HOW TO SURVIVE YOUR FIRST NIGHT ON CALL

Objectives

Have a few tools for common on-call issues

Give appropriate checkout Prevent disasters

Your first night on call

The pager goes off…

Potential news on the other end of the phone

“You have (another) direct admission on F8.”

“Your patient in F 605 is crashing.” “The lady in H 613 would like something

to help her sleep.”

When it is scenario #3

Many calls you receive will be for non-urgent patient complaints

When called for such complaints, you have several options: Ignore them Be careless Be overly cautious Respond appropriately

It NEVER hurts to go say hi to the patient

Cross-Cover

When on call, many (if not most) of the patients for whom you are responsible will not be YOUR patients.

You must depend upon your colleagues to tell you what you need to know about these patients when they check out

Once your colleagues leave, it’s all YOU

CHECK OUTWhere 102% of all medical errors occur

Check Out List

List of patients on a service Used by on-call person (usually intern)

when called about a patient Often the only information the person on

call will know about the patient Usually includes patient names,

locations, principal diagnoses, and any issues that need to be followed up overnight.

Check Out List

Should also include any other information someone might reasonably need on call Diabetes Renal dysfunction Hepatic dysfunction (cirrhosis) Unstable psychiatric conditions Any medications you want or don’t want

given Known potential for instability/overnight

issues

Check Out

Unless not possible, should also include a face-to-face discussion of

major issues

Check Out- If then statements Crappy checkout: “BMP at 1900” Good checkout:

“BMP at 1700, K was 2.5 and we replaced, if still less than 4.0 give 40 more mEq PO”

Crappy checkout: “Watch this guy’s BP” Good checkout:

“He was hypotensive, responded to 1L NS, I think it was just dehydration but we’ve got abx on board for pneumonia. If he drops again you can give another 1-2L, but if that doesn’t cut it move him to MICU”

Check Out- If then statements Crappy checkout: “This guy is totally

crazy” Good checkout:

“He’s been delirious, probably from this UTI. He responded to haloperidol 1mg IM earlier, no QTc issues, can try this again if need be. Definitely avoid opiates/benzos”

Specific issues on Call

Pain Nausea/Vomiting Insomnia Anxiety Agitation Constipation

Heartburn Pruritus A couple of more

urgent issues Electrolytes

Obviously, for any new, unexpected change in a patient, the first thing to

do is to GO SEE THE PATIENT.

THE “SIMPLE,” “MUNDANE,” AND OFTEN ANNOYING…

Pain-Opiates

Morphine 2.5-5 mg IV May repeat q 4 hrs prn

Oxycodone 5-10mg PO May repeat q 4 hrs prn

Avoid Demerol Increased euphoria, risk of seizures

Conversions of Opiates

Morphine 5mg IV = Morphine 15mg PO = hydrocodone 15mg PO The IV is 3x the PO form

Oxycodone is about twice as potent as PO morphine/hydrocodone

You will get a card that has these details, and if you google “opioid conversion” you get good calculators

Pain-Opiates

Opioids (cont) Dose adjustments

Start with ½ dose in elderly or in renal/hepatic dysfunction

Use caution in patients with respiratory illness May have to use more in patients on chronic

opiates PO:IV conversion for morphine is 3:1

If you give too much, remember: Narcan 0.4mg IV

Pain-Acetaminophen

Acetaminophen The SAFEST for most patients Also good for fever 650mg PO/PR Very safe as long as you give less than 4gm

per day in most people and <2gm/day in cirrhotic patients Probably should avoid in active alcoholics

and certainly for patients w acute alcoholic hepatitis

Pain-Combo drugs

Opioid/acetaminophen combinations Percocet

Oxycodone 5mg/APAP 325mg Vicodin

Hydrocodone 5-10mg/APAP 325mg Many other dose combinations available

Quick rule of thumb: most patients can have 1 percocet 5/325 q4h prn pain and be fine

Pain

NSAIDs AVOID in kidney injury, CKD, cirrhosis, CHF,

ACS and UGIB So avoid them in most of our patients

Naproxen 500mg PO q 12 hrs Ibuprofen 800mg PO q 8 hrs Ketorolac (Toradol) 60mg IM/IV once, then

30mg IV/PO q 6 hrs Cannot use for > 5 days

Nausea/Vomiting

Ondansetron (Zofran) 8mg po or IV q 8 hrs prn Safest side effect profile for elderly Not that expensive anymore, and very

cheap PO now. Should be first line PO nausea medicine

Nausea/Vomiting

Promethazine (Phenergan) 25mg IV/IM q 4 hrs prn 50mg PO/PR q 4 hrs prn Causes sedation, agitation, delirium

NauseaphenergandeliriumbenzofallSDHMICUdeathM and M conference presentation +/- lawsuit

Use lower doses (try half) in elderly due to increased side effects (or just avoid in the elderly)

Nausea/Vomiting

Metoclopramide (Reglan) 10mg IV/PO q 6 hrs prn Remember it stimulates gut motility

Avoid in suspected bowel obstruction or diarrhea

Sedating in some patients Use half dose in dialysis patients or elderly Dystonic reaction

Treat with Benadryl 25-50mg IV

Insomnia

Diphenhydramine (Benadryl) 50mg PO 25mg IV Avoid in elderly (anticholinergic), and

certainly in elderly patients with dementia InsomniabenadryldeliriumbenzofallS

DHMICUdeathM and M conference presentation +/- lawsuit

Insomnia

Trazodone 50-100mg qHS Safe in elderly Side effects

Hypotension Priapism falls

Insomnia

Zolpidem (Ambien) 10mg qHS 5mg in elderly (if at all) InsomniazolpidemdeliriumbenzofallSD

HMICUdeathM and M conference presentation +/- lawsuit

Dickey Stephens Park

Acute Anxiety

Why is the patient anxious? Actively dying always makes me anxious too.

Keep in mind a common scenario Anxious pt anxious nurse intern gives benzos

code blue anxious program director Short-acting benzodiazepines (very

dangerous) Lorazepam (Ativan)

1-2mg PO/IV q 4-6 hrs prn Alprazolam (Xanax) do not use it Can try trazodone in elderly first, or can try

hydroxyzine if drug-seeking

Anxiety can be from bad things Anxiety + tachypnea = PE, pneumonia,

sepsis, or MI Anxiety + disorientation =

hypoglycemia, delirium, shock, sepsis Anxiety + fever = sepsis Anxiety + fever + tachycardia +

hypotension = severe sepsis nearing death

Anxiety in 25 yo healthy person w normal vitals except heart rate 96 = anxiety

Agitation

This is not a “nuisance call.” Probably is delirium 9 times out of 10 in inpatients 30% of delirium is caused by our drugs. Other

causes include dehydration, shock, hypoglycemia, hyponatremia, and alcohol withdrawal

Worst thing you can do: “Ok, Ms. Jones is a little agitiated, give her ativan 2mg IV now and let me know how she does” If you do that, the code pager will go off before your

personal pager 1 time in 4 Get on the computer and read the notes, check

the vitals, ask yourself if she is a withdrawing alcoholic, if she is hypoglycemic, if she is septic

Agitation

Haloperidol (Haldol) 2mg-5mg PO/IM/IV In elderly, use 0.5-1mg PO/IM/IV Watch for dystonic reaction

Ativan 2mg PO/IV Avoid in confused elderly patients If delirious, then give haldol without benzo.

May need higher dose if patient uses medication chronically

Constipation

Constipation = miralax deficiency

Constipation Miralax

17 gm 1- ∞ x/day Milk of Magnesia

30 mL PO Magnesium Citrate

8 oz (240mL) bottle PO Fleet’s enema

One enema PR

AVOID THESE IN DIALYSIS PATIENTSRisk of hyperMg/hyperPO4

Constipation

Lactulose 30mL PO Can cause bloating/gas Unless they have hepatic enceph, use

miralax instead Bisacodyl (Dulcolax)

10mg PO/PR Can cause cramping

Combinations also work well

Heartburn

MgOH/AlOH (Maalox) 30mL PO Avoid in dialysis patients

CaCO3 (Tums) 2 tablets PO Safe in dialysis patients

Ranitidine (Zantac) 150mg po BID prn Dose once daily in dialysis patients

Heartburn

GI cocktail Usually combination of Maalox, viscous

lidocaine, and another medication (Benadryl or Donnatal)

Usually complicated to order and is delayed by Pharmacy

Some studies say no better than Maalox alone

Do not give PPI alone for acute heartburn Onset of action is delayed by several hours

Pruritus

Benadryl 25-50mg PO/IV q 4 hrs Avoid or reduce dose in elderly

Hydroxyzine (Atarax, Vistaril) 25-100mg PO/IM q 6 hrs Avoid in elderly Cannot be given IV

Itchingbenadryl or hydroxyzinedeliriumbenzofallSDHMICUdeathM and M conference presentation +/- lawsuit

If one does not work, try the other

MORE URGENT ISSUES

Chest Pain

“What are his vitals? … Ok, Give him SLNG 0.4mg and call for a stat ECG, troponin now and in 4-6 hours, I’m on the way”

Give nitroglycerin 0.4mg sublingual Response does not predict cardiac source, but

may give the patient relief. Will decrease BP every time

EKG Troponin/cardiac enzymes If no response to NTG x 3 and EKG is negative,

can try Maalox or GI cocktail

Chest Pain

7 lethal causes Acute MI Pulmonary embolus Pericarditis with tamponade Tension pneumothorax Aortic dissection Boerhaave’s syndrome (esophageal

rupture) Severe pneumonia

Fever

2 Rules: 1) Get blood cultures before starting any

antibiotics 2) Get blood cultures before starting any

antibiotics

Fever

Obtain blood cultures before starting antibiotics

Causes in hospitalized patients: UTI (foley) Pneumonia Wounds (surgical, trauma, decubiti) Plastic (IV’s, CVL’s, drainage catheters, etc.) DVT C. difficile colitis (if diarrhea present) Sinusitis (if NG tube has been used)

ELECTROLYTES: SOME QUICK REMINDERS

But first more of my favorite city

Electrolytes

Potassium 10mEq for every 0.1mEq above 3.0 20mEq for every 0.1mEq below 3.0

K 2.8, want to correct to 4.0 (20x2)+(10x10) = 140mEq

Electrolytes

Potassium (cont.) For urgent replacement, give PO powder or

tablets and IV IV rates

10mEq/hr through peripheral 20mEq/hr through CVL

Use caution when replacing patients with chronic kidney disease (but still replace if they need it!)

Be even more careful in dialysis patients, but they still need it.

Electrolytes

Magnesium Safe to give in large amounts

“Symptomatic patients, such as those with tetany, arrhythmias, or seizures should receive intravenous magnesium. Such patients should have continuous cardiac monitoring.”

Can be given quickly Give 2-4g MgSO4 IV, and schedule some PO

(like MgOx 400mg BID or TID) 1gm of Mg sulfate IV = 8 mEq Mg Sulfate IV

Only replace if absolutely necessary in dialysis patients

Electrolytes

Calcium Very dangerous to replace IV. In asymptomatic

patients, should be replaced PO. Calcium carbonate (tums) 1250 PO 4x/day

If low, first check serum albumin: [Measured Ca] + [(4.0 – albumin) x 0.8] = corrected Ca

If replacing, know PO4 first Replacement IV for long QT, Vtach, seizure

Ca gluconate 1 amp (10mL of 10% solution) = 1g 1g Ca gluconate = 4.65 mEq Usual replacement is with 1-2g Ca gluconate IV

Electrolytes

Phosphorus If mildly low (>1.5), replace PO

Neutra-Phos 2 packets BID-TID Milk

If very low or symptomatic, pt needs IV as well Ask for help

Do not replace in dialysis patients unless absolutely necessary

(tired of hearing this yet?)

Sodium

2 rules: All hyponatremic patients should have

serum and urine osmolality drawn Get help to make sure all corrections are

slow

Questions