ACLS Summary
ACLS Summary Adapted from Handbook of Emergency Cardiovascular Care for Healthcare Providers, American Heart Association 2006 Pulseless Arrest - BLS Algorithm, begin CPR - Oxygen - Monitor/Defibrillator Yes V. Fib/V. Tach Shockable? No Asystole/PEA CPR 2 min - Give 1 shock - Monophasic: 360 J - Biphasic: 200 J - Resume CPR - Epinephrine 1 mg IV Q3-5 min - May give Vasopressin 40 units IVP x 1 instead of 1st or 2nd dose of Epi - For asystole or slow PEA, consider Atropine 1 mg IV Q3-5 min x 3 doses CPR 2 min No Shockable? CPR 2 min Yes Yes No Shockable? - Give 1 shock - Monophasic: 360 J - Biphasic: 200 J - Resume CPR - Epinephrine 1 mg IV Q3-5 min - May give Vasopressin 40 units IVP x 1 instead of 1st or 2nd dose of Epi CPR 2 min No Shockable? Yes - Give 1 shock - Monophasic: 360 J - Biphasic: 200 J - Resume CPR - Epinephrine 1 mg IV Q3-5 min - Consider antiarrhythmics: give during CPR, before, or after shock - Amiodarone 300 mg IV x 1, may repeat 150 mg IV x 1, or - Lidocaine 1-1.5 mg/kg IV x 1, then 0.75 mg/kg IV, max 3 mg/kg - Magnesium 1-2 gm IV for torsade Search for and treat possible Contributing Factors: 5H’s, 5T’s Hypovolemia – give IVF Hypoxia – give oxygen Hydrogen ions (acidosis) – get ABG (consider Sodium Bicarbonate) Hypo/hyperkalemia – check labs Hypothermia – check temp Toxins Tamponade – check handheld echo Tension pneumothorax – check breath sounds, insert needle thoracotomy in 2nd ICS, midclavicular line Thrombosis (coronary or pulmonary) – get hx Trauma During CPR - Push Hard and Fast (100/min) - 30 compressions/2 breaths until advanced airway, then 8-10 breaths/minute - Ensure full chest recoil - Minimize interruptions - Check rhythm and pulse Q2 minutes Cedars-Sinai Medical Center Intern Survival Guide Page 1 of 88 BRADYCARDIA HR <60 bpm and Inadequate for clinical condition - Airway - Assist breathing prn - Oxygen - Monitor - Establish IV access No Signs/Sxs of poor perfusion? (AMS, CP, hypotension, other signs of shock) Observe/Monitor Yes - Prepare for Transcutaneous Pacing for type II, 2nd-degree or 3rd-degree AV block - Consider Atropine 0.5 mg IVP, may repeat to total dose of 3 mg - Consider Epinephrine 2-10 mcg/min or Dopamine 2-10 mcg/kg/min gtt - Prepare for Transvenous Pacing - Treat contributing causes (5H’s, 5T’s) Cedars-Sinai Medical Center Intern Survival Guide Page 2 of 88 TACHYCARDIA with pulses NARROW QRS (<0.12 sec) Yes - ABCs as needed - Oxygen - Monitor (rhythm, BP, pulse ox) - Identify and treat reversible causes - Establish IV access - Obtain 12-lead EKG or rhythm strip Is QRS narrow (<0.12 sec, 3 small boxes)? Regular No WIDE QRS (>0.12 sec) If V. Tach or uncertain rhythm - Amiodarone 150 mg IV over 10 min, repeat to maximum dose of 2.2 gm/24 hr - Prepare for elective synchronized Cardioversion If SVT with aberrancy - Adenosine 6 mg rapid IVP, if no conversion, 12 mg IVP, may repeat x 1 Converts? No Yes Irregular Narrow-Complex Tachycardia Probable A. Fib vs. A. Flutter vs. MFAT - Rate control with Diltiazem, or β-blockers If rhythm converts, probable reentry SVT - Observe for recurrence - Treat with Adenosine or AV nodal blocking agents: Diltiazem, or β-blockers Yes No Immediate Synchronized Cardioversion - Establish IV access - Sedate if possible - If cardiac arrest, proceed to Pulseless Arrest Algorithm! Irregular Regular Irregular - Vagal Maneuvers - Adenosine 6 mg rapid IVP, if no conversion, 12 mg IVP, may repeat x 1 Patient stable? (unstable signs: AMS, CP, hypotension, other signs of shock), raterelated sxs uncommon if HR<150 If A. Fib with Aberrancy - Rate control with Diltiazem, or β-blockers If pre-excited A. Fib (A. Fib + WPW) - Avoid AV nodal blocking agents (e.g., Adenosine, Dig, Diltiazem, Verapamil, β-blockers) - Consider antiarrhythmics (amiodarone 150 mg IV over 10 min) If Recurrent Polymorphic VT - Seek consultation If Torsade de pointes - Magnesium 1-2 gm over 2-60 min, then gtt Obtain Expert Consultation as needed at any point! If rhythm does NOT convert, possible A. Flutter, Ectopic Atrial Tachy., or Junctional Tachy. - Rate control with Diltiazem, or β-blockers - Tx underlying cause Cedars-Sinai Medical Center Intern Survival Guide Page 3 of 88 Synchronized Cardioversion - Oxygen, IV, Suction, Intubation tray/Crash cart - Sedate if possible (etomidate, midazolam, fentanyl, propofol, etc.) - Shock at 100 J, 200 J, 300 J, 360 J monophasic - Resynchronize prior to each shock A Note to the Reader This book is meant as a guide and not as a reference for acute medical problems. Not every pathway given may apply to each patient. Additionally, no book or reference source can supersede good clinical judgment. If in doubt, seek help from more senior housestaff, fellows, or attending physicians. Acknowledgements For several years, Chief Residents at Cedars-Sinai have organized and distributed the Intern Survival Guide. These past chiefs have compiled data, facts, and phone numbers to help ease new interns into the Cedars-Sinai system. The new Housestaff Survival Guide represents a change to a more comprehensive kind of handbook that we hope residents can use throughout their years at Cedars-Sinai. This new Survival Guide, we hope, is much more comprehensive with both medical facts and the nuances of individual rotations at Cedars-Sinai. Another innovation that this Survival Guide represents is a move to the electronic age. While a paper copy will continue to be distributed each year, an electronic version will also exist, allowing us to continuously update the Survival Guide as we get feedback from interns and residents. The electronic version can be accessed via the GIM Homepage from within the hospital at: http://web/gimportal With all of these changes, we have several people we would like to thank for their help in putting together this new version of the Survival Guide. Foremost, we would like to thank the countless interns and residents who we have bounced ideas off, given us feedback, and made valuable suggestions as we have put together this Guide. We must specifically thank Drs. Gary Chen, Odelia Cooper, Shervin Eshaghian, Alison Kole, and Kei Yamada for compiling new sections; Drs. Ray Duncan and Robert Jenders for assistance in implementing the guide on the web; Drs. Mark Noah, Rob Goodman, Ben Lee, and Dorothy Lowe for their help in editing this Guide. Thank you also to Robert Urban, for printing and reprographics, and his help in improving the paper version of the Survival Guide. Thank you! Ashkan Naraghi, Erica Palys, and Nirav Patel (Chief Residents 2007-2008) and Former Chief Residents Updated June 2006 Cedars-Sinai Medical Center Intern Survival Guide Page 4 of 88 Table of Contents ACLS Summary .............................................................................................................................1 Notes, Orders, and Dictations .....................................................................................................8 Dictation Instructions.................................................................................................8 Admission Orders .......................................................................................................9 PRN Medications................................................................................... 10 History and Physical ................................................................................................ 10 H&P Dictation Template ....................................................................... 11 Discharge ................................................................................................................. 12 Discharge Orders .................................................................................. 12 Discharge Summary Dictation Template ............................................ 13 Procedure Note ....................................................................................................... 13 Emergency Consent ................................................................................................ 14 CareVue Notes......................................................................................................... 14 SOAP Notes.............................................................................................................. 14 Ward Progress Note .............................................................................. 15 ICU Note ................................................................................................. 16 Web/VS Sign-Out..................................................................................................... 17 Death Note............................................................................................................... 18 Death Summary....................................................................................................... 18 Transferring a Patient ............................................................................................. 18 Consults ................................................................................................................... 19 Guide to Rotations..................................................................................................................... 20 Medicine Wards....................................................................................................... 20 ICU’s ......................................................................................................................... 20 MICU....................................................................................................... 21 RICU........................................................................................................ 21 CICU........................................................................................................ 21 Heme-Onc Wards..................................................................................................... 22 Senior-In-House ....................................................................................................... 22 Acute Emergencies.................................................................................................................... 24 Altered Mental Status ............................................................................................. 24 Seizures.................................................................................................................... 25 Chest Pain................................................................................................................ 26 Shortness of Breath ................................................................................................ 27 CVA/TIA .................................................................................................................... 29 Cardiology................................................................................................................................... 30 Simple EKG Reading ............................................................................................... 30 Atrial Fibrillation ...................................................................................................... 32 Hypertension............................................................................................................ 33 Hypotension/Shock................................................................................................. 34 Vasopressors ......................................................................................... 34 Rule Out Myocardial Infarction............................................................................... 36 Cedars-Sinai Medical Center Intern Survival Guide Page 5 of 88 Congestive Heart Failure ........................................................................................ 37 Infectious Diseases ................................................................................................................... 39 Neutropenic Fever................................................................................................... 39 CD4 Counts and Infection Risks .......................................................... 40 Prophylaxis............................................................................................. 40 HAART Therapy ...................................................................................... 40 HIV/AIDS Patient with diarrhea .............................................................................. 40 Line Sepsis............................................................................................................... 41 CSF Studies.............................................................................................................. 42 Fever Work-Up ......................................................................................................... 43 CSMC Guidelines for Fluoroquinolones................................................................. 44 CSMC 2005 Antimicrobial Susceptibility Summary (Antibiogram)...................... 45 CSMC 2005 Empiric Antibiotic Treatment Recommendations ........................... 46 CSMC Algorithm for Isolation of Suspected TB Patients...................................... 50 CSMC Isolation Reference Table............................................................................ 51 Pulmonary .................................................................................................................................. 52 COPD Exacerbation ................................................................................................. 52 Asthma Exacerbation .............................................................................................. 52 Vents......................................................................................................................... 53 Trouble Shooting Vents......................................................................... 54 Weaning ................................................................................................. 54 Pulmonary Embolism .............................................................................................. 55 Gastroenterology ....................................................................................................................... 57 Pancreatitis .............................................................................................................. 57 End-Stage Liver Disease/Ascites ........................................................................... 57 IBD Patient with diarrhea/possible flare ............................................................... 58 Upper GI Bleed......................................................................................................... 59 Renal/Electrolytes ..................................................................................................................... 60 Hyperkalemia........................................................................................................... 60 Electrolyte Replacement......................................................................................... 61 Potassium .............................................................................................. 61 Magnesium ............................................................................................ 61 Phosphorus............................................................................................ 62 Calcium .................................................................................................. 62 Acid/Base Disturbances ......................................................................................... 63 Determining Compensation ................................................................. 64 Continuous Renal Replacement Therapy.............................................................. 64 Low Urine Output..................................................................................................... 65 Radiology.................................................................................................................................... 66 Cranial Problems ..................................................................................................... 66 Face/Neck ............................................................................................................... 66 Chest ........................................................................................................................ 66 Vascular.................................................................................................................... 67 GI/Abdomen/GU...................................................................................................... 67 MSK .......................................................................................................................... 67 Miscellaneous............................................................................................................................ 68 Cedars-Sinai Medical Center Intern Survival Guide Page 6 of 88 Inpatient Guide For Diabetics ................................................................................ 68 Sliding Scales/Correctional Insulin/Supplemental Insulin................ 70 Supportive Care in Heme-Onc ................................................................................ 72 Heparin..................................................................................................................... 74 Alcohol Withdrawal.................................................................................................. 75 CIWA-AR ................................................................................................. 75 CSMC CIWA Protocol............................................................................. 76 Pain Control ............................................................................................................. 78 Pain Medication Equivalencies ............................................................ 79 Steroid Equivalencies ............................................................................................. 79 Mini-Mental State Exam ......................................................................................... 80 Pager and Phone Directory....................................................................................................... 81 Pagers ...................................................................................................................... 81 Patient Care Areas ................................................................................ 84 Clinics..................................................................................................... 84 Medicine Residency.............................................................................. 85 Outside Hospitals .................................................................................. 85 Email Info ................................................................................................................. 85 Useful Websites....................................................................................................... 85 Cedars-Sinai Medical Center Intern Survival Guide Page 7 of 88 Notes, Orders, and Dictations Dictation Instructions 1. From outside of the hospital, dial (310) 423-2255 or (877) 531-2912, or from inside, dial 101 or *99#, to access the system 2. Wait for the voice prompt to answer 3. Enter your physician ID number, followed by the # key 4. Enter the work type, followed by the # key Work Types History & Physicals 1 Consultations 2 Operative Reports 3 Discharge Summaries 4 Psychiatric 5 Transfer Summaries 6 Pre Operative Reports 7 5. Enter the patient’s medical record number, followed by the # key 6. Press 2 to begin recording 7. State and spell your full name, type of report, patient name and spelling, and the patient’s medical record number 8. To pause press 2, to resume dictating press 2 again 9. After pressing any function key, always press 2 to resume dictating. 10. Press 8 to end this report (and dictate another) or 5 to end the dictation session. (Note the dictation number down, in case it the dictation transcript is lost) Function Keys 1 Hold 2 Record/Pause 3 Short Review 4 Fast Forward 44 Move to End 5 Disconnect 7 Rewind and pause 77 Move to beginning *Remember when dictating to say, “Next paragraph” and state when you want to use punctuation marks to make your dictations clearer Cedars-Sinai Medical Center Intern Survival Guide Page 8 of 88 Admission Orders “ADC VAAN DISML” Admit to: Service name (“Medicine Teaching”), type of bed (“Monitored,” “ICU,” etc.) Team color and cross-cover pager Intern name and pager Resident name and pager Attending name (In ICUs, note Attending of Record) Diagnosis: Condition: “stable,” “guarded,” “critical,” etc. Vitals: Frequency, orthostatics, pulse ox (must be specifically ordered), daily weights, or “per routine” Activities: “bed rest,” “oob to chair,” “oob with assistance only,” “plaza privileges,” etc. Allergies: note type of reaction Nursing: Foley, strict I/Os, aspiration precautions (head of bed >30degrees), fall/seizure precautions, wound care, neuro checks Q___hr Call MD for HR >___<___, SBP >___<___, RR>___<___, T>___<___, Pulse Ox <___, Urine output < ___ cc over ___hours, otherwise can be “per routine” Diet: “strict NPO,” “NPO except meds,” “ADA 2400 kcal,” “Cardiac,” “Kosher,” etc. IVF: “HLIV,” or specify IVF contents, rate, and duration, e.g., “NS at 250 cc per hour x 4 hours then, D5 ½ NS + 20 KCl at 125 cc per hour” Special Studies: Echo, Imaging, Stress Testing, etc. Meds: “O2 via nasal cannula to keep O2 sat > ___” DVT prophylaxis: “Heparin 5000 units Sub-Q Q8-12hrs”, or “SCD’s Bilat LE” GI prophylaxis: “Zantac 75-150 mg PO BID”, or “Prevacid 30 mg PO daily” PRN meds *Don’t forget holding parameters for pain meds/antihypertensives/sleep meds/anxiety meds (e.g., “hold for RR<10, SBP<90, or sedation”—adjust these for each patient). Labs: Labs now, Labs at (specified time), and AM labs. (Don’t forget AM imaging and/or EKGs) Other orders: Code status - Must be written in the chart on a separate order blank in the form: “Patient is DNR, DNI,” and must include the phrase, “Attending to cosign in 24 hours.” Social Work Consult for ______ (e.g., homelessness, funding sources, placement, etc.) “PT Mobility Protocol” “OT Protocol” “Speech, Language Pathology Protocol” “Swallow Protocol” Ventilator orders: Mode of ventilation, rate, independent variable (tidal volume or control pressure), PEEP, and FiO2 Cedars-Sinai Medical Center Intern Survival Guide Page 9 of 88 PRN Medications *Note dose and frequency provided as a range; adjust depending upon your individual patient. Remember holding parameters! **Also refer to the Heme-Onc section for additional prn medications. Tylenol 650 - 1000 mg PO Q6-8 hours prn fever/pain, max dose 2-4 grams/24 hours) (2 grams max in liver failure patients, otherwise 4 grams) Vicodin 1-2 tabs PO Q4 hours prn moderate pain (include Tylenol limitation as above) Morphine 2-4 mg IV/Sub-Q Q4 hours prn severe pain Dilaudid 0.25-1 mg IV/Sub-Q Q3 hours prn severe pain Ambien 5-10 mg PO QHS prn insomnia Restoril 7.5-15 mg PO QHS prn insomnia Seroquel 12.5-25 mg PO QHS prn insomnia (useful in delirious or elderly patients prone to sundowning or at risk for agitation from benzodiazepines) Ativan 1 mg IV/PO/SL Q4 hours prn agitation/anxiety Haldol 2-5 mg IV Q4-6 hours prn agitation Mylanta/Maalox 10-20 cc (15 cc is the usual dose) PO QID prn dyspepsia Compazine 10 mg IV Q6 hours prn N/V Reglan 10 mg IV Q6 hours prn N/V Phenergan 25 mg IVPB Q6 hours prn N/V Zofran 4 mg IV Q4 hours prn breakthrough N/V History and Physical There must be an H&P on the chart at all times. Additionally, on all patients newly admitted to the hospital (transferred from an outside facility, from Thalians, from 7th Floor Rehab, direct admits, or admitted through the ED), an Intern H&P form must be present, along with a resident dictation. When you admit a patient, DO NOT take the H&P form with you. Instead, make a copy of it and place the original in the chart. There have been many instances where there was no H&P on the chart and the patient has crashed, transferred to another service, or been taken to the OR, and significant clinical history is not available. To facilitate copying the H&P form, the housestaff copy machine has been programmed to produce a one sheet, double-sided output of the H&P form that is much easier to manage than four loose sheets: 1. 2. 3. 4. 5. 6. 7. 8. Press the “Reset” button to clear the copier. On the main screen, at the bottom, press the “Programs” tab. Press the “h&p copying” button (program #1). Do not use the automatic document feeder. Instead, place the LAST page on the copy machine, and hit the green “Start” button. Flip over to the first page and copy that by hitting the “Start” button. Copy the inside two pages (order is less important here). After you’ve copied the four sides of the form, hit “Scanning Finished.” You should have a single-sheet of paper, with two pages on each side. Additionally, you should be able to fold the sheet in half and it should be exactly the same as the Cedars-Sinai Medical Center Intern Survival Guide Page 10 of 88 H&P form in layout. This allows you to use it as a “folder” of sorts for any other information/papers that you have for your patients (EKG’s, labs, reports, etc.) H&P Dictation Template 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. Your name (with spelling) Attending of record (with spelling) (Attending who is going to round on patient) Type of Dictation Patient’s name (with spelling) Patient’s medical record number Service patient is being admitted to (Medicine Teaching Service) Date of Admission Chief Complaint Reason for Admission (esp. in the ICU, e.g., “Hypotension”) HPI (begin with a 1-line descriptor, e.g., “This is a 56 year-old male with a history of coronary artery disease, status post PCI in 2004 with 3 vessel stenting and history of diabetes, who presents with a chief complaint of chest pain x 6 hours.”) Past Medical History Past Surgical History Medications Allergies Social History Family History ROS Physical Exam f. Cardiovascular a. Vitals g. Abdomen b. General h. GU (if indicated) c. HEENT i. Extremities d. Neck j. Neurological e. Chest Labs/EKG/Imaging/Other relevant studies Assessment and Plan Sign by stating your name Cosign by stating the attending’s name Mnemonic for Systems-based Assessment and Plan: “CPR FINE HOG” Cardiovascular Pulmonary Renal Fluids/Electrolytes/Nutrition Infectious Disease Neuro Endocrine/Metabolic Heme-Onc GI Also remember Rheum and Prophylaxis (GI, DVT, pneumonia, dermal ulcer, etc.). Cedars-Sinai Medical Center Intern Survival Guide Page 11 of 88 Discharge Discharging patients can be just as, or even more difficult than admitting them. Make sure you have a good follow-up plan prior to discharge. Schedule appointments at the ACC by calling the appointment desk at x36327. Use post-discharge clinic appointments to follow-up labs, pathology, or particular studies that may still be pending upon discharge; or to check-up on the general state of a patient post-hospitalization. If the patient has regular follow-up at the ACC though, a post-discharge visit may not be needed if they can get a regular appointment in time. Discharge Orders D/C Home (nursing home or other destination) D/C IV Date of Admission: Date of Discharge: Discharge Diagnosis: Discharge Condition: (should be “stable” or better) Discharge Activity: (any activity limitations) Discharge Diet: Discharge Medications: (you should write out all of the medications; do not say, “resume prior medications.”) Discharge Follow-up: (make sure you schedule the appointment and provide a number for patients to call to reschedule or if they have questions about their appointment: x32811. Also, make sure you give them a lab slip/prescription for a lab check if needed prior to their appointment). Special Instructions: Return to ED if ________ or other significant patient concerns. Other Orders: Educate/Instruct patient to quit smoking, drinking alcohol, and/or using drugs. Home Health: Many patients can be discharged with home health (e.g., for IV antibiotics, etc.). Make sure you contact the home health coordinator early, and write an order for the specific medication and duration of treatment, with specific end date. This should be written on a separate order blank, (i.e., Home health to arrange for IV antibiotics: Vancomycin 1 gram IVPB Q12 hours until 8/3/06). Cedars-Sinai Medical Center Intern Survival Guide Page 12 of 88 Discharge Summary Dictation Template 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. Your name (with spelling) Attending of record (with spelling) (Last regular (not covering) Attending taking care of the pt) Type of Dictation Patient’s name (with spelling) Patient’s medical record number Date of Admission and date of discharge Admission Diagnosis (or diagnoses) Discharge Diagnosis (or diagnoses) Procedures (with dates) Brief HPI (no need to recapitulate admission summary) Pertinent Physical Exam from Admission Pertinent Admission Laboratories (include EKG and CXR) Hospital Course (including complications, can be problem-based, systems-based, or chronologic) Condition on discharge Disposition/Follow up Discharge: Medications dose and frequency Discharge Diet: Discharge Activities: Special Instructions: Problem List (active and past medical problems) Sign by stating your name Cosign by stating the attending’s name Procedure Note Date Time Procedure: Indication: Physician(s) performing procedure: Patient consent: (document that risks/benefits were discussed with the pt and that they understood. Their questions answered. Also note that alternatives to the procedure were offered—including doing nothing). Sample note: Skin in the midline ½ way between the pubic symphisis and umbilicus was prepped and draped in the usual sterile fashion with (iodine). The skin was anesthetized with __cc of 1% lidocaine (+/- epinephrine) and a 18G needle was introduced. 1000cc of turbid ascitic fluid was collected and sent to the lab for _______. Patient tolerated the procedure well without any immediate complications. Joe/Joanna Intern, M.D. Cedars-Sinai Medical Center Intern Survival Guide Page 13 of 88 *Note: Make sure you have appropriate consent prior to the procedure, either from the patient, family, or surrogate decision-maker. Ensure that you have the consent signed (either directly or via telephone) and the “Physician Attestation" form filled out. Additionally, make sure the nurse fills out a “Time-Out” form to help prevent errors. **Note: A special procedure note form exists for central lines. Emergency Consent Date/Time Emergency ______________ (name of procedure) is indicated in this patient who is unable to give consent because of ____________ (AMS, ALOC, etc.). Indications for performing this procedure include ____________. *Note: Two physicians DO NOT need to sign this note, nor sign the consent form, though nursing staff may suggest otherwise. Emergency Consent should be used when the procedure is necessary for life, limb, or pain management. As the physician performing the procedure, you should carefully, and completely, DOCUMENT the indications in the progress note section. Of course, try to obtain telephone consent or family consent prior to utilizing emergency consent. You should also sign the hospital consent and “Physician Attestation” forms. CareVue Notes In the ICU all procedure notes should be done on CareVue. Most of these notes can be written in the “Progress Notes” section. A special option exists for “Physician Notes,” and many procedure-related notes have pre-built templates where you can point-and-click through many of the commonly used phrases. The only exception to this is the “Central Ven Cath Proc/Daily Note” which is under the main CareVue menu. This is also a point-and-click type note and is very user friendly. As a point of reference, the “regular” central line used in the ICUs is a 7-french antibiotic-coated Cook catheter. Additionally, a daily assessment of all central venous access catheters needs to be performed on every ICU patient. This should be documented under the same subheading, “Central Ven Cath Proc/Daily Note”, but as a “Daily Central Line Note.” SOAP Notes Daily progress notes on patients should be completed PRIOR to ward rounds so that the attending can sign below your note. In general, once the note is signed by the attending, it should remain in the chart. Theoretically, notes should convey to other healthcare providers what the current status of the patient is, what objective measures are being Cedars-Sinai Medical Center Intern Survival Guide Page 14 of 88 used to determine the patient’s status, and what the overall plan for care is. You should strive to achieve those three goals in your daily progress notes; the hardest of which is the last goal. Progress notes are also style dependent; everyone organizes and arranges their note differently based on their personal preferences. Additionally, given how the notes are required to be completed prior to attending rounds, many houseofficers use the note as a patient tracking sheet, documenting more information than what is presented on rounds, but having additional data available if asked. A word about medical student progress notes: They should always be labeled, “Rx/MS3 PN” and be cosigned by the intern/resident, and by the attending. While the following section highlights some key aspects of the notes, feel free to modify this basic template based on your and your patients’ specific needs: Ward Progress Note R1 Medicine ([list team color and pager here] team) Progress Note Date/Time S/ON Events: Subjective complaints and overnight events O: Vitals: Temp (max or min, including time), BP ranges, HR ranges, Resp Rate ranges, O2 sat on what level of supplementation (e.g., 95% on 3 L NC) I/Os: Separate In’s and Outs, note IVF content and rate, UOP, BM’s, etc. Physical Exam: General: HEENT: Chest: CV: Abd: Ext: Other systems as relevant (e.g. skin, neuro, etc.) Lines: (Central line sites/PICC sites, especially important in Heme-Onc or ICUs) Medications: Hot debate rages about whether to include this, either in the main note or as a sidebar. One of the editors of the Survival Guide feels it is essential, while other senior housestaff note the easy, online availability of patient medication lists. Regardless, some meds should be noted: Total amount of pain medication used in 24 hours, either prn or PCA, or amount of benzodiazepines required for alcohol withdrawal, antibiotics and day number, etc. Labs: Daily labs, any new labs (easily missed: updated culture/sensitivities results (use the “cultures” flowsheet if needed on WebVS), send-out labs, pathology reports). Cedars-Sinai Medical Center Intern Survival Guide Page 15 of 88 Also, trend out relevant labs (e.g., Hgb in a GI bleeder, creatinine in a patient with acute renal failure, blood glucose values in a diabetic) Other studies/Imaging: Any new study/imaging results if relevant A/P: “1-liner” or “Bullet statement” about the patient with relevant background history coupled with objective data to paint the patient’s overall clinical picture. It should be clear and concise. (e.g., 29 yo ♂with HIV, CD4 45 on 8/12/06, with h/o medication non-compliance p/w fever, cough, and SOB) A specific problem-based or systems-based assessment and plan can then be listed. Again, it is helpful to paint a background picture, followed by an actual assessment of the problem, with a status assessment (e.g., “improving”, or “worsening”). Plans should include first the other pending diagnostic work-up, followed by current treatment regiments. While there is not one absolutely correct method to accomplish this, try to be systematic and methodical. This will make it easier for you to more completely analyze the problem and allow others to understand your reasoning, especially if you are doing something outside the normal mode of practice: 1. CHF: Pt with h/o multiple MI’s, s/p 3 v CABG, with ischemic cardiomyopathy, EF 35% --> <20%, now with exacerbation likely secondary to UTI vs. medication noncompliance, currently improving. - Troponin x 2 negative, 3rd pending in this highrisk patient - Cardiac MRI to assess for myocardial viability - Consider EP consult for AICD placement - Continue diuresis with Lasix, Aldactone - Continue afterload reduction with ACE-I, consider Bi-Dil - Tx UTI as described below - Adjust medication regiment for increased outpt compliance ICU Note R1 ICU Progress Note Date/Time S/ON Events: Maybe more detail on ON events, less subjective information O: As before, may need to highlight particular abnormal vitals with further information (BP: 60-90/20-40 on Levophed @ 10 mcg/min). Vent: Provide vent information here (AC/VC R 12, TV 450, PEEP 5, 60% FiO2) I/O: Separate In’s and Out’s, note Dialysis balances, CRRT, IVF’s content and rate, other Cedars-Sinai Medical Center Intern Survival Guide Page 16 of 88 pertinent details. Also note total body negative/positive over the course of the ICU admission (easily done under CareVue, “Lab Summary by Day”) Physical Exam: as above (including central line info such as signs of infection, # of days in place) Labs: as above, note blood gases, and note trends in various labs (increasing/decreasing Hgb, Cr, CO2, etc.) Imaging: Daily CXR (note ETT position, central line position, and screening for pneumothorax in patients on positive pressure ventilation) EKG: Daily essential in the CCU, and important in any cardiac patient. Make sure you read and interpret it, and ensure that you have the actual tracing and prior tracings for rounds. Other studies: as needed/relevant A/P: As above, can be problem or systems-based. “1-liner” should also include reason for ICU admission and/or continued ICU stay. Intubated patients should also include a comment about the number of days the ET tube has been in place. A vascular access assessment should also be made daily, and documented as noted above in the CareVue section. All vascular access devices have risks (infection and thrombus formation), and you should discuss with your superiors as to whether an individual pt needs that device or if it can be discontinued. Web/VS Sign-Out Ward and ICU sign-outs are done via Web/VS. In general, the sign-out should include the active issues and what is being done about them, as well as what needs to be done overnight. If you are having a lab or test checked, it is not enough to simply write: Check Hgb at 1800 or F/U CXR. You must also elaborate what to do with abnormal lab values tests, i.e., Check Hgb at 1800, goal Hgb > 8, transfuse if needed, or F/U CXR r/o infiltrate, start Abx for CAP if positive. Make sure when you are giving and receiving sign-out that you evaluate how a particular test is going to change your overnight management. If it is not going to change overnight management, maybe it does not need to be signed-out. If it is not going to change overall patient management, maybe it does not need to be ordered in the first place! Intern: Resident: Code Status: Allergies/Medications to Avoid: 1-liner: Problem List: To-Do: Cedars-Sinai Medical Center Intern Survival Guide Page 17 of 88 Death Note *Note: If called to pronounce, use this as a guide; obviously, your actual note should reflect the pt’s clinical situation. **Note: Make sure the pt is really dead prior to pronouncing. Date/Time I was called by nursing to see this No Code Blue patient who was pulseless and breathless. On my physical exam, the patient was found to be without carotid pulses, heart tones, or breath sounds. Pupils were fixed and dilated. Patient was pronounced dead at (time and date) . (*Note: you must you this exact phrase). Dr. PMD was notified. Family was present at bedside (if they were). Joe/Joanna Intern, MD Death Summary (if your patient dies- this is your discharge summary to dictate) Date Time Pt. was admitted on ____ with the diagnosis of _______. The hospital course was complicated by ________, _________. The patient expired on __________ after ______. Joe/Joanna Intern, MD Transferring a Patient A transfer note is similar to a Discharge Summary; pertinent history, procedures, and events should be summarized. Note the important dates (Date of Admission, Date of Transfer, Date of ICU Admission, etc.), and highlight the hospital course to date. For stable patients, Transfer Orders should be placed in the chart prior to a patient’s transfer off the floor. For unstable patients, it is obviously acceptable to have the orders done after the patient has been stabilized or transferred and stabilized. It is important to note on the orders, the new interns and residents who will be taking care of the patient. For patients that are transferring to another facility, an “Inter-facility Transfer Order” form must be completed, in addition to an order on the standard order sheets in the form of, “Transfer patient to ________.” Make sure the details of the transfer have been finalized through the social worker, the case manager, the transfer center, and the accepting facility. If you are transferring to another hospital, make sure you give sign-out to the accepting physician. This information should be available through the transfer center. Hint: start working on transfers early in the patient’s admission, early in the course of the week, and early in the day. Nobody likes transfers on Friday afternoon at 4 PM. Cedars-Sinai Medical Center Intern Survival Guide Page 18 of 88 Consults When you are calling a consult (GI, rheumatology, ID, etc.), there are a few points you should ALWAYS convey to the consult fellow: 1. Identify your name and context of the call (i.e., My name is Dorothy Lowe and I am the resident on the wards) 2. Identify the nature of the call (i.e., I am calling because we are admitting a patient that I would like you to consult on OR This is not a formal consult, but I would like to ask you a curbside question) 3. Identify the question you are asking—THERE MUST ALWAYS BE A QUESTION! (i.e., for colonoscopy on a rectal bleeder OR for bronchoscopy on a pt with suspected PCP pneumonia OR to help us in the evaluation/management of a patient with advanced AIDS and mental status change, etc.) 4. Give a brief outline of the patient’s history and presentation You should always assess the patient yourself prior to calling the consult! Do not ask the fellow to see the patient before you do! Formulate your own ideas of what is going on with the patient and convey this to the consult fellow so that you can have an educated and educational discussion! You should have as much pertinent information as possible prior to calling the consult (i.e., vital signs and Hemoglobin in a GI bleeder, CD4 count for an HIV patient, etc.). If you are not certain why you are calling a consult, figure it out before calling—“my attending wants a consult but I don’t know why” is not appropriate. Try to call consults as EARLY as possible (prior to rounds, or at least before noon conference)—otherwise you may not get input from the consult attending until the following day. Please be appropriate and professional in your interactions with fellows and attendings— remember that we are all working together in order to take care of patients in the best possible way, and this requires collaboration that requires effective communication. Cedars-Sinai Medical Center Intern Survival Guide Page 19 of 88 Guide to Rotations Medicine Wards – CSMC - Morning report typically starts at 8:00 or 8:30; check web schedule or whiteboard in housestaff office - Attending rounds after morning report. Style varies by attending - Patients must be seen, notes written, and AM labs ordered before morning report - Rounds usually end before lunch and attendance at noon conference is mandatory while on the wards - Attendance at morning report and Grand Rounds (Friday 8:30) also mandatory - Try to call all consultants and write major orders before noon - On-call intern must use pre-printed H&P form and resident must dictate an H&P for all new patient admissions - A & P may be in “problem list” format or based on organ systems. However, always include a section on FEN (Fluids, Electrolytes and Nutrition) and Prophylaxis (GI and DVT/PE) - Daily progress notes are in the SOAP format - DO NOT take the H & P out of the chart to present. You may make a copy if you wish. - Intern call is Q4. There are 3 interns on call (Early, Late 1 and Late 2). Early intern prerounds on all patients with the Early resident and admits until 8 PM or until capped (5 new patients). Late interns come to the medical center at noon. They carry the code pagers and get sign out from other teams. Late interns start admitting after early has capped or at 8 PM. They admit all night (until 6 AM) or until they cap. - Late 1 gets sign-out from the post-call team and early intern (“post-call and on-call”) - Late 2 gets sign-out from post-post call and pre-call teams (“everyone else”) - Intern code pagers are carried by the pre-early intern until noon and by both late interns after noon - You MUST see all cross cover patients you are called on AND write a cross-cover note - If you are done with your work, you may sign-out after 2 PM. Otherwise, you may sign out after you are done with your work for the day or at 5 PM. The typical intern workday is from 6 AM to 5 PM. Additionally, if you finish your work and sign-out at 2 PM, you must keep your pager on at home until 5 PM. DO NOT sign-out work that could be completed before 5 PM. - Always confer with your resident after noon conference and before you leave - If you are seeing a private patient on the wards you must talk with the private attending at least once-a-day. These patients are not presented on teaching rounds. - If any patients need to be transferred to an ICU you must write a detailed transfer note and transfer orders. ICU’s – CSMC - ALL ICU’s are Q3 at Cedars-Sinai - To comply with the 80 hour work week you MUST be signed-out by noon, attend noon conference, and leave the hospital by 1 PM - You MUST sign out ALL unfinished work to the on-call team Cedars-Sinai Medical Center Intern Survival Guide Page 20 of 88 - Saperstein ICU tower code pagers are carried by the on-call interns and residents from all of the ICU’s - You are required to go to Grand Rounds and noon conference unless you are tending to a critical patient - As an intern, DO NOT involve yourself with patient triaging. This is done by the ED, bed reservation, and with some input from your resident. As far as you should be concerned every ICU should be able to take care of any critically ill adult patient - With the Q3 structure and people leaving post-call, every patient in your ICU is your patient. You must know about all the patients. Pay attention on rounds and know the plan! - Learn to use CareVue (ICU computer system) well - Document all procedures on CareVue - When looking at vitals, look at the past 24 hours. Record all hemodynamic parameters as ranges. - Have a low threshold to call your resident or fellow - All teams cap at 5 post-call, so any patient after that number is a hold over for the next team MICU - Daily routine is very attending dependent - Rounds are typically at 9 AM - Present from memory. Do not keep looking back at your progress note - On all clinic patients the ICU fellow is the attending/PMD and must be called at the time of the admission - All private attendings must be called at the time of admission and at least once a day - Goals and Values are a big part of this rotation, as they should be in any rotation - Sign out rounds are with the fellow +/- attending, usually around 4 PM RICU - Daily routine is very attending dependent - Rounds are typically at 9 AM - On all clinic patients the ICU fellow is the attending/PMD and must be called at the time of the admission - All private attendings must be called at the time of admission and at least once a day - Vent management is a big part of this rotation - Sign out rounds are with the fellow +/- attending, usually around 4 PM CICU - Rounds are usually at 8 AM - Attending cardiologists and cardiology fellows staff this unit. - Most attendings are also very well versed in critical care medicine - Be prepared to discuss the cardiac issues at length - Have all EKG’s ready to present on rounds - Always know the Echo, Cath, etc., information - Discuss all critical care issues with your resident and fellow Cedars-Sinai Medical Center Intern Survival Guide Page 21 of 88 - Post-call team on Monday presents an interesting case to Dr. P. K. Shah. Typically, you should have EKG’s as transparencies and should prepare in advance Heme-Onc Wards – CSMC - There are no residents on this rotation - 3 interns with Q3 call - Call is until 8 PM - On-call intern signs out to Senior-in-House at 8 PM. However, intern MUST take all admissions that come up to that time, even if that means staying later than 8 PM - Any admission to LIM/LILL/STEWART on 4SE or 4SW must be done by the Heme-Onc service. Often, private MD’s will admit to you as well - Many of the patients have charts in the cancer center, open 24 hours/day. Go to the Cancer Center and request the chart if you need - Discuss all admissions with the fellow - DO NOT write chemo orders. They may only be written by the fellow - An intern must be on the ward at all times when a patient is receiving a stem cell transplant - Fellow will provide you with info on stem cell transplants on the first day - Rounds are in the conference room on 4SW at 9 AM. As you are presenting the attending is writing his/her own note. Speak at the pace at which they are writing. Also, DO NOT discuss aspects of the plan prior to the A/P section (“plan leak”). - These patients are very sick and you must take every call very seriously - Have a low threshold for unit transfer - You ALWAYS have back up. Be able to contact the fellow at any time and know who the Senior-in-House is when you are on call alone - Look at all lines and in the patient’s mouth every day - As in the ICU, every patient is your patient - Your pre-call Friday, Saturday, or Sunday is your day off Senior-In-House - Cross-cover all patients on the Med-Consult Service - For NEW consults: see urgent consults ASAP; non-urgent consults will be done by the Med-Consult team in the morning (For Thalians pts, see below) - Cross-cover Heme-Onc Wards Service; admit new Heme-Onc pts AFTER 8 PM - Help to manage TEACHING patients in the ED waiting for an ICU bed - Urgently consult and write admission orders for TEACHING pts going to a SICU with MEDICAL ISSUES ONLY (see below) - Follow post-op patients of Dr. Lo with no other acute issues (see below) - Admit pts for Med-Teaching Wards AFTER the late resident has capped at 10 (if you are too busy with other duties, PLEASE PAGE THE CHIEF RESIDENT SO THAT THE DH RESIDENT MAY BE CALLED IN!!!) - Temporarily assist any Med-Teaching resident/intern, assist in the ICU, etc… - House Doc covers ALL urgent calls for private patients, regardless of specialty. If House Doc is busy managing a crashing pt, s/he may call Senior for help seeing Cedars-Sinai Medical Center Intern Survival Guide Page 22 of 88 another urgent pt. House Doc should NOT call Senior for help just because s/he is busy. Senior should evaluate the new urgent pt, and decide if that pt can wait for House Doc or if Senior needs to step in to manage the pt until House Doc is free. Patients of Dr. Simon Lo: - Generally, two types of patients are appropriate for Med-Consult: - Pts being admitted from home for scheduled procedures with no acute issues. - Pts who recently had a procedure and will need post-op inpt follow-up, e.g.: - Direct admission from GI suite post-ERCP. - Recently d/c’ed from hospital post-ERCP now in ED with procedurerelated pain/Sx - If you are confused about to which service a patient belongs, during business hours, M-F, contact the Med-Consult attending. At all other times, leave a message for the HOSPITALIST LONG CALL attending at 310-423-0032 (listed in amion.com, password is “cedarsim”), and your call will be returned Thalians: - When called for an admission H&P, please fill out a yellow card with the pt’s information. Then, write down a) the time you were paged, and ask b) what time the pt was admitted. Give this to the Med-Consult resident in the morning. IF ≥24 HOURS WILL HAVE LAPSED SINCE TIME OF ADMISSION BEFORE YOU SIGN OUT THE PAGER, you need to go to Thalians and do the H&P and give the info to the Med-Consult resident in the morning - ALL urgent consults from Thalians (or any other service) should be seen promptly - If a Thalians pt was admitted by his/her own private internist, that doctor should be called for all medicine issues and NOT Med-Consult - If you need to discuss any consult situation with an attending, leave a message for the HOSPITALIST LONG CALL attending at 310-423-0032 (listed in amion.com, password is “cedarsim”), and your call will be returned Teaching patients going to a SICU/CSICU: - See the pt ASAP and write an urgent med consult note leaving specific recs - Write the following orders: - Attending of record (Med consult attending) - Med-consult pager 4946 for non-urgent issues - ONLY THE MOST NECESSARY ORDERS, i.e. ABx, labs, studies, IVF's - Then write “SICU resident to write other routine orders” - Present the case to the Pulm/CC fellow and call whatever consults YOU think are necessary. Call the Pulm/CC attending if you need an urgent consult - For these patients, the med-consult team is the primary, and Pulm/CC consult service follows closely. For minute-to-minute issues, the SICU resident/team is still responsible for managing the patient WHEN IN DOUBT, ALWAYS SEE AND EVALUATE THE PATIENT!! Cedars-Sinai Medical Center Intern Survival Guide Page 23 of 88 Acute Emergencies - You Must See the Patient Immediately! Altered Mental Status 1. Questions during initial phone call: - Vital Signs - What is the change in level of consciousness? - Is the patient diabetic? - How old is the patient? 2. Orders over telephone: - Accu-Chek, O2 saturation, new set of vitals (if not done already), chart and MAR ready, ± EKG 3. Differential Diagnosis of AMS: “MOVE STUPID” Metabolic – B12, thiamine deficiency, hepatic encephalopathy (rare: Wilson’s dz, niacin deficiency) Oxygen – hypoxemia, hypercarbia, anemia, decreased cerebral blood flow (e.g., from low cardiac output), sepsis, carbon monoxide Vascular – stroke, hemorrhage, vasculitis, TTP, DIC Endocrine – hyper/hypoglycemia, hyper/hypothyroidism, high/low cortisol Electrolyte – low Na, hyper/hypocalcaemia, hypermag, hypophos, abnl LFTs Seizures – post-ictal, status epilepticus (nonconvulsive), complex partial sz Structural – lesions with mass effect, hydrocephalus Tumor, Trauma, Temperature (either fever or hypothermia) Uremia – also dialysis disequilibrium syndrome Psychiatric – dx of exclusion, ICU psychosis, “sundowning” Infection – CNS, sepsis Drugs – intoxication or withdrawal (opiates, benzos, ETOH, anticholinergics) Degenerative diseases – Alzheimer’s, Parkinson’s, Huntington’s 4. Initial Evaluation: DON’T - Accu-Chek if available, then 1 amp D50 after thiamine - Oxygen with oropharyngeal airway if necessary - Naloxone, usually 0.4-1.2 mg IV if even remote possibility of opiate OD - Thiamine, 100 mg IV (before glucose) - Physical exam especially Neuro - Fever, tachycardia, O2 saturation, myoclonus (uremia, cerebral hypoxia, HONC), tremor (withdrawal, autonomic sx, hyperactive), asterixis (liver/renal failure, drug intoxication) - Labs: CBC, BMP, Mg/phos, LFTs, Utox, U/A, ABG, EKG, blood/urine cx, CXR - Low threshold for non-contrast head CT if focal neurologic signs or risk for CVA - Consider LP especially if fever/meningeal signs/immunosuppressed Cedars-Sinai Medical Center Intern Survival Guide Page 24 of 88 Seizures 1. If patient is still seizing—remember your ABC's: - O2 by face mask, position pt on side to prevent aspiration. Suction airway as needed. Do not try to insert airway - Prevent patient from injuring himself/herself - If seizures continue after 2-3 minutes, try to start an IV and abort the seizure with Ativan 2 mg. Alternatively, Ativan IM Q5 minutes to max 8 mg or Valium PR 20 mg - Give thiamine 100 mg IV first, then 1 amp D50 IV - If seizure is >10 minutes or is not easily responsive to benzodiazepines, the pt is likely in status epilepticus and the patient will need ICU management - Only if an absolute certain diagnosis of severe hyponatremia is established should treatments such as iso- or hypertonic saline be used to halt a seizure 2. Once seizure has stopped: - Place oral airway. Get ABG if patient appears cyanotic - Establish IV access and send basic labs (CBC with differential, BMP, Mg/phos, albumin, antiepileptic levels) - Evaluate if this is status: continuing seizing for > 30 minutes, no consciousness after 30 minutes, if patient seizes again without achieving normal consciousness. If the patient is in status epilepticus, send the patient to the ICU and consult neurology. 3. Load with phenytoin 20 mg/kg in 3 divided doses at 50 mg/min (usually 1 g total); use fosphenytoin when available at the same dose as its load is better tolerated. - Remember, phenytoin (but not fosphenytoin) is not compatible with glucosecontaining solutions or with Valium. If you have given these meds earlier, you need a second IV 4. Consider common causes of seizures (i.e. basic labs and a head CT for new onset seizures): - Alcohol withdrawal (2 mg ativan IV post-seizure may help to prevent recurrence) - CNS lesion/infxns (tumor, CVA, head injury, meningitis/encephalitis, etc.) - Meds (Demerol, benzo withdrawal, penicillin [imipenem], lidocaine toxicity, INH [only stops after giving Vitamin B6], ASA, TCA, cocaine, Benadryl, amphotericin, theophylline, buproprion etc.) - Metabolic (low glucose, Na, Ca, or Mg) - Toxins (CO, heavy metals, many drugs of abuse or withdrawal from these drugs) - Other (HIV, malignant hypertension, hypoxia, uremia). 5. Write for seizure precautions. Watch for metabolic acidosis and rhabdomyolysis Cedars-Sinai Medical Center Intern Survival Guide Page 25 of 88 Chest Pain Initial Evaluation: 1. Over telephone: Vital Signs, recent telemetry data, EKG, chart at bedside 2. History: prior h/o CAD, onset: exertional/nonexertional, character, quality, location, associations, duration, relief 3. Examine the pt: vitals, evidence of heart failure 4. Check EKG and compare to old EKG Workup: You will need to rule out life-threatening diagnoses rather than diagnose definitively MI: typically “pressure-like” pain associated with SOB, diaphoresis, radiation to left jaw/arm, nausea/vomiting, cardiac risk factors present; remember, MI can present atypically, and not only in women and diabetics Aortic dissection: “tearing” pain, assoc w/HTN, smoking, radiation to back, unequal pulses - Transfer to ICU to reduce BP and inotropy with ß–blocker - Emergent CT scan with contrast, or echo and call vascular surgery - EKG may show evidence of ischemia in RCA distribution if dissection is proximal Pneumothorax: COPD, trauma, decreased breath sounds, hyperresonance, deviation of trachea away from side with pneumothorax, and hypoxia - CXR and call surgery for chest tube placement - If tension pneumothorax (hemodynamic instability), don’t wait for the CXR! Insert a 14 gauge angiocath into the 2nd intercostal space at the midclavicular line on the side of the pneumothorax PE: dyspnea, tachypnea, tachycardia, pleuritic chest pain, hypoxia, A-a O2 gradient, hemoptysis - obtain chest CT with PE protocol or V/Q scan if available. Begin anticoagulation (if there are no contraindications) while you are waiting for the results Other etiologies: pericarditis, pneumonia/pleurisy, GERD, PUD, esophageal spasm (may respond to nitroglycerin), esophageal rupture (Boerhaave’s) or tear (MalloryWeiss), candidiasis, herpes zoster, costochondritis, rib fracture, anxiety (a diagnosis of exclusion) Treatment: “MONA” - Morphine 2-4 mg IV (watch BP and for oversedation) - Consider Metoprolol 5 mg IV Q5 min x 3 (avoid in COPD/asthma or CHF, and watch BP) - Oxygen via NC - Nitroglycerin 0.4 mg SL Q5 min x 3, hold for SBP <100. Can proceed to Nitropaste 1” (note: variable and poor absorption). Remember, just because the chest pain responds to NTG does not automatically rule in angina - If patient is not already on aspirin and has no contraindications, give ASA 325 mg - Transfer to monitored bed, heparin gtt if no contraindication, check troponins, serial EKGs Cedars-Sinai Medical Center Intern Survival Guide Page 26 of 88 Shortness of Breath Initial Evaluation: 1. History - Acuity of onset - Associated symptoms (cough, chest pain, palpitations, fever) - New events or medications given (including IV fluids!) around the onset - Relevant PMH and admitting diagnosis 2. Physical Exam - Vital signs (include O2 sat; measure the respiratory rate yourself!) - Lungs: respiratory distress (cyanotic, accessory muscle use), wheezes, rales, stridor, symmetry of breath sounds. Remember that adventitious lung sounds may be absent in someone with severe airflow limitation - Cardiac: JVP, carotids, rate/rhythm, and murmurs or rubs - Extremities: edema (unilateral vs. bilateral) and perfusion (cool vs. warm, capillary refill, cyanosis) - Mental status: gives an idea of cerebral oxygen delivery 3. Labs/ studies - CXR, EKG, ABG, CBC (better to order all of these if there are any questions) Differential Diagnosis: 1. Pulmonary - Pneumonia - Pneumothorax: acute onset, pleuritic CP, consider in intubated patients, especially if peak and plateau pressures elevated - PE: often difficult to rule in/out by history/exam. Consider early - Aspiration: common in pts with altered sensorium - Bronchospasm: can occur in CHF, pneumonia, and asthma/COPD - Upper airway obstruction: often acute onset, stridor/ focal wheezing - ARDS: usually in pts hospitalized with another dx (e.g. sepsis) - TRALI: Usually very rapid onset post-transfusion - Pleural effusion 2. Cardiac: - MI/ischemia: dyspnea can be an anginal equivalent - CHF: common in elderly pts on IVF, or due to ischemia - Arrhythmia: can cause SOB even without CHF/ischemia - Tamponade: consider when pt has signs of isolated right heart failure 3. Metabolic - Sepsis: dyspnea can be an early, non-specific sign - Metabolic Acidosis: pts become tachypneic to blow off CO2 Cedars-Sinai Medical Center Intern Survival Guide Page 27 of 88 4. Hematologic: - Anemia: easy to miss this by history/general exam - Methemoglobinemia: rare; consider in pts taking dapsone or certain other meds with cyanosis/low sat, normal PaO2 5. Psychiatric: - Anxiety: common, but a diagnosis of exclusion! 6. GI: - Massive ascites, abdominal mass: compressive Initial Management 1. Oxygen: - Your goal is a PaO2 > 60, or O2 sat > 92%. If nasal cannula isn't enough (max FiO2 is ~35-40%), try mask (up to 50%), non–rebreather (70%), or high-flow setup (90%) - Call RT early if you’re having any trouble, and they will help with nebulizers, suction, masks, ABGs, oral/nasal airways 2. Beta agonists: - Patients with wheezing from any etiology can benefit from bronchodilators - All that wheezes is not asthma! (e.g., CHF, pneumonia) 3. Diuretics: - Consider Lasix in a pt w/history or exam c/w CHF; other processes associated with increase in lung fluid (pneumonia, ARDS) may also improve temporarily with diuresis, and a single IV dose of Lasix is unlikely to do any irreversible damage. Be careful in renal disease! 4. Assess potential need for intubation. BiPAP trial may be helpful method of temporizing while making this decision. - BiPAP is most helpful to correct ventilation deficits (i.e., helps reduce pCO2), and in pts with CHF or COPD, but can assist any patient to help move air - BiPAP can be started at “12/5” and rapidly titrated as needed. Top number refers to IPAP (Inspiratory Positive Airway Pressure) while bottom number refers to EPAP (Expiratory PAP, equivalent to PEEP). You will also need to set the respiratory rate and FiO2 - BiPAP is contraindicated in patients who are at risk of aspirating, on tube feeds, have excessive secretions, AMS, or respiratory arrest 5. Once you have the patient stabilized and the results of your initial studies, you can initiate therapy directed at the specific etiology of the patient’s dyspnea Cedars-Sinai Medical Center Intern Survival Guide Page 28 of 88 CVA/TIA Work Up: 1. Time of onset of symptoms (important for use of t-PA) 2. Vitals, including pulse ox, and complete physical exam 3. Detailed Neuro Exam (find the lesion!) 6. EKG, CBC, BMP/Mg/PO4, PT/PTT, fibrinogen, ESR, LFTs, cholesterol 7. Noncontrast Head CT Management: 1. BP control: Permissive hypertension in acute stroke. Goal SBP recommendations vary depending upon the type of the stroke. Ask the neurologist for their current recommendations, but aim for SBP ~160-180 - If DBP >140 Start Nipride gtt - SBP >230 and/or DBP 121-140 Labetalol* 20 mg IV Q10 min (max 150 mg); consider gtt at 2-8 mg/min - SBP 180-230 and/or DBP 105-120 Labetalol* 10 mg IV Q10 min * if labetalol contraindicated (e.g. CHF), consider Nitroglycerin gtt (esp. if coronary ischemia), Enalaprilat IV (IV ACE-I, useful in LV dysfxn; avoid if acute MI), or Hydralazine IVP DO NOT LOWER BP MORE THAN 25% 2. Establish Risk Factors - A-fib – Check EKG - Carotid Dz – Check U/S bilateral carotids - Endocarditis – Check TTE - Cancer – eval risk factors and health maintenance hx (mammo? PSA? colo?) - HTN – Check BP, eval hx and tx - CAD – Check EKG, lipid panel, consider stress test - DM – fasting blood sugar - Peripheral Vasc Dz – u/s LE - Autoimmune Dz – Check ANA, ds DNA, RF, etc 3. Consider CODE BRAIN protocol if needed: - Sxs < 3 hours - Evaluated and stabilize patient - Emergent Head CT perfusion scan (“Code Brain” protocol) - Check coags, plt, glucose, and Cr STAT - Neurology consult - Weekdays 8 AM to 4 PM: Dr. Waters p2951, who will contact Neuro resident p2551 - Afterhours/Weekends/Holidays: Page panel neurologist who will contact House Physician p1878 Cedars-Sinai Medical Center Intern Survival Guide Page 29 of 88 Cardiology Simple EKG Reading Note Height: 0.1 mV = 1mm Duration: 0.4 s = 1mm Rate 60-100 bpm - Normal <60 bpm - Bradycardia >100 bpm - Tachycardia QRS Axis normal axis is between -30 to +90 degrees Normal Axis Predominate upward deflection in leads I and aVF Right Axis Deviation: >90° is right axis, Upward in I and Downward in aVF Left Axis Deviation: < -30° is left axis, Downward in I and Upward in aVF Intervals PR QRS normal 0.12-0.20s normal <0.09s, abnormal >0.12s QTc 0.45 ( measured QT ) RR Right atrial abnormality lead II P>0.25 mV or >25% QRS amplitude lead V1 P is biphasic and the initial phase is >0.15 mV Left atrial abnormality lead II P >0.12s with notches separated by at least 0.04s lead V1 P is biphasic and the terminal phase is >0.04s and >1mV Left ventricular hypertrophy R in aVL >11 mm (men), >9 mm (women) R in aVL + S in V3 >20 mm (women) and >25 mm (men) S in V1+(R in V5 or R in V6) >35 min Right ventricular hypertrophy Right axis deviation R:S ratio > 1 in V1 (in absence of RBBB or posterior MI) RBBB (Right Bundle Branch Block) QRS >0.12s Wide S wave in I, V5, V6 Secondary R wave (R') in right precordial leads with R' greater than initial R Cedars-Sinai Medical Center Intern Survival Guide Page 30 of 88 LBBB (Left Bundle Branch Block) QRS > 0.12s, broad R in I and V6, broad S in V1, and normal axis QRS > 0.12s, broad R wave in I, broad S in V1, RS in V6, and left axis deviation LAFS (Left Anterior Fascicular Block) Axis is more negative than -45 degrees Q in aVL, and time from onset of QRS to peak of R wave is >0.05s. Also helpful is pattern of Q in I, S in III LPFB (Left Posterior Fascicular Block) Axis >100 and QIII, Sl pattern Q Waves Pathologic Q's are at least 0.4s and 0.1 mV deep V1, V2, V3: "any, any, any" V4, V5, V6: "20, 30, 30" I, II, aVL, aVF: "30, 30, 30, 30" V1, V2: "R > 40, R > 50" *Numbers refer to width of Q wave in milliseconds. DDx of Left Axis Deviation: LAFB Inferior MI WPW with posteroseptal pathway COPD PE DDx of Right Axis Deviation: RVH Lateral or anterolateral MI WPW with left freewall pathway LPFB Cedars-Sinai Medical Center Intern Survival Guide Page 31 of 88 Atrial Fibrillation Common Etiologies: PIRATES (most acute episodes/exacerbations related to various etiologies of sympathetic stimulation) Pulmonary (COPD, pna, PE, pericardial dz) Infarction, Infxn Rheumatic Mitral Stenosis (or other valve dz) Alcohol or Atrial myxoma Thyrotoxicosis Electrolyte disturbances Systemic Illness (sepsis, CA, DM) or Stress (post-op) Rate Control - Calcium Channel Blockers (onset: ~5-15 mins, WILL drop BP!) - Diltiazem: 0.25 mg/kg IVP (10-20 mg), repeat 0.35 mg/kg IVP (5-10 mg) Drip: 1-15 mg/h IV gtt Oral: 120-240 mg PO daily - Verapamil: 0.15 mg/kg IVP (over 2 min), repeat 0.3 mg/kg IVP (5-10 mg) Drip: 5-20 mg/h IV gtt - Reverse with calcium gluconate 10%, 10 mg IV - Beta Blockers (onset: ~5-10 min; do not use in CHF/COPD, WILL drop BP!) - Metoprolol: 5 mg IVP (over 2 mins) Q5 min x 3 Oral: 25-50 mg PO BID - Esmolol: 500 mcg/kg IVP (1 min), repeat 25-50 mcg/kg/min IV Q4min - Reverse with glucagon - Digoxin: (onset: >5 hr. Will not affect BP. Useful in pts in CHF, careful in renal failure) - Digoxin: 0.25-0.5 mg IVP Q6h x 2-3 doses (max load 1 g in 24 hr) Oral: 0.125-0.25 mg PO/IV daily Anti-Coagulation - ASA 325mg PO daily - Coumadin – in high risk pts with risk factors for embolic events - Consider heparinization while waiting for INR to become therapeutic Cardioversion If onset of Afib is within 72h, can cardiovert without 3wk of anticoagulation. When in doubt, TEE, and anticoagulate and convert at a later date. See UpToDate on how to safely cardiovert either chemically or electrically. Cedars-Sinai Medical Center Intern Survival Guide Page 32 of 88 Hypertension 1. Recheck the blood pressure yourself and check cuff size 2. Check chart: how long has the BP been elevated? 3. Check current meds 4. Identify causes of secondary hypertension first, (e.g. early hypotension, pain, agitation, EtOH withdrawal, drug withdrawal [Beta-blockers, ACE-I, central alpha-blockers], increased ICP, ESRD, renal failure, renal artery stenosis, eclampsia, aortic dissection, pheo, Cushing’s, or hypoxia) Hypertensive emergency: elevated BP of >200/120 with associated with end–organ damage (brain, eye, heart, and kidney) Hypertensive urgency: elevated BP of >200/120 but no end-organ damage. Ask about and examine: - Brain: headache, confusion, lethargy, stroke - Eye: blurred vision, papilledema, flame hemorrhages - Heart: chest pain, SOB, S3, S4, EKG strain or ischemic changes - Kidney: low urine output, edema, hematuria Hypertensive emergencies require ICU admission and reduction of BP by 25% over 6-12 hours with IV medications: - Nitroprusside 0.3 mcg/kg/min and titrate up (requires A-line BP monitoring) - Labetolol 20 mg IVP Q10 min until BP decreases; or infusion dosed at 0.5 – 3 mg/min. - Nitroglycerin 5 mcg/min and titrate up (use when heart disease present) 5. If 1° HTN, increase the patient's current regimen. Oral therapy is preferable in nonemergencies. Once the regimen is maximized, if the patient is still hypertensive, consider: - Clonidine 0.1-0.2 mg PO repeat with 0.1 mg Q1hr prn to total of 0.8 mg (works within 30 min-2 hrs, watch for rebound for doses >1.0 g). - Metoprolol 25 mg PO BID - Nitropaste ½" to chest wall Q6hr, wipe off for BP< ____ - Captopril 6.25-25 mg SL/PO TID (check K, Cr, allergies before. May titrate dose up rapidly to desired BP correction) - Norvasc 5-10 mg PO daily - Avoid short acting nifedipine (increased mortality) - Nitroprusside and Labetolol are available IV for emergencies 6. Check BP 45 minutes after your intervention NOTE: For hypertensive urgencies, remember that in a pt that has “lived at this level” of hypertension for a while, a large, acute drop in BP may make an asymptomatic patient symptomatic (precipitate cerebral/myocardial ischemia) Cedars-Sinai Medical Center Intern Survival Guide Page 33 of 88 Hypotension/Shock Adapted from Critical Care Handbook of the Massachusetts General Hospital, 3rd Edition, Tarascon Pharmacopoeia Deluxe, 2006, and UCLA Internal Medicine Inpatient Housestaff Handbook, 2005-2006 *Note: This is NOT a guide to the emergent management of hypotension. When faced with a crashing patient, ensure ABC’s established, start supplemental oxygen, IVFs, and call more senior housestaff to assist in the management! Shock: Decreased end-organ perfusion - Hypovolemic: Acute loss of >20-25% circulating blood volume - Cardiogenic: Primary failure of heart to generate adequate cardiac output - Distributive: Decreased vascular tone with arterial vasodilation, venous pooling, and redistribution of blood flow - Examples: SIRS, sepsis, anaphylaxis, loss of vascular tone during neurogenic shock - Obstructive: Mechanical impediment to venous return to and/or arterial outflow from the heart - Examples: Tension PTX, tamponade, aortic dissection, positivepressure ventilation CVP: PCWP: CO/SV: Hypovolemic: È È È Cardiogenic – LV: – Ç È –/È Cardiogenic – RV: Ç È Distributive – Septic: –/È – Ç –/Ç Distributive – Anaphylactic: È È – Distributive – Neurogenic: È È Obstructive: Ç/È1 È/Ç2 Ç 1 Increased PAP in PE, depending on location of PA catheter, PCWP can be increased or decreased. In other conditions, PCWP primarily low 2 Decreased in general, but possible for compensatory increase in CO/SV depending on location of obstruction (e.g., aortic dissection, increased CO/SV at level of aortic valve, but functionally decreased in periphery) Vasopressors Epinephrine (Adrenalin) (α1, α2, β1, β2) - Uses: Cardiac arrest, refractory hypotension, status asthmaticus, anaphylaxis - Cardiac Arrest: 1 mg IVP (premixed injector solution is 1:10,000) Q3-5 mins, gtt: 1-4 mcg/min (mix 1 mg in 250 mL D5W, thus 4 mcg/mL, run at 15-60 mL/hr) - Via endotracheal tube: 2-3 x usual dose diluted in 10 cc NS - Anaphylaxis: 0.1-0.5 mg SC/IM (usual dose is 0.3 mg, 1:1,000) - Highly arrhythmogenic, can cause myocardial ischemia/infarct; not for prolonged use, watch for unopposed α stimulation in patients on βblockers Cedars-Sinai Medical Center Intern Survival Guide Page 34 of 88 Norepinephrine (Levophed) (α1, α2, β1) - Use: Hypotension from low peripheral vascular tone, myocardial depression, or both - Convenient initial pressor choice as it causes peripheral vasoconstriction, via α effect, and increased inotropy/chronotropy, via β1 effect - Continuous infusion for hypotension: Start 5-15 mcg/min, titrate to effect (~SBP>90, MAP>60), range: 0.5-70 mcg/min - Potent α vasoconstriction can cause significant distal tissue hypoxia; ensure appropriate volume resuscitation Dopamine (Intropin) (dose dependent D, β1, α1) - Use: At lower doses, hypotension from decreased myocardial contractility and at higher doses, from low peripheral vascular tone - Previous favorite pressor as it was felt to be renal-protective 2°/2 dopaminergic activity, though this has been refuted - Continuous infusion for hypotension: Start 2-3 mcg/kg/min, titrate to effect, range: 0.5-20 mcg/kg/min (0-2 mcg/kg/min “renal dose”, 2-5 mcg/kg/min β1 dose, >5 mcg/kg/min α1 dose) - Less potent α vasoconstriction, but increased risk of tachyarrhythmias 2°/2 β activity vs. norepinephrine Phenylephrine (Neo-Synephrine) (α1) - Use: Hypotension from low peripheral vascular tone - Pressor of choice for septic patients with cardiovascular disease, though patients likely have significant intrinsic sympathetic (and consequent) β1 stimulation anyway - Continuous infusion for hypotension: Start at 30 mcg/min, titrate to effect, range: 30-300 mcg/min - Watch for reflex bradycardia - Potent α vasoconstriction can cause significant distal tissue hypoxia; ensure appropriate volume resuscitation Dobutamine (Dobutrex) (β1, β2, minimal α1) - Use: Low cardiac output states; produces significant inotropy/chronotropy, and “afterload” reduction with peripheral vasodilation - Used in CHF, can even be used in an ambulatory setting - Continuous infusion: Start at 2 mcg/kg/min, titrate to effect (usually Cardiac Index > 2), range: 2-20 mcg/kg/min - EXPECT hypotension, if needed support BP with dopamine first, and then start dobutamine - Risk of tachyarrhythmias, though less then epinephrine, dopamine, and isoproterenol; increased myocardial oxygen consumption, with resultant risk of ischemia - Potential for tachphylaxis with infusions greater than 72 hours Cedars-Sinai Medical Center Intern Survival Guide Page 35 of 88 Isoproterenol (Isuprel) (β1 chronotropy only, β2, minimal α1) - Use: Low cardiac output 2°/2 bradycardia or unstable heart block - Provides chronotropy with significantly less inotropy vs. dobutamine - Continuous infusion: Start at 5 mcg/min, titrate to effect (HR as needed to produce acceptable BP), range: 2-20 mcg/min - EXPECT hypotension as with dobutamine - Risk of tachyarrhythmias Vasopressin (Pitressin, ADH) (peripheral smooth muscle constriction) - Uses: Low peripheral vascular tone esp. septic shock, cardiac arrest, bleeding esophageal varices - Cardiac Arrest: 40 units IVP, may repeat after 3 min if no effect - Continuous infusion for hypotension in sepsis: Usual dose is 0.04 units/min, no titration - Causes severe tissue necrosis with extravasation 2°/2 potent vasoconstriction Rule Out Myocardial Infarction 1. Admit to telemetry 2. Bed rest until ruled out 3. NPO except meds if possible catheterization or functional study in AM 4. Oxygen via NC at 2 L/min 5. EKG on admission and QAM, also check with each Troponin check 6. CXR on admission (portable acceptable) 7. Labs: If high suspicion, Troponin Q8hr x 3, and if low suspicion, Q12hr x 2, PT/PTT, fasting cholesterol panel, consider HgbA1c if diabetic 8. ASA 325 mg PO daily. Have patient chew and swallow first dose for rapid absorption 9. NTG 0.4 mg SL Q 5 min x 3 doses max PRN chest pain; or if pt has continued CP, start NTG drip; if pain not controlled on NTG, use morphine IVP. If using Nitropaste Q6hr to chest wall, wipe off Q night 12AM-6AM, note variable absorption. Use of nitroglycerin is contraindicated in right-sided infarct 10. Beta–blocker: consider starting within first 24 hours if there are no contraindications. Typical starting dose is metoprolol 25 mg PO BID. Alternatively, a trial of metoprolol 5 mg IV Q 5 min x 3 can be given initially. If this IV dose is tolerated you can usually start 25 mg PO BID, hold for SBP <90, HR <60. Goal HR 5060’s 11. Heparin drip with pharmacy protocol if >moderate risk Cedars-Sinai Medical Center Intern Survival Guide Page 36 of 88 Congestive Heart Failure 1. Admit to floor if pressor support not needed (i. e. patient not in shock) or intubation not likely 2. Decide whether patient is in left-sided or right-sided failure or both. Left-Sided CHF Right-Sided CHF Rales Elevated JVP Tachypnea Hepatojugular Reflux Left-sided S3 Ascites Peripheral Edema Hepatic Congestion 3. Look at old echo results for prior EF and evidence for diastolic dysfunction (E to A reversal) 4. If CHF exacerbation, determine possible reason(s) based on H&P: “FAILURE” - Forgot medications - Arrhythmia/Anemia - Ischemia/Infarction/Infection - Lifestyle (dietary) - Upregulation of cardiac output: pregnancy, hyperthyroidism - Renal failure - Embolism Also remember Valvular disease 5. Check NPA 6. Monitor Ins and Outs, and Daily weights 7. For systolic dysfunction, treatment may include: - ACE-I - The mainstay of CHF treatment - Start with Captopril 6.25 mg PO TID and increase dose as BP allows - Once stable, switch to equivalent dose of once-daily ACE inhibitor ACE-I Conversion: Ratio: Captopril : Enalapril ~7.5-10 : 1 Benazepril : Enalapril 1:1 Fosinopril : Enalapril 1:1 Lisinopril : Enalapril 2:1 Perindopril : Enalapril 1:5 Quinapril : Enalapril 1:1 Ramipril : Enalapril 1:4 Trandolapril : Enalapril 1 : 10 Cedars-Sinai Medical Center Intern Survival Guide Page 37 of 88 - Beta-blockers - Can continue beta-blockers if pt already on them, but don’t start beta-blockers during an acute exacerbation - Beta-blockers proven in RCTs to have mortality benefit include Carvedilol, Toprol XL, bisoprolol - Spironolactone - Demonstrated mortality benefit in Class III-IV CHF - Dose is 25 mg PO daily. Contraindicated if Cr > 2.5 or K+ > 5.0. Follow K+ closely after spironolactone started, especially when used in combination with ACE inhibitor - Diuretic - Used to reduce symptoms of pulmonary edema - Start with furosemide; doses can vary from 20-400 mg IV Q6hr - When giving furosemide, watch BP carefully - To convert IV to PO, double the dose (i.e., 20 mg IV is equivalent to 40 mg PO) - If furosemide diuresis is ineffective, try adding metolazone 5-20 mg PO daily - Watch serum electrolytes (especially K+) and replace as necessary - Consider hydralazine/isosorbide dinitrate (37.5/20) (BiDil) in African Americans if BP tolerates - Consider digoxin loading if patient not responding well to initial therapy - Load 0.5 mg IV then 6hrs later 0.25 mg IV Q6hr x 2, up to 1 mg total; then 0.125-0.25 PO or IV daily - Adjust dose in renal failure, with amiodarone, etc. 8. Other important considerations: - All patients should be on a low salt diet (2 gram) and Fluid restriction (2 Liter) - Oxygen by NC or facemask to relieve dyspnea - Nitrates as BP tolerates to reduce preload and as antianginal (start with Isordil 10 mg PO TID) - Morphine 0.5-2 mg IV Q4hr to relieve dyspnea if distressful to pt - Consider underlying infection and treat accordingly - Consider ischemia/MI and r/o appropriately 9. If low ejection fraction (<30%), consult cardiology for ICD and BiV pacer evaluation. Can order Tissue Doppler Imaging (TDI) to begin evaluation 10. Consider evaluation for revascularization if first presentation 11. If poorly compensated, may need ICU stay with dobutamine/dopamine drips Cedars-Sinai Medical Center Intern Survival Guide Page 38 of 88 Infectious Diseases Neutropenic Fever Based on Hughes et al. 2002 Guidelines for the Use of Antimicrobial Agents in Neutropenic Patients Fever (100.4) + Neutropenia (ANC ≤ 500 or expected to reach in 1-2d) Low Risk Oral Cipro + Amox-Clav High Risk IV Vanc not needed Monotherapy: Cefepime or Carbapenem Risk Assessment: Extent of Illness No Symptoms Mild Symptoms Moderate Symptoms No Hypotension No COPD Solid Tumor or No Fungal Infection No Dehydration Outpatient at Onset of Fever Age <60 years Two Drugs: Cefepime or Carbapenem or Antipseudomonal PCN + Aminoglycoside Vanc needed Vanc + Cefepime or Carbapenem ± Aminoglycoside Points: – 5 5 3 4 4 4 3 3 2 Total: ≥ 21 is “Low Risk,” < 21 is “High Risk” *Note: Applies for first episode of neutropenia. See CSMC 2005 Empiric Antibiotic Treatment Recommendations for further information and obtain resident, fellow, attending, or infectious disease consultation as needed. Cedars-Sinai Medical Center Intern Survival Guide Page 39 of 88 HIV and Opportunistic Infections CD4 Counts and Infection Risks CD4 Count: OI’s: <350 <200 <100 <50 - S. pneumoniae - Kaposi’s sarcoma - TB - Oral Thrush - Oral Hairy leukoplakia - PCP - Lymphoma - Toxoplasmosis - Cryptococcus - Disseminated Candida - MAC - CMV - PML Prophylaxis CD4 Count: PPx: <200 <100 <50 - Bactrim DS daily (Toxo) and daily to 3x/week (PCP) - Fluconazole 200 mg daily (crypto) or weekly (candida) - Azithromycin 1200 mg weekly (MAC) - Consider ganciclovir if pt is CMV+ HAART Therapy - Start tx if: - pt is symptomatic - plasma HIV RNA >20,000 copies/mL - CD4 <200 - disease progression HIV/AIDS Patient with diarrhea Send Stool for: Treatment: - O&P x 3 - Cryptosporidium - Microspora - Isospora - C. difficile toxin x 3 - Stool Cx (consider x 3) - FOB x 3 - Stool WBCs - consider serum CMV PCR - No anti-diarrheals until bacterial cultures negative - Imodium or Lomotil - Octreotide if AIDS-related and intractable - Treat any positive cultures - Anticipate multiple organisms/cultures positive - (+) Stool WBCs suggests inflammatory process Cedars-Sinai Medical Center Intern Survival Guide Page 40 of 88 - Should perform thorough w/u in HIV/AIDS pts that have diarrhea >1 month w/ >10% unexplained wt loss - Infectious causes in the small bowel: cryptosporidium, microsporidia, Isospora belli, Cyclospora cayetanensis, MAC, MTB, Histoplasma capsulatum, salmonella sp., campylobacter sp., Giardia lamblia, HIV enteropathy - Infectious causes in the colon: CMV, cryptosporidium, MAC, MTB, shigella group D, C. diff, Campylobacter jejuni, E. coli, Entamoeba histolytica, adenovirus, HSV, pneumocystis (rare) - Misc. causes: drugs, lactose intolerance, fungal infections, Kaposi’s sarcoma, lymphoma, amyloidosis, pancreatitis - Initial w/u: consider checking CD4 count, stool cx, stool O&P x 3, C. diff toxin x 3, stool AFB smear & cx, modified trichrome stain for stool microsporidia, stool isospora, stool cyclospora, stool cryptosporidium, stool viral cx, can send stool giardia antigen if have high index of suspicion for giardiasis, consider serum CMV PCR - Aggressive fluid and electrolyte replacement - After acute bacterial agents have been ruled out, in patients with profuse watery diarrhea, it is recommended to use anti-diarrhea meds such as kaopectate, Imodium, Lomotil - A GI consult is only needed if initial infectious w/u negative; if pt is toxic appearing; if suspect Kaposi’s sarcoma, lymphoma, or other etiologies requiring bx like CMV; or if pt needs urgent/emergent endoscopy eval Line Sepsis Discuss the removal of the line with your Attending, ID consultants and/or PICC service; especially if it is the only vascular access 1. If tunnel infection d/c line after sending: - 1 BCx through the line and 2 BCx sets peripherally - Catheter tip for culture (removal in a sterile manner and do not touch skin as the line is removed) 2. If mild erythema, no fluctuance and no purulence: - 1 BCx thru line, 2 BCx peripherally - Consider ID consult 3. Draw fungal BCx when indicated Cedars-Sinai Medical Center Intern Survival Guide Page 41 of 88 CSF Studies - Do not forget to measure the opening and closing pressure - normal <20 cm - Besides actually obtaining the sample, the most difficult part is ensuring that the labels for each of the tubes are done properly. NEVER expect the nurse to label the tubes properly. Write the orders first, and have the nurse get the labels as they print from the computer. Then separate the tubes and appropriate labels into 4 different bags with the appropriate labels in each bag. Take the tubes to the lab yourself (4th floor, South tower, back hall) - In an IMMUNOCOMPETENT host, if opening pressure < 20 cm H20, or protein <45 mg/dl and normal cell count, no further studies are usually required - You may request CSF to be held in the lab for future analysis as necessary. Remember that chemistry and microbiology are separate areas and their storage methodology differs. It is probably prudent to send extra CSF to micro as the chemistry lab can still run their tests, but bacterial growth can be adversely affected if samples are stored in the chemistry lab Tube #: Amount: Studies: Tube #1: 1 cc Cell count & diff Tube #2: 1 cc Glucose, protein Tube #3: 3-5 cc HIV- HIV+ - Gram stain - Culture - India Ink - VDRL (and serum RPR) - Cocci serology - Crypto antigen - Fungal Culture - AFB smear/Culture If Indicated: - Viral culture - Cytology - TB PCR (need large amount of CSF) - Bacterial Antigen Panel (if h/o partial Abx Tx) - Gram stain - Culture - India Ink - VDRL (and serum RPR) - Cocci serology - Crypto antigen - Fungal Culture - Viral culture - AFB smear/Culture - Toxo serology - Cytology to eval for CNS lymphoma - Consider JC Virus PCR Tube #4: 1 cc Cell count & diff Cedars-Sinai Medical Center Intern Survival Guide Page 42 of 88 Fever Work-Up Basic fever w/u: Review the chart and examine the patient Vital signs: signs of sepsis (tachycardia, tachypnea, hypotension)? Blood cultures x 2 sets Urine for u/a, C&S Consider sputum for gram stain, C&S Consider CXR Consider other cultures: Blood cultures through central lines Percutaneous drainage catheters Pleural effusion Ascites CSF Blisters Wounds/sinuses/ulcers Any other loculated collection Consider the high likelihood sources: Review earlier culture results Central lines Heparin locks and IV Pulmonary Aspiration Urinary tract Foley catheter Wounds/Ulcers Pulmonary emboli Consider: - Starting/changing/adding ABx - Broadening coverage - ICU/monitored bed (esp. if hemodynamically unstable) - Other studies: PPD, sputum DFA for PCP, AFB, fungal cxs - Ruling out PE if high clinical suspicion - Stopping tube feeds if aspiration is a possibility Cedars-Sinai Medical Center Intern Survival Guide Page 43 of 88 CSMC Guidelines for Fluoroquinolones Cedars-Sinai Medical Center Intern Survival Guide Page 44 of 88 CSMC 2005 Antimicrobial Susceptibility Summary (Antibiogram) Cedars-Sinai Medical Center Intern Survival Guide Page 45 of 88 CSMC 2005 Empiric Antibiotic Treatment Recommendations Cedars-Sinai Medical Center Intern Survival Guide Page 46 of 88 Cedars-Sinai Medical Center Intern Survival Guide Page 47 of 88 Cedars-Sinai Medical Center Intern Survival Guide Page 48 of 88 Cedars-Sinai Medical Center Intern Survival Guide Page 49 of 88 CSMC Algorithm for Isolation of Suspected TB Patients Cedars-Sinai Medical Center Intern Survival Guide Page 50 of 88 CSMC Isolation Reference Table Cedars-Sinai Medical Center Intern Survival Guide Page 51 of 88 Pulmonary COPD Exacerbation Work Up: - CXR to eval severity and r/o other causes of SOB (e.g., PNA) - ABG to eval severity and need for intubation - Do not get PFTs in acute exacerbation; get as outpt if never done Treatment: - Methylprednisolone 125 mg IV Q6-8° x 72° then Prednisone 60mg PO daily x 4 d, then taper by 20 mg Q3-4 d - ABx for presumed PNA causing exac (Cefotaxime/Azithro vs. Bactrim vs. Amox) - Nebs: Albuterol 2.5 mg HHN Q4° ATC and 2° prn, ipratropium (Atrovent) 500 mcg HHN Q4° ATC. Transition to MDIs when pt improves - O2 via NC to keep sats between 90-94% - BiPAP: consider BiPAP as a bridge to prevent intubation (see “SOB” section for further details) - Nicotine patch if pt is a smoker Asthma Exacerbation Work Up: - Assess pt’s previous needs for intubations (pts often know when they will need to be intubated), as well has h/o ER visits, hospitalizations, steroid courses, etc. for asthma - ABG – watch for a “normal” gas (specifically PCO2) in a pt with asthma. They are tiring and unable to compensate with a rapid RR - CXR to eval for causes (e.g., PNA) - RT to check Peak Flows pre- and post-nebulizer treatment (also good to get historical PF info from pt) Treatment: - O2 via NC to keep sats >90% - Nebs: Albuterol 2.5 mg HHN Q4° ATC and Q2° prn, ipratropium 500 mcg HHN Q4° (can give Q30min x 3 initially; check with ED on what’s been given) - Prednisone 60 mg PO or methylprednisolone 80 mg IV (IV is not superior to PO); taper when PF >50% - ABx if PNA suspected (though unlike COPD where empiric ABx are indicated, there is no data showing benefit from ABx unless PNA is confirmed) Cedars-Sinai Medical Center Intern Survival Guide Page 52 of 88 Vents Based on Critical Care Medicine, by Brenner and Safani Trigger: Assist Control (AC) vs. Synchronized Intermittent Mandatory Ventilation (SIMV) vs. Pressure Support (PS): AC: Full ventilator breaths are given at set rate AND with each additional patient initiated breath SIMV: Full ventilator breaths are given at set rate. For additional breaths, patient pulls in own tidal volume - Can incorporate PS during unassisted breaths PS: No ventilator provided breaths; all breaths patient initiated. Ventilator provides pressure support to all patient initiated breaths Control: Volume Control (VC) vs. Pressure Control (PC) VC: Set tidal volume is delivered with each ventilator provided breath - Concern is for barotrauma 2°/2 high Ppeak (ARDS, restrictive lung dz) PC: Set amount of pressure is applied with each ventilator provided breath - Concern is for inadequate ventilation as a set TV is not delivered and there may be a significant breath-to-breath variation in volumes SIMV BiPAP RR, TV, FiO2, RR, IPAP, EPAP, PEEP, (PS) FiO2 RR: 12/min RR: 12/min TV: 450 IPAP: 12 cm H20 EPAP: 5 cm H20 PEEP: 5 cm H20 PS: set to achieve TV ~300-400, usually ~12 Indications: - Initial vent - ARDS with high - Occasionally - Attempt to used for long mode Ppeak. prevent weaning though intubation not initial choice RR: Respiratory Rate IPAP: Inspiratory Positive Airway TV: Tidal Volume Pressure FiO2: Fraction of Inspired Oxygen EPAP: Expiratory Positive Airway ∆P: Control Pressure Pressure PEEP: Positive End Expiratory Pressure Ppeak: Peak airway pressure I-time: Inspiratory time (sets I:E ratio, 1:2-4 = physiologic) - Increases amount of time in inspiration, allowing for increased oxygen diffusion - Directly proportional to RR - Increasing I-time reduces time for expiration, thus reduces ventilation Initial Settings: Sample Settings: AC/VC RR, TV, FiO2, PEEP RR: 12/min TV: 450 (suggest 6 mL/kg from ARDSnet) PEEP: 5 cm H20 AC/PC RR, ∆P, I-time, FiO2, PEEP RR: 12/min ∆P: set to achieve avg TV ~300-400, with goal Ppeak <50 PEEP: 5 cm H20 Cedars-Sinai Medical Center Intern Survival Guide Page 53 of 88 Trouble Shooting Vents Oxygenation (pO2): Increase FiO2, PEEP, or I-time Ventilation (pCO2): Increase RR, TV, or decrease I-time Arterial Saturation >94% & pO2 > 100: È FiO2 (FiO2 È by 1% = pO2 È by 7 mmHg) until <60%, then È PEEP by 2 cm H2O until PEEP = 3-5. Keep O2 >90%, pO2 >60 Arterial Saturation <90% & pO2 <60: Ç FiO2 up to 60-100% then consider Ç PEEP by 3-5 Low pH (<7.33 – respiratory acidosis/hypercapnia): Ç RR and/or TV; keep PAP <40-50 cm H2O if possible High pH (>7.48 – respiratory alkalosis/hypocapnia): È RR and/or TV; if pt overbreathing vent, consider sedation Pt “fighting vent”: Consider SIMV or add sedation ± paralysis È TV (TV delivered is not what TV is set at): Check for leak in vent or inspiratory line. Check for poor seal or malposition of ET tube cuff in subglottic area. If pt has chest tube, check for air leak (bubbles leaking through water seal) High Peak Pressures (>40-50): Consider bronchospasm, secretions, pneumothorax (PTX), ARDS, agitation - suction pt and listen to lungs - CXR if PTX or ARDS suspected - Check plateau pressure to differentiate airway resistance vs. compliance causes Weaning 1. Consider whether patient needs to be weaned or not. Healthy patients, without intrinsic lung disease probably do not need to be weaned 2. Make sure pt is stable enough to place on CPAP/Flow-by trial - Vent/Blood gas criteria: - FiO2 ≤ 50% and PEEP ≤ 5cm and SaO2 > 90% - pH ≥ 7.32 within 2 hours of starting trial - MD confirms presence of Medical Stability Criteria - Underlying reason for ventilation improved - Afebrile (<101.4) - Hgb > 8 and stable - Off pressors - No heavy sedation, pt is alert and can follow commands - Electrolyte disorders corrected Cedars-Sinai Medical Center Intern Survival Guide Page 54 of 88 - Cardiac function optimized - RT confirms presence of bedside criteria - Rapid Shallow Breathing Index (RSBI) ≤ 105 after 3 minutes on trial (RSBI = RR/TV) - Spontaneous RR must be <35/min, >8/min - Spontaneous TV must be ≥ 5 mL/kg 3. After extubation, place pt on humidified O2 by face mask for 1 hr, then titrate down to NC (keep sats >94% unless COPD) Pulmonary Embolism Work-Up: - Assess Pretest Probability with chart below - Dopplers of LE to look for DVT - CXR to look for causes of SOB (eg, signs of PE, pna, CHF) - EKG to look for right heart strain (TWI V1-V3, RAD, RBBB, SIQIIITIII) - ABG: hypoxemia, hypocapnea, resp alk, Ç A-a gradient - +/- D-dimer, after pretest probability calculated and depending on pt’s comorbidities (e.g., infection or malignancy will cause Ç D-dimer) - V/Q scan after pretest probability calculated (PIOPED data below) - CT of Chest w/ contrast: if V/Q equivocal and would change your management of pt Pretest Probability of PE Variable - Clinical signs/Sx of DVT - HR > 100bpm - Immobilization (bed rest >3d) or surgery w/i 4 wks - Prior DVT or PE - Hemoptysis - Malignancy (tx’d w/i past 6 mo or palliative) - PE as likely or more likely than any alternative dx Low (0-2 points) Intermediate (2-6 pts) Overall ~3% ~20% (-) D-Dimer ~2% ~6% (+) D-Dimer ~7% ~`36% V/Q Scan Results: Low Intermed High Point Score 3 1.5 1.5 1.5 1 1 3 High (>6 points) ~60% ~20% ~75% PIOPED Study: Likelihood of PE Clinical Suspicion (based on pretest probability) Low Intermediate High 4% 16% 40% 16% 28% 66% 56% 88% 96% Cedars-Sinai Medical Center Intern Survival Guide Page 55 of 88 Treatment: - Anticoagulation with heparin via protocol; can start coumadin via protocol when pt is stable and therapeutic on heparin. Must overlap either heparin or LMWH with coumadin for 5 days - Coumadin can elevate PT before the pt is truly anticoagulated 2°/2 Factor VII having shorter half-life than Factor II - Concern for hypercoagulable state before fully anticoagulation achieved 2°/2 Protein C having half-life shorter than Factor II - goal INR = 2-3 - cont Coumadin for at least 6 mo if 1st PE - cont Coumadin for 12 mo if 2nd PE, cancer, or irreversible risk factor; may need to be on it lifelong - Removable IVC Filter if unable to anticoagulate - If contraindications to anticoagulation have been addressed, the pt should be fully anticoagulated and the filter should be removed - Remember: IVC filters are inherently thrombogenic and should be used in conjunction with anticoagulation. They help prevent massive PE’s, but help propagate smaller PE’s. Additionally, they have associated complications, including potentially fatal filter migration. Use IVC filters with the utmost caution and consideration! Cedars-Sinai Medical Center Intern Survival Guide Page 56 of 88 Gastroenterology Pancreatitis Workup: - amylase (peaks at 20-30 hours) - lipase (peaks at 24 hours) - Ranson’s criteria: At 24 hours: At 48 hours: Age > 55 ↓ HCT > 10% WBC > 16,000 BUN ↑ > 5 Glucose > 200 Ca2+ < 8 LDH > 350 PaO2 < 60 mmHg AST > 250 Base deficit > 4 Fluid sequestered > 6L Mortality: < 3 criteria Æ 1% 3-4 Æ 15% 5-6 Æ 40% > 7 Æ 100% Treatment: - NPO - IVF (NS + KCl 20mEq at ≥ 200cc/h); TPN if pt is NPO for a long time - Pain control (usually via PCA). Classic teaching is to use Demerol as it causes less sphincter of Oddi spasm, but both Dilaudid and Morphine are preferred because of a better side-effect profile - R/O infection w/BCxs, CXR, UCx – hold ABx unless worrisome signs and Sx Complications: (more common if more Ranson Criteria Positive): - Pseudocysts or Abscesses - Necrotizing pancreatitis (seen on CT), give Imipenem (better penetration) - ARDS - Hemorrhage into pancreas (reimage with U/S vs. CT) - SIRS and/or Septic Shock End-Stage Liver Disease/Ascites Work Up: SAAG = Serum albumin – Ascitic albumin. An elevated SAAG suggests portal hypertension. >1.1 <1.1 Chronic liver disease Peritoneal CA Hepatic metastasis Peritoneal inflammation Veno-occlusive disease TB, fungal Budd-Chiari Serositis Cardiac failure Viscus leak: pancreatic, bilious, chylous, ureteric Spontaneous bacterial peritonitis Nephrotic syndrome Myxedema Protein-losing enteropathy Idiopathic from Huang ES et al., Internal Medicine Handbook for Clinicians, Scrub Hill Press Inc. 1st ed, 2000 Cedars-Sinai Medical Center Intern Survival Guide Page 57 of 88 Management: - Bed rest - Low Na+ diet - Paracentesis for SOB, tesnse ascites, early satiety - Diuretics: Lasix 40mg/d and spironolactone 100mg/d - if no wt loss and/or urinary sodium <20mEq/day, Ç Lasix by 40mg and spironolactone by 100mg (repeat until Lasix 160mg/d and spironolactone 400mg/d) - Stop diuretics if: renal dysfxn, hepatic enceph., or no wt loss at max dosing - Liver consult for transplant w/u IBD Patient with diarrhea/possible flare - Must r/o infectious etiology first: send stool cx, stool O&P x 3, stool C. diff toxin x 3 (though can stop after one positive), CMV PCR, ESR, CRP (C-reactive peptide), CBC w/manual diff (follow daily to assess for bandemia; may be only sign of interabdominal catastrophe given their level of immunosuppression. Acutely, steroids cause a left-shift because of demargination of fully matured PMNs, but DO NOT cause a bandemia) - For newly diagnosed IBD patients or patients newly referred to CSMC, consider sending off IBD panel to Prometheus Laboratory - For patients that are you are suspecting bowel perforation, severe colitis, toxic megacolon, obstruction, intra-abdominal fistula, or intra-abdominal abscess, consider imaging evaluation such as CT abd/pelvis and/or KUB. Have a very lowthreshold to image, given these patients may not mount much of an inflammatory response because of their immunosuppression. You should also strongly consider repeat imaging in any patient transferred from an outside facility. (Read: Unless you have a really good reason, just get the scan) - Initial steroid dose for a flare is Solu-Medrol 20 mg IV Q8hr - For stable and non-toxic appearing patients, it is okay to feed the patients (unless patient is scheduled to go for endoscopic evaluation the next day per GI/IBD team); only need to give low residual diet in patients that have moderate to severe mucosal inflammation/involvement - For UC patients that will get cyclosporine infusion, will need to check LFT and fasting lipid panel (might require lipid infusion if lipid level is too low), and will need PICC placement. Check Cyclosporine level daily and MUST be drawn from a peripheral source or second port. CSA counts the lumen of the line through which it is infused and thus the level can be falsely elevated. Also, follow BP closely. Daily PE should check if pt has tremor of hands - Daily Labs: BMP, Mg, CBC with manual diff - Every other day: CMP - Weekly: Lipid panel - For CD/UC pts that will get Remicade, check a PPD - For pts that will get 6MP/6TG, check a TPMT level Cedars-Sinai Medical Center Intern Survival Guide Page 58 of 88 Upper GI Bleed - Assess pt’s hemodynamics and history - Immediate fluid resuscitation, early transfusion of blood products, and correction of any coagulopathy - Consider NGT lavage (pt more likely to need endoscopy sooner if doesn’t clear after 250cc NS) - PUD approx causes 30-35% of UGIB while esophageal varices and Mallory-Weiss tear cause 15% and 5-10%, respectively. - For pts suspected of UGIB 2°/2 PUD, should give PPI IV (Prevacid 30 mg IV Q12h), or consider PPI gtt - For pts suspected of EVB, should give both PPI IV and Octreotide gtt (classic teaching suggests the use of Octreotide only in variceal bleeds, but there is data available that suggests that it may work in other UGIB settings) - For pts w/concurrent renal failure and possible platelet dysfunction due to uremia, can consider DDAVP (avoid if pt has h/o stenting of coronary vessels) - Should monitor CBC Q4-8h, coags Q6-24h - Pt should be NPO - Pt should be placed on aspiration precautions - Note that most pts don’t require emergent endoscopic eval, rather, most pts will require urgent endoscopic eval Cedars-Sinai Medical Center Intern Survival Guide Page 59 of 88 Renal/Electrolytes Hyperkalemia Potassium lab ranges: Normal: Mild: Moderate: Severe: 3.5 – 5.0 5.0 – 6.0 6.0 – 7.0 > 7 or any EKG changes - Consider rechecking K+ on a stat basis. - Check STAT EKG. Changes – peaked T's, ectopy, widened QRS complex. (Transfer pt to a monitored bed/ICU if EKG changes or severe hyperkalemia) Treatment: - Antiarrhythmic - 5-10 cc 10% Calcium gluconate IV if the patient has widened QRS complex (Note: Ca2+ may precipitate digoxin toxicity and never give CaCl via a peripheral line) - Shift K+ into the cells with acidosis correction and glucose movement: - 1 amp HCO3 - 1 amp D50 + Regular insulin 5 units IV - Beta agonists (not a first choice) - Eliminate K+ - Kayexalate 15-50 g in 100-200 ml 20% sorbitol solution PO or retention enema without sorbitol, repeating Q3 until diarrhea - Lasix 20-40 mg IVP - Dialysis *Better than treatment, is avoiding the problem in the first place. Make sure renal patients have low potassium diets. Remember that ACE-inhibitors and spironolactone cause potassium retention. Periodically monitor potassium in patients receiving potassium supplements. Cedars-Sinai Medical Center Intern Survival Guide Page 60 of 88 Electrolyte Replacement *Note in general about electrolyte repletion: Most other guides that we have reviewed are not very clear on the doses and the actual correction that occurs, and/or are significantly underdosed. Nevertheless, replete electrolytes cautiously, especially in the setting of renal dysfunction. The Hospitalist Handbook at the UCSF website has excellent sliding scales for potassium and magnesium. Potassium - Narrow “therapeutic” window - Replete cautiously - Be aware of ongoing losses (renal wasting with diuretics, GI loss, etc.) - Utilize both PO and IV potassium chloride (or other potassium salt if needed). IV potassium burns during infusion, while oral potassium pills are huge, and suspensions, “salty” - Potassium is still a drug, and while the nursing staff has pre-mixed solutions and have an established rate of infusion, consider modification if clinically indicated (i.e. “Potassium Chloride 40 mEq IVPB mixed in D5W at 10 cc/hour”) - Consider adding potassium to maintenance IVFs - Maximum rate of infusion is ~10 cc/hr peripherally and 15-20 cc/hr centrally - Repletion: - Normal Creatinine: Replete ~10 mEq per 0.1 mmol/L reduction in serum potassium, with goal ~4.0. Levels <3.2 may need 20 mEq to raise level 0.1 mmol/L - Elevated Creatinine: Calculate their creatinine clearance. Multiply the above replacement by the estimated reduction in creatinine clearance, ROUNDING DOWN (so if the clearance is reduced by 50%, then use half or less of the dose) Magnesium - Replete prior to potassium and calcium repletion - Oral magnesium has relatively poor absorption and may cause diarrhea (magnesium oxide usually used if needed, magnesium hydroxide also available) - No significant clinical adverse reactions in most healthy patients from mild hypermagnesimia (READ: okay to give IV magnesium without significant fear) - Usual IV infusion rate is 1 gram/hour, though can be rapidly pushed in a code situation (i.e., Torsades de pointes) - Repletion: - Normal Creatinine: Replete ~1 gram Magnesium sulfate IV per 0.1 mmol/L reduction in serum magnesium, with goal ~2.0 - Elevated Creatinine: As with potassium, dose reduce based on percentage reduction in creatinine clearance Cedars-Sinai Medical Center Intern Survival Guide Page 61 of 88 Phosphorus - Universally over checked without significant clinical indication, and usually underdosed during repletion - Usually only abnormal in renal patients (usually high), and low in patients with significant malnourishment and ventilator dependence, or high metabolic demands (high ATP turnover, e.g., sepsis), or in patients with significant diarrhea (GI loss) - Ergo, should really only be checked in those patients where it is clinically indicated, and repleted only in those patients who are not able to take enteral nutrition - Be aware of the calcium/phosphorus ion product and avoid precipitation - PO repletion also slow and may be unsatisfying (available as Neutra-phos, a buffered, mainly sodium phosphate powder). Avoid oral repletion in patients with diarrhea - IV available as Na-Phos and K-Phos, in 15 and 30 mmol amounts - Should be given IVPB over 2-4 hours; there is historical concern about rapid administration with resultant hypocalcemia and precipitation - Repletion: - Normal Creatinine: No well established guidelines for repletion. Consider Neutra-phos 1 packet TID with meals x 3 days. In critically ill patients, and in vent-dependent patients consider Na-Phos 15 to 30 mmol IVPB or K-Phos 15-30 mmol IVPB, which is ~22-44 mEq of potassium. Goal is ~3.5 - Elevated Creatinine: Consult with renal, but if needed replete at half the dose or less. Usually patients are hyperphospatemic Calcium - Traditional teaching suggests repletion only if patient is symptomatic from hypocalcemia - Consider repletion in ICU or chronically ill patients even if they are asymptomatic - Replete magnesium prior to calcium repletion - Be aware of the calcium/phosphorus ion product and avoid precipitation - Be aware of low albumin and either correct for albumin (cheaper) or check a free calcium - PO available as calcium carbonate. Use TID dosing as tolerated if pt is osteopenic/osteoporotic. Also available as calcium acetate (but this is a phosphorus binder) - IV available as calcium chloride (should only be used in code situations as the elemental calcium content is much higher, and should only be used centrally; watch for tissue necrosis if IV infiltrates), calcium gluconate - Repletion: - Normal Creatinine: Calcium gluconate 1-4 amps IVPB as needed, 1 gram/hr infusion, goal >8.5 Cedars-Sinai Medical Center Intern Survival Guide Page 62 of 88 Acid/Base Disturbances Adapted from Walter Reed Army Medical Center’s “Acid Base Disorders Work Sheet” Step 1: Get BMP and ABG Step 2: Look at pH. > 7.4 = primary alkalosis Æ go to 3a < 7.4 = primary acidosis Æ go to 3b Step 3: Look at pCO2 for primary disorder 3a: if pCO2 > 40, pt has metabolic alkalosis; if < 40, then respiratory 3b: if pCO2 > 40, pt has respiratory acidosis; if < 40, then metabolic Step 4: Look for anion gap (normal = 8-12) for possible secondary disorder AG = Na – Cl – HCO3 If yes, they have a metabolic acidosis in addition to (or confirming) Steps 1 & 2. If no significant gap, skip to Step 6. Step 5: Calculate the Delta-Delta (nl = 23-25) for possible tertiary disorder ∆∆ = [AG – 12] + pt’s HCO3 If ∆∆ > 30, pt has underlying metabolic alkalosis in addition to Steps 1-4 If ∆∆ < 23, pt has underlying (non gap) metabolic acidosis in addition to Steps 1-4 Step 6: Diagnose and Treat based on Table below. AG Metabolic Acidosis Non-Gap Metabolic Acidosis “MUDPILERS” “HARDUPS” Methanol Uremia DKA/EtOH KA Paraldehyde INH Lactic Acid. EtOH/ Ethylene Glycol Rhabdo/ RF Salicylates Hyperalimentation Acetazolamide RTA Diarrhea Uretero-Pelvic Shunt Post-hypocapnia Spironolactone Acute Respiratory Acidosis anything that causes hypovent. CNS depres’n Airway obst PNA PE Hemo/PTX Myopathy Chronic Resp Acid. is caused by COPD and restrictive lung dz Metabolic Alkalosis Respiratory Alkalosis “CLEVER PD” “CHAMPS” Contraction Licorice* Endo (Conn’s Cushing’s Bartter’s) Vomiting Excess alkali* Refeeding alkalosis* Posthypercapnia Diuretics* assoc w/ ↑ U Cl levels * Step 7: Fix it! Cedars-Sinai Medical Center Intern Survival Guide Page 63 of 88 anything that causes hypervent. CNS dz Hypoxiz Anxiety Mech Ventil. Progesterone Salicylates/ Sepsis Determining Compensation from Huang ES et al., Internal Medicine Handbook for Clinicians, Scrub Hill Press Inc. 1st ed, 2000 Respiratory Acidosis for each ↑ PCO2 of 10 mmHg… Acute Chronic HCO3 ↑ 1 mEq HCO3 ↑ 3 mEq pH ↓ 0.08 pH ↓ 0.03 Respiratory Alkalosis for each ↓ PCO2 of 10 mmHg… Acute Chronic HCO3 ↓ 2 mEq HCO3 ↓ 5 mEq pH ↑ 0.07 pH ↑ 0.02 Metabolic Acidosis for each ↓ HCO3 of 1 mEq… PCO2 ↓ 1.25 mmHg Metabolic Alkalosis for each ↑ HCO3 of 1 mEq… PCO2 ↑ 0.75 mmHg Continuous Renal Replacement Therapy CRRT is a spectrum of renal replacement technologies SCUF: Slow continuous ultrafiltration. Pass blood through a filter and remove an ultrafiltrate. Simply takes off volume CVVH: Continuous veno-venous hemofiltration CVVHD: Continuous veno-venous hemodialysis CVVHDF: Continuous veno-venous hemodialysis with filtration To institute CRRT in the ICU, must have renal and critical care attending approval, ± ethics consult. Also establishes 1:1 nursing for the patient, and may require the patient to transfer to the ICU that is designated the CRRT unit (basically the unit that has the most patients on CRRT so it is easier to manage all of the patients from a nursing standpoint) Cedars-Sinai Medical Center Intern Survival Guide Page 64 of 88 Low Urine Output Normal urine output is typically at least 0.5 cc/kg/hr. Oliguria is defined as urine output < 400 cc/day, and anuria is < 100 cc/day 1. Double check urine output Flush Foley catheter, check I/O sheet, weights, and ask pt about urine output 2. Examine the patient, assess volume status: - Mucous membranes, skin pallor/dryness, edema, complaints of thirst - Neck veins, crackles in lungs - Bladder palpable on abdominal exam, prostate exam 3. Abrupt onset of anuria most often suggests obstructive uropathy. Other causes to consider if obstruction is not the case are: - Progression of preexisting renal failure - Renal cortical necrosis - Necrotizing glomerular disease (RPGN) 4. Rule out obstructive uropathy: check a post–void residual by inserting Foley after patient voids. If volume > 200 cc then leave the Foley in; this indicates urinary retention. Some reasons for urinary retention include prostatic hypertrophy, anticholinergic side– effects of medications (narcotics, Benadryl, anesthetics, etc.). Consider renal ultrasound to r/o hydronephrosis 5. Work-up: If patient is not volume overloaded or obstructed and has no history of CHF, then a fluid challenge is usually appropriate (250-500 cc NS IV bolus). - Always consider hypovolemia, decreased cardiac output, infection, sepsis, contrast nephropathy, and drug toxicity as potential causes - Beware of associated volume overload, acidosis, and hyperkalemia - Consider increasing lab frequency and adjust drug dosages for È GFR 7. If patient is in CHF or is volume overloaded, initiate diuresis. Remember, that unless the patient is truly volume overloaded, diuresis just for the sake of increasing urine output is pointless - Patients with functioning kidneys and overaggressive hydration usually will diurese themselves just by lowering the IV fluid rate - If in CHF or with symptoms, use furosemide 20-80 mg IV - If in renal failure, may require hemodialysis. Sometimes patients in renal failure can still respond to high dose furosemide while waiting for the renal consult (160-240 mg IV slowly) Cedars-Sinai Medical Center Intern Survival Guide Page 65 of 88 Radiology Basic Initial Imaging studies organized by systems Cranial Problems - Head trauma: CT - Acute hemorrhage: Non-contrasted CT - TIA: Non-contrasted CT - MRI with and without contrast if vertebrobasilar findings (CT not effective in evaluating posterior fossa) - Acute Stroke: Non-contrasted CT - If ischemic stroke: MRI with and without contrast better in identifying and evaluating extent of stroke - MS: brain MRI with and without contrast - Tumor or metastasis: MRI with and without contrast, though can use contrasted CT - Aneurysm: MR angiogram or contrasted CT - Abscess: Contrasted CT or MRI - Sinuses: Frontal skull film: frontal/ethmoid sinues - Frontal Water’s view: maxillary sinuses - CT sinus: superior study to evaluate paranasal/mastoid sinuses and adjacent bone Face/Neck - Unilateral proptosis, periorbital swelling or mass: CT or MRI - Facial fracture: plain x-ray or CT for complicated cases - Mandible fracture: panorex - Carotid Bruit: Duplex ultrasound - Epiglottitis: lateral soft tissue x-ray of the neck Chest Typically start out with plain PA/lateral chest x-ray - Trauma: Chest CT - CHF (new or worsening): CXR + 2D echocardiogram - Foreign body: inspiration/expiration chest x-ray - Mediastinal mass: Chest CT - Lung Mass: CXR, CT chest - Solitary Pulmonary Nodule: PA/lateral CXR, hi-res CT of the chest - Pericardial Effusion: 2D echocardiogram ± transesophageal echocardiogram - Aortic Aneurysm: contrasted CT or transesophageal echocardiogram - Aortic Dissection: contrasted CT or transesophageal echocardiogram - Endocarditis/valvular disease: 2D echocardiogram ± transesophageal echocardiogram - Pulmonary Embolism: VQ scan or CT angiogram PE protocol Cedars-Sinai Medical Center Intern Survival Guide Page 66 of 88 Vascular - Deep Vein Thrombosis: Duplex ultrasonography of involved veins - Carotid Bruit: Carotid Duplex ultrasonography - Claudication: Arterial Duplex ultrasonography/ABI GI/Abdomen/GU - KUB (kidney, ureter, bladder) or abdominal plain film: typically done supine, most common imaging study of the abdomen - Abdominal series, “acute abdominal series”: KUB, upright PA CXR, and upright abdominal film: upright CXR done to look for free air under diaphragm, upright abdomen done to look at the air fluid levels within the bowel to help differentiate ileus vs. obstruction. Obstruction typically has more air fluid levels - Esophageal obstruction: Barium swallow - Bowel perforation or free air: upright chest and supine abdominal film; supine and left lateral decubitus if patient is unable to stand - Trauma, blunt or penetrating: Supine/upright abdomen (look for free air), FAST scan (4quadrant ultrasound of the abdomen to look for free fluid/organ damage), and/or CT Abd/Pelvis (will likely need both GI and IV contrast for good delineation of structures, but may not be available in the trauma setting) - Abdominal aortic aneurysm: ultrasound or contrasted CT - Pancreatic Mass: CT with IV and GI contrast - Abdominal abscess: CT with IV and GI contrast - Gallbladder: Right upper quadrant ultrasound, Nuclear medicine hepatobiliary scan (HIDA) - Appendicitis: CT with IV and GI contrast - Pelvic Abscess: CT or ultrasound - Uretral Stone: Noncontrast CT (CT Urogram) or IVP - Uterine or ovarian pathology: Pelvic Ultrasound - Acute diverticulitis: CT with IV and GI contrast - Bladder cancer: Cystoscopy, CT with IV contrast - Testicular Torsion: Doppler US - Cervical/ovarian/uterine Cancer: CT with IV and GI contrast - Uterine fibroids: ultrasound - Vaginal bleeding: ultrasound MSK - Fracture: X-ray “series” (e.g. shoulder series) - Occult hip fracture: MRI or bone scan - Metastasis: bone scan, plain film in area of pain - Osteomyelitis: plain X-ray, if negative, then nuclear medicine three-phase bone scan or MRI - Arthritis: X-ray Cedars-Sinai Medical Center Intern Survival Guide Page 67 of 88 Miscellaneous Inpatient Guide For Diabetics Based on Diabetes Facts and Guidelines 2005 by Yale General Principles: 1. Type 1 patients require at least some basal insulin at ALL times to prevent ketosis, even when they are NPO 2. Review diabetic meds 3. Order fingersticks QID in all pts with diabetes (QAC and HS if eating; Q6 hr if NPO) for at least first 48 hrs. If pt stable and under good glycemic control and if on oral agent or one insulin injection/day, can decrease to BID. 4. In-hospital glucose target in most pt should be <110 mg/dL pre-meal; <180 mg/dL at all other times. Pregnant women and critically ill pt (in ICU) require tighter control (80-110). 5. Revise insulin regimen continuously (every 1-2 days) Ç AM intermediate-acting insulin (e.g. NPH) to È pre-supper BG (blood glucose) Ç PM long/intermediate-acting insulin (eg glargine, NPH) to È fasting BG Ç AM short/rapid-acting insulin (e.g. regular, lispro) to È pre-lunch BG Ç PM short/rapid-acting insulin (e.g. regular, lispro) to È bedtime BG 6. Don’t leave pt on RISS (regular insulin sliding scale) as ONLY form of treatment. Adding long acting insulin (e.g. glargine) will stabilize glycemic control. 7. Try to approximate at-home regimen as long as possible BEFORE discharge 8. Call diabetes educator to teach pt about managing diabetes Oral Agent Patients: A. The hospitalized pt who is NPO (or in whom oral intake is doubtful) 1. Pt well-controlled on oral hypoglycemic agent (OHA) i.e. sulfonylurea - D/C OHA and use RISS or lispro SS - If need SS >24-48 hr, add long acting insulin 2. Pt well controlled on oral agent that does not cause hypoglycemia (e.g. metformin, TZDs) - D/C metformin (due to contrast studies, dehydration, renal fxn) - If pills ok, can continue TZD unless have abnl LFTs or new edema 3. Pt poorly controlled on oral agents - Place pt on insulin; can try SS for 24-48 hr to assess insulin requirements or proceed straight to regimen with long-acting insulin B. Hospitalized pt who is eating 1. Pt well controlled on OHA - May continue. Consider dose reduction by 25-50% due to more rigid diet - D/C metformin if hemodynamic instability, CHF, dehydration, or altered renal or hepatic fxn, or if plan to do contrast studies - continue TZDs unless abnl LFTs or new edema 2. Pt poorly controlled on oral agents Cedars-Sinai Medical Center Intern Survival Guide Page 68 of 88 - Calorie restricted diet - Then add insulin while adding other orals Insulin-treated patients: A. Hospitalized pt who is NPO Type I DM - Can use IV insulin drip - Can give ½-2/3 of long acting insulin + SS - Unless very hyperglycemic, give D5W or D5 1/2NS@75-125 cc/hr to prevent catabolism - Check BG Q6 hr - Consider short acting insulin if need rapid correction of hyperglycemia Type II DM - May be able control with diet restriction and SS - Can give ½ long acting insulin + SS - If giving insulin, give D5W or D5 1/2NS - Check BG Q6 hr B. Hospitalized pt who is eating -Continue insulin but consider dose reduction by 25% in controlled pt Bedside glucose monitoring: - Order QID for insulin pt - If on oral agents alone or only one insulin injection per day, can decrease sticks to BID (pre-breakfast and pre-supper) if good control - If NPO, do sticks Q6 hr Hypoglycemia: - If pt alert, give 15-30g carbs via: 8 oz juice/soda = 30 g carbs 2 graham cracker squares = 10 g carbs - 15 g carbs will increase BG by 25-50 mg/dL - Non-alert pt: give 25 g dextrose IV (1 amp D50) or 1 mg glucagon IM if no IV access and recheck BG after 5-10 min - If severe or recurrent hypoglycemia, use D5 or D10 drip Cedars-Sinai Medical Center Intern Survival Guide Page 69 of 88 Sliding Scales/Correctional Insulin/Supplemental Insulin: AC HS BG: Very Insulin NL Insulin Very Insulin Sensitive: Sensitivity: Resistant: <100 0 units 0 units 0 units 100-149 0-1 unit(s) 0-2 unit(s) 0-5 unit(s) 150-199 1 unit 2 units 5 units 200-249 2 units 4 units 10 units 250-299 3 units 6 units 15 units 0-2 unit(s) 300-349 4 units 8 units 20 units 2-4 units >350 5 units 10 units 25 units 4-6 units - Give regular insulin 20-30 min prior to meals - Give rapid acting insulin (e.g. Lispro) 0-10 min with meal at bedside - In pts who are NPO, give regular insulin every 6 hr. If using Lispro (though not preferred if NPO), dosing is every 4 hr. Start SS at higher threshold (>200 mg/dL) to avoid hypoglycemia, especially in type 1 DM - Glycemic targets should be higher in those at high risk of hypoglycemia, such as malnourished, those with decreasing renal fxn, adrenal insufficiency, gastroparesis, hypoglycemia unawareness, or h/o brittle DM - Remember: A sliding scale should not be a pt’s ONLY source of insulin! Rather, patients should have a basal insulin dose, and be provided with supplemental insulin as needed for rapid correction of hyperglycemia. Every day thereafter, the pt’s daily supplemental insulin should then be considered, and potentially incorporated into their basal dosing, as highlighted in the prior sections. Peri-op and peri-procedure: - Check BG Q1-2 hr before, during, and after procedure - Not best to use RISS A. Type I DM - Put on insulin drip (about 1-2 units/hr) with D5W@75-125 cc/hr to keep BG 100-150 mg/dL OR - Give ½-2/3 of NPH on morning of procedure. Do not give Lispro unless BG >200 and then in small doses (1-4 units to get to BG 100-150). If pt on HS glargine, can give usual dose the night before but best to reduce dose by 20% B. Type II DM - Hold sulfonylurea or secretagogue on day of procedure and resume when tolerates NL diet - Hold metformin for safety concern the day of procedure and resume 48 hr post-op if renal fxn normal or near normal - Can continue TZDs Cedars-Sinai Medical Center Intern Survival Guide Page 70 of 88 - If on insulin, give ½ NPH on morning of procedure. Do not give Lispro unless BG >200 and then 1-4 units to keep BG 100-150. Reduce HS glargine by 20% OR - Put on insulin drip as above Insulin Drips: Indications DKA Hyperosmolar hyperglycemic state Very poorly controlled diabetes despite Sub-Q insulin (BG >300-350 x 2 over 612 hr) TPN Type I DM who are NPO, periop, or in L & D Post-MI with hyperglycemia ICU pt with hyperglycemia Suspect poor subQ absorption of insulin Transition - When put back on Sub-Q insulin, give lispro 1-2 hr or long acting insulin 2-3 hr prior to stopping drip Insulin regimens: A. Type 2 DM - Can start on small doses of long acting insulin 1-2 x/day. Start at 0.2-1.5 units/kg per day - When pt has hyperglycemia on full insulin dosing, begin with 0.5 units/kg divided into 2 injections per day - Split regimen—give 60% insulin in AM and 40% in PM with 2:1 ratio of long to short in AM and 1:1 in PM B. Type 1 DM - Treat with at least BID injections of short acting and long acting - Total daily dose is 0.4-1.0 unit/kg - Proportions are 60% in AM and 40% in PM with 2:1 ratio of long to short in AM and 1:1 in PM - Changes in insulin regimen should be slow Cedars-Sinai Medical Center Intern Survival Guide Page 71 of 88 Supportive Care in Heme-Onc Oral Care and Mucositis Nausea and Vomiting Diarrhea Constipation Peridex 15 cc PO swish and spit QAC, QHS “MMX” Susp, 10 cc PO swish and spit/swallow QAC, QHS, prn (Mylanta/Maalox, Mycelex, Xylocaine) Viscous Lidocaine 2%, 10 cc PO swish and spit/swallow QAC, QHS, prn Hurricane Spray to mouth/throat QAC, QHS, prn Topical Cocaine 2-4% swish or swab Q4hr prn1 Stanford Susp 10 cc swish and spit/swallow QAC, QHS, prn Carafate Susp/tab 1 gm swish and swallow/PO QAC, QHS Compazine 10 mg IV/PO Q6 hr prn (ATC if needed) Droperidol 0.625-1.25 mg IV Q4hr prn2 Reglan 10 mg IV/PO QAC, QHS, or Q6hr prn (ATC if needed) Phenergan 25 mg IVPB Q6 hr prn Ativan 0.5-2 mg IV/PO/SL Q4hr prn Decadron 4-8 mg IV/PO Q12-24hr prn Marinol 2.5-5 mg PO Q4hr prn Zofran 4 mg IV or 8 mg PO Q4hr prn (ATC if needed) Imodium 2 mg PO after each loose stool, max 8 tabs per day (16 mg) Lomotil 2.5 mg PO after each loose stool, max 8 tabs per day Tincture of Opium 0.5-1 cc PO Q4hr prn Metamucil 5 cc PO TID Questran 4 gm PO TID3 Lactinex 1 tab/packet PO TID Octreotide 100-500 mcg Sub-Q Q8hr Dulcolax 10 mg PO/PR daily prn Glycerin supp PR daily prn MOM 30 cc PO Q6hr prn, Magnesium Citrate 150-300 cc PO daily prn4 Mineral Oil 30 cc PO prn Senokot 2 tabs PO daily prn (up to 4 tabs BID), Cascara 5-10 cc PO QHS prn Metamucil 5-10 cc PO daily prn Sorbitol 30 cc PO daily prn, Lactulose 30 cc PO daily prn4 Cedars-Sinai Medical Center Intern Survival Guide Page 72 of 88 Neutropenic mouth care, antibacterial and antifungal activity Consider IV Narcotics for pain control Beware of EPS with dopaminergic antagonists Consider anti-emetics ATC to prevent sxs. Antimotility agents Probiotic Antisecretory Onset 30-60 minutes Onset 30-60 minutes Onset 3-6 hrs Onset 6-8 hrs Onset 6-10 hrs Onset 12-24 hrs Onset 24-48 hrs Onset 24-72 hrs Colace 100-250 mg PO daily-TID prn (up to 250 mg PO BID)5 Growth G-CSF (Neupogen) 5 mcg/kg Sub-Q daily, given D/C after ANC > 2000 Factors at 2200 daily because of cost-containment issues (available in bulk vials of 300 mcg and 420 mcg). Pegylated G-CSF (Neulasta) Epogen/Procrit 150 units/kg Sub-Q QMWF Electrolytes See Renal Section Iron: Oral: Ferrous sulfate 325 mg PO TID, use colace along with repletion IV: Venofer 100 mg IVPB daily x 10 days Consider adjunctive iron use in patients on Epogen/Procrit Pain Control See Narcotic Section 1 Use with caution, may not be available without special approval 2 Use with caution, significant adverse effects 3 Binding resin, interferes with the PO absorption of many medications. Use as a third or fourth line agent 4 Beware of significant electrolyte shifts that can occur with osmotic agents. Use magnesium containing products with caution in renal patients 5 Beware of the significant sodium load with Colace. Use with caution in CHF patients Cedars-Sinai Medical Center Intern Survival Guide Page 73 of 88 Heparin 1. Check baseline coags 2. Dosing - ACS (unstable angina, STEMI, NSTEMI), “low intensity” - 60 units/kg IV bolus (max: 5,000 units) - 12 units/kg/hour gtt - DVT/PE, “high intensity” - 80 units/kg IV bolus - 18 units/kg/hour gtt 3. Check PTT in 6 hours and adjust as follows (round to 50 units/hr increment): DVT/PE (“high intensity”): Goal PTT: 78-115 PTT: Hold Infusion: <60 61-77 78-115 116-132 1 hour >132 1 hour Rate Adjustment: Ç 2.5 units/kg/hr Ç 1 unit/kg/hr No Change È 1 unit/kg/hr È 2.5 units/kg/hr Next PTT: 4 hr 4 hr Next AM 4 hr 4 hr ACS (“low intensity”): Goal PTT: 70-101 PTT: Hold Infusion: <57 57-69 70-101 102-114 1 hour >114 1 hour Rate Adjustment: Ç 3 units/kg/hr Ç 1.5 units/kg/hr No Change È 1.5 units/kg/hr È 3 units/kg/hr Next PTT: 4 hr 4 hr Next AM 4 hr 4 hr *Note: Pts get a significant fluid load with heparin. In addition, heparin is usually mixed in D5W, and thus pts can become hyponatremic. Consider writing to have heparin mixed in NS if needed. **Note: On the floor, the pharmacy can dose the heparin gtt for you, simply write an order, “Heparin per pharmacy protocol” and the gtt and PTT checks will be carried out. Consider also “Coumadin per pharmacy protocol” if outpatient anticoagulation is planned. In the ICU, you will have to dose both of these medications, but do not hesitate to ask any of the ICU pharmacists for assistance if needed; they are VERY helpful Cedars-Sinai Medical Center Intern Survival Guide Page 74 of 88 Alcohol Withdrawal Taken from The Hospitalist Handbook, UCSF School of Medicine, 2004 Clinical Institute Withdrawal Assessment Scale for Alcohol, Revised (CIWA-AR) Nausea and vomiting 0 No nausea or vomiting 1 2 3 4 Intermittent nausea with dry heaves 5 6 7 Constant nausea, frequent dry heaves and vomiting Headache 0 Not present 1 Very mild 2 Mild 3 Moderate 4 Moderately Severe 5 Severe 6 Very Severe 7 Exteremely Severe Paroxysmal sweats 0 No sweats visible 1 Barely perceptible sweating, palms moist 2 3 4 Beads of sweat obvious on forehead 5 6 7 Drenching sweats Auditory disturbances 0 Not present 1 Very mild harshness or ability to frighten 2 Mild harshness or ability to frighten 3 Moderate harshness or ability to frighten 4 Moderately severe hallucinations 5 Severe hallucinations 6 Extremely severe hallucinations 7 Continuous hallucinations Anxiety 0 No anxiety, at east 1 2 3 4 Moderately anxious, guarded 5 6 7 Acute panic state, consistent with severe delirium or acute schizophrenia Visual disturbances 0 Not present 1 Very mild photosensitivity 2 Mild photosensitivity 3 Moderate photosensitivity 4 Moderately severe visual hallucinations 5 Severe visual hallucinations 6 Extremely severe visual hallucinations 7 Continuous visual hallucinations Agitation 0 Normal activity 1 Somewhat more than normal activity 2 3 4 Moderately fidgety and restless 5 6 7 Paces back and forth during most of interview or constantly thrashes about Tremor 0 No tremor 1 Not visible but can be felt on fingertips 2 3 4 Moderate when patient’s hand extended 5 6 7 Severe, even with arms not extended Tactile disturbances 0 None 1 Very mild paresthesias 2 Mild paresthesias 3 Moderate paresthesias 4 Moderately severe hallucinations 5 Severe hallucinations 6 Extremely severe hallucinations 7 Continuous hallucinations Orientation and clouding of sensorium 0 Oriented and can do serial additions 1 Cannot do serial additions 2 Disoriented for date by no more than 2 calendar days 3 Disoriented for date by more than 2 calendar days 4 Disoriented for place or person TOTAL SCORE IS THE SUM OF EACH ITEM SCORE MAX=67 Cedars-Sinai Medical Center Intern Survival Guide Page 75 of 88 CSMC CIWA Protocol 1. Mechanism: multifactorial; withdrawal symptoms are the opposite of depressant effects of ETOH: increased adrenergic, serotonergic, and cholinergic activity 2. For all alcohol withdrawal hospitalizations, evaluate for co-morbid medical conditions (alcoholic hepatitis, pancreatitis, liver failure, gastrointestinal bleed, infection, trauma, hypoglycemia, co-ingestions, arrhythmias, dilated cardiomyopathy, altered electrolytes). Treat with: - Thiamine, multivitamins, folate - Hydrate and correct electrolytes - Follow blood sugars and always give glucose before giving thiamine - Restrain for safety PRN - Seizure precautions if deemed at risk - Substance abuse counseling services referral (if available) - Charcoal is not helpful with alcohol intoxication Cedars-Sinai Medical Center Intern Survival Guide Page 76 of 88 3. Tremulousness: 6-36 hours after last drink, occurs in 75-100% - Signs/ Symptoms: Irritable, hypervigilant, diaphoretic, GI upset, tachycardia, HTN, coarse tremor of hands, tongue wag. Resolves in 24-48 hr - Treatment: Thiamine 100 mg IV x 3 d, MVI, Folate. Ativan or Valium per CIWA guidelines. Consider beta-blockers for uncontrolled HTN 4. Seizures: 6-48 hours after last drink; an early phenomenon - Signs/ Symptoms: Generalized tonic-clonic seizures, post-ictal state. If the patient is febrile, seizure is focal in onset, or if the patient has no history of seizure, evaluate for secondary seizure (LP, CT, electrolytes, tox screen, etc.) - Treatment: Treat as other seizures with Ativan. No need to load DPH unless patient has focal seizures, brain injury, or is supposed to be on anticonvulsants for other reasons (epilepsy, etc.) 5. Alcoholic hallucinations: 25% of patients within 12-48 hours after the last drink - Signs/ Symptoms: Unlike DTs, patient’s sensorium is clear except for primarily visual hallucinations - Treatment: Follow CIWA protocol, thiamine, MVI, folate. Consider Haldol 1-2 mg Q 1 hour prn severe hallucinations (careful: may lower sz threshold!!!) 6. Delirium tremens: 2-7 days after last drink. 4-5% of patients: this is a MEDICAL EMERGENCY-5% mortality (often due to PNA or arrhythmia) - Signs/Symptoms: Lasts 2-5 days to weeks. Clouded consciousness, delerium, diaphoresis, agitation, hallucinations (visual> tactile> auditory), hypertension, tachycardia, low grade fever (<38.5) - Treatment: Thiamine, Folate, MVI, replete electrolytes, rule out infection. Admit to telemetry. Benzos per CIWA protocol. Ativan is usually preferred due to IV route. May require gtt. Haldol 1-2 mg Q 1 hour prn severe agitation/hallucination/delirium Cedars-Sinai Medical Center Intern Survival Guide Page 77 of 88 Pain Control General Points: - Write holding parameters for all narcotic (and benzo) medications (e.g., “hold for RR < 8 or sedation”) - Route of administration - IVP: Rapid onset - IVPB: Useful in patients in pain, but seeking a “rush” (e.g., Dilaudid 1 mg IVPB over 10-20 mins Q3hr prn pain) - SQ: Slower onset vs. IV, but absorption is slower, and thus has a longer effect - PO: Slowest onset, but still equally efficacious at pain relief Patients can be divided into three categories regarding pain control: acute pain, chronic pain without acute increase in pain, and chronic pain with acute increase in pain Patients with acute pain (e.g., pancreatitis, cellulitis): begin with just prn medications to assess how much pain medication the patient will require. The biggest mistake made in these patients is underdosing of pain medications - Start with Morphine 2-4 mg IV/SQ Q4hr prn pain for moderate pain and adjust as needed - May use breakthrough doses as needed, either as a supplemental dose or at an increased frequency (e.g., Morphine 2 mg IV Q2hr prn breakthrough pain) - Note starting dose listed in Pharmacopeia is Morphine 10 mg IV for acute, severe pain For patients with chronic pain, without an acute increase in pain, simply continue their outpatient regiment For patients with chronic pain, with acute exacerbation of pain, the key to pain control is to continuous readjustment 1. Ask the patient if they have a home regimen. Begin with medications as close to the home regimen as possible 2. Always have a long-acting pain medication for basal control e.g., MS Contin 30mg BID 3. For breakthrough pain medications (SQ or IV or PO), know the half-life - e.g., Dilaudid only lasts ~3h when given IV, so don’t make it Q4h prn 4. The following morning, add up how much pain medication the patient used - do not forget to convert narcotics to a common equivalent, because Dilaudid 1 mg does not equal Morphine 1 mg - Use this total as the NEW baseline amount, dividing BID or TID - continue with the old prn system - recalculate every morning, until the pt reports good pain control Example: - MS Contin 30 mg BID for long acting so, pt uses 60 mg in 24h Cedars-Sinai Medical Center Intern Survival Guide Page 78 of 88 - Morphine 5 mg IV Q3hr prn for breakthrough, if pt asks for breakthrough dose 6 times, the pt uses 30 mg in 24h 1. Conversion: Morphine 30mg IV = about 90 mg PO 2. Total: 90 mg (breakthrough equivalent) + 60 mg (long-acting) = 150 mg 3. Divide this for new long acting: MS Contin 75 mg BID 4. Keep same breakthrough dose: Morphine 5 mg IV Q3hr prn 5. Recalculate the next morning. Pain Medication Equivalencies Adapted from Tarascon Pharmacopoeia Deluxe, 2006, and UCLA Internal Medicine Inpatient Housestaff Handbook, 2005-2006 Medication: PO: IV/SQ/IM: Fentanyl1 N/A 0.1 mg Dilaudid (hydromorphone) 7.5 mg 1.5 mg Morphine 30 mg, 60 mg2 10 mg Meperidine3 300 mg 100 mg Oxycodone 30 mg N/A Hydrocodone 30 mg N/A Codeine 130 mg 75 mg 1 Fentanyl is available as the Duragesic transdermal patch, 50 mcg/hr ≈ Morphine 100 mg PO total dose per day 2 30 mg used with divided/ATC dosing, 60 mg if short-acting, one-time dose 3 Doses should be limited to <600 mg/24 hours, total duration of use <48 hours. Not available in CSMC ED at all. Use STRONGLY discouraged on floors except for rigors Steroid Equivalencies - Adapted from Tarascon Pharmacopoeia Deluxe, 2006 *Note: PO steroids enjoy excellent bioavailability; use them! Medication: Equivalent Dose: Relative Antiinflammatory Potency: Cortisone 25 mg 0.8 Hydrocortisone 20 mg 1 Dexamethasone 0.75 mg 20-30 Prednisolone 5 mg 4 Methylprednisolone 4 mg 5 Prednisone 5 mg 4 Fludrocortisone N/A 10 Cedars-Sinai Medical Center Intern Survival Guide Page 79 of 88 Relative Mineralocorticoid Potency: 2 2 0 1 0 1 125 Mini-Mental State Exam Adapted from Folstein et. al: J Psych Res 12:189, 1975 Question: Orientation Registration Attention and Calculation Recall Language Year, Season, Date, Day, Month State, Country, Town, Building, Floor Name three words (Apple, Honesty, Wind) Record number of trials to learn Serial 7’s (93, 86, 79,72, 65) or Spell “World” backwards (dlrow) Recall 3 objects above Name a pencil and a watch Repeat, “No ifs, ands, or buts” Follow a 3-step command (Take a paper in your right hand, fold it in half, and put it on the floor) Read and obey (Close your eyes) Write a Sentence Copy intersecting pentagons Max Score: 5 5 3 Patient Score: – 5 3 2 1 3 1 1 1 Total 30 *Note: A score of less than 24 points is suggestive of dementia or delirium with a sensitivity of 87% and specificity of 82% (from Crum RM et. al., “Population-based norms for the Mini-Mental State Examination by age and educational level.” JAMA 1993 May 12;269(18):2386-91) Cedars-Sinai Medical Center Intern Survival Guide Page 80 of 88 Pager and Phone Directory Pagers Dialing Instructions - IN-HOUSE ACCESS: dial 103 then enter the 4-digit pager number and then call-back number - FROM OUTSIDE CEDARS: dial 310-423-5520 then enter the 4-digit pager number and then call-back number Chief Residents Peter Chung 2690 Alexis Peraino 2691 Ward Pagers Medicine Admitting Resident 1875 Red Cross-Cover 1874 Blue Cross-Cover 1876 Green Cross-Cover 1877 Gold Cross-Cover 1879 Senior-In-House 4946 Medicine Consult 4946 Faculty Attending On Call 229-4091 House Physician 1878 Surgery Resident On-Call 0946 Please check on-call schedule on Cedars Clinical Workstation Home Page for appropriate resident. Psychiatry Consult Liaison 2333 Anesthesiolgy 0689/1392 Cardiology CCU Fellow 2266 Endocrinology 4455 Gastroenterology 2249 Infectious Disease 5707 Nephrology 2222 Neurology 2551 Pediatric Ward Resident 0731 Pediatric ICU Resident 0931 Podiatry 3704 Renal Transplant 4321 Transfusion Medicine 1700 CCU Intern 3-8264 CCU Resident 3-8233 RICU Intern 3-7997 RICU Resident 3-7950 MICU Intern 3-7867 MICU Resident 3-7860 Cedars-Sinai Medical Center Intern Survival Guide Page 81 of 88 Phone Numbers Dialing Instructions: In-house: Dial 3-XXXX Outside: Dial 310-423-XXXX Numbers beginning with 6-XXXX CANNOT receive calls MAIN OPERATOR PHONE NUMBER 109, 423-CEDARS (3-3277) AHF Main 310-688-7200 Hollywood 323-662-0492 Dr. Laveeza Bhapti 310-657-9353 ext 5633 leave message with pt's info, resident's pager, any info resident needs to care for pt ADMISSIONS 3-3778 ANESTHESIOLOGY 3-5841 pagers 0689/1392 BED RESERVATIONS 3-3761 BIOETHICS 3-9636 BLOOD BANK 3-5411 On-call fellow p. 1517 BLOOD GAS LAB 3-5196 CAFETERIA 3-4541 Hours: 6:30AM-12 AM daily CANCER CENTER 3-8030 CARDIOLOGY Cath lab 3-3975 EKG 3-4851 Echo/stress Testing 3-4861 Holter 3-4857 Nuclear 3-4216 Outpatient Scheduling 3-8000 CARL BEAN 323-766-2326 CASE MANAGEMENT 3-3075 CENTRAL ISSUES 3-3224 CHAPLAIN 3-5550 CREDIT UNION 3-5540 DIABETES PROGRAM DENTAL CONSULT 3-6339 DENTAL CLINIC 3-6361 DOTEC 3-3870 DIALYSIS UNIT (6-S) 3-6933 DIABETIC NURSE 3-5594 EIS HELP DESK 3-6428 ELLIS EYE CENTER 3-9992 EMERGENCY DEPARTMENT Acute care 3-0808 Front desk 3-2295 Imaging 3-8734, 3-4900 Lab 3-6537 Sub-acute 3-0807 Triage 3-8605 EMPLOYEE HEALTH SERVICE Appointments 3-3322 Needlestick Hotline 3-3322 ENDOCRINOLOGY 3-4774 EPIDEMIOLOGIST NURSE 3-5574 On-call 310-298-4360 FOOD SERVICES (hours listed under individual headings Cafeteria 3-4541 Plaza Café 3-4544 Starbuck’s GASTROENTEROLOGY 3-6056 GI holding area 3-6146 IBD Center 3-7723 OR 3-4100 GIFT SHOP 3-5241 GYNE CONSULT 2680 HEME/ONCOLOGY 3-6487 Radiation Oncology 3-0645 HOME CARE SERVICES 3-9800 Referrals 3-9831 HOME INFUSION 3-9570 HOSPICE PROGRAM 3-9520 IMAGING Copies (CD) 3-3691 CT 3-2228 Interventional/Neuro 3-2468 Mammography 3-2626 MRI 3-2674 Nuclear Medicine 3-4682 PACS 3-5500 Radiology 3-2723 Reading Room 3-5720 Taper Imaging 3-8000 Ultrasound 3-2263 Cedars-Sinai Medical Center Intern Survival Guide Page 82 of 88 Vascular U/S 3-2887 INFECTIOUS DISEASES 3-3896 TB Liaison 3-3443 TB Public Health Lab 213-250-8670 INTERPRETER SVCS 3-5353 LAB COATS 3-0772 Hours: M-F 6-9 AM, 2-4 PM LABORATORY (see also pathology/lab medicine) 3-5431 Blood culture 3-2491 Blood Gas 3-5196 HLA typing 3-4979 Microbiology 3-4777 Phlebotomy 3-5394 LEGAL AFFAIRS 3-5708 LITHOTRIPSY/Stone Ctr 3-3741 LIVER OFFICE 3-2641 MEDICAL GENETICS 3-6451 MEDICAL LIBRARY 3-3751 MEDICAL MEDIA 3-2665 MEDICAL RECORDS 3-3331 Incomplete Charts 3-3738 METABOLIC SUPPORT TEAM (TPN) 3-6144 NEPHROLOGY 3-7880 NEUROLOGY 3-6472 EEG 3-6841 Stat EEG p1900 EMG 3-9844 NEUROSURGICAL INST. 3-7900 NURSING ADMIN. 3-5181 CPR Training 3-5189 OB/GYN 3-9942 OCCUPATIONAL THERAPY 3-6265 OPERATOR (MD line) 109, 3-3254 OUTPATIENT REHAB 3-9200 PAGE OVERHEAD 109 PAIN MANAGEMENT 3-5870 PARKING OFFICE 3-5535 PATHOLOGY/LAB MED 3-5431 AFB Bench 3-3134 Anatomic 3-6611 Autopsy Suite 3-5310 Blood Gas 3-5196 Bone Marrow 3-5471 Cytology 3-2363 Procedures 3-6199, 3-6621 Immunology 3-5571 Microbiology 3-4775 Phlebotomy 3-5394 Reference Lab 3-7445 Transfusion Med 3-5411 PATIENT LOCATION 3-2000 PATIENT RELATIONS 3-3683 PEDIATRICS 3-4431 Residency Program 3-4780 Ward Resident pager 0731 PICU Resident pager 0931 PHARMACY SERVICES 3rd Floor 3-5631 4th Floor 3-5633 5th Floor 3-5635 6TH Floor 3-5637 7TH Floor 3-5639 SCCT 3-6858 Drug Information 3-5640 Outpatient pharmacy 3-7484 PHYSICAL THERAPY 3-6281 PHYSICIAN REFERRALS 1-800-4-CEDARS or 3-3400 PICC SERVICE 3-1763 PLAZA CAFÉ 3-4544 Hours: M-F 7AM- 7PM PODIATRY CONSULT p3704 PROCEDURE CENTER 3-6364 PSYCHIATRY Residency 3-3481 Addiction Svcs 3-3411 Child psychiatry 3-3566 Consult Liaison 3-3465 Pager 2333 Information 3-3491 RN Station 3-E 3-3621 RN Station 3-W 3-3421 Thallians Admission 3-4714 Thallians partial hospitalization 30040 PULMONARY MEDICINE 3-4685 PFT 3-6330 Pulmonary Rehab 3-9566 RADIATION ONCOLOGY 3-4207 REHAB DEPT (7SW) 3-6765 Cedars-Sinai Medical Center Intern Survival Guide Page 83 of 88 RESEARCH INSTITUTE 3-7602 RESP. THERAPY 3-6138/3-6175 RIDESHARE OFFICE 3-5789 RISK MANAGEMENT 3-5935 SECURITY 3-5511 SKULL BASE INSTITUTE 3-8091 SPEECH THERAPY 3-6287 SPINE INSTITUTE 3-9900 STARBUCK’S 3-6664 Hours: M-F 6AM-8PM, Sat 6AM-1PM SURGERY 3-5874 TELECOMMUNICATIONS General 3-3276 Beeper Repair 3-3261 Help Desk 3-6428 TRANSFER CENTER 3-2400 TRANSFUSION MEDICINE p1700 TRANSPLANTATION SERVICES Bone Marrow 3-5351 Heart/Lung 3-2454 Kidney 3-4627 Liver/Pancreas 3-2641 VASCULAR LAB 3-2887 WOUND CARE 3-5646/3-4325 PATIENT CARE AREAS WARDS To call any inpatient ward, dial 3-0 + ward location (e.g., 3-06SW) Labor & Delivery 3-3601 3-NE 3-4301 3-NW 3-4305 3-SE 3-4311 3-SW 3-4315 4-NE 3-4401 4-NW 3-4406 4-SE 34411 4-SW 3-4415 5-NE 3-4581 5-NW 3-4585 5-SE 3-4591 5-SW 3-4595 6-NE 3-4651 6-NW 3-4655 6-SE 3-6881 6-SW 3-4665 7-NE 3-6751 7-NW 3-4222 7-SE 3-4661 7-SW 3-2920 8-NE 3-6871 8-NW 3-6875 8-SE 3-6883 8-SW 3-6882 SCCT 3N-UNIV 3-3UNN/3-3866 3S-UNIV 3-3UNS/3-3867 4N-ICU 3-4ICN/3-4426 4S-ICU 3-4ICS/3-4427 5N-ICU 3-5ICN/3-5426 5S-ICU 3-5ICS/3-5427 6N-CSICU 3-6CSN/3-6276 6S-CICU 3-6CIS/3-6247 7N-MICU 3-7MIN/3-7646 7S-RICU 3-7RIS/3-7747 8N-SICU 3-8SIN/3-8746 8S-SICU 3-8SIS/3-8747 ORs 3RD Floor 3-4351 6TH Floor 3-5671 7TH Floor 3-5731 8TH Floor 3-5136 PACUs 3RD Floor 3-4363 6TH Floor 3-5677 7TH Floor 3-5737 8TH Floor 3-5158 CLINICS ACC Appt Desk 3-2802/3 Physicians 3-6327 Back Room 3-6354 Cashier 3-6331 Coumadin Clinic 3-2710 Dentistry 3-6361 Drug info center 3-5640 Cedars-Sinai Medical Center Intern Survival Guide Page 84 of 88 Emergency Line 3-2020 Mailbox #76480 Password #76480 Laboratory 3-6365 Nurses’ Station 3-6351 Pharmacy 3-5606 For patients 3-5604 Physician Line 3-2811 Procedure Ctr 3-6364 Resident Scheduling Betsy Macalino 3-2812 ACC Social Work 3-6346 Triage Clinic 3-6341 Jeffery Goodman Clinic 323-993-7500 LA Mission 213-893-1960 Fax: 213-893-1967 LA Free 323-653-8622 323-330-1610 Parking lot code 8622 Clinica Oscar Romero 213-989-7700 Valley Clinic 818-763-0726 Venice Family 310-664-7627 MEDICINE RESIDENCY Virna Chan 3-5161 Cassie Evans 3-2924 Judy Jacobs 3-4658 Lee Lipinski 3-4612 Peter Chung 3-5586 Alexis Peraino 3-5585 Fax (Rm 5610) 3-0052 OUTSIDE HOSPITALS UCLA 310-825-4321 Paging System 1-800-BEEP-231 www.mednet.ucla.edu USC 323-226-2622 Medical Records 323-226-6118 Olive View (San Fernando Valley) OVMC 818-364-4411 OVMC-ED 818-364-3644 Medicine Dept 818-364-3205 Medicine On-Call (p) 818-372-6803 Cedars Intern (p) 818-313-1714 Sepulveda VA (PACE) Chief Residents 818-891-7711 (x2178) West LA VA Medical Center Chief Residents 310-2683191/3626 Main Hospital 310-478-3711 Harbor UCLA Medical Center Chief’s Office 310-222-2490 Kaiser Medical Records 323-783-5291 Fax 323-783-5200 Midway Medical Records 323-932-5008 Fax 323-932-5053 Queen of Angels/Hollywood Pres 213-413-3000 California Hospital 213-742-5580 Rancho Los Amigos 562-401-7111 Email Info Cedars-Sinai Housestaff Email Address Format: FirstName.LastName@cshs.org Web Access: https://webmail.csmc.edu POP3 Server Name: POPMAIL.CSMC.EDU Useful Websites http://www.amion.com - Medicine Residency: “cedarsim” - House Physician Schedule: “HouseDoc” - Medicine Attendings: “cedarsmed” Cedars-Sinai Medical Center Intern Survival Guide Page 85 of 88 https://www.new-innov.com/Login - Rotation evaluations - Resident evaluations - Faculty evaluations - Housestaff surveys - Rotation curricula - Procedure logs http://web/gimportal (accessible only from intranet) - ACC Curriculum (links to articles) - CICU Intern/Resident Guide - Critical Care Curriculum - Medicine Consult Curriculum - Housestaff Survival Guide http://www.ccmtutorials.com (Critical Care Medicine site) http://www.csmc.edu/clinws (CSMC Off-Campus Resources) http://www.geocities.com/wells4pe (Josh Pevnick’s site which lets you calculated pre-test probability for PE) http://www.google.com (consider "Google Scholar" and "images" for dermatologic diseases) http://www.icsi.org/knowledge/browse_bydate.asp?catID=178 (Institute for Clinical Systems Improvement order sets) http://www.nejm (New England Journal of Medicine) http://www.medicine.ucsf.edu/housestaff/handbook (UCSF Hospitalist Handbook) http://www.utdol.com (UpToDate) http://www.walterreedmedicine.com (Walter Reed Residents’ Page – Excellent tools/worksheets) http://web.csmc.edu/mlic/resources/thirdlevel/samedinter.html (ACP Medicine formerly Scientific American Medicine Online) Cedars-Sinai Medical Center Intern Survival Guide Page 86 of 88 Cedars-Sinai Medical Center Intern Survival Guide Page 87 of 88 Cedars-Sinai Medical Center Intern Survival Guide Page 88 of 88
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