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Things That Go Bump in the Night

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					Things That Go “Bump” in
        the Night
        Kate Goodrich, MD
    GENERAL PRINCIPLES
• Always go SEE the patient
• Review your sign-out AND the chart
• Ask the nurses what they know
• Recheck the vital signs yourself
• Remember: A senior resident and an ICU
  resident are available—use them!!
• Trust your instincts—if you feel scared,
  there’s probably a good reason for it.
     GENERAL PRINCIPLES
• Call the attending if the patient dies or gets
  transferred to the ICU.
• Also call the FAMILY if the patient gets
  transferred to the ICU.
• In a Code Blue, help out any way you can
  (lines, bagging, chest compressions, etc.)
• Just remember your ABCs.
• DOCUMENT! ALWAYS write a note!
                      Case # 1
54 y.o. man with HTN admitted with infectious diarrhea. He
  is responding well to antibiotics. You are called at 2 a.m.
  when his routine vitals show a BP of 200/115. His pulse
  is 77, and he is afebrile. He is annoyed at being
  awakened for something as trivial as asymptomatic
  hypertension and asks for meds for his abdominal pain.
CV: RRR with a 1/6 TR murmur
Lungs: clear
Neck: No JVD
Ext: trace edema
                Asymptomatic HTN
                Points to Consider
• Is there an obvious reason for the high pressure? Pain?
  Distress? Annoyed?
• How fast do you need to get the blood pressure down?
• What should be your BP goal?
• Should you use intravenous, topical, or oral agents?
• What is the patient’s baseline blood pressure?
• Is there ANY evidence of end organ damage?
                    Asymptomatic HTN
                      Management
• There is NO proven benefit to RAPID BP reduction—
  can, in fact, be harmful in some patients
• Goal should be to decrease BP to around 160/110 over
  several hours.
• Clonidine?
• Recommended medications/maneuvers:
   –   Loop diuretic in a euvolemic patient with normal renal fxn
   –   Short acting calcium channel blocker (amlodipine, e.g.)
   –   Short acting ACE inhibitor (captopril , e.g.)
   –   Beta Blocker: Labetolol, Metoprolol
   –   Quiet, restful room (not easy to achieve in the hospital!)
                          Case # 2
45 y.o. woman admitted with pneumonia the previous day. You are
   called at 11 p.m. for a BP of 70/40. Although she feels a bit dizzy,
   and appears moderately dyspneic, she is her cheerful self, and
   thoughtfully asks how ―that internship is coming along.‖ Her
   medications include Ceftriaxone, Robitussin with codeine, and prn
   Ambien.

T: 103.3 Manual BP: 72/39 P: 125 R: 26
CV: tachy
Lungs: crackles in both bases
Neuro: A&O x 3; generalized weakness
Ext: thready pulses
                 HYPOTENSION
• Recheck the BP yourself
• What is the patient’s baseline BP?
• Place the patient in Trendelenberg
• IVF: NS vs. D5W
• IVF: Bolus vs. Rate
• Recheck the BP yourself after treatment
• Call the ICU if no response to fluids, or evidence of end organ
  damage (MS changes, oliguria, etc.) is present
• Consider etiologies
   – Sepsis
   – Medications (antihypertensives, opiods, benzodiazepines, etc.)
   – Volume depletion (diarrhea, vomiting, insensible losses)
                       Case # 3

38 y.o. man admitted with pancreatitis from a scorpion bite
  he got while on safari. You are called to see him after
  his nurse finds him talking in soothing tones to his
  incentive spirometer. On exam he has no abdominal
  pain, but thinks his name is Zeus and that he is sitting on
  top of Mount Olympus.
T: 36.8 P 64 BP 110/57
Neuro: alert, but not remotely oriented
CV: RRR Lungs: normal
Abd: soft as butter—no pain to palpation
      Mental Status Changes
• What is the baseline mental status (check your sign-out!)
• Common etiologies in the hospital
• Quick and Dirty—Pox and fingerstick
   – Medications (opiods, benzodiazepines, e.g.)
   – Severe electrolyte disturbances
   – Infections (nosocomial if MS change is new)
   – ―sundowning‖
   – PE/MI—especially in geriatric population
        MS changes: work up
• Head CT—particularly if pt is somnolent
• Review medications given—both sign out and Kardex
• Labs: Chem 7, CBC, ?cardiac enzymes (Pox and
  fingerstick should already be done)
• Infectious workup if relevant
• Sundowning
   – Chemical vs. physical restraints
   – Behavioral modification
                      Case # 4
65 y.o. man with a h/o rheumatic heart disease admitted
  with endocarditis. Earlier that day he underwent an
  abdominal CT to r/o septic emboli. He has been
  improving on Vancomycin and Gentamicin over the last
  week, and generally has no complaints. You are called
  for a urine output of 100 cc from his Foley catheter over
  the last 8 hour shift.
T: 37.6 BP: 145/87 P: 83
Physical exam: Normal except for a 2/6 systolic murmur
  and mild abdominal tenderness to palpation
          Low Urine Output
• Post-Renal
  – FIRST thing you should do--Check the Foley!
    Have the RN flush the catheter
  – If no Foley, in and out catheterize the bladder
  – What if 2 liters of urine comes rushing out?
     • Frequent BP checks
     • Check chem 7
     • Start IVF—pt will become volume depleted with a
       post-obstructive diuresis
          Low Urine Output
• Pre-Renal
  – Is the patient hypotensive?
  – Any signs of volume depletion on physical exam?
  – Any obvious cause of volume depletion from looking
    at sign out and chart (diarrhea, vomiting, sepsis,
    insensible losses, bleeding, diuretics, etc.)?
  – IVF: NS vs. D5W
  – IVF: bolus vs. rate
  – Labs: chem 7, urine studies for the morning (the
    primary team will love you!!)
          Low Urine Output
• Intra-Renal
  – Medications: antibiotics (aminoglycosides),
    chemotherapy, cyclosporine, NSAIDs
  – Check Chem 7, especially for hyperkalemia
  – Order urine studies for the morning
  – Maintain BP—give IVF to avoid hypoperfusion
  – Diuretics if any signs of volume overload
  – Causes: Medications and IV contrast are the most
    common causes in the hospital setting
  – Stop all nephrotoxic drugs
                          Case # 5
46 y.o. man in good health admitted with a debilitating RLE cellulitis
   which began after an insect bite. You are called for acute onset of
   dyspnea at 2 a.m. Other than being annoyed at your presence in
   his room at this wee hour, and his mild subjective breathlessness,
   he feels fine, and asks for his next dose of antibiotics.
T: 38 BP: 154/88 P: 125 R: 28
CV: tachy
Lungs: clear
Ext: swollen right leg, with receding erythema and warmth from
   previously drawn margins.
              ACUTE DYSPNEA
• In the hospitalized patient, the most common cause of
  ACUTE onset of SOB is always PE.
• Other common etiologies: CHF, MI, pleural effusion,
  nosocomial/aspiration pneumonia, anxiety
• Initial Tests: stat CXR, ABG, EKG (look at CXR with the
  radiology resident on call)
• Further testing: Spiral CT, cardiac enzymes
• Treatment: Empiric anticoagulation, oxygen
   – Diuretics/Nitrates if CHF
   – Antibiotics if pneumonia
   – Anxiolytics if freaking out
                        FEVER
• Is this a new fever? (Check your sign out!)
• What is the likely source? If not readily apparent, ask
  about diarrhea, look at IV sites, how long has the central
  line been in place?
• Orders: Two (2!) sets of blood cx from separate sites or
  from same site 15 minutes apart. If central line present,
  one from the line; one from the periphery. UA/C&S (esp.
  if Foley), CXR (r/o nosocomial pneumonia or effusion)
• Antibiotics: Start empirically if source is obvious or if pt
  looks septic. Draw all cultures first. If you’re not sure
  what to start, call your senior or junior resident!
                CHEST PAIN
• Location, Duration, Radiation, Characterization
• Take a good hx: similar to previous episodes?
• Associated VS: Hypertension? Tachycardia?
  Hypoxemia?
• Always get an EKG. Get your senior resident or Gold
  team resident to read it with you. Don’t rely on the
  computer reading!
• Other tests: CXR, ABG, Cardiac enzymes, Spiral CT
• Treatment: NTG? Oxygen? Maalox? Anticoagulation?
       Insulin Sliding Scale


•ISS have been shown to lead to more hyper-
and hypo-glycemia in the hospital setting
•Only use ISS to treat pre-prandial
hyperglycemia
•Always use a Lispro sliding scale--never
Regular insulin!
 Lispro sliding scale orders

•Check FS qac and qhs
•For ac FS 151-200 3 units; 201-250 6 units;
251-300 9 units etc.
•For hs FS < 350 do nothing
•For hs FS > 350, call H.O.
•(For hs FS > 350, give 1/2 the dose of insulin
you normally would on a sliding scale)