! | + | * Not the same principle of replacement as in other electrolytes! Sodium imbalances are a problem of water imbalance |
| - | * If patient requires 50% of more FiO2 and you expect it to stay as is or deteriorate, then call the rapid response team and consider transfer to ICU | + | * Most issues of hyponatremia overnight will be chronic and best managed with a fluid replacement or restriction strategy |
| - | * Verify what kind of supplemental oxygen is being given: | + | * So long as Na > 122, do not worry too much if overnight and on-call |
| - | * Nasal prongs (low flow -- change) | + | * Hold any diuretics |
| - | * Face mask (low flow -- change) | + | * Order urine electrolytes and urine osmolality |
| - | * Venturi mask (higher flow, color coded, 50% FiO2 is orange color) | + | * Safest action overnight is to do nothing unless there are acute signs and symptoms of deterioration |
| - | * Non-rebreather “100% - although really is not” | + | * If acutely hyponatremic (Na < 120), and there are complications such as seizure or mental status change, the patient needs hypertonic saline and ICU/neprhology involvement |
| - | * Optiflow -- high flow nasal cannula with FiO2 up to ‘100%’ though with air entraining it is much less. | + | * Avoid rapid correction 6-8/24h for risk of osmotic demyelination syndrome |
| - | * ABGs are useless in an acute respiratory emergency. If the patient is already desaturating or having low normal saturation on high FiO2, then they are hypoxic. Doing an ABG will NOT help you in this acute situation. | + | |
| - | * You may send a VBG if a RN is taking blood work, and this would be to rule out a hypercapnic component to the respiratory failure | + | |
| - | ===== Altered Level of Consciousness ====== | ||
| - | <WRAP group> | ||
| - | <WRAP half column> | ||
| - | <callout type="success">{{fa>arrow-circle-right?color=green}} See main article: **[[neurology:1-approach-neuro-emergencies#altered-level-of-consciousness|Approach to Neurologic Emergencies: Altered Level of Consciousness]]**</callout> | ||
| - | </WRAP> | ||
| - | <WRAP half column> | ||
| - | <callout type="success">{{fa>arrow-circle-right?color=green}} See main article: **[[cl:1-delirium|]]**</callout> | ||
| - | </WRAP> | ||
| - | </WRAP> | ||
| ===== Pain ===== | ===== Pain ===== | ||
| - | <callout type="success">{{fa>arrow-circle-right?color=green}} See main article: **[[pain-medicine:home]]**</callout> | + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> |
| + | See main article: **[[pain-medicine:home]]** | ||
| + | </alert> | ||
| * What is the etiology of the pain? | * What is the etiology of the pain? | ||
| * Is the patient already on pain medication? | * Is the patient already on pain medication? | ||
| Line 355: | Line 431: | ||
| ===== Insomnia ===== | ===== Insomnia ===== | ||
| - | <callout type="success">{{fa>arrow-circle-right?color=green}} See main article: **[[sleep:2-insomnia-disorder]]**</callout> | + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> |
| + | See main article: **[[sleep:2-insomnia-disorder]]** | ||
| + | </alert> | ||
| + | * Always try non-pharmacological interventions first | ||
| + | * Earplugs | ||
| + | * Eye mask | ||
| + | * Are there other sources of environmental disturbance? | ||
| * If a patient is chronically on a benzodiazepine at home, do not stop them abruptly | * If a patient is chronically on a benzodiazepine at home, do not stop them abruptly | ||
| * Can trial melatonin 3mg PO qHS (though there is poor evidence for use of melatonin in insomnia) | * Can trial melatonin 3mg PO qHS (though there is poor evidence for use of melatonin in insomnia) | ||
| Line 368: | Line 450: | ||
| == Treatment == | == Treatment == | ||
| <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> | ||
| - | See main article: **[[meds:antipsychotics:constipation|]]** | + | See main article: **[[meds:antipsychotics:constipation|Constipation]]** |
| </alert> | </alert> | ||
| * Lactulose (30cc PO can give BID) or PEG 3350 (17g PO) are most effective. Never use docusate sodium (//Colace//), it is not an effective drug! | * Lactulose (30cc PO can give BID) or PEG 3350 (17g PO) are most effective. Never use docusate sodium (//Colace//), it is not an effective drug! | ||
| - | ===== Seizures ===== | + | ===== Urinary Tract Infections ===== |
| - | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> | + | * Do not treat asymptomatic bacteria in the elderly.[([[https://academic.oup.com/cid/article/68/10/e83/5407612|Nicolle, L. E., Gupta, K., Bradley, S. F., Colgan, R., DeMuri, G. P., Drekonja, D., ... & Siemieniuk, R. (2019). Clinical practice guideline for the management of asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 68(10), e83-e110.]])] |
| - | See main article: **[[neurology:approach-seizures#treatment|Approach to Seizures: Treatment]]** | + | |
| - | </alert> | + | |
| - | If you witness a seizure, call for help, as the patient will likely have decreased LOC following the event. It is appropriate to call a code blue (“Medical Emergency”) if you need medications or more support. The first line treatment is with benzodiazepines either IV (preferred or IM). Give lorazepam 2mg, or midazolam 2mg, or diazepam 5mg q2-5minutes PRN until seizures are controlled. If not already on antiepileptics, it is reasonable to load them with dilantin (20mg/kg) to prevent further seizures. | + | ===== Other Lab Abnormalities ===== |
| + | * **Elevated WBC** | ||
| + | * 50% of the time this is NOT due to infection (e.g., stress reaction, steroids) | ||
| + | * **Elevated hemoglobin** | ||
| + | * Often hemoconcentrated. Differential diagnosis is hypoxia (from COPD), EPO, renal (NOT CKD), adrenal (Cushing's) | ||
| + | * **Low hemoglobin** | ||
| + | * If < 70 they need iron and likely blood | ||
| + | * If 70-80 & no active bleeding maybe hold antiplatelet/anticoagulant. | ||
| + | * **New thrombocytopenia in hospital** | ||
| + | * 90% of the time = sepsis, medication related, or HIT [heparin induced thrombocytopenia] | ||
| + | * **Low ferritin** | ||
| + | * Ferritin < 50 is likely iron deficiency. If old, think cancer. If young woman, think menorrhagia (consider OCP) | ||
| + | * **High ferritin** | ||
| + | * Any inflammatory condition, including critical illness | ||
| + | * Other causes include alcohol use, NASH, hepatitis | ||
| + | * **Low B12** | ||
| + | * Autoimmune causes (e.g. - pernicious anemia), malabsorption (e.g. - gastric bypass), meds (e.g. - metformin) | ||
| + | * **High B12** | ||
| + | * cirrhosis, liver cancer or mets, myeloproliferative disorders, critical illness | ||
| + | * **Prolonged PT** | ||
| + | * Often artifact. If bleeding think anticoagulant med (e.g., DOAC), liver disease, hemophilia. | ||
| + | * **Prolonged aPTT** | ||
| + | * Often artifact. If bleeding think: anticoagulant med, liver disease, hemophilia, APLA | ||
| + | * Are PT/aPTT good coagulation tests? No! | ||
| + | * **LTFs** | ||
| + | * High AST | ||
| + | * The //S// stands for //S//ometimes it is from the liver (ddx, rhabdo, viral infection, celiac, toxins, meds, etc.) | ||
| + | * High ALT | ||
| + | * The //L// stands for //L//iver (work them up accordingly) | ||
| + | * High ALP | ||
| + | * Biliary (stone, infection, inflammatory, cancer), bones (cancer, Paget's), liver, pregnancy. | ||
| + | * High bilirubin | ||
| + | * Biliary causes, liver (cirrhosis), heme (hemolysis, transfusion), inherited disorders (Gilbert's), sepsis. | ||
| ===== Resources ===== | ===== Resources ===== | ||
| + | * {{ :on-call_stat_notes.pdf |STAT Notes - Toronto Notes}} | ||