Selected In-Hospital Emergencies...

[Contrarian]

In-Hospital Emergencies demand a playbook in your head for rapid evaluation and

management.

 

The general rules are:

Get as much information as quickly as possible (emergencies are the

only situation when and “H&P” is not “what you should do first.” The

patient’s medex is critical information.

•Rule out life-threatening things.

• Treat treatable things.

• Call for back-up.

 

Common In-Hospital Presentations:

 

 

ABDOMINAL PAIN

Quick Points

• Check the medications (narcotics, anticholinergics, and others can cause vomiting or obstruction).

• Rule out surgical abdomen (appendicitis, cholecystitis).

• Look also for pancreatitis, bowel obstruction, constipation, enteritis, peptic ulcer disease/gastritis, and GI bleeding. Tables 2–1 and 2–2

display diagnostics for abdominal conditions and differential diagnosis

of obstruction.

• Intussusception is usually in the pediatric population; it can present with currant jelly stool, which is also seen in Meckel’s diverticulum (another pediatric entity) and in enteric or colonic ischemia. In adults, intussusception usually occurs when a leading edge of mass pulls one segment of GI tract into another.

Management depends on the cause; get Gastroenterology and/or

Surgery involved earlier rather than later.

 

ALTERED MENTAL STATUS

Quick points

Look for medication effects, other causes of delirium, a history of dementia, acute medical conditions (especially toxic-metabolic encephalopathies), and sundowning (common in alert elderly patients with a new change in environment [eg, intensive care unit (ICU) psychosis]). Do a proper neurologic examination. Consider head CT. Consider a neurologic evaluation.

Haloperidol (Haldol) and lorazepam (Ativan) (0.5–2 mg PO/IM/IV prn) are effective for severe agitation.

 

BACK PAIN

Quick Points

• Rule out epidural abscess, cord compression, and aortic dissection (a

lot of this can be done just by H&P).

• Perform a thorough neurologic examination looking for sensory levels

and Babinski reflexes; muscle strength is essential. Symptoms of

bowel/bladder dysfunction, radiation of pain, dermatomal numbness,

and weakness are also vital.

• If the patient is an injection drug user (IDU), has endocarditis, or has

had recent spine surgery, epidural abscess is high up in the differential.

• For those with cancer, new-onset back pain is metastatic until proven

otherwise. MRI is essential to rule out cord compression and epidural

abscess (consider emergent radiation therapy for cord compression and

neurosurgery evaluation for cord compression and epidural abscess).

• Dissection often occurs in smokers and those with a history of vascular

problems and presents with excruciating pain.

• Look for asymmetric pulses and HTN.

• Transesophageal echocardiography (TEE) and MRI are procedures

of choice for dissection.

• For dissection, use labetalol and/or nitroprusside to control blood

pressure (BP).

• Surgical dissections are those involving the aortic arch, not the

descending aortic dissections (unless other vessels are being compromised

[eg, subclavian, renal]).

 

BRADYCARDIA

Quick Points

• Look at the electrocardiogram (EKG) carefully for blocks.

• Look at the medex (beta-blockers, alpha-2 agonists, and calcium

blockers can cause bradycardia).

• Consider cardiac and cerebral disease.

 

If the patient is hemodynamically unstable or symptomatic, consider

these Possible Interventions:

Atropine 1 mg IV

Epinephrine 1 mg IV

Isoproterenol drip

Pacemaker (transcutaneous or transvenous)

 

TACHYCARDIA

Quick Points

• Rule 1: If it is sinus tachycardia, then the patient has a separate problem

that needs to be treated (myocardial infarction [MI], fever/sepsis,

hypotension, hypovolemia, pulmonary embolus [PE], etc).

• If it is not sinus tachycardia, determine the heart’s rhythm.

Initial Management

The following are the usual options to slow heart rate:

• Beta-blockers (eg, metoprolol [Lopressor]) 5 mg IV or esmolol drip

(load 500 μg/kg, then 50–200 μg/kg/min)

• Diltiazem (Cardizem) 25 mg IV followed by drip (5–15 mg/hr)

• Adenosine 6 mg, then 12 mg, and then another 12 mg IV

Try to avoid verapamil. Use procainamide for Wolff-Parkinson-White

syndrome. Use lidocaine and procainamide for ventricular tachycardia.

Use ibutilide (Corvert) for atrial flutter. Shock is always a consideration;

shock immediately if the patient is hemodynamically unstable.

 

CHEST PAIN

Quick Points

• As soon as you are called for this by the floor or ER, tell the person

calling over the phone to get an EKG so that by the time you arrive,

it is waiting for you.

• A description of the pain and the number of risk factors (see Chapter

6 for a full discussion) are essential to how aggressive you will be

in your work-up.

• Basic differential:

• Acute coronary syndrome (unstable angina/MI)

• Stable angina

• Costochondritis (pain to palpation at costochrondral junction; can

be pleuritic in nature)

• Aortic dissection

• Pericarditis (pleuritic and positional pain; friction rub; sinus

tachycardia elevation all over EKG; young patient after recent

viral illness); treat with indomethacin

• Gastroesophageal reflux

• Pneumonia or other causes of pleuritic pain

 

Critical Interventions in Acute Myocardial Infarction:

Aspirin 325 mg PO × 1 (chew and swollow)

Nitroglycerin 0.4 mg sublingual q5 min × 3

Oxygen

Beta-blockers (metoprolol [Lopressor] 5 mg IV q10 min × 3; hold for pulse < 60)

Heparinization (as for pulmonary embolus)

Consider enalapril (Vasotec) 1.25 mg IV × 1

Call Cardiology for consideration of thrombolytics or angioplasty

 

LOWER GASTROINTESTINAL BLEED

Quick Points

Differential:

• Arteriovenous malformations (AVMs)/angiodysplasia

• Colon cancer (the right colon causes more anemia, whereas the

left colon causes more obstruction)

• Diverticulosis (not diverticulitis)

• Mesenteric/colonic ischemia (look for postprandial pain, clinical

set-up [a history of atrial fibrillation, vascular disease, and HTN/

diabetes])

 

Initial Management

• Support with fluids and blood.

• Surgery and Gastroenterology need to be involved early.

• Consider colonoscopy, angiography, and tagged-cell scan. Angiography

can be used as a therapeutic measure with options for embolization.

Red blood cell (RBC) scans are very sensitive but not specific.

• If the source is unclear but the patient is bleeding out, hemicolectomy

is the option of last resort.

 

UPPER GASTROINTESTINAL BLEEDING

Quick Points

• Differential:

• Peptic ulcer disease (PUD)

• Esophageal varices

• Esophagitis

• In Mallory-Weiss and Boerhaave’s syndromes a history of retching

and vomiting is important; Boerhaave’s syndrome causes

pleural effusion and can be diagnosed with barium swallow; do

not use meglumine diatrizoate [Gastrografin] if Boerhaave’s is a

concern [vice versa for colonic perforation]).

• Dieulafoy’s lesions (rare)

• Diagnostics revolve around esophagogastroduodenoscopy (EGD),

and management should be as per Gastroenterology.

 

 

Initial Management

• Aggressively resuscitate with fluids and blood.

• Table 2–5 lists commonly used agents to reduce acid production.

• In renal failure patients, halve the dose given (eg, use qd dosing).

• Cimetidine (Tagamet; older H2-blocker) is falling out of favor due to

drug interactions.

• Beta-blockers (eg, propranolol [inderal] 40 mg PO bid) are indicated

for varices.

• Antibiotics should be used for infectious esophagitis.

 

HYPOTENSION

Quick Points

• Get a clinical picture of events leading to hypotension and general

medical condition.

• Check to see how BP has been running. Get a good handle on volume

status and lung status.

• The basic differential is:

 

Cardiac (congestive heart failure, myocardial infarction)

Sepsis

Hypovolemia/severe blood loss

Anaphylaxis

Neurogenic (spinal cord trauma)

Addisonian crisis

.

• Differential diagnosis of addisonian crisis: rapid steroid taper in a

dependent patient, TB/cytomegalovirus (CMV) adrenalitis, classic

Addison’s, adrenal infiltration, Waterhouse-Friderichsen syndrome.

 

Initial Management

• Treat the cause.

• Fluids (nomal saline [titrate to patient’s weight, BP, and cardiorespiratory

status])

• Hespan (hetastarch; artificial colloid) 250 to 500 cc IV bolus.

• Blood (for bleeding patients)

• Pressors: norepinephrine (Levophed) (16 mg/250 cc 5% dextrose in

water [D5W] titrated to BP) is a mainstay. Many use dopamine

(400 mg/250 cc D5W) initially.

 

Further Discussion

Crystalloids (NS, Ringer’s lactate) are the standard fluid resuscitation measure employed. However, significant amounts of crystalloids leave the vasculature within hours. Colloids (eg, albumin, hetastarch) stay in the vasculature much longer. Another advantage of hetastarch and albumin is that they provide equivalent amounts of hemodynamic support as crystalloids with far less volume, which can be a great plus in patients with cardiac, hepatic, or renal failure. For reasons of expense, hetastarch is generally preferred to albumin, except in patients with cirrhosis. In the actively bleeding patient, blood is, of course, the preferred fluid replacement.

 

Acute Pharmacologic Interventions in Anaphylaxis

Epinephrine 0.1 mg SQ × 1

Diphenhydramine (Benadryl) 50 mg IV × 1

Hydrocortisone 100 mg IV × 1

 

HYPERTENSION

Quick Points

• Check the medex (see if the patient is due to get BP medications in

an hour; if so, give them now).

• Check trends on vital signs (200 mm Hg may not be a big deal acutely

in someone who lives at 180 but 160 can be a problem in a patient

whose baseline is 90).

• Look for end-organ damage, which indicates a hypertensive emergency

(ie, altered mental status, headache, visual changes, retinal

hemorrhages, cardiac ischemia, renal dysfunction).

 

Initial Management

• If no end-organ signs of dysfunction are present and BP is less than

200/100 and not that much higher than baseline, it can be okay to tell

the nurse “Okay, let’s watch it.”

• Find out if there is a reason for an acute rise in BP, especially following

serious causes.

Differential of Serious Causes of Acute Hypertension:

Stroke

Myocardial infarction

Renal stenosis

Pheochromocytoma

Aortic dissection

 

• If you feel that you have to intervene or just need to fix the number,

bear in mind the following:

• Rule 1: Nifedipine (Procardia) is bad. In the 1980s and early

1990s (and still in other industrialized countries), nifedipine is

often used just to fix the numbers. It’s very effective, but its induction

of reflex tachycardia can be very detrimental as it can cause

MI. By the way, sublingual nifedipine is really bad.

• Rule 2: If the patient is having or recently had a CVA, don’t lower

the BP to normal. Systolic BP of ~160 to 180 is necessary in these

patients to maintain cerebral perfusion.

 

When the nurse calls you with a high BP, determine if it is malignant

or not.

• If not malignant, you may want to use extra doses of what the

patient is already on or use the patient’s current drugs sooner than

the schedule frequency. Other options are

 

Nonmalignant Hypertension Malignant Hypertension

Clonidine 0.1 mg PO × 1 Nitroprusside drip

Nitro-paste 1 inch to chest wall Labetalol drip

Enalapril (Vasotec) 10 mg PO Esmolol drip

 

• Remember that exact drip formulations vary from hospital to hospital

and that over 48 hours of nitroprusside can lead to cyanide toxicity.

 

HYPERTHERMIA

Quick Points

• Look for infection, stroke/intracranial hemorrhage, and malignant

hyperthermia.

• Causes of malignant hyperthermia include anesthetics, phenothiazines,

haloperidol, and tricyclic antidepressants.

• Signs and symptoms include hyperthermia, muscle rigidity, rigors,

dry skin, increased creatine phosphokinase (CPK), renal failure, and

pupillary dilation.

 

Initial Management

• Treat the cause.

• Replete IV fluids generously.

• Give an ice/cooling blanket.

• Use acetaminophen and NSAIDs to break fever.

• If the hyperthermia is malignant, use dantrolene 100 mg PO bid-qid

and/or bromocriptine.

• Procainamide (2–6 mg/min) can prevent ventricular fibrillation in a

patient with malignant hyperthermia; stop if QRS widens > 50%,

hypotension occurs, or after 1 g is given.

• As this group of patients frequently develops rhabdomyolysis, acidosis,

and renal failure, consider alkalinizing urine with sodium

bicarbonate IV.

• Meperidine (Demerol) 25 mg IV as needed is useful for rigors due to

amphotericin B.

 

HYPOTHERMIA

Look for sepsis and cold exposure. Use a warming blanket and warm all

IV fluids and blood.

 

SHORTNESS OF BREATH

Quick Point

Think of the etiologies of dyspnea:

Differential of Common Causes of Dyspnea

Cardiac Pulmonary

Congestive heart failure Pneumonia

Myocardial infarction Chronic obstructive pulmonary disease/asthma

Pneumothorax

Interstitial disease (cancer, pneumonoconiosis)

Pulmonary embolus

 

Initial Management

• Do a quick physical (vitals, rales, wheezes, breath sounds should

help you focus your diagnosis).

• In general, always get an arterial blood gas (ABG), CXR, and an

EKG. Know the alveolar-arterial gradient (Appendix D).

• Knowing whether the blood gas is venous or arterial is important:

skill and technique are critical, depending on drawing only when

you see pulsation and arterial-color blood.

• Pulse oximetry is handy too, but it can be fooled: carboxyhemoglobin

(smokers, carbon monoxide) and methemoglobinemia (which

occurs after exposure to many agents, including dapsone, nitrite,

primaquine, and sulfonamides) give falsely elevated levels,

and patients with poor extremity perfusion have falsely low levels.

• Intubation. The decision to intubate is primarily clinical (how the patient

is doing and what his or her reserve is), not based on ABG or x-ray.

• Not uncommonly, at 2 AM, you will be called on an elderly smoker

with chronic obstructive pulmonary disease (COPD) and heart disease

with features of pneumonia, CHF, COPD, cancer, and PE. You

may not get the diagnostic of choice (CT/ventilation-perfusion [V/Q]

scan/bronchoscopy) at that hour, in which case, it is often all right to

use all of the major non-contraindicated interventions.

• For PE, the index of suspicion is critical and is based on a history of

cancer/DVT/immobilization and symptoms (acuteness and severity).

• If spiral CT is inconclusive, go to the angiogram. The V/Q scan is out of

favor because studies showed that 30% of people with low-probability V/Q

and a high index of suspicion had a PE. In our experience, too many V/Qs

are indeterminate, intermediate, or low probability for them to be of use.

• For roundsmanship, know that the most common sign of PE on EKG is

sinus tachycardia; the most classic sign is the S wave in I, Q in III, and

inverted T in III. The most common sign of PE on CXR is a normal xray;

the most classic sign is Westermark’s hump/sign (a wedge-shaped

opacity in the area of infarction). You can also get pleural effusion.

 

THE CODE

 

It is vital to keep in your pocket an Advanced Cardiac Life Support

(ACLS) card (the CodeRunner from the Committee of Interns and Residents

is great), with the management algorithms (which will not be included here, as this is meant more as a general and philosophical discussion).

 

Also, don’t take bad results to heart. As someone once said, “If

you can’t save them when they’re alive, how can you save them when

they’re dead?”

 

Critical initial steps are to

• Ensure IV access (and rapid central line placement),

• Manage airway and rapidly intubate,

• Perform chest compressions, and

• Make sure someone is running the code.

 

You only need four or five doctors in the room.

The only laboratories you need are those that can make a difference: potassium

magnesium

Calcium

 

ABG will not be of use until the patient is stable on a ventilator.

 

The ethics of coding are important, from a personal and professional

perspective. “Slow” and “Hollywood” codes (going through the motions

of the code) should be avoided if at all possible; it does the patient no service but does cause considerable indignity. Proper communication with

the patient, family, and attending physician prior to a crisis is essential.

However, sometimes you have little choice, especially if you are the covering

house staff in the middle of the night.

 

If you feel you are running a futile code, keep the code brief and simple.

In terms of technical aspects, bear in mind the following rules of thumb:

• Shock is good for almost everything except aystole.

• You can never go wrong with epinephrine or atropine.

• Atropine, Lidocaine, Narcan and Epinephrine can be given by endotracheal

(ET) tube.

• Don’t give bicarbonate unless the patient has a history of metabolic

acidosis (the addition of bicarbonate in a setting of poor ventilation

causes paradoxical intracellular acidosis).

• If there is no response after 20 to 30 minutes, call the code; in a patient

whom you are coding futilely for whatever reason (unreasonable/ adamant patient or family), call it after three epinephrines/atropines if there is no response.

 

As background, the code is not really meant for medically ill patients;

it works in acute trauma and cardiac settings, but for the elderly patient

with multiple medical problems, 99% of patients do not live to 1 year

after the code, and probably more than 90% don’t leave the hospital alive.

 

Excerpted from:

 

Residents

Manual of Medicine

For House Staff, by House Staff

 

Balamurali K. Ambati, MD

Harvard Medical School

Boston, Massachusetts

 

W. Tyler Smith, MD

Marie T. Azer-Bentsianov, MD

Albert Einstein College of Medicine

Bronx, New York

 

BC Decker

[andersenpa]

Great reference, Contrarian.

 

One note:

 

 

"The only laboratories you need are those that can make a difference: potassium

magnesium

Calcium

ABG will not be of use until the patient is stable on a ventilator."

Additional labs that are helpful are the H/H and serum lactic acid/base deficit.

An occult GI bleeder (without melena/hematochezia) may benefit from trannsfusion, as sometimes these patients present w/ a mixed picture (at risk for other causes of hypotension/SOB- ACS, PE, etc).

The base deficit is a useful tool in guiding the success (or failure!) in fluid resuscitaiton (septic shock).

Additionally, in the patient with altered mental status, hypercapnea can be readily resolved with BiPAP.

[troygem]

I agree, great reference.

 

Just a couple things from an old medic talking out the side of his head.

 

For V-tach, do we not like amiodirone anymore?

 

Also for the "Altered Mental Status" and "The only laboratories you need..." I didn't see mention of Blood Glucose level.

 

Humbly,

Troy

[EMEDPA]

Acute Pharmacologic Interventions in Anaphylaxis

Epinephrine 0.1 mg SQ × 1

Diphenhydramine (Benadryl) 50 mg IV × 1

Hydrocortisone 100 mg IV × 1

 

we do it a little differently...

0.1 mg of 1:1000 epi subq is the correct dose for a 10kg child. large adults can get significantly more. I often use 0.2-0.5 mg subq. if they are really bad you go to an epi drip 1 mg of 1:1000 in either 100 or 250 cc ns. titate to bp and resp effect.

 

benadryl dose is right on. we also use pepcid 20-40 mg iv to cover other histaminic sites.

albuterol neb on o2 is an option as well for wheezing

we usually use decadron 10 mg or solumedrol 125 mg iv instead of hydrocortisone

also anyone with anaphylaxis needs fluid boluses with crystalloid x 2-3 liters as they are 1st and foremost in shock.....(of the distibutive variety)

 

note: be prepared to intubate +/or crich anyone with real anaphylaxis as they can go downhill fast.

last yr I had a guy with a severe rxn to a new bp med who was unresponsive to all of the above txs. we ended up intubating him and sending him to the icu on a dopamine drip to keep his bp at 90 systolic. he went home a few days later without any problems.

[leahk]

i love this thread. it should def be stickied! i keep coming back to it.

[andersenpa]

i love this thread. it should def be stickied! i keep coming back to it.

 

done.........

[Guest pagirl1]

I happen to think an ABG is one of the most valuable tests! If I had a pt come in unresponsive and I had absolutley no idea what was going on and I could do only 1 test I would get an ABG. An ABG provides so much info in just a moment's time. ph, oxygen level, hgb--I think ABG's are often under utilized!

[Guest pagirl1]

Epi IM can provide quicker onset than SC route

[jbwpac]

GOOD STUFF-Thanks for the info quys........