Hospital Medicine 2 IP emergencies (Bockern) (Midterm) Flashcards
Define MET and RRT and what are they?
- MET: Medical Emergency Team
- RRT: Rapid Response Team
Two names for the same thing: “A multidisciplinary team most frequently consisting of ICU-trained personnel … for evaluation of patients not in the ICU who develop signs or symptoms of clinical deterioration.”
The rationale for having MET/RRT?
- Identify deterioration and intervene early (prior to “code blue”)
- Often signs of decompensation for several hours before cardiac arrest
- Goals or RRT: Prevent cardiac arrest and ensure goals of care have been addressed
Typical members of the RRT?
- ICU resident/fellow/attending
- Medicine floor team
- Critical care RN
- RT
- Pharmacist
- House supervisor
- Security
Activation criteria for a Rapid Response?
- Threatened airway
- RR < 6 or > 30
- HR < 40 or > 140
- SBP < 90
- Symptomatic hypertension
- Decrease in level of consciousness
- Unexplained agitation
- Seizure
- Significant fall in urine output
- Subjective concern about the patient
Most common causes for RRT activation?
- Altered neuro/mental status (28%)
- Tachycardia (23%)
- Tachypnea (13%)
- Hypotension (12%)
- Hypoxia (8%)
- Staff worried (7%)
- Chest pain (3%)
- Bradycardia (4%)
- Hypopnea (2%)
Stepwise approach to inpatient emergencies include?
- •BLS assessment
- Are they breathing?
- Do they have a pulse?
- Primary assessment:
- ABCDE
- Secondary assessment:
- SAMPLE
- DDx
The ABCDE of primary assessment during an inpatient emergency?
- Airway
- +/- O2
- +/- NIPPV or intubation
- Breathing
- +/- O2
- +/- NIPPV or intubation
- Circulation
- IV
- Monitors
- Vitals
- Disability
- Glucose
- Neuro assessment
- Exposure
- Look at Pts surgical sites, ect.
What does SAMPLE stand for in the secondary assessment of a Pt during an IP emergency?
- Signs and symptoms
- Allergies
- Medications
- Past medical history
- Last oral intake
- Events leading up to emergency
Three steps of making a DDx during the secondary assessment during an IP emergency?
- What do you think is most likely the diagnosis?
- Four or five alternative differentials
- Comprehensive differential: systems-based; mnemonics
A rapid response is called by the RN for a Pt with AMS. The Pt is a general surgery Pt, but as the hospital medicine PA you respond first. The Pt is 69F hx HTN, T2DM, now s/p gastric antrectomy for severe peptic ulcer disease. She is POD5 due to post-op ileus and inability to tolerate enteral nutrition.
What do you do first?
- BLS
- Is she breathing
- Does she have a pulse??
A rapid response is called by the RN for a Pt with AMS. The Pt is a general surgery Pt, but as the hospital medicine PA you respond first. The Pt is 69F hx HTN, T2DM, now s/p gastric antrectomy for severe peptic ulcer disease. She is POD5 due to post-op ileus and inability to tolerate enteral nutrition.
After checking BLS what should you do next?
- Primary assessment
- Airway
- +/- O2
- +/- NIPPV or intubation
- Breathing
- +/- O2
- +/- NIPPV or intubation
- Circulation
- IV
- Monitors
- Vitals
- Disability
- Glucose
- Neuro assessment
- Exposure
- Look at Pts surgical sites, ect.
- Airway
A rapid response is called by the RN for a Pt with AMS. The Pt is a general surgery Pt, but as the hospital medicine PA you respond first. The Pt is 69F hx HTN, T2DM, now s/p gastric antrectomy for severe peptic ulcer disease. She is POD5 due to post-op ileus and inability to tolerate enteral nutrition.
The ABCDE of the primary assessment shows the following:
A: patent
B: mild tachypnea, speaking in full sentences
C: sinus tachycardia, warm extremities
D: moves all extremities, glucose 83
E: surgical incision without erythema or discharge
HR 120, T 38.5, RR 22, BP 86/50, SpO2 94%
Monitor: sinus tachycardia
Glucose: 83
Access: 24-gauge that doesn’t work
What immediate interventions need to be made before moving on to the secondary assessment?
- Address IV access
- Consider fluid bolus for hypotension
- Tylenol for fever
A rapid response is called by the RN for a Pt with AMS. The Pt is a general surgery Pt, but as the hospital medicine PA you respond first. The Pt is 69F hx HTN, T2DM, now s/p gastric antrectomy for severe peptic ulcer disease. She is POD5 due to post-op ileus and inability to tolerate enteral nutrition.
- Lab results reveal the following:
- WBC 16 (8.0 yesterday)
- Cr 2.1 (baseline 1.0)
- Lactate 4.2
- CXR shows bibasilar infiltrate
What is her Dx?
- Severe sepsis
- Hospital acquired pneumonia
- AKI
A rapid response is called by the RN for a Pt with AMS. The Pt is a general surgery Pt, but as the hospital medicine PA you respond first. The Pt is 69F hx HTN, T2DM, now s/p gastric antrectomy for severe peptic ulcer disease. She is POD5 due to post-op ileus and inability to tolerate enteral nutrition.
After performing the primary assessment and making the needed interventions what is your next step?
Perform the secondary assessment Including SAMPLE and DDx
A rapid response is called by the RN for a Pt with AMS. The Pt is a general surgery Pt, but as the hospital medicine PA you respond first. The Pt is 69F hx HTN, T2DM, now s/p gastric antrectomy for severe peptic ulcer disease. She is POD5 due to post-op ileus and inability to tolerate enteral nutrition.
After a thorough work up she is Dxed with Sepsis, HAPNA, and AKI what is your treatment plan?
- Start Vanco and cefepime
- Fluids for hypotension
- Trended lactate until cleared
- Follow blood cultures
- When stable D/C IV ABx and transition to PO
A rapid response is called by the RN for a Pt with AMS. The Pt is a general surgery Pt, but as the hospital medicine PA you respond first. The Pt is 69F hx HTN, T2DM, now s/p gastric antrectomy for severe peptic ulcer disease. She is POD5 due to post-op ileus and inability to tolerate enteral nutrition.
The secondary assessment reveals the following:
S: Became gradually more confused today
A: Doxycycline
M: MAR notable for frequent Dilaudid dosing
P: HTN, T2DM, now s/p gastric antrectomy for severe peptic ulcer disease, POD5
L: NPO
E: See S
What should you order?
- Labs
- CBC
- CMP
- Lactate
- Blood cultures
- UA
- Imaging
- CT-H
- CXR
- CT Abd/Pel
For Pts with AMS what mnemonic helps determine possible DDxs?
- AEIOU-TIPS
- A
- Abuse of alcohol/drugs
- Acidosis
- E
- Epilepsy
- Electrolytes
- Encephalopathy (Wernicke’s)
- Endocrine
- I
- Infection
- O
- Overdose
- Oxygen (hypoxia)
- U
- Uremia
- T
- Trauma
- Tumor
- I
- Insulin
- P
- Psychiatric
- Psychosis
- Poisons
- S
- Stroke
- Shock
- A
80 y/o M hx HTN, T2DM, CKD3, was admitted with chest pain, found to have NSTEMI. He was given aspirin and started on a heparin gtt with plans for cardiac catheterization in the morning. At shift change, the night nurse notices the patient is aphasic and has left-sided weakness. She calls a stroke alert. You respond as the hospitalist. What do you do next?
- Brief neuro exam
- Figure out last time Pt was known to be at baseline
- Check glucose
- Start NIHSS
80 y/o M hx HTN, T2DM, CKD3, was admitted with chest pain, found to have NSTEMI. He was given aspirin and started on a heparin gtt with plans for cardiac catheterization in the morning. At shift change, the night nurse notices the patient is aphasic and has left-sided weakness. She calls a stroke alert. You respond as the hospitalist. What do you want to order?
- STAT Non-contrast head CT
- STAT Neuro consult
Describe the time frame of a stroke alert.
- 10 minutes: “Doctor to door”
- 15 minutes: Neurologist to see Pt
- 25 minutes: Door to CT scan completion
- 45 minutes: Door to CT interpretation
- 60 minutes: Door to treatment
- 3 hours: Admission to ICU
Following a large-vessel stroke (E.g. MCA) what procedure may need to be done?
Mechanical Thrombectomy may be done up to 24 hours post-stroke, can be done after administration of tPA
Define status epilepticus
Seizures lasting greater than 5 minutes or recurrent seizures without return to baseline. (Techincal definition is a seizure lasting greater than 30 minutes, but that definition is no longer used)
69 y.o. male with PMH including HLD who was brought in by ambulance from the Broncos game with shortness of breath. EMS reports that the patient has been experiencing shortness of breath for the last 2-3 weeks which has been progressing but he attributes this to the poor air quality from the smoke (forest fires) while riding his bike. Then over the last hour symptoms have been persistent and have lasted longer than normal so he was evaluated by medical at the game and was found to be tachycardic. He reports some accompanying diaphoresis but denies palpitations, fevers, cough, abdominal pain or chest pain and denies recent trauma. Denies tobacco use or daily alcohol use. Denies history or family history of atrial fibrillation, cardiac disease, cancer, hypertension, GI bleed, diabetes or blood clots. NKDA.
VS PTA: 124/80, pulse 130s-140s, 92% on 2L
Exam:
Gen: in acute distress
CV: Tachycardic with irregular rhythm
Resp: Clear lungs
What is your diagnosis?
New-onset A-fib with RVR
68 year old female with history of ESRD (on HD), HLD, HTN, who is admitted for acute hyperkalemia (k 6.8 with peaked T waves). She received emergent HD and now is on the floor. The nurse calls you and states that the patient is having chest pain. You go see the patient, order ECG (see picture), and Trop
What does the ECG show?
It shows Wellen’s sign which is deep inverted T waves in the precordial leads (best seen in V2 and V3 in this case)
