ON CALL CHEAT SHEET (CONTINUED) HYPERTENSION 1. If patient is symptomatic in any way go see patient. 2.

If patient is, asynrptomatic and HTN is chronic and not alarmingly high (sys >200) or dias>120) avoid reflex clonidine order. Consider Beta blocker or Ace Inhibitor. 3. If patient is symptomatic or HTN is severe adjustment of patients current regimen maybe necessary, i.e. increase dose or frequency. Goal is a % 15 reduction of the patient's MABP over 2-3 hours. Rapid declines in BP may cause hemodymamic collapse or stroke. INSOMNIA Don't be stingy patient's need to get some sleep! 1. Benadryl 25-50mg po qhs pin 2. Arubien 5-10mg po qhs 3. Restoril 15mg po qhs prn 4. Sonata 5-10mg po NAUSEA AND VOMITING 1. Phenergen 12.5-25mg IM or IV or, pr may be given q 4-6hr, however beware patient who get to much in 24 hr may become very agitated or even comatose. 2. Compazine lOmg poor pr 3. Thorazine 25mg po q8hr pro. Also works for intractable hiccups. PAIN 1. Tylenol lg po q 4-6hr prn (Ask if pt has liver disease prior to giving Tylenol) 2. Motrin 400-600mg po q4-6hr prn (Ask if pt has renal insufficiency prior to giving NSAIDS) 3. Tylenol #3 1 tab po q6hr prn 4. Duragcsic patch 1 to CW q 72hr 5. MS contin 30-60mg po q12-246r 6. Morphine 2-5mg IVP q 4hr prn 7. Toradol: 60 mg. but after that, 30 mg SEIZURES go see patient 1. If no history of seizures in the past think of DT's, electrolyte abnormalities, hypoxemia, or a CNS lesion. Accu check, Chem 7, ABG consider CT of head. 2. Begin Thiamine 100mg, MVI, and D50 stat.

3. If a second seizure occurs or patient in status epilepticus insure that the patient's airway is protected and give Ativan 4mg IV and repeat as needed to stop seizure. Consider Dilantin loading dose of 500-1000mg (approx 15mg/kg) IV slow push with cardiac monitoring, then begin Dilantin 100mg po q 8hr. TRANSFUSIONS 1. Premeditate for transfusion with Tylenol 1 g po, Benadryl 25mg IV or po. 2. Transfuse 2u PRBC (or 8-10u Platelets) If over 2-3 hr each. 3. If patient is at risk of volume overload order Iasix 20-40mg IV after 2u (or after each unit). 4. Always consent the patient.

MISCELLANEOUS ON CALL INFO 1. Peak levels are drawn 30 min after an IV drugs goes in. 2. Trough levels are drawn right before the next dose. 3. For full heparinization bolus patient with 5000 10,000 units of heparin then begin a drip at 1,000 u/hr. Order PTT to be drawn 6 hr after the bolus. Adjust drip up or down a few 100 units per hour as needed for low or high PTT values. Goal is PTT 60 90. If PTT is very high. Hold heparin for 30 45 min and restart at lower rate. If PTT is very low, give a larger bolus and increase rate of drip. 4. Pronouncing a death: Observe for spontaneous respirations, listen to thorax for heartbeat or BS, check carotid pulses, finally check papillary response to light(should be mid-range in size and fixed). Title your progress note Death/Discharge Summary record and final events, the exact time and date and the cause of death. Make sure the family is notified and document their notification. Notify family in person whenever possible and not over the phone. 5. If you go see a patient for any reason, WRITE A NOTE! Obtain VS and pulse ox over the phone if possible. Order EKG over the phone. Try to obtain it while patient has CP, prior to NTG if patient's diagnosis is unclear. If patient's diagnosis has been made and pain is clearly cardiac (and pt is not hypotensive) NTG 0.4 mg SL q5' X 3 can be ordered immediately. CHEST PAIN 1. Obtain V/S and pulse ox over the phone if possible 2. Order EKG over the phone. Try to obtain it while patient has CP, prior to NTG if patient's diagnosis is unclear. If patient's diagnosis has been made and pain is clearly cardiac (and pt is not hypotensive) NTG 0.4 mg SL q5' X 3 can be ordered immediately.

3. Go see patient. Review EKG. Call your upper level if theres any changes or abnormalities. 4. O2 by nasal cannula and ABG if patient is SOB or hypoxic. 5. Have IV(SL or HL) placed if no access is available. 6. ASA 325 mg po. CONSTIPATION. 1. 2. 3. 4. 5. 6. Dulcolax 5-15mg po Q 6-8 hrs Dulcolax supp 10mg pr prn Glycerine supp 3gr. Pr prn. MOM 15-30 cc po 1-2 x daily prn Fleets enema 120ml pr x 3 (avoid in ESRD patients). Caster oil 15-30 cc po

DT 1. Go see the pt. 2. Prophylaxis: for admit orders, Ativan 2mg po or iv q 6-8h or Librium 10-25mg po q6-8hr. Thiamine 100mg po or in first bag of IVF q day x 3. MVI po or in IVF, Mg 2g in first bag of IVF 1 day x 3 3. R/O hepatic encephalopathy(asterixis, coagulopathy, worsening MS after BZD) 4. Soft restraints may be ordered. Specify the duration and the reason for the restraints in your order and/or progress note. DIARRHEA 1. Peptobismol 30cc po q 4hr prn 2. Lomotil 2 tab po q 4hr prn 3. Imodium 4mg, then 2mg po q 4hr prn 4. Assess fluid status rehydrate orally if possible DYSPNEA 1. Phone call: get VS, find out admit diagnosis, is SOB acute or gradual?, with or Without CP? Order ABG, (normal POZ is approx 103-Age), protable stat CXR, EKG and code cart to bedside if pt is Severly SOB. Begin 02 40-100% 2. For CHF order Lasix 40-80 mg IVP, place NTP(nitro) 1.5 to CW. If necessary MS 2-5mg IVP 3. For Asthma or COPD give Proventil neb 2.5mg in 3cc NS q 2-6hr. 4. Diff Dx: Acute SOB-PE, Pneumothorax, MI, bronchospasm, aspiration, laryngospasm. Gradual onset - pneumonia, asthma. 5. Never give COPD patient more than 2-4 L oxygen by nasal cannula initially. If needed, start ventimask and titrate up. FEVER 1. If fever is new for the patient go see diem before ordering Tylenol !! 2. Review chart for possible causes: admit diag of pneumonia, new antibiotics, old central lines, etc. 3. Interview and examine patient for dysuria, cough, pain at IV sites, perirectal pain, skin breakdown, etc. 4. Order UA C&S, BCX x2, CXR, etc. as needed.

5. For severe fever T>102, or 38.5 or if the patient is uncomfortable order Tylenol 1g po q6hr, or rectally or ibuprofen to decrease temp. Cooling blankets are available but not usually necessary. Use caution with Tylenol if patient has liver disease or is alcoholic. HEADACHE 1. Obtain VS if hypertensive go see patient. Ask about nitrates. 2. Ask about MS and Neuro status if abnormal go see patient. 3. Tylenol 1 g po q4-6hr prn or ASA 325mg if no GI contraindications. HEMATOCHEZIA/HEMATEMESIS l . Go see the patient. 2. Type and cross for 4u PRBC, get stet CBC, plt, PT/PTT and Chem 7, make pt NPO 3. Place NG tube and lavage with room temp water until coffee ground material or BRB clears. 4. Bolus with normal saline transfuse when blood available if bleed is signif. 5. Consult MICU, GI and possibly Surg if patient fails to clear, vomits or passes > 100cc of BRB, is hypotensive or orthostatic, or if HCT decreases by >5. HEMOPTYSIS 1. Go see patient. If large amount of blood get CBC, PT/PTT, Chem 7 Type and cross for 4u PRBC. 2. If patient in rasp distress get ABG, EKG and CXR stAt. Call MICU. 3. Listen for B/L BS if decreased on one side have patient lie on that side. 4. If small amount of blood. Correct HTN, check Pt/PTT, give cough suppressant. (Codeine 15-30mg po q4-6hr.) HYPERGLYCEMIA/HYPOGLYCEMIA 1. HHH-draw chem 7 and serum ketones stat. If ketones present check ABG and blood CX. 2. Sliding Scale Insulin For accu check. give Regular insulin SQ. 0-60 give 1 amp D50 or juice 61-200nothing 201-250 4u 251-300 6u 301-350 8u 351-400 IOU HHH>400 12u SQ and see #1 above. 3. Hypo-pt may experience confusion, diaphoresis, syncope or seizure. As above give DSo or if no po or IV access give Glucagon 1mg IM. Check orders so that patient does not receive more insulin before the next meal, etc.

HYPE RKALEMIA Order an EKG-check for peaked T waves, widened QRS if present give Ca gluconate 10?20 ml IV over 3-5 min, D5o and reg insulin 15u IVP, then give Kayexalate 30g po q3hr x3. If no EKG changes and K<6 give kayexalate only. (Kayexalate may be given 50-100g in 200cc H20 enema retain for 30min q 2-4 hr. HYPOKALEMIA 1. KCL (Kdur) 20-40 meq po q day or 2-3 X per day for very low levels. 2. KCL 10 meq in 100cc of IVF over I hr X 3. Never give more than 10 meq KCI as an IV prep in one hour. 3. K is difficult to correct if Mg is low. HYPOMAGNESEMIA 1. Magnesium 250-500 mg po qd-bid. 2. MgSO4 2g im in each hip 3. Add MgSO4 to IVF (1 amp = 2gm/4ml. Medicine Cheat sheeet> 1. TPN procalamine 1000 + MVIs + 10ml KPO4 + 100mEq NaCl @ 50ml/h x 2000 ml (20mEq = 2or 3ml) NS 1000 + 2 amp Bicarb with 30mEq KCl @160 ml/h x 3000 2. Anemia Epogen/Procrit 10000 units SQ daily x 3, then QOD. Iron dextran 10ml (100mg/2ml) iv PB(piggy bag) over 3 hours tomorrow - may do test dose prior to administration 3. HypoMg MgSO4 1 amp iv over 20 min x 1 (or 1 amp in 100ml NS piggy bag over 20 min) 4. Renal failure: 50 gm protein, low fat diet Hypoglycemia Hypoglycemic> <60: 1) check mental stauts 2gm/100ml IVF for 60)

2) juice or sweet beverage altered mental or <40 --> 50% dextrose IV, see pt. if cause if oral hypoglycemic, continue dextrose infusion for longer perid Hyperglycemic Pt> 1) Not under DM med. a) <300 : observe b) >300 : repeat c) >400: accucheck immediate 2) Under oral hypoglycemic had evening dose & night <300 : OK > 300: treat 3) RI, more than 4 Hr ago: a) got NPH >8 hr ago --> a dose RI consider (NPH lasts 24 Hrs) b) >450 --> order ketone, mental status < sliding scale> Accucheck (mg/dl), 0-60 1amp D50 121-150.. 2 151-200: RI 3U 201-250: 4U 251-300: 6U 301-350: 8U 351-400: 10U >400: call MD p.o supplement nutrition) glucerna(for DM) 1 can tid + 1~2 promal tid lncreased INR ; vitK lmg iv prep p.o and drink orange juice

Beruti's Interns Survival Guide The Interns Bible.. dedicated to those who have come before us By Paul Marik, MD and Dan Beruti, DO Death Sleepers SOB Insulin Chest Pain Low K High K Low Phos H/T Poopers N/V Pain Falls Low BP Anuria Oliguria Tachycardia Arrhythmias Disclaimer The three laws of call Sleep when you can, eat when you can Bring a pillow from home. You are not alone, call for back up early <Pronouncing Death> - Check the following: Pupils - they should be dilated and not reactive Auscultate the heart and lungs Check for pain response. Sternal rub/supraorbital nerve - Example of a note for the chart: Called to evaluate a patient-in-asystole. Pupils were noted to be dilated and unresponsive to light. No heart or lung sounds were noted on auscultation. Patient had no response to noxious stimuli. The patient was pronounced dead a time on date. - Call attending to notify them of death. The AA's on the floor will usually help you with this. Top Sleepers Zolpidem (Ambien 5 mg po)- Can increase to 10 mg; however, don't forget the motto Start low, you can always increase the dose Temazepam (Restoril) 7.5 - 15 mg po Benadryl 12.5 - 25 mg po. Drug of choice in COPD Use sedative drugs with extreme caution in COPD, and then very small dose Top <Shortness of Breath> Ask the Nurse?

Vital signs, including a pulse ox. Also ABG if pulse ox < 90. Medical history and why the patient was admitted. What to do! Oxygen is good Nasal Canula: 1- 6 Lpm 1L=24, 3L=32, (Add 4 per liter) ** Use low flow for COPD patients, anything high will shut off their hypoxic drive. Venti-mask: Flow varies 24-55% adjustable Delivers a fixed amount of oxygen, it is not dependent on respiratory rate. Non-rebreather mask Not for COPD 50-80%, dependant on inspiratory flow rate One way valve between mask and bag prevents entrapment of exhaled air. If the nurse states patients is crashing Call resident and RT Get an ABG Call anestheisa if pt needs intubation Is it asthma/COPD? Breathing treatment: Proventil 2.5mg via nebulizer Is it CHF? Look to see what diuretic the patient is on (if any) and give an extra dose of what they are normally on. Furosemide (Lasix) 40mg usually does the job Top Insulin Sliding Scale BG ...... Insulin R SO dose q 6 < 60 ..... Call H.O. 60 -150 ..... 0 151 - 200 .... 2u 201 - 250 .... 4u 251 - 300 .... 6-8u 301 - 350 .... 8-10u 351- 400.....10-12u and call H.O. Top Chest Pain 1. Ask the nurse? Why was the patient admitted? Have they tried anything? (SL nitro, MS. . .)

2. Orders before getting there EKG now!!! Preferably before giving SL nitroglycerin; so, you can see if there are any ischemic changes. Nitro 1/150 SL q5 minutes x3 O2 at 2 L via nasal cannula 3. Evaluate the Patient: Read the EKG If there is ST elevation, call for help (resident, attending) - patient may need urgent intervention Is the chest pain getting better with the SL nitro? - If not, start a nitro drip. - Written: Nitro gtt 50mg in 250 cc of D5W, start at 5cc/hr and titrate for pain. - CALL THE ATTENDING* ** - If you feel this is unsatble angina, you should ask the attending if they want the patient on Heparin Protocol, Beta-Blocker. If pain does get better with SL nitro, if not already written for, do the following: - CPK with CK-MB and troponin now and q 6 hours x 3 - ASA 325 mg PO qd - Nitro SL 1/150 q5 min x3 for chest pain - If not on beta-blocker, may be required - Chem Panel and Mg level in the am 4. If you think this is GI (and you had better be sure): Try: GI Cocktail - Maalox 30 cc + Viscous Lido 10 cc + Donnatol 10 cc Top Hypokalemia ** If the stomach works, use it! *** Be sure to order K level for 2 hours later during your call. ORAL: K-Dur 20-40 mEq PO K-lyte (25-mEq) or K-lyte DS (50mEq) - this is a liquid, and great for the NGT. PERIPHERAL LINES: KCL 20 mEq in 250 cc NS over 2 hours CENTRAL LINE: KCL 40 mEq in 250 cc NS over 1 hour

Top Hyperkalemia Repeat blood draw (?hemolysed) Get Stat ECG Treat when K > 5.5 meq/l Stop K containing fluids Rehydrate Correct coexixting low NA, Mg Ca and acidosis Kayexelate 15-60g PO/PR If ECG changes of hyperkalemia or K > 7 meq/l; start emergency Rx immediately Call resident 10% Ca gluconate: 10Ml over 2-5 min Sodium bicarbonate 50ml 0ver 2 -5 min Gluose/insulin: 50ml 50% D/W + 10U regualr insulin push Kayexelate 15-60g PO/PR ECG Changes with hyperkalemia Tall peaked T waves Flattened P Prolonged PR interval Widening of QRS Sine wave: big trouble

<Hypophosphatemia> Severe (< 1.0) -7ml of NaPO4 in 250 cc NS over 4 hours (21 meq PO4; 3 meq/ml) or -7ml of KPO4 in 250 cc NS over 4 hours (21 meq PO4; 3 meq/ml) Mild/Mod (1.0 - 2.2) -Neutra-Phos 1g/day PO <Hypertension> 1. What to do first Check BP yourself in both arms Check optic fundi Is the pt short of breath/auscultate chest? Does pt have chest pain? Does pt have blurred vision, alt mental status? 2. If BP > 180/110 and any of following give Labetalol 20mg and admit STAT to ICU Chest pain Pulmonary edema

Encephalopathy 3. If the BP > 180/110 and none of above Vasotec 0.625 - 1.25 mg IV or Metoprolol 5mg IV or Catapres 0.1 mg PO - can give another dose in 1 hour if needed 4. If the BP > 140/90 and < 180/110 PO medication only Give the patients BP medication early Catapres 0.1 mg PO Top Poopers(constipation) Dulcolax(bisacodyl)10 mg po/pr Colace 100 mg po Peri-Colace (docusate/casanthranol 100/30) 1-2 caps PO qd.bid or 15-30 ml PO qd/bid MgCitrate 120 ml PO Lactulose 15-30 ml PO qd Fleets enema/Soap suds enema Top Nausea/Emesis Compazine (prochlorperazine) 5-10 mg IV/PO Inapsine (droperidol) 1.25 mg IV Phenergan (promethazine) 25 mg IM/IV Vistaril (hydroxyzine) 25 mg IM Zofran (ondansteron) 4 mg IV Expensive Top Pain Management: Very Severe - Morphine 2 mg IV - Morphine PCA - Demerol 50 mg IM ***/+ Vistaril (hydroxyzine) 25 mg IM Severe - Demerol 25- 50 mg IM ***/+ Vistaril (hydroxyzine) 25 mg IM - Lortab (acetaminophen/hydrocodone) 7.5/500 1-2 tabs PO q 4-6 PRN Moderate - Darvocet N-100 (acetaminophen/propoxyphene 650/100) 1 PO q4 PRN - Tylenol #3 (acetaminophen/codein 300/30) 1-2 PO q4 PRN

- Lortab 5/500 1-2 tabs PO q 4-6 PRN Mild - Tylenol 650 mg PO - Motrin 600-800 mg PO *** DO NOT GIVE TO PTS IN RENAL FIALURE OR SEIZURE DISORDER Falls Fill out the damn form Evaluate the patient x-ray or CT whatever is necessary (if anything). Write for fall precautions. Hypotension ** Figure out why!!! Sepsis - check temperature, WBC Cardiogenic - check for medical history Hypovolemic - check hemoglobin ** Give FLUID BOLUS of 250 cc NS and repeat according to response If a patient has had recent surgery or is known to be a GI bleeder. . . Get a stat H+H Open fluids wide Type and cross PRBC's Start Hespan until blood arrives Top Anuria Examine for enlarged bladder Flush/change urinary catheter NEVER give lasix Oliguria Give FLUID challenge NEVER give lasix Top Sinus Tachycardia Get ECG: confirm SR Determine cause Give fluid bolus and monitor response NEVER, EVER give B blocker (except AMI/angina) <Arrhythmias> Call your resident early

Get vital signs!!! Get an EKG - you cannot diagnose anything from a rhythm strip Check lytes + Ca, Mg, Phos V-TACH -Get STAT electrolytes and Mg level. -If patient is unstable (hypotension) - cardioversion -If sustained: lidocaine, procainamide or amiodarone; call resident/attending A-FIB -Cardiazem: Bolus with 0.25 mg/kg (if BP is ok) then start a drip. 125 mg in 100 cc D5W at 5 mg/hr-- titrate to keep HR between 80-100. Do not go higher than 15 mg/hr. -Digoxin: 0.25 mg bolus IV q6 hours, then maintenance dose is 0.125-0.25 mg qd (reduce loading and maintenance dose in renal failure). SVT -Adenosine 6 mg then 12 mg -Cardiazem: Bolus with 0.25 mg/kg (if BP is ok) then start a drip. 125 mg in 100 cc D5W at 5 mg/hr-- titrate to keep HR between 80-100. Do not go higher than 15 mg/hr. Last Thoughts: Relax, this is a great learning experience Enjoy yourself, listen to other interns, residents and nurses You will get through this, most of us did. . . (except the intern who is still sitting in the corner of the MICU drooling) Be good to yourself, and your other interns. . . Top Note to reader: The author of this protocol has checked with sources believed to be reliable and up to date in an effort to provide information that is complete and generally in accord with standards of practice at the time of publication. However, in view of the possibility of human error or changes in medical science the author of this protocol cannot warrant that the information contained herein is in every respect accurate or complete. Readers are encouraged to confirm the information contained herein with other sources. Disclaimer: Use at your own risk! Verify all information before initiating treatment. Feedback: Please e-mail comments, corrections or suggestions to pmarik@zbzoom.net Top