COVER SHIFT SURVIVAL TIPS - PowerPoint Presentation

1. COVER SHIFT SURVIVAL TIPSDr Carol ChongSupervisor of Intern TrainingNorthern Health2019Part 1

2. PRIORITISINGYou can only do one thing at a time!Let nurses know how long you’ll be roughlyWrite down your to do list as you go, ward based.Ask nurses to leave a list of jobs at one module on each unitThe cover shift is about

3. ASK FOR HELPRegistrars and other interns are there to help you.You are not expected to make major management changes – you need a registrar to help.You can only do one thing at a time!Don’t be afraid to call a MET CALLIf not sure on cover

4. If you are having problems taking bloods or putting in iv’s …First ask your RegDon’t try more than three timesTry not to use up the last vein!!Can try the footCan try taking blood from radial artery (like an abg)Or femoral vein if confidentAsk anaesthetics or ICU often helpfulDon’t forget if hard to get blood, can use paediatric tube as last resort (eg. 1ml of blood for INR)Bloods

5. HTHypotension an overviewHyperkalaemiaHypokalaemia(Delirium Management Tips if time)Week 1 Cover Shift Topics

6. Diabetes BSL managementChest pain(Nausea and Vomiting(Gi Bleedingconsent/ person responsible)Cover Shift Issues part 2

7. ConstipationWarfarin OrdersOliguriaHypoxiaTachycardiaCover Shifts part 3

8. HTHypotension an overviewHyperkalaemiaHypokalaemiaDelirium Management Tips if timeWeek 1 Cover Shift Topics

9. Which one is more worrying in general when you’re on cover?Hypertension and Hypotension

10. Which one is more worrying in general when you’re on cover?In general, hypotension is much much much worse – decreased cerebral perfusion and unconsciousness can happen, as well as decreased perfusion to other major organsHypertension and Hypotension

11. What are the common causes of hypertension you will be called for on a cover shift?Hypertension

12. Can be elevated for a number of reasons.Eg. pain, pain, pain (post surgery, post fall, post fracture)Missed normal medicationseg. W/H due to sepsisEssential hypertension (pt asymptomatic)Anxiety/StressSerious causes to consider:Malignant hypertension is rare and often is diagnosed before the cover shift! Think of this if headache/ visual changes/ focal neurologyRaised Intracerebral pressure – coning. Hypertension and bradycardia AGH!!Post-stroke – still want cerebral perfusion, don’t lower unless greater than 180/110- follow stroke guidelinesDETERMINING THE CAUSE IS THE KEY TO MANAGEMENTHypertension

13. You are paged by a nurse in Unit B at 18:00 and ring back – “Mr Xu’s b.p is 180/95 – do we need to do anything about this?”What will you do?Hypertension on cover

14. ASK more questionsWhat are the Key Questions to ask over the phone?“Mr Xu’s b.p is 180/95 – do you want me to do anything about this?”

15. Reason for admission (eg.could be in pain)Is there a past history of HT?Is he on any blood pressure meds?Symptomatic or not ?headache, blurred vision?in pain What is his usual b.p? ie. What has the BP been like in hospital on the obs chart.Are the other obs stable/normal? HT on cover key questions to ask

16. Reason for admission (eg.could be in pain)Is there a past history of HT?Is he on any blood pressure meds? Symptomatic or not ?headache, blurred vision?in pain What is his usual b.p? ie. What has the BP been like in hospital on the obs chart.Are the other obs stable/normal? Bp 180/95Mr Xu was admitted with gout this morning. PMHx HT on Coversyl (perindopril) 10mg o dailyNurse says quite a bit of pain in the left 1st MTP. No other pain or headacheB.p on admission 140/80, then 130/60 at midday, 145/90 16:00Pulse 90, sats 100% RA, T37.0What is your Management plan?

17. Since it is probably related to pain – make sure he is written up for analgesia. Eg. Paracetamol 1g o qid.Phone order – ask Does the patient have any allergies? before giving orderGive phone order for paracetamol 1g o stat (then go chart it when you have time)Already on paracetamol (consider endone 5mg o daily)

18. Has a background of HT (probably Essential HT) or anxiety/stressDon’t need to lower it .Thanks for letting me know, can you check the BP in an hour and let me know if it’s greater than 200/100 or if the patient has symptoms.If not in pain

19. Get BP repeated –eg. check again in 30 minutes, 1 hr. Ask to be rung back if bp >200/100 or symptomatic (headache/blurred vision).If BP> 200/100 you probably want to see the patient and measure it yourself manually. Eg. Correct cuff size for large ptsIf BP >220/110 then usually need to treat (find cause too).Don’t be in a major hurry to lower it (can cause more problems eg. Dizziness, nausea)Hypertension on cover

20. “Mrs M’s b.p is 220/110 – what do you want me to do?”Px with cellulitis of left legAsymptomtatic from hypertension, leg not painfulPMHx: IHD, Type II Diabetes on insulin, HT, AF, CCFMeds: avapro (irbesartan) 300mg o daily, perindopril 10mg o daily, warfarin, metoprolol 25mg o b.d, lasix 40mg o daily, Flucloxacillin 1g iv qidOther obs stable pulse 80 temp 36.7 (was 38.5 yesterday), RR 12, sats 98% RA.Hypertension on cover

21. Nurses repeat the b.p – it’s 220/110.You go and take the b.p – its’ also 220/110Hypertension on cover

22. Lowering b.p often causes more problems – dizziness (eg. with gtn patch).AVOID the GTN patch for HT.If you need to lower, try oral medications firstAmlodipine 2.5-5mg po stat (max 10mg/day). Go up in 2.5mg o increments. Another dose can be given in 1-2 hours.If patient is already on an antihypertensive – can give increased dose if not already max eg. Pt could have extra dose beta blocker this pt is on metoprolol 25mg o b.d, so could give another 25mg stat if not bradycardic.Leave it to the unit to increase the regular anti-HT if asymptomatic. Just chart a stat order.Can try other meds eg. Beta blocker, ACEI, ATII blocker etc. but amlodipine has little S.E- safe and effective (long term can cause SOA)Hypertension on cover

23. Worrying.Need to see the patient can’t deal with it over the phone.Often MET called.Hypotension

24. Really need to determine the cause…People DIE from SHOCK.Patient is really unwell usually unless… ….. has low b.p ordinarily (young woman) or given antihypertensives but uncommon cause in hospitalWhat are the causes?Hypotension

25. Hypovolaemic – eg. Dehydration, fluid, blood lossSepticCardiogenic AnaphylacticNeurogenic shock from spinal cord traumaCauses of shock/hypotension

26. You are paged and ring back to find out that Mrs P who has a blood pressure of 80/40 and looks unwell and feels dizzy according to the nurses.What are you going to do?Case Scenario

27. DRABC and Does the patient look unwell?Hx – looking for evidence of all the above causes – ?admitted with dehydration, Sepsis, CCF, ?fluid losses from surgery etc.Examination - ?Dehydrated, ?Febrile and source of infection evident eg. Crackles in chest versus Overloaded with cardiac failure JVP (fluid balance chart, weights useful)What to do at the MET Call?

28. At the MET call – (1) Determine cause of hypotension(2) Treat in the meantime (if on examination not fluid overloaded) with a fluid bolus –N saline 200-250ml bolus statHydrocolloid – haemacel 500ml bag, give 250mls stat,(avoid dextrose fluid boluses as this will be redistributed into the tissues rather than staying intravascularly)Treatment of hypotension

29. Treat the hypotension – fluid boluses if not fluid overloaded eg. (N saline 200mls iv over 1/24)Treat the cause – sepsis – antibiotics, treat the source… (?upgrade antibiotics)If fluid overload AND hypotension call your reg!! May need ICU/ inotropes. At Met Call can consider 1mg increments of aramine (metaraminol) – potent sympathomimetic amine increases b.p. eg. noradrenalineNeed to determine losses, calculate how much fluid they’ve had- Eg. post –op – fluid losses during op etcdon’t forget intra-op fluidCardiac cause – inotropic support may be needed (not IV fluids!!)Anaphylaxis – adrenaline and steroids .Principles of treatment of hypotension

30. Withhold all anti-hypertensives on drug chart.Ensure b.p and other obs checked more regularly 15 min, 30 min, 1hourly etc…Inform seniors if no improvementMET call if no better May need to be in ICU despite all you do.Treatment of hypotension

31. Why is it important?Nurse rings you – “Mr AC has a potassium of 7.0 what do we do about this?”Why is the K+ 7.0? Why? Why? Why?CausesHyperkalaemia

32. Excessive Production - excessive intake -Slow K, chlorvescent, too much iv K+! Excessive release from cells-rhabdomyolysis, burns, tumor lysis syndrome, Massive blood transfusion, massive hemolysisShift, transport out of cells – acidosis, low insulin levels, digoxin overdoseIneffective elimination:RenalRenal ImpairmentMedications- ACEI, ATII blockersPotassium sparing diuretics amiloride, spironolactone((Hormonal Rarer things: Mineralocorticoid deficiency or resistance Addison’s disease, aldosterone deficiency, renal tubular acidosis, congenital adrenal hyperplasia))Causes of hyperkalaemia

33. Pseudohyperkalaemia haemolysis after venipuncture, excessive tourniquet time or fist clenching during phlebotomy (efflux of potassium from the muscle cells in to the blood stream, delay of processing of specimen (can also have abnormally high platelets, WCC, erhyrocytes (haemotocrit >55%)Read pathology report to look for this.Common

34. Hyperkalemia develops when there is excessive production (oral intake, tissue breakdown) or ineffective elimination of potassium. Ineffective elimination can be hormonal (in aldosterone deficiency) or due to causes in the renal parenchyma that impair excretion.Why treat hyperkalaemia?

35. Increased extracellular potassium reduces myocardial excitability with depression of both pacemaking and conducting tissuesLeads to suppression of impulse generation from SA node and reduces conduction by AV node and His-Purkinje system – leads to bradycardia, conduction block and arrest.Risk of cardiac arrythmias and death

36. If you want to know the physiology:Increased extracellular potassium levels result in depolarization of the membrane potentials of cells. This depolarization opens some voltage-gated sodium channels, but not enough to generate an action potential. After a short while, the open sodium channels inactivate and become refractory. It raises the charge closer to the action potential threshold, thus less calcium entry is needed to produce an action potential. This leads to the impairment of neuromuscular, cardiac, and gastrointestinal organ systems. Of most concern is the impairment of cardiac conduction which can result in ventricular fibrillation or asystole.Risk of cardiac arrythmias and death

37. What level would you treat hyperkalaemia?

38. Need to at least think of treatment once K+ over 5.5. Eg. Mild K+ 5.5-6.0 – cease slow K, could the offending medication be stopped eg. ACEI. Moderate K+ >6.0 -6.5 Take note – usually have to do something extra to lower the level eg. Not just stop K+ raising meds (see next slide)Mod-Severe K+>6.5 – 7.0Severe >7.0 How to treat at these levels?What level would you treat hyperkalaemia?

39. Does depend on the cause and likelihood of Hyperkalaemia continuing (eg. Ongoing renal failure (treat more aggressively) vs took too much slow K)Don’t forget the ECG particularly if K+>6.0 and could continueIf K+>6.0 give oral resonium 15-30g or can give resonium PR. Treatment – rough guide depends on cause

40. If K+ >6.3 –(1) can give resonium. (2) Worry about cardiac events – calcium gluconate or calcium carbonate (10mls of 10% slow iv injection)(4) Dextrose – 25mls of 50% dextrose (slow iv push to raise the BSL level so you can then give(3) Insulin – novorapid 6 units iv or s.c- iv better.(all written on drug chart as a stat order)Treatment of severe hyperkalaemia

41. May need to repeat the management again... and again.Other things to consider: Don’t forget to retest K+ in an hour after treating

42. Also might need to organise telemetry ifK+>6.5 or ECG changes or likelihood of reversing hyperkalaemia quickly is low eg. ESRF – ideal treatment would be dialysis.Telemetry if K+>6.5 or ECG changes in general

43. ECG findings in Hyperkalaemia

44. Mild K+ 5.5-6 – Repolarization abN – Peaked T wave (usually earliest sign of hyperK)6.5-7.0 progressive paralysis of atriaP wave widens and flattensPR segment lengthensP wave eventually disappearK+>7.0 conduction abN and bradycardiaECG findings in HyperkalaemiaThanks to lifeinthefastlane.com

45. K+>7.0 conduction abN and bradycardiaProlonged QRS interval with bizarre QRS morphologyHigh grade AV block, slow junctional and ventricular escape rhythmsAny kind of conduction block (BBB, fascicular blocks) Sinus bradycardia or slow AFSine Wave (pre-terminal)ECG findings in Hyperkalaemia

46. K+>9.0mEq/LAsystoleVFPEA with bizarre, wide complex rhythmECG findings in Hyperkalaemia

47. Tall peaked T waves and ST segment depression. As conduction becomes further delayed, there is prolongation of the PR interval with decreased amplitude and disappearance of the P wave Widening QRS complex with blending of the QRS complex and T wave ("sine wave")Ventricular tachycardia, ventricular fibrillation or asystole may ensue. ECG - Hyperkalaemia

48. Hyperkalaemia

49. Hyperkalaemia

50. CausesTreatmentHypokalaemia

51. Inadequate potassium intake – malnutrition (however rare without excessive K+ loss from body)Gastrointestinal losses –diarrhoea (COMMON), excessive perspiration, losses assoc with surgical procedures. -vomiting – (not much lost in vomit, heavy urinary losses of K+ in setting of post-emetic bicarbonaturia that force urinary K+ out too.Causes of hypokalaemia

52. Urinary losses – certain medicationsDiuretics – thiazide and loop diureticsAmphotericin, cancer drugs – cisplatin cause long term hypokalaemiaHypomagnesemia – mg is needed for adequate processing of potassium.High aldosterone levels- hypertension and urinary losses of potassium eg. Conn’s syndromeHereditary defects in renal salt transporters – bartter syndrome, gitelman syndromeAlkolosisCauses of hypokalaemia

53. Alkalosis can cause transient hypokalemia by two mechanisms. First, the alkalosis causes a shift of potassium from the plasma and interstitial fluids into cells; perhaps mediated by stimulation of Na+-H+ exchange and a subsequent activation of Na+/K+-ATPase activity.[4] Second, an acute rise of plasma HCO3- concentration (caused by vomiting, for example) will exceed the capacity of the renal proximal tubule to reabsorb this anion, and potassium will be excreted as an obligate cation partner to the bicarbonate.[5] Metabolic alkalosis is often present in states of volume depletion, so potassium is also lost via aldosterone-mediated mechanisms. Alkolosis mechanism of causing hypokalaemia

54. DefinitionsHypokalaemia is defined as a potassium level < 3.5 mEq/L Moderate hypokalemia is a serum level of < 3.0 mEq/L Severe hypokalemia is defined as a level < 2.5 mEq/L Definitions

55. Why is hypokalaemia bad?

56. Decreased extracellular potassium causes myocardial hyperexcitability with the potential to develop re-entrant arrhythmias.Why is hypokalaemia bad?

57. Changes to look for with hypokalaemiaECG

58. Increased amplitude and width of the P wave (peaked P waves)Prolongation of the PR interval T wave flattening and inversion ST depression Prominent U waves (best seen in the precordial leads) Apparent long QT interval due to fusion of the T and U waves (= long QU interval) With worsening hypokalaemia:Frequent supraventricular and ventricular ectopics Supraventricular tachyarrhythmias: AF, atrial flutter, atrial tachycardia Potential to develop life-threatening ventricular arrhythmias, e.g. VT, VF and Torsades de Pointes Changes appear when K+ falls below about 2.7 mmol/lLifeinthefastlane.com

59. Hypokalaemia alters the resting membrane potential and slows repolarisation. These changes are reflected in the electrocardiogram by depression of ST segments, flattening of the T wave, and prominence of the U wave (rarely). The absence of a visible T wave and the presence of a U wave may mimic QT prolongation. ECG - hypokalaemia

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62. Hypokalaemia is defined as a potassium level < 3.5 mEq/L Moderate hypokalemia is a serum level of < 3.0 mEq/L Severe hypokalemia is defined as a level < 2.5 mEq/L Treatment of hypokalamia

63. Mild 3.0 - 3.5 mEq/L - oral potassium should be okay unless ongoing losses (diarrhoea). Give Slow K II or III stat (or Chlorvescent )Consider charting them regularly if pt on regular loop diuretic eg. lasix 80mg o b.d (will likely need supplementary oral K+) Eg. Slow K II o b.dChlorvescent has more K+ so useful to use if K+ closer to 3.0 to bring up K+ faster but not very nice to taste on a regular basis! - ie. Pt started in hospital on lasix 40mg iv b.d for newly dx CCF K+3.1 today – give Chlorvescent III o stat or b.d. Check K+ again tomorrow (versus ongoing diarrhoea faster K+ loss – need to check K+ again today after replacing and might be better oral and iv)(Slow K = 8 mmol per tablet)(Chlorvescent dissolved = 14mmol)Treatment of hypokalamia

64. Moderate hypokalemia is a serum level of < 3.0 mEq/L - iv potassium and oral K+.Severe hypokalemia is defined as a level < 2.5 mEq/L - needs iv potassium +++ consider HDU monitoring/Telemetry. Write on iv fluid chart: N Saline 100mls +10mmols KCL iv 1/24 (pre-made bag) (this is the max dose and fastest rate on the wards) write it up a number of times eg. 4 times then repeat K+ testing)(very rough rule 10-20mmol might bring K+ up by 0.05 – 0.1)Mod-Severe Hypokalemia

65. Eg. Pt with ongoing profuse diarrhoea (or high output ileostomy)K+ 2.5 – written up on iv chart for:N Saline 100mls +10mmols KCL iv 1/24N Saline 100mls +10mmols KCL iv 1/24N Saline 100mls +10mmols KCL iv 1/24N Saline 100mls +10mmols KCL iv 1/24You tell the nurses to check U+E’s after thisThen has K+ repeatedPerhaps K+ will come up to 2.7-2.9 So, repeat management again and keep retesting K+! Can Supplement orally in addition to above! Eg. Chlorvescent III o statExample

66. Think about the cause of hypokalaemiaThink about the severity and if telemetry/HDU is needed eg. K+<2.5.Remember to retest K+ again after treatment may need more K+ again. And to test K+ again tomorrow.Treatment of hypokalaemia

67. If you are called about a patient who is delirious…What are the principles of MxAgitated/Delirious patient

68. Determine the cause of the delirium and agitation In older people any infection can cause this!Drugs, drugs, drugs (review drug chart) – speak to registrar about possible offending agents ?withhold/stopOpiates, benzodiazepinesAnticholinergic agentsAgitated/Delirious patient

69. Metabolic – hyponatraemia, hypernatraemia, hypoglycaemia, hypoxiaInfectiveStructural – Subarachnoid haemorrhage, Urinary Retention (good to check in elderly)Toxic – DRUGSEnvironmental – just being in hospital (unfamiliar environment!)CAUSES to think about - MISTE

70. Agitated patient –Aggressive, Intrusive, At risk to themselves and othersMust review the patient (don’t give a phone order) – Hx, Ex, Ix – go through everything to find the cause.Consider non-pharmalogical causes – involve the family (Nurses can help you here if you’re busy)If very agitated, intrusive at risk of falling hurting themselves or others can try an antipsychotic (but best to run this past your registrar first)

71. Must do all the non-pharmalogical things 1st – eg. Try to get single room close to nurses station, involve family.Can consider low dose antipsychotic:Haloperidol (typical antipsychotic – most evidence for helping in delirium)Less side effects – less anticholinergic, less hypotension, less sedating than other antipsychoticsHaloperidol (tablet) 0.25 – 0.5mg orally stat in antipsychotic naïve patient.Eg. Frail elderly woman 0.25mg, elderly man 0.5mg starting doseIf won’t take oral meds – haloperidol 0.5mg im stat.R/v in 1-2 hours, can repeat the dose if no better. Try not to give more than total haloperidol 2mg/24hr.Other options – pt will open mouth but won’t/can’t swallow tablets;Try …Haloperidol

72. Cochrane review – atypical antipsychotics similar efficacy to haloperidol (versus placebo)Risperidone (tablet or quicklet (dissolves in mouth) – dose like haloperidol 0.25-5mg o stat, max dose 2mg/24hrs.Olanzapine (Xyprexa) – 2.5-5mg o stat (tablet or wafer – dissolves in mouth), Max dose 20mg/daily in elderlyEg. Usual type of doses for delirium: haloperidol 0.5mg o b.d, risperidone 0.5mg o b.d, olanzapine 5mg o b.d (unit to copnsider starting this and cease when better)Other options (atypical antipsychotics)

73. Quetiapine (less EPSE than other atypicals) (Can use in delirium in Parkinsons disease)Start with 12.5mg o stat Eg. Usual starting type of dose 12.5mg o b.d in elderly with Parkinsons with deliriumCould consider benzodiazapines for delirium if antipsychotics not helping (1st line alcohol withdrawal ie DTs, or withdrawing from benzo’s)Eg. Oxazepam 7.5-15mg o tds prn in elderly.For DT’s – valium 5mg-10mg qid prn(longer half life of valium is useful here)Other options part 2

74. Do not use physical restraints. In this hospital we prefer to order in a special eg. 1:1 nursing (1 Nurse:1 pt) – costs money but better for the patient until pt settled.Don’t use haloperidol in Parkinson’s pt’s – EPSE side effects. Instead can try quetiapine 12.5mg o stat. Won’t take oral meds – try midazolam 0.5mg im stat.Unit B has a secure area that might be better for wandering delirious patients (also used for patients with dementia with BPSD – behavioural and psychological symptoms)Tips