Common Night Float Calls - PowerPoint Presentation

1. Common Night Float CallsJonathan Burgei, DOInternal Medicine Chief Resident

2. Night Float6:30 PM – ~ 7:30 AMMeet in resident loungeResponds to pages regarding med team patientsDocument ALL calls (even minor issues)Responds to ALL code blues, stroke teams, rapid responses Always go and see the patient if an issue arisesUnsure what to do  Senior resident (you are not alone on nights!)Morning report: Brief run of night events / notable encounters

3. Chest PainNothing  Life threatening (ACS)When called, ask about SymptomsVITALSStable vs Crashing Orders: STAT EKG, CXR, ABG (hypoxia), troponinReview chart (PMHx, Labs, Past EKG, Vitals)Tell senior and go see patient!

4. DifferentialsEmergent : (calling senior, cardiology fellow) ACS: STEMI, NSTEMI, unstable anginaDissectionPEPneumothoraxCardiac tamponadeEsophageal ruptureHypertensive EmergencyLess acuteStable Angina Pneumonia Pericarditis Cocaine/methEsophageal spasm / GERD CostochondritisPanic attack/anxiety

5. Abdominal PainHistory History History Location / radiation? Groin (renal colic) vs Back (pancreatitis) Onset, frequency, durationSteady (pancreatitis) vs sudden (peritonitis)Aggravating / alleviating factorsAfter meals (chronic mesenteric ischemic)

6. Differentials

7. LabsGlucose (DKA), Lipase, triglycerides, EtOH, Lactate, Beta-HCG, UA, consider troponin / EKGImaging Abdominal X-ray, US, CT scan, bladder scan

8. Pain Diagnosing the cause of pain is essential! Approach;Review H&P / Progress notes Review Handoff! Evaluate the patient Vital signs Physical examLab abnormalities

9. Treatment optionsNon-pharmacologic options Ice packHeating padTLC

10. Treatment optionsStep up treatmentLidocaine patch  localized, MSKTopical Capsaicin  neuropathic painScheduled / PRN acetaminophen (max 2g/24 hours for hepatic impairment or 4g/24 hours otherwise)NSAIDs  younger patients, MSK / arthritis, low comorbidity, with meals / PPI Neurontin  neuropathic pain, DM2, post-herpetic neuralgiaToradol  Nephrolithiasis / renal colic, migraines (only for <5 days d/t AKI)

11. Treatment OptionsStep up treatmentNarcotics

12. Take home points Acknowledge / empathize Even if pain seeking, they believe they are in painBe strong, you will be yelled at a few times….Start low and escalate When in doubt, ask your senior

13. Falls

14. Immediate QuestionsPatient statusLOC, Neurological status, vitals, blood sugar Circumstances Admission diagnosis, hx of traumaSymptoms SOB, CP, palpitations, pre-syncopal symptoms, syncopePMHx Dementia, DM type II, CAD, strokeMedicationsNarcotics, sedatives, anti-cholinergics

15. Physical assessmentFull physical / neuro exam Look for signs of trauma  Especially headCan call rapid response to place c-collarOrthostatics

16. Cause ExtrinsicPoor lighting, wet floors, tethered to lines IntrinsicVisual impairment / deconditioningNeuro: Seizure, stroke, deliriumCardiac: Arrhythmia, MI, vasovagal, orthostatic Metabolic: Hypoglycemia, electrolyte, uremiaInfection: Delerium Toxin: EtOH withdrawal, benzos

17. What to do?Labs:BMP, CBC, UA, Glucose, Coags, Tox screenEKGImagingX-rayCXRCT head

18. PlanTreat underlying causeRemove offending agents (Meds, lines, tethers)Treat infection, electrolytes, seizure…PreventionSitter Delirium protocolFall precautions

19. Agitation Delirium protocol, sitter, avoid restraints if possible Medications HaloperidolQuetiapine OlanzapineAvoid benzodiazepines Pain controlMay require dexmedetomidine  ICU

20. Hypertension UrgencySBP > 180 or DBP > 120NO end organ damage EmergencySBP >180 or DBP > 120End organ damageHA / Dizziness, Nausea, vomiting, seizures, CP, SOB, blurry vision

21. Exceptions include strokes!

22. Treatment – Hypertensive Emergency

23. Treatment Check MARHome BP meds PRN IV medsIV Hydralazine IV labetalolRapid reduction may  MI or cerebral ischemic

24. Shortness of breathQuestions to ask nurseVital signs Oxygen saturation Mental status Open EpicPMHx Reason for admissionRecent chest imaging? DNR status Would they want to be intubated if needed?

25. History and Physical ExamOnsetDurationAspiration?Fever / Chills CoughChest pain?Allergies

26. Lab work CBC, BMPABG STAT CXR STAT EKG STAT Troponin TreatmentAerosols+/- Diuretics NC  Non-rebreather  HFNC  NIV  Intubation

27. HypotensionAsk for all vitals, not just BP Repeat vitals while you are on your way (different arm) Go see patient and get senior

28. Causes of hypotension Distributive shock: Septic…Cardiogenic: HF…Hypovolemic: Fluid loss…Obstructive: PE….tension pneumothorax

29. Initial EvaluationLook at patientSymptoms? Signs of bleeding? Signs of infection?Physical examCurrent Vital signs Telemetry?Mental Status?Signs of infection?EPIC / Chart reviewVitals trendReason for admissionPMHx Recent medications (BP meds, Lasix, NPO?)

30. Initial ManagementConsider initial fluid bolus (caution in ESRD and HF patients) +/- AlbuminLabs: CBC, lactic acid, procalcitonin, troponin, ABG, blood cultures, type and screenImaging: EKG, CXR, CTA-chest

31. Management Treat underlying cause of hypotensionSepsisAggressive fluid management (30cc/kg), cultures, broad spectrum antibiotics May require pressors (levophed through peripheral IV temporarily)  ICUCardiogenicEKG and troponin. Assess for arrhythmias / MI  CCU Hemorrhagic IVF first while waiting for type and screen / blood  ICU evaluation

32. Summary Go see the patient Document everything your thinking and doingTalk with your senior, you are not alone!