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on-call:approach-to-im-on-call-emergencies-issues [on April 13, 2020]
on-call:approach-to-im-on-call-emergencies-issues [on February 4, 2024] (current)
psychdb [Table]
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 ====== Approach to On-Call Internal Medicine Emergencies and Issues ====== ====== Approach to On-Call Internal Medicine Emergencies and Issues ======
 +{{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//​. ​These are some indications that a patient is seriously ill and need more support: +Never forget the vital signs because they are //​vital//​. ​Always remember the A-B-C-Ds
- +  * **Airway**: Threatened ​airway, stridor, excessive secretions
-  * **Airway**: Threatened, 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
   * **Circulation**:​ Systolic blood pressure ≤ 90 mmHg or ≥ 200 mmHg or decrease >40 mmHg, HR ≤40 or ≥130   * **Circulation**:​ Systolic blood pressure ≤ 90 mmHg or ≥ 200 mmHg or decrease >40 mmHg, HR ≤40 or ≥130
   * **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)
-  ​Any other serious concern ​for the patient+ 
 +==== 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> +== Initial ​==
-<WRAP half column>​ +
-== 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. +
-    * Think cardiac, thorax (not heart), chest wall, GI +
-    * 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) +
-</​WRAP>​ +
-<WRAP half column>+
   * Assess the patient   * Assess the patient
   * Monitor the vitals closely over time   * Monitor the vitals closely over time
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     * Chest X-Ray should also be considered if relevant     * Chest X-Ray should also be considered if relevant
   * Can also empirically order Tylenol, morphine to temporize pain (if there are no contraindications to the above)   * Can also empirically order Tylenol, morphine to temporize pain (if there are no contraindications to the above)
 +
 == Physical Exam == == Physical Exam ==
   * Inspect, palpate, auscultate   * Inspect, palpate, auscultate
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   * What is the quality of the pain? (Sharp and stabbing?)   * What is the quality of the pain? (Sharp and stabbing?)
  
-</​WRAP>​ +== Differential Diagnosis == 
-</​WRAP>​+  * 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. 
 +    * Think cardiac, thorax (not heart), chest wall, GI 
 +    * 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)
  
 == Investigations == == Investigations ==
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 </​WRAP>​ </​WRAP>​
  
 +<​imgcaption image1|>​{{ :​on-call:​schematic_of_atrial_repol_wave_from_my_book.png?​600 |The ECG In Acute MI, Stephen W. Smith, MD}}
 +</​imgcaption>​
 +
 +===== Tachycardia =====
 +  * First question is always "is the patient stable?"​
 +    * If unstable:
 +      * Call a ''​CODE BLUE''​ or activate Rapid Response
 +    * If stable:
 +      * What is the rhythm of their pulse?
 +      * Get an ECG
 +
 +<callout type="​info"​ title="​ECG Strip Reading"​ icon="​true">​
 +Is the QRS narrow or wide?
 +  * If wide: it is VT until proven otherwise
 +  * If narrow: it is either sinus tachycardia vs SVT
 +    * Sinus tachycardia
 +      * ECG shows: P before every QRS, QRS after every P, P is upright in leads I, II, PR is fixed
 +      * Differential diagnosis: Pain, agitation, withdrawal, sepsis, volume depletion, PE, heart failure, pain, agitation, withdrawal, sepsis, volume depletion, heart failure
 +    * SVT
 +      * Most commonly will be due to Atrial fibrillation (AF) or Atrial flutter
 +        * How fast is the HR?
 +        * Are they on rate control agents already?
 +        * Again, if unstable, call for help!
 +        * Think of why this is happening! Treat underlying cause first, rather than just increasing meds
 +</​callout>​
 +
 +==== Atrial Fibrillation ====
 +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:
-<WRAP col2> 
   - **Hypotensive Bad**: BP is //low// and the patient is dying!   - **Hypotensive Bad**: BP is //low// and the patient is dying!
   - **Hypotensive Fine**: BP is //low//, patient is fine, should we hold antihypertensives?​   - **Hypotensive Fine**: BP is //low//, patient is fine, should we hold antihypertensives?​
   - **Hypertensive Fine**: BP is //high//, patient is fine, do we treat with antihypertensives?​   - **Hypertensive Fine**: BP is //high//, patient is fine, do we treat with antihypertensives?​
   - **Hypertensive Bad**: BP is //high//, and patient is having associated symptoms   - **Hypertensive Bad**: BP is //high//, and patient is having associated symptoms
-</​WRAP>​ +==== 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), and 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:
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   * Management   * Management
     * If due to sepsis, give more IV fluids and repeat lactate     * If due to sepsis, give more IV fluids and repeat lactate
 +    * If due to dehydration,​ give IV fluids (consider 0.9% NS to avoid inducing hyponatremia)[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC4096820/​|Bhave,​ G., & Neilson, E. G. (2011). Volume depletion versus dehydration:​ how understanding the difference can guide therapy. American journal of kidney diseases, 58(2), 302-309.]])] ​
     * 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.
  
-== Hypertension ==+<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 ​====
 <WRAP group> <WRAP group>
 <WRAP half column> <WRAP half column>
 <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%. ​                              |
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 ===== Glucose Abnormalities ===== ===== Glucose Abnormalities =====
-== Hyperglycemia == +==== Hyperglycemia ​==== 
-  * Hyperglycemia is of little significance acutely ​UNLESS they are in DKA from it, and that usually requires at least a few days’ ​worth of insulin deficiency before ​it happens. +<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw">​ 
-    * The key here is that in DKA the patient will be acidotic (low bicarb, high AG). In the context of positive ketones and known diabetes -- this is DKA regardless of the glucose value (euglycemic DKA is possible and much higher incidence with SGLT2 inhibitors) +See also: 
-  * You will likely be paged for blood glucose >20 because that’s how the default sliding scale orders are written +  * ** {{:​on-call:​insulinstarttool_e_print.pdf |Guide to Starting and Adjusting Insulin for Type 2 Diabetes}}** 
-  Rule of thumb to fix hyperglycemia +  * **[[https://​www.saem.org/​about-saem/​academies-interest-groups-affiliates2/​cdem/​for-students/​online-education/​m4-curriculum/​group-m4-endocrine-electrolytes/​hyperglycemia|Hyperglycemia:​ Society for Academic Emergency Medicine]]** 
-    * Easy version: just give the max dose according to the sliding scale, or just give 2 units of insulin and ride it out+</​alert>​ 
 +<WRAP group> 
 +<WRAP half column> 
 +  * Hyperglycemia is usually ​of little significance acutely ​**unless** the patient is in diabetic ketoacidosis (DKA) or in a hyperosmolar hyperglycemic state (HHS) from it, and that usually requires at least a few day'​s ​worth of insulin deficiency before ​this happens
 +    * Diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) are the most serious, acute metabolic complications of diabetes, but other differentials include dietary indiscretion and new onset or uncontrolled diabetes 
 +      * **DKA** is a state of absolute insulin deficiency, hyperglycemia,​ anion gap acidosis, and dehydration. It classically occurs in younger patients (<65 years) with Type 1 diabetes and usually evolves rapidly over 24 hours. The most common causes are infections, disruption of insulin therapy, or as the presentation of new onset diabetes. 
 +      * **HHS** is a state of hyperglycemia,​ hyperosmolarity,​ and dehydration without significant ketoacidosis. It is typically seen in Type 2 diabetics, and has a higher mortality rate compared to DKA, and occurs in older patients. It most commonly occurs in older patients (>65 years old) with infections and/or poorly controlled Type 2 diabetes and evolves over several days. 
 +      * Both DKA and HHS originate from a //​reduction//​ in insulin and an //​increase//​ in counter-regulatory stress hormones
 +    * The key here is that in DKA the patient will be acidotic (low bicarb, high anion gap). In the context of positive ketones and known diabetes -- this is DKA regardless of the glucose value (euglycemic DKA is possible and has a much higher incidence with SGLT2 inhibitors) 
 +</​WRAP>​ 
 +<WRAP half column>​ 
 +<callout icon="​fa fa-lightbulb-o"​ type="​success"​ title="​Mnemonic">​ 
 +The 6 ''​**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) 
 +</​callout>​ 
 + 
 +</​WRAP>​ 
 +</​WRAP>​ 
 + 
 +<WRAP group> 
 +<WRAP half column>​ 
 +  * **Correcting Hyperglycemia** 
 +    ​* 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 
 +      * Most sliding scales will have insulin Lispro (fast-acting insulin) 
 +    * Before administration of insulin, always ask: 
 +      * When was the last meal or snacks? 
 +      * What are the vitals? 
 +      * Look at the blood sugar trends over past week and baseline (if available) 
 +      * Remember that treating hyperglycemia can cause potassium shifts and may result in ECG abnormalities 
 +    * Most individuals with hyperglycemia will in fact be asymptomatic 
 +      * The classic symptoms that you should ask about include: 
 +        * Polyuria 
 +        * Polydipsia 
 +        * Polyphagia 
 +        * Weight loss 
 +    * Ask about symptoms of DKA: 
 +      * Abdominal pain 
 +      * Hyperpneic respirations (fast and deep Kussmaul respirations) 
 +      * Hypotension 
 +      * Ketotic breath (fruity odor in DKA) 
 +      * 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) 
 +</​WRAP>​ 
 +<WRAP half column>​ 
 +<callout type="​info"​ title="​General Blood Sugar Targets"​ icon="​true">​ 
 +  * **General Blood Sugar Targets** 
 +    * Pre-prandial goal: 5-8 
 +    * Random blood glucose: <10 
 +    * Start correcting if the BG > 10  
 +    * **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 ​(risk of seizures, decreased LOC, 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
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   * 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.
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 ===== 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 ​(ACEARB, spironolactone,​ Septra, tacrolimus
-  * Think of precipitating conditions (renal failure/volume depletion/TLS)+  * Think of precipitating conditions (renal failurevolume depletionTLS)
   * 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
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   * 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
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     * 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 ==== 
 +<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw"> 
 +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!
  
-== Hypomagnesemia ​== +==== Hypophosphatemia ==== 
-  * If critically low (<0.5)order an ECG to assess QT segment +  * Common causes include [[addictions:alcohol:​1-use-disorder|alcohol use]] or minimal oral intake 
-  * 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+  * 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
  
-== Hypophosphatemia ​== +====Hypernatremia==== 
-  * If critically low: check Kthen replace IV with KPhos 15mmol ​in 500cc D5W if K < 3.5, OR use NaPhos 15mmol in 500cc D5W if K > 3.5 +  * This is a problem of water balance (too little)can be common ​in dementia patients 
-  * If non critical: replace with phosphate novartis 500mg PO+  * Give them water to drink by mouth 
 +  * Again, unlikely to be acute issue overnight 
 +  * 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
  
-<WRAP group> +==== Hyponatremia ​==== 
-== Sodium (Hyponatremia/​Hypernatremia) ​== +<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw"
-<WRAP half column+See also: **[[cl:​hyponatremia|]]** 
-**Hyponatremia**+</​alert>​
   * Not the same principle of replacement as in other electrolytes! Sodium imbalances are a problem of water imbalance   * 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   * Most issues of hyponatremia overnight will be chronic and best managed with a fluid replacement or restriction strategy
 +  * So long as Na > 122, do not worry too much if overnight and on-call
 +    * Hold any diuretics
 +    * Order urine electrolytes and urine osmolality
 +    * Safest action overnight is to do nothing unless there are acute signs and symptoms of deterioration
 +  * 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
   * Avoid rapid correction 6-8/24h for risk of osmotic demyelination syndrome   * 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 
-  * 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) 
-  * Avoid rapid correction due to risk of cerebral edema 
-</​WRAP>​ 
-</​WRAP>​ 
-===== Respiratory Distress ===== 
-== Management == 
-  * Check vital signs (O2 saturation, respiratory rate 
-  * 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 
-===== Tachycardia ===== 
-<WRAP group> 
-<WRAP half column> 
-== Stable or Unstable == 
-  * First question is always "is the patient stable?"​ 
-    * If unstable 
-      * Call a ''​CODE BLUE''​ or activate Rapid Response 
-    * If stable: 
-      * What is the rhythm of their pulse? 
-      * Get an ECG 
  
-</​WRAP>​ 
-<WRAP half column> 
-<callout type="​info"​ title="​ECG Strip Reading"​ icon="​true">​ 
-Is the QRS narrow or wide? 
-  * If wide: it is VT until proven otherwise 
-  * If narrow: it is either sinus tachycardia vs SVT 
-    * Sinus tachycardia 
-      * ECG shows: P before every QRS, QRS after every P, P is upright in leads I, II, PR is fixed 
-      * Differential diagnosis: Pain, agitation, withdrawal, sepsis, volume depletion, PE, heart failure, pain, agitation, withdrawal, sepsis, volume depletion, heart failure 
-    * SVT 
-      * Most commonly will be due to Atrial fibrillation (AF) or Atrial flutter 
-        * How fast is the HR? 
-        * Are they on rate control agents already? 
-        * Again, if unstable, call for help! 
-        * Think of why this is happening! Treat underlying cause first, rather than just increasing meds 
-</​callout>​ 
-</​WRAP>​ 
-</​WRAP>​ 
-== Atrial Fibrillation Management == 
-A HR <110 is acceptable. Don’t need to be aggressive unless there are ischemic symptoms (angina, troponin bump, ECG changes, etc). 
  
-===== 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?
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 ===== 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)
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 ===== Constipation ===== ===== Constipation =====
-Assess the timeline of symptoms. It is only urgent ​if there is impaction with large fecaloma (bacterial translocation,​ mucosal ischemia)+  * Assess the timeline of symptoms 
 +  * Constipation ​is only an emergency ​if there is impaction with large fecaloma (bacterial translocation,​ mucosal ischemia) 
 == Treatment == == Treatment ==
-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!+<alert icon="​fa fa-arrow-circle-right fa-lg fa-fw" type="​success">​ 
 +See main article: **[[meds:​antipsychotics:​constipation|Constipation]]** 
 +</​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! 
 + 
 +===== Urinary Tract Infections ===== 
 +  * 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.]])]
  
-===== Seizures ​===== +===== Other Lab Abnormalities ​===== 
-<callout type="​success">​{{fa>​arrow-circle-right?​color=green}} See main article: ​**[[neurology:​approaches:​seizures#​treatment|Approach ​to Seizures: Treatment]]**</​callout>​ +  * **Elevated WBC** 
-If you witness a seizurecall for helpas the patient will likely ​have decreased LOC following the eventIt is appropriate to call a code blue (“Medical Emergency”if you need medications or more supportThe first line treatment is with benzodiazepines either IV (preferred or IM). Give lorazepam 2mg, or midazolam 2mgor diazepam 5mg q2-5minutes PRN until seizures are controlled. If not already on antiepileptics, it is reasonable to load them with dilantin ​(20mg/kgto prevent further seizures.+    * 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 = sepsismedication relatedor HIT [heparin induced thrombocytopenia] 
 +  * **Low ferritin** 
 +    * Ferritin < 50 is likely ​iron deficiencyIf 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** 
 +    * cirrhosisliver cancer ​or metsmyeloproliferative 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}}