Intern ConferenceJuly 11, 2012

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Today First Night on Call Top 10 Surgical Intern Calls

Top 10 Intern Calls1. Fever2. Chest pain3. Hypotension4. Respiratory Distress5. Pain6. Tachycardia7. Hypertension8. Electrolytes9. Insomnia10. Agitation Death

First Night on Call

You are never alone at the hospital! Ask up front “when should I call?” If you don’t know- ask If you are worried- ask

Who? Your senior resident, Your attending, ICU nurses,

charge nurses, pharmacists, cardiology fellow, ICU on call resident

When to call your attending Call an Attending directly (or positively ascertain that an Attending has been notified) upon

the following situations:

Death (even if expected)

Cardiac arrest

Respiratory failure either requiring intubation or significantly increased O2 demands

Severe respiratory distress

Airway issues

Transfer to ICU or higher level of care

Concern that patient needs a procedure or operation

A new need for acute dialysis

Bleeding requiring transfusion

Hypotension/hemodynamic instability

Symptomatic and severe hypertension

Significant new arrythmia

Suspected MI

Suspected PE

New onset severe chest pain

New onset severe abdominal pain

Abrupt deterioration in neurologic exam or profound decreased mental status

Significant change in neurovascular exam of extremity

Patient or family wishes to speak to the attending

Patient wishes to be discharged AMA

PLUS

Any other significant change in clinical status of patient that is of major concern.

Any new admission.

The arrival of a patient accepted in transfer from another institution.

Service specific items

KTU: abrupt loss of urine output in recent kidney transplant pt that was previously making urine; ultrasound showing vascular/ureteral problem.

LTU: ultrasound showing absence of hepatic arterial flow

VASCULAR: loss of a pulse or Doppler signal that was present earlier

PLASTICS: abrupt change in signal /duskiness of free flap

First Night On Call 8:45 pm on your first night call of intern year &

you are paged to the 9th floor nurses station.

You: “Hi, this is ____ from Surgery returning a page.” RN: “Thanks for calling back. Are you taking care of

Mr. Johnson in Room 13?” You: “Uhh…Mr. Johnson…(flipping through papers)…

yes! What is going on? RN: “Well, I’m calling because Mr. Johnson just

spiked a temperature to 39.2.”

What do you ask?

What do you ask?

Vital signs

What do you ask?

Vital signs Vital signs are always vital Ask for vital signs with any new complaint Get complete set of vital signs Gives you critical information (sick vs. not

sick)

Which patients to see?

Any major new vital sign change New altered mental status If the nurse asks you to come see the patient If you are worried about something If someone who signed out to you is worried about

something Unless it’s immediately life threatening, see the patient

before calling someone. Err on the side of seeing everyone

Looking at your signout…

Mr. Johnson is a 28 yo M with UC who is POD3 s/p total colectomy. NTD.

Looking at your signout…

Mr. Johnson is a 28 yo M with UC who is POD3 s/p total colectomy. NTD.

Do you want to go see the patient?

In the Elevator…

Differential Diagnosis

In the Elevator…

Differential Diagnosis 5 Ws

In the Elevator… Differential Diagnosis 5 Ws

Wind Water Walk Wound Weird/Wonder drugs

In the Elevator… Differential Diagnosis 5 Ws

Wind Water Walk Wound Weird/Wonder drugs

Drains? Dressings?

Wind

Water

Walk

Wound

Wonder Drugs

Back to Mr. Johnson… T 39.2 HR 108 BP 120/72 R18 O2 sat 99% RA General appearance- Lungs- CV- Abdomen- Extremities- Mental status-

Physical Exam T 39.2 HR 108 BP 120/72 R18 O2 sat 99% RA General appearance- Awake, watching TV, NAD Lungs- crackles at bilateral bases CV- mildly tachycardic Abdomen- dressing c/d/I, no staining. JP drain

serosang fluid, scant Extremities- no edema, no calf tenderness Mental status- alert, oriented

What do you want to do?Do you take off the dressing?Do you probe the wound?

It depends, but in general, yes.Look at the wounds, even early.

What do you want to do? Blood cultures UA, Ucx Sputum cx CXR BLE US Wound exploration Antibiotics CT scan- Abdomen/pelvis? PE protocol? Incentive spirometry Tylenol

Who do you want to call?

Report the data Convey a plan

Next case

54 yo F POD4 s/p lap gastric bypass. RN calls to tell you patient is febrile to 38.5.

Next case

54 yo F POD4 s/p lap gastric bypass. RN calls to tell you patient is febrile to 38.5.

HR 110 BP 117/68 R20 94% RA You go to see her

Having a lot of pain Started taking PO yesterday Hasn’t been OOB

What are you worried about in this patient?

What are you worried about in this patient?

DVT/PE Atelectasis Anastomotic leak

Next case…

62 yo F POD 5 s/p lap appy for perforated appendicitis. Febrile to 39.0. On Ertapenem.

Next case…

62 yo F POD 5 s/p lap appy for perforated appendicitis. Febrile to 39.0. On Ertapenem.

Looking back, patient has been spiking fevers for >24h.

Pancultured last night. All pending.

Next case…

62 yo F POD 5 s/p lap appy for perforated appendicitis. Febrile to 39.0. On Ertapenem.

Looking back, patient has been spiking fevers for >24h. Pancultured last night. All pending.

Do you need to resend cultures? When do you get a CT scan?

Electrolytes

Electrolyte Repletion

This is your job as an intern! Labs often not resulted before other members

of your team go to the OR All patients do not need AM labs every

morning

Electrolyte RepletionHypokalemia

Check Creatinine! Is patient taking PO? Is patient on IVF with KcL? Is patient on any diuretics? NGT? Diarrhea?

Electrolytes

Hypokalemia In general- replete K for < 4.0

Give PO if patient taking PO, and if K is >3.3 3.8-3.9, give 20 mEq of KCL 3.6-3.7, give 40 mEq of KCL 3.4-3.5, give 60 mEq of KCL 3.2-3.3 , give 80 mEq of KCL 3.0-3.1 , give 100 mEq of KCL If <3.3 or there is a reason they will continue to

waste potassium, recheck K after repletion

Electrolyte RepletionHyperkalemia (K >5.3)

Is specimen hemolyzed? Call the lab/repeat draw

Check ECG, Creatinine, BUN, electrolytes EKG abnormalities (peaked T waves,

reduced P waves, widened QRS

If ECG changes Calcium gluconate 1ampule IV over 3 min Can repeat in 5 min if ECG does not

improve

Call your senior!

ElectrolytesHyperkalemia

Think about: Is patient taking PO potassium? Dietary? Is patient on IVF with KcL? Is patient on TPN? Is patient on any K sparing diuretics, ARBs,

ACEis? Necrosis? Burns? Tumor lysis? Rhabdo?

ElectrolytesHyperkalemia

Regular insulin10 units IV(with 50ml of 50% dextrose to prevent hypoglycemia)

NaHC03 1 ampule (50mEq) IV over 5 minutes

Albuterol 10mg neb over 15-20 min

Kayexelate 15-30mg PO or PR Lasix 40-80mg IV Hemodialysis

Shift potassium into cells

Excretion/elimination

Electrolyte RepletionMagnesium Replete for < 2.0 If taking PO

Mag oxide 400- 800 mg PO – may cause diarrhea

If repleting IV Mag 1.8 -2 -> give Mag sulfate 1 g IV Mag 1.6-1.7 -> give Mag sulfate 2g IV Mag <1.5 -> give Mag sulfate 3g IV

Electrolyte RepletionPhosphate

Replete for < 3.0

Give PO when possible NeutraPhos 8mmols per packet K Phos 4mmols per tablet

Repletion guidelines Phos 2.5- 2.9 Replete PO if possible- NeutraPhos 2 packets PO Phos 2.0-2.5 Give NaPhos 15 mmols IV over 4 hours Phos 1-1.9 Give NaPhos 21- 30 mmols IV over 4 hours.

Recheck after repletion Phos <1 Give NaPhos 30mmols IV over 4 hours. Recheck,

may need to repeat.

Questions?