PGY1 Survival Skills

General approach to ward problems:

1) Is this something I will deal with over the phone or in person?
2) What are the patient’s vitals?
3) Should I ask the nurse to initiate investigations before I get there (e.g. ECG, CXR, labs)
4) Is the problem new?
5) Assessment- brief history, relevant physical
6) Working diagnosis, differential diagnosis
7) Investigations as needed
8) Treatment
9) Documentation (can be brief)
10) Follow-up, accurate signover in AM

What can be dealt with over the phone most of the time?
-Sedatives (be careful)
-Glycemic control issues (unless v. low or v. high)
-Laxatives
-minor electrolyte issues

What should not be dealt with over the phone?

-Anything cardiac or potentially cardiac
-Bleeding
-Anything neurological (inc. sz, new h/a, LOC issues, etc)
-SOB, hypoxia, tachypnea
-new or worsened hypotension
-new fever
-v. low urine output (e.g. <30cc/h)
-significant hyperkalemia (definitely see >6, have good reason not to see >5.5)

These are only a guide; judgement call. When in doubt, see the pt! If someone asks you to see
the pt, see them, even if seems trivial

Tips:
-Tachycardia, tachypnea often mean patient is sicker than they may seem
-Low threshold to get ECG, CXR
-ABG’s, lactate for severe dyspnea, hypotension
 On Call: Approach to the Abnormal Vital Sign
Paul Szmitko, CMR SMH 2008-9. Updated by Luke Devine 2009

Abnormal Heart Rate

Called re: increased HR

- Is the patient unstable/symptomatic?
- What are the other vitals? Any other abnormalities or is it isolated tachycardia?
- Baseline HR – What was it in the morning?

Stable/Asymptomatic Unstable/Symptomatic
1. Determine why the nurse called/what they are 1. Does the nurse need to call a code?
concerned about 2. See patient immediately to asses
2. Ensure the other vitals are stable 3. Once the patient is seen, do you need to call a code?
3. Ask for an ECG If so, follow the tachycardia with pulse algorithm.
4. Generally if >110/min or new tachycardia, should Perform immediate synchronized cardioversion if
assess patient unstable, establish iv access, get rhythm strip.

Unstable symptoms due to tachycardia include CP, CHF,

Patient Assessment (minimum)
1. What was the patient admitted for?
2. Ask patient if they have any symptoms (CP, SOB,
palpitations, presyncope, pain, etc)
3. Repeat the vitals yourself to confirm
4. PEx – mental status, cardiac, resp, gross neuro +/-
other systems as appropriate
5. Investigations – ECG is key to assess rhythm +/-
others based on clinical picture
6. Is my patient safe to stay on medicine, do they need a
telemetry bed, does cardiology need to be called?
hypotension, altered LOC
If not a code situation assess and treat as appropriate –
though likely requires a greater degree of monitoring
than just a regular medicine bed and more aggressive
management.
Patient Assessment (as in stable situation)
Management (based on rhythm)

Management (based on rhythm)

- If patient unstable, synchronized cardioversion; if stable, may attempt drug therapy

General principles for wide complex tachycardia (QRS>0.12s or 3 small squares)

1. Regular or irregular?
2. If Regular – DDx: monomorphic VT, SVT with aberrancy, SVT down accessory pathway
- safer to err on the side of caution and assume VT
- call rapid response to get monitor, call cardiology, arrange for monitoring and start amiodarone 150mg iv over
10min then 900mg iv over 24hrs (will need monitored setting for iv amio infusion)
3. If Irregular – DDx: polymorphic VT, AFib with aberrancy
- if previous ECG did not show AFib with conduction abnormalities, assume VT
- treat as above; treat ischemia, check/treat electrolyte abnormalities, if QT prolonged see if any offending
medications

General principles for narrow complex tachycardia (QRS<0.12s or 3 small squares)

1. Regular or irregular?
2. If Regular – DDx: sinus tach, atrial tachycardia, junctional tachycardia, Aflutter with regular block, AVNRT,
AVRT; may consider vagal maneuvers or trying adenosine (6mg iv push, followed by 12mg iv push x 2 – give as
close to central vein as possible, use port closest to patient, raise arm if given through peripheral IV, flush with NS
afeter)—may convert rhythm but ensure to warn patient that they may feel horrible (burning sensation, awareness of
heart beat, headache, flushed, etc) and have a monitor because they may developed a fairly long pause
- SinusTach – manage underlying cause not AV nodal blockade - is there pain, fever, hypovolemia, hypoxia,
anemia, anxiety, EtOH withdrawal, beta-agonists, etc. Sinus is almost always physiologic and you will do more
harm if you slow it down.
3. If Irregular – DDx: AFib, aFlutter with variable block, MAT
Treatment: - Atrial tach/junctional tach/Aflutter – beta-blockers, CCB
- MAT – manage underlying (usually pulmonary cause) +/- CCB
- AFib – rate control (beta-blocker [caution if asthmatic], CCB [caution if low EF], dig, amio (amio may
lead to chemical cardioversion – consider this risk if longstanding pAfib and no anticoagulation)
anticoagulate (generally not while you are covering on call, but mention post call/in your note)

Abnormal Heart Rate

Called re: decreased HR

- Is the patient unstable/symptomatic?
- What are the other vitals? Any other abnormalities or is it isolated bradycardia?
- Baseline HR – What was it in the morning?

Stable/Asymptomatic
1. Determine why the nurse called/what they are
concerned about
2. Ensure the other vitals are stable
3. Ask for an ECG
4. Generally if <45/min or new bradycardia, should
assess patient even if asymptomatic.
Unstable/Symptomatic
1. Does the nurse need to call a code?
2. See patient immediately to asses
3. Once the patient is seen, do you need to call a code? If
so, follow the bradycardia with pulse algorithm. Prepare
for transcutaneous pacing, establish iv access, consider
atropine while awaiting pacer and start dopamine (2-10
ug/kg/min) if pacing ineffective, get rhythm strip.

Patient Assessment (minimum) Unstable symptoms due to bradycardia include CP,

1. What was the patient admitted for?
2. Ask patient if they have any symptoms (CP, SOB,
syncope, presyncope, etc)
3. Repeat the vitals yourself to confirm
4. PEx – mental status, cardiac, resp, gross neuro +/-
other systems as appropriate
5. Investigations – ECG is key to assess rhythm +/-
others based on clinical picture
6. Is my patient safe to stay on medicine, do they need a
telemetry bed, does cardiology need to be called?
CHF, hypotension, altered mental status.
If transcutaneous pacing initiated, call cardiology to
consider transvenous pacing.
If not a code situation (adequate perfusion) assess and
treat as appropriate – though likely requires a greater
degree of monitoring than just a regular medicine bed
Patient Assessment (as in stable situation)

Management (based on rhythm) Management (based on rhythm)

- If patient unstable, transcutaneous followed by transvenous pacing +/- dopamine infusion (may be given
peripherally)
- If stable, observe and monitor with atropine at the bedside and search for underlying etiology
- any offending medications? – consider holding them or decreasing the dose; check digoxin level if on
digoxin
- metabolic derangement? – assess for hypoxia, sepsis
- evidence for increased ICP?
- evidence for sick sinus syndrome? – paroxysms of sinus brady and atrial tachyarrhythmias
- nature of AV block? – first degree (PR>0.2s), second degree (Mobitz 1 or Wenckebach progressive PR
prolongation until not conducted; Mobitz II – occasional or repetitive blocked impulses without PR
prolongation), or third degree (complete)
- call cardiology for Mobitz II or third degree AV block which may require transvenous pacing and monitoring in
CCU
Abnormal Blood Pressure
Called re: increased BP
- Is the patient symptomatic?
- What are the other vitals? Any other abnormalities or is it isolated hypertension?
- Any history of hypertension, baseline BP – What was the BP this morning, last night at this time?
Stable/Asymptomatic
1. Determine why the nurse called/what they are
concerned about
2. Ensure the other vitals are stable
3. Ask for repeat in 5 minutes with patient at rest and BP
in both arms
4. Generally if sBP>190 or dBP>110 or new
hypertension, should assess patient and consider
treatment
Patient Assessment (minimum)
1. Why was the patient admitted? Was it for this reason?
2. Ensure patient does not have any symptoms secondary
to HTN (see symptomatic section)
3. Repeat the vitals yourself to confirm – ensure BP and
pulses done in both arms
4. PEx – mental status, fundoscopy if able, cardiac, resp,
peripheral pulses, gross neuro +/- other systems as
appropriate
5. Investigations – guided based on clinical picture
6. Is my patient safe to stay on medicine? Is this their
normal pattern, an urgency or an emergency? Does
cardiology or the ICU need to be called?
Management
- most commonly seen in chronic hypertensive patient
who is experiencing pain, missed their morning meds for
a procedure/NPO, EtOH withdrawal
- may consider giving scheduled medication somewhat
earlier, increasing their regular BP medication dose
slightly, do nothing if asymptomatic and isolated
increase in BP (can recheck BP in a few minutes to an
hour to see if it goes down and ask patient to report any
symptoms to nursing staff) and let team know in am
- initiating treatment best done by the medicine team,
though I like starting with low dose CCB (Norvasc
2.5mg), ACEi if indicated in patient and no
contraindications (perindopril 2-4mg), or nitrodur
0.4mg/hr overnight with team to reassess in am
Hypertensive Urgency: the sBP >210 or dBP>120 with
minimal or no target-organ damage present; goal is to
decrease BP to < 160/100 in several hours to days using
oral medications --- choice of therapies depends on the
age, comorbidities of the patient
Symptomatic
1. See patient immediately to assess if it is indeed a
hypertensive emergency
2. What are the symptoms experienced and is there any
indication of acute target-organ damage?
Hypertensive Emergency: marked increase in BP,
usually >180/120, with acute target-organ damage:
- CNS: papilledema, encephalopathy, hemorrhagic or
ischemic stroke
- CVS: ACS, CHF, aortic dissection
- Renal: proteinuria, hematuria, acute renal failure
- hematologic: microangiopathic hemolytic anemia
If any of the above are present, need to treat BP, with iv
agents, to bring down the MAP, where the MAP = [(2 x
dBP) + sBP)/3], by no more than 25% which will
require a monitored setting such as an ICU/CCU
- you also need to address the target-organ damage (will
likely need to consult other services)
Management (iv agents acutely – not a complete list)
1. Labetalol – 20 mg iv bolus over 2 min followed by
0.5-2mg/min iv infusion; acts in 5-10 minutes; good for
most except if acute heart failure
2. sodium nitroprusside – 0.25-10 ug/kg/min iv infusion;
acts immediately and wears off within 1-2 min, good in
most cases; caution with high ICP and azotemia
3. Hydralazine – 10-20mg iv q 30 min; onset within 10-
20min; good in eclampsia
4. Nitroglycerin iv – 10-200 ug/min; onset within 5 min;
especially useful when coronary ischemia
5. Phentolamine 5-15mg iv bolus prn; onset 1-2 min;
useful in catecholamine excess states
Abnormal Blood Pressure
Called re: decreased BP
- Is the patient symptomatic? – change in LOC, CP, CHF, (pre)syncope
- What are the other vitals? Any other abnormalities or is it isolated hypotension?
- What is the baseline BP – What was the BP this morning, last night at this time?
- Why was the patient admitted?
- Is the patient on antihypertensives?
Stable/Asymptomatic
1. Determine why the nurse called/what they are
concerned about
2. Ensure the other vitals are stable
3. Ask for repeat in 5 minutes with patient at rest and BP
in both arms
4. Generally if sBP<90 or new hypotension, should
assess patient
Patient Assessment (minimum)
1. Why was the patient admitted? Was it for this reason?
2. Any relevant info from signover, any new drugs,
transfusions?
3. Ensure patient does not have any symptoms secondary
to hypotension (change in mental status, presyncope,
CP, CHF, peripheral shut down)
3. Repeat the vitals yourself to confirm – ensure done in
both arms, postural vitals; if patient has AFib, automatic
BP not reliable
4. PEx – mental status, JVP, cardiac, resp, peripheral
pulses, gross neuro +/- pulsus paradox, urine output and
other systems as appropriate
5. Investigations – guided based on clinical picture,
often need ECG and/or CXR, CBC, lytes, Cr, Lactate,
trop, CK, ?liver enz, coags (?DIC), consider cultures
6. Is my patient safe to stay on the medicine floor? Is
this their normal pattern? Does the ICU/CCRT need to
be called?
Management
- if it is not new, it may be secondary to poor cardiac
function at baseline (grade 4 LV), end stage liver
disease, consequence of medical therapy
- hold any antihypertensive medications (don’t forget to
remove the nitro patch), hold nonessential meds that
cause hypotension (opiods, etc.)
- if volume status is low, consider iv fluid bolus and
reassess; check to see what urine output is if recorded
and the trend in urea/creatinine if available
- Is this an early presentation of shock? If so, assess
more fully and initiate appropriate management (see
right side)
Symptomatic
1. See patient immediately to assess if the patient is
experiencing some form of shock
2. What are the symptoms experienced and is there any
indication of etiology?
Patient Assessment (minimum)
Same as for stable patient. Consider checking for pulsus
paradoxus
Types of Shock:
1. Hypovolemic – Hemorrhage-induced (GI bleed,
ruptured aneurysm, hemorrhagic pancreatitis, etc) or
Fluid-loss induced (vomiting, diarrhea, aggressive
diuresis, third space losses as in pancreatitis)
- due to decreased preload, systemic vascular resistance
(SVR) typically increased
2. Cardiogenic – may be secondary to cardiomyopathies
such as massive MI, arrhythmias, mechanical causes
such as acute AR, extracardiac causes such as massive
PE or tamponade; consequence of cardiac pump failure
resulting in decreased cardiac output
3. Distributive (vasodilatory) – sepsis, SIRS,
anaphylaxis, neurogenic shock after spinal cord injury);
consequence of severely decreased SVR
Management
1. Identify the most likely underlying cause and address
it; may need to get rapid response, CCU or ICU involved
--- better to have them come early then when you are
running the code
2. iv fluids in most cases will not hurt as long as there is
no evidence of pulmonary edema
3. initial pressor that may be given peripherally is
dopamine (start at 5ug/kg/min) as patient getting
lined/transferred
4. to buy you some time consider giving some
phenylephrine (100 mcg iv at a time to support BP) ---
though your senior should be there by this stage
5. order appropriate investigations during/following
acute resuscitation.
SPECIFIC MANAGEMENT FOR CAUSES OF SHOCK:
Brief overview only.

SEPSIS:
ABCs. Consider additional support/monitoring. Fluids ++ (often 6-8L crystalloid), caution if significant
renal failure, poor LVEF. Cultures, broad spectrum abx, source control. Involve CCRT/ICU for central
lines, art line, pressors/inotropes, transfer

CARDIOGENIC:
ABCs. Consider additional support/monitoring If hypotension more significant than pulmonary edema
can give fluids (small bolus and R/A). Call CCU/cardiology and/or ICU for consideration of cath,
inotropes, BiPAP, Intubation, IABP

ANAPHYLAXIS:
ABCs. Consider additional support/monitoring. Assess +/- secure airway (call code blue). Stop
offending agent (antibiotic, blood, etc.). Epi 0.3 mg IM (or consider IV, bolus 0.1 mg +/- infusion (2-10
mcg/min), Fluids, Ventolin, Diphenhydramine 50 mg IV (for utricaria/pruritis), Ranitidine 50 mg IV,
Methylprednisolone 125 mg IV

PE:
ABCs. Consider additional support/monitoring . Fluids (500 cc- 1L +/- repeat) – caution as too much
may worsen RV function. Consider need for vasopressors (norepi). Consider empiric anticoagulation
before investigation (risk vs benefit). Consider thrombolysis if persistent hypotension.

TAMPONADE:
ABCs. Consider additional support/monitoring. Call CCU. Fluids (500 cc- 1L). Intubation may worsen
filling – avoid if possible. If hypotension attributable to tamponade - need pericardiocentesis.

HYPOVOLEMIA/HEMORRHAGE:
ABCs. Consider additional support/monitoring. Establish large bore peripheral IVs. Give fluids +++
and/or blood if haemorrhaging. Reverse coagulopathy. Identify source of fluid/blood loss and treat
(consider need or embolization, OR, etc.)
Approach to Chest pain on call

Chest pain is an issue that must be addressed in person.

 Things to ask for over the phone:

1) Vitals, ECG, Oxygen, May try spray of NTG if BP is OK.
 Review the signout list - known CAD/angina? reason to have demand-related angina
(e.g. bleed, infection, etc)?

Ddx: Common- ACS, angina, PE, pneumonia, reflux, PUD. Rare in hospital but possible:
pericarditis. Rare but fatal: Aortic dissection, pneumothorax (esp. If tension)

 Focused history: Onset, duration, activity when onset occurred, character (e.g. pleuritic
or not), dyspnea, associated symptoms, etc.
 Focused physical: Vitals (inc. BP in both arms). If new discrepancy >10-20mmHg,
suspect dissection. If tachycardic or hypoxic, this is likely a very sick patient. Examine
for heart failure (lung fields, JVP, edema), check pulses bilaterally, do screening
precordial exam.
 Investigations: ECG (STAT), ?consider 15 lead: Compare to previous.
o New ST elevation >1mm in 2 contiguous leads or new LBBB: If present and new
or unknown duration, stat cardiology consult for possible code STEMI
o New ST depression or T-inversion: Indicate ongoing ischemia.
o +/- CXR for pulm edema or wide mediastinum
o CBC (for precipitants)
o Troponin, CK q8h x 3- remember that this will not usually help you at the bedside
(initial usually not positive in MI)
o INR, PTT, lytes, Cr (to help guide treatment)

Treatment:
o If ST elevation or new LBBB with ongoing chest pain: code STEMI
o If not, treat as NSTACS (NSTEMI or unstable angina) consider cardiology consult,
CCRT/ICU as appropriate:
o ASA 160mg PO chewed
o B-blocker: not if HR already <60-70 or CHF. Careful with conduction
abnormalities on ECG. If on monitor, metoprolol 5mg IV. Otherwise, metoprolol
12.5-25mg PO.
o Heparin: if no contraindication and ongoing pain with ECG changes
unfractionated heparin or LMWH is indicated. UFH infusion if >75, obese,
consider about need to possibly rapidly reverse or significant renal failure- fill
nomogram. LMWH otherwise.
o Plavix load: is an option in NSTACS, but if considered would usually talk to
cardiology first.
o NTG 0.3mg SLq5 min x 3. May consider NTG patch, but if ongoing pain without
patch, will probably need more definitive treatment. If drops BP with NTG, give
fluid and think about RV infarct (do 15-lead). NB- NTG is symptomatic relief only.
o Morphine: Symptomatic relief; 1-2mg iv/sc x 1.

o If precipitant present, reverse it: Transfuse, volume resuscitation, etc as needed.

DYSPNEA
Dyspnea is an issue that must be addressed in person.

 Things to ask for over the phone:

Vitals, Trend in Oxygen sat, increase oxygen delivery. Does the nurse need to call a
code?
 Review the signout list – resp/cardiac disease? Recent change in med or procedure?

Ddx: Airway – asthma, COPD, mucous plug; Parenchymal – pneumonia, ILD; Mecahnical –
pleural effusion, pneumothorax, neuromuscular; Vascular – PE, pHTN
Cardiac, Metabolic, anxiety, other
o If saturation relatively normal but significant tachypnea consider the possibility of
compensation for a metabolic acidosis.

 Focused history: Onset, duration, sudden, chest pain, aspiration, orthopnea, associated
symptoms, etc.
 Focused physical: Vitals (inc. BP in both arms). If tachycardic or hypoxic, this is likely a
very sick patient. Examine for heart failure (lung fields, JVP, edema), cardiorespiratory
exam, signs of respiratory distress.
 Investigations: CXR – portable (STAT): Compare to previous.
o CBC (for precipitants), lytes, Cr, INR, PTT, Troponin, CK q8h x 3- remember that
this will not usually help you at the bedside (initial usually not positive in MI).
ABG. ?CT to rule out PE
Treatment:
o Directed at the underlying cause
o Consider need for non-invasive or invasive ventilation
o If requiring >40% by face mask, signs of respiratory distress or fatigue, consider need for
closer monitoring
o If unsure what to do next, call senior, consider RT (generally very helpful), CCRT/ICU
involvement

-
SEIZURE

Most seizures last 1-2 minutes (i.e. they are over before you have returned your page). If patient still
seizing when you return the page, urgent intervention required, consider having the nurse call a code blue
as you go to manage patient.

Management
 ABCs. Roll on side, apply oxygen. Apply monitors.
 Consider accucheck or empiric administration of D50 IV. Can use glucagon if no IV.
 Lorazepam 2-4 mg IV push over 1-2 min. May give up to 8-10 mg (beyond this need code blue/ICU
backup). If no IV consider Versed 5 mg IM.
1. If seizure persists/you want to try to prevent recurrent seizure, consider dilantin 20mg/kg IV (1-
1.5g over 20 minutes). Patient will need cardiac monitoring during load. Can load dilantin PO
with no cardiac monitoring, give 20 mg/kg total, but divide it into 3 doses spaced 4 hours apart.
 Beyond this (or during dilantin infusion if ongoing seizure) need ICU, intubation, consideration of
propofol, phenobarb, etc.

Investigate cause
 Examine patient, collateral history, review chart
 CBC, lytes, renal, Ca profile, liver enzymes, +/-anticonvulsant levels, +/-tox screen, consider CT head
Causes:
 Structural: trauma, mass, bleed, stroke
 Metabolic: Hypoglycemia, hypoNA, other lytes/metabolic abnormailities
 Drugs: Intoxication or withdraw
 Infection: encephalitis, meningitis
Hypoglycemia, Hyperglycemia and Diabetes

Practical Tips
 NEVER leave patients with Type 1 DM without insulin (can use low dose long acting with
IV glucose or insulin infusion if NPO)
 If using sliding scale, reassess dose frequently so you have approximate daily insulin
requirements for discharge (plan ahead).
 Goal is not perfect control for inpatients, it is to prevent acute complications (a sugar of 12
won’t kill anyone acutely, but a sugar of 1 can); usually aim for 7-11
 Hypoglycemia is generally more of an oncall concern than hyperglycemia

HYPOGLYCEMIA:
If patient is awake, alert, able to eat can often deal with over the phone
Fix the sugar
o if awake, give sugar water or feed patient (e.g., PB and J sandwich, Orange Juice)
o if decreased LOC or BG <2.5 give IV sugar (D10W infusion, D50W push)
o if no IV, give Glucagon 1mg SC/IM
o octreotide can be used for treatment of sulfonylurea-induced hypoglycaemia
o consider need for further dextrose infusion
o Check glucose q15 mins until >5, then frequently to ensure it does not decrease again
(depends on etiology of hypoglycaemia)
o NEVER leave patients with Type 1 DM without insulin

Find the cause

o Often in hospital secondary to sulfonylurea or insulin in a patient who has missed a
meal
o Consider the kinetics of the medication/insulin to determine the likelihood for
recurrence and need for ongoing monitoring/dextrose
o Sulfonylurea overdose can lead to prolonged hypocalcemia (days) especially if
coexisting renal failure

HYPERGLYCEMIA:
Tight glycemic control is not necessary in medical inpatients, especially over a short
period. The major goal should be to prevent hypoglycaemia with a secondary goal of achieving
fasting sugars of 4-7 and post prandial of 5-10. I generally am not worried by sugars in the teens
(but would consider small doses of insulin)
o Find when the patient last ate/when they will eat next
o Find out when they last got insulin or other DM meds
o Ensure that the insulin on board has almost worn of, or sugar is still very high after
the last dose has peaked before adding more insulin
o If they are on standing insulin, determine how insulin sensitive they are (see below
for sensitivity factor) and prescribe insulin to bring the sugar closer to normal
o Inform the team of the high sugar, so they can take long term action to prevent it from
happening next time you are on call
I. Background and Review

Type 1 DM – absolute insulin deficiency; patients require insulin therapy to prevent

ketoacidosis and hyperglycemia
Type 2 DM – relative insulin deficiency/insulin resistance; control of sugars with
diet/oral agents/insulin to prevent long-term consequences and short-term complications
(e.g., HONK)

Oral Agents
 Biguanides (e.g., metformin), thiazolidinediones (e.g., rosiglitazone) are peripheral
insulin sensitizers (liver and muscle) and generally do not cause hypoglycemia
 Sulfonylureas (e.g., glyburide), meglitinides (e.g., repaglinide) increase pancreatic insulin
secretion and can cause clinically significant hypoglycemia
 Alpha-glucosidase inhibitors (e.g., acarbose) slow intestinal absorption of starch and
sucrose; not frequently used
Insulin Formulations:
 Can be Novolin® or Humulin® brand (different types of injectors, different names)
Formulation Onset Peak Duration
Rapid (Lispro/Humalog,Aspart/Novorapid) 5-15 min 30-60 m 2-4 h
Regular (R, Toronto) ~30 min 2-4 h 5-8 h
Long-Acting (NPH, N, Lente) ~2 h 6-10 h ~24h
Very Long-Acting (glargine/Lantus, ~2 h None ~24h
detemir)
*note: times are approximate, depend on the patient and vary according to reference.

II. Common Regimens

Type 2 DM
 Daily dose estimation can be based on 24h insulin requirements from sliding scale, or by
multiplying weight (in kg) x 0.5
 Once Daily Insulin
o Long-acting insulin at bedtime (in addition to oral agents)
o Use low dose (0.1-0.2 units/kg), titrate up by 1-2u q24h
 BID dosing of mix
o 2/3 of dose in am, 1/3 at supper, 2/3 of each dose long acting, 1/3 short acting
o approximates to 30/70 mix (Regular + NPH), 2/3 at breakfast and 1/3 daily dose
before supper

 MDI (many variations)

o 40% total daily insulin NPH/glargine (can be all qhs, or 60%am 40%hs)
o 60% total daily insulin Regular (or rapid-acting) divided between 3 meals
Type 1 DM
 MDI and continuous insulin pump are most common for tight control

III. Sliding Scales

Basics
 Reactive, not proactive
 See MSH website for sample sliding scales
 NEVER leave patients with Type 1 DM without insulin (need some standing insulin)
 Useful during hospital admission because of flexibility (frequently NPO, variable diet and
insulin requirements due to illness)
 Aim in Type 2 DM is not optimal control, but prevention of acute complications
 Everyone has their own style based on experience (e.g., “tightness” of control)
 Need to be reassessed frequently to optimize control, may need to add standing doses if
requirements high
 Can be TID ac meals or QID (with hs dose)
o If QID, remember that patient is not eating with last dose as is the case during the
day, so will require less insulin or risk overnight hypoglycaemia (or consider evening
snack)
 Can be tailored to each patient’s own requirements
o Can estimate “insulin sensitivity” based on total daily insulin requirements
o 100/(total daily insulin) = sensitivity factor (SF)
o 1 unit of insulin (rapid or regular) will cause decrease in BG of SF mmol/L

MDI Dosing with Correction Factor

 Be aware that a better approach (but more complicated to order for inpatients) is to continue
MDI regimen with addition of “Correction Factor” of rapid acting insulin
o e.g., for SF=2, can order “If fasting sugar is 8-10 add additional 1u Rapid-acting
insulin; If fasting sugar is 10-12 add additional 2u Rapid-acting insulin, etc.”
o May need to educate the nurses about this approach

Intravenous Insulin Nomograms

 Usually required when Type 1 diabetics are NPO or in DKA, or type 2 DM with severe
illness, periop control
 Some sites have pre-printed orders, others do not
 Be aware that IV insulin may not be allowed on certain wards, as it requires frequent
monitoring (usually q2-4h), avoid/monitor if patient cannot report hypoglycemia
 Quick Approach to Sleep

Patients have a hard time sleeping in the hospital for various reasons. Maybe they are anxious,
maybe they are in a loud room or uncomfortable. You will be called about patients who can’t
sleep all the time. Usually this is an easy, though perhaps annoying (as you may have been
asleep yourself) call to deal with. My approach is as follows:

Quickly think about why a patient can’t sleep and make sure that:
 They aren’t getting stimulants like PREDNISONE or RITALIN late in the day, if
possible
 They aren’t withdrawing from benzos or ETOH.
 They aren’t urinating excessively because of poorly timed diuretics
 They aren’t suffering with poorly controlled pain.

Then think quickly about whether or not there is a reason why that patient should not receive a
sleeping/sedative medication.
 Are they at severe risk of falls?
 Is their LOC already significantly impaired?
 Do they have sleep apnea/other reasons for resp. depression? (avoid in these pts)
 Are they delirious or prone to delerium? Will your medication make them worse?

 PEARL: Benzodiazepines in the frail elderly are like giving them a pitcher of beer to
drink. Some people will be happy drunks, some people will go to sleep, and others will
turn into brawlers. You don’t know who is who until you give the drug, then you can’t
take it back
 Do they need to be alert and awake in <6 hours?

Then prescribe a mild sedative for a short period (not to exceed 1-2 weeks). If on call and this is
not your patient, order the dose x 1, then sign over in the morning to see if the team wants to
continue
 zopiclone 7.5 mg po QHS PRN (3.75 mg in smaller elderly)
 lorazepam 1 mg po QHS PRN (0.5 mg in smaller elderly)
 "Acute" Management of Constipation
Isaac Bogoch, 2008

Ensure that the patient is only constipated, not impacted, obstructed or perforated.

Not having 1BM per day is *not* constipation. Unfortunately many don't appreciate this.
Think about causes and fix those that you can:
 Drugs: narcotics, antidepressants, calcium/iron supplements, calcium channel blockers,
others
 Metabolic: hypercalcemia, hypothyroidism, hypoK/Mg
 Structural: Recent abdominal surgery, abdominal masses
 Other: Poor intake (nothing in = nothing out), diet, fluid intake, age, immobility,
neurogenic
 Significant discomfort, bloating, nausea associated with constipation lasting several days
consider plain films of the abdomen to exclude ileus, obstruction and to "grade the
constipation"
 If full of stool on the X-ray will probably need what I call the "two-pronged" or
"pincer" approach

 Therapies:
o Start from above if not impacted or no suspicion of obstruction
o Start at initiation of narcotics to avoid this side effect
 Stimulants: Senna 2 tabs po QHS or po BID PRN. Expect effect in AM.
Avoid long term use. Helpful with narcotic induced constipation. Alternative:
Bisacodyl (Dulcolax) 15mg PO OD PRN.
 Osmotic: lactulose 15-30cc po QHS or PO BID PRN. If on narcotics may
need daily dose

o Add an "attack from below" if severely constipated or no response to oral therapy

after 2 days (and no contraindication to PR -- i.e. not febrile neutropenia)
 Bisacodyl suppository 10mg PR OD PRN
 Glycerin suppository PR OD PRN
 If not working with suppositories I then "send in the fleet"
 Fleet enema 1 PR OD PRN (caution in renal failure because of
phosphate load)
 Lactulose enema 300cc lactulose in 700cc H2O
 Tap water enema
 Soap suds enema

 "Two pronged approach" - simultaneous administration of upper and lower regimens.

 If "really stuck" and not impacted/obstructed can try Go-Lytely 2L over 4 hours but risk
of electrolyte derangement
 If impacted.... Manual dis-impaction first, then when not impacted start the "two-
pronged" approach
Approach to Correction of Mild to Moderately Low Potassium, Phosphate, Magnesium
and Calcium *Not Critically Low*

Many hospitals have replacement guidelines – see the intranet.

Can often be dealt with over the phone

Potassium (Mild = 3-3.5): Think about cause of hypokalemia (diuretics, diarrhea,

hyperaldosteronism)
Don't replace mildly low K+ in HEMODIALYSIS patients or those with ESRD.
 each 1 point represents 150-200 mEq total K+ loss (general rule)
 can't treat if low magnesium, so need to correct this too
 Oral: K-Dur 40 mEq now and in 4 hours. Lytes in 8 hours
 Alternative: KCL elixir 40meq now and in 4 hours. Lytes in 8 hours
 May need more aggressive monitoring/replacement if ongoing rapid loss
 IV (if absolutely can't give po):
 monitor q6h lytes
 max concentration: peripheral line 40 mEq/L, central line 40 mEq/100 mL
 max rate: peripheral 10 mEq/h, central 20 mEq/h

Calcium (Mild = 2.0-2.2) consider need to correct for albumin

 Oral: Calcium Carbonate 1250mg PO TID between meals x 3 days. +/- Vitamin D
1000IU PO QHS
 Alternative: Calcium Rougier 25cc po TID x 3 days +/- Vitamin D 1000IU PO QHS
 IV: Calcium gluconate 1-2g in 100cc NS/D5W over 1 hour repeat level in AM. Slower
in patients on digoxin.

Magnesium (Mild = 0.55-0.70)

 Oral: Magnesium Oxide 1 tablet PO TID x 3 days
 Alternative: Magnesium Rougier 30cc PO TID x 3 days --> Side effects include diarrhea
 IV: Magnesium Sulfate 1-2g IV in 100cc NS over >1 hour --> Avoid more rapid infusion
which can cause muscle weakness and respiratory depression. Repeat level in AM.

Phosphate (Mild= 0.6-0.89)

 Treatment optional
 Oral: Phosphate Novartis 1-2 tablets PO TID x 3 days then repeat level
 Alternative: Sodium phosphate liquid 4ml PO TID x 3d
 IV: Potassium Phosphate 6-15 mmol (5cc=15mmol phos., 22mEq potassium) in 500cc
NS or D5W or Sodium Phosphate 6-15mmol in 500 cc NS or D5W >5 hours
 Quick Approach to Hyperkalemia

 Is this an emergency?
 Is the patient arresting  ACT NOW, Call Code Blue
 Is the patient unstable  ACT NOW
 Is the potassium >=7  ACT NOW, confirm it is real
 Are there ECG changes (see page 2)  ACT NOW
 If you are ACTING you must remember to THINK later
 ACT 1: Stop the exogenous potassium and hold potassium increasing medications
(such as NSAIDs, TMP/SMX, ACEi/ARB, K+ sparing diuretics)
 ACT 2: Stabilize the myocardium
 If arresting Calcium Chloride 1 AMP IV push
 If ECG changes, unstable, and/or K~>=6.5** you should give Calcium
Gluconate 1 AMP IV slow push over 5 minutes. Repeat in ~10-15 minutes
if ECG changes persist.
NB: Caution in patient on DIGOXIN (can precipitate arrhythmia)
 ACT 3: Shift the potassium into cells (if K+>=5.8 or ECG changes)
 IV Humulin R 15-20 units IV PUSH after 1-2AMPS of D50 IV push.
 Accucheck Q20mins x 3 to watch for hypoglycemia
 Ventolin 4-8 puffs STAT. NB: Caution for tachycardia
 Sodium Bicarbonate 1 AMP IV slow push over 5 minutes.
 May need to repeat shifting in 2-4 hours. Recheck the potassium and re-
shift as necessary.
 ACT 4: Eliminate Potassium from the Body.
 URINE (if the patient makes urine):
 If volume overloaded FUROSEMIDE 40mg IV for normal kidneys,
may need more for abnormal kidneys
 If euvolemic or mildly hypovolemic then you should give ~500cc-
1L NS over 1-2h with FUROSEMIDE as above
 If hypovolemic then give normal saline alone.
 STOOL (if patient can swallow)
 Calcium Resonium 15-30g in 60cc PO SORBITOL. Caution in
patients post-op from bowel surgery, if ileus is present or if on
opiods as cases of gut necrosis with sorbitol are reported
 DIALYSIS
 Always an option. Especially in patients already dialysis dependent.
Usually shifting will get you enough time to get dialysis ready.
 THINK
 Why was the patient hyperkalemic?
 Was it a problem with too much exogenous potassium?
 i.e. on IV NS with 40K+ for days and days.
 Dietary -- Does this patient need a low-potassium diet

 Was it a problem with impaired renal excretion? New meds?

Adrenal Insufficiency
  TTKG = (Urine K/ Serum K) / (Urine OSM / Serum OSM)
If <10 indicates some problem with renal excretion.
If <7 suggestive of hypoaldosteronism.

ECG Changes in HYPERKALEMIA (changes can skip steps):

 Tall peaked T-waves
 Increase PR interval
 QRS widening
 “Sine-Wave”
 Asystole/VT/VF
 Approach to Altered Mental Status

GLASGOW COMA SCALE

Differential Diagnoses to Consider: DIMS
Motor
D : drug (withdrawal and intoxication)
6 - Follows Commands
I : infectious
5 - Localizes Pain
M : metabolic
4 - Withdraws Pain
S : structural
3 - Decorticate Flexion
2 - Decerebrate Extension ON EXAMINATION (after collateral history):
• ABC: airway, breathing, circulation
1 - No Response • Vitals (including accucheck )
• GCS, mental status exam
Verbal • CVS, Resp , abdo , PVS
5 - Alert and Oriented • Neurological: ? Focal neurological deficits, asterixis , neck stiffness,
reflexes including corneal, pupillary , gag, deep tendon, Babinski, papiledema,
4 - Disoriented, confused
3 - Inappropriate words
2 - Moans, Unintelligible INVESTIGATION:
1 - No Response • CBC, electrolytes, creatinine, AST,ALT, ALP,
albumin, Ca 2+, Mg 2+ PO 43-, INR/PTT
Eyes • Blood sugar, urine dip
4 - Opens Spontaneously • +/- ABG: CO 2 / acid base disorders
• +/- CT brain
3 - Opens to voice
• +/- cultures: urine, blood, sputum CXR, LP
2 - Opens to Pain
• +/- TSH (T 3/T4) / B12
1 - No Response • +/- Toxicology screen (urine / blood)
• +/- ECG. troponin

EXPANDED DIFFERENTIAL TREATMENT

•Consider the need for increase monitoring /
Drugs: ICU, ?neurovitals
•Withdrawal : ETOH, BDZ, Narcotics, nicotine, antipsychotics •Consider ‘universal antidotes’ :
•Intoxication / interaction: anticholinergics (gravol), BDZ, •O2, thiamine (100mg iv Q24 x3),
narcotics glucose (1 amp D 50), narcan (0.2-
0.4 mg iv if unconscious otherwise
Infections: mix 1 amp (0.4mg in 9cc NS and
•urine, bacteremia, pneumonia, meningitis, encephalitis give 1cc at a time until effect)
•Treat Underlying Cause
Metabolic: •Non-pharmacologicl
•Endocrine: Hypoglycemia / hyperglycemia, Thyroid •Sitter
•Major organ failure: Lung;  Co2 /  O2, Kidney, Liver
•Pharmacological (check liver/renal
•Electrolytes:  Ca 2+,  Na+,  Mg2+ function) – use only if pt at risk of harming
•Other: thiamine def. B12 def. self / others
Structural •Benzodiazepines e.g. diazepam /
lorazepam (use lorazepam in liver
•Stroke : ischemic / hemorrhagic
failure / elderly patients)
•Subarachnoid Hemorrhage,
•Antipsychotics (watch in patients
•Subdural hemorrhage
with prolonged QT interval) eg
•Subacute: abscess, tumor
Haldol (im,iv,po), Risperidone (po),
•Seizure (post ictall Olanzapine (sl, po), Seroquel (po)
Clot, TTP, vasculitis
 Death Pronouncement

Prepare yourself:
Ask the RN to provide you with a brief history:
 Was the death expected? Was the patient “DNR”?
 Is the family at the bedside? Have they been informed?
 You may wish to ask the RN to accompany you to the patient’s room to introduce you to
family members present and to provide additional support
Quickly look at the chart/signout:
 Timing and reason for admission
 Discussions pertaining to philosophy of care
 Events immediately preceding the death
 Likely cause of death, when staff should be notified, organ donation etc.

Entering the Room:

 Quiet, respectful environment
 Introduce yourself to family members present
 Tell the family that you are there to pronounce their loved ones’ death
 Whether or not you invite the family to stay in the room depends on your comfort level
o If you ask the family to leave the room, request that the RN lead them to a quiet
room where you can meet them after the pronouncement

Clinical Examination:
1. Check ID band
2. Check response to tactile stimuli
3. Check for heart sounds and pulse
4. Check for spontaneous respiration
5. Check pupil position and response to light
6. Record the time of death

Follow-Up:
 Approach the family to answer any questions that they may have
 Families are often uncertain of what to do next
 Ask if they have made funeral arrangements and let them know that they should
contact the funeral home who will then make all subsequent arrangements with
respect to their loved one
 Ask if the would like an autopsy to be performed and if yes, then complete an
autopsy consent form, contact the pathology department and ensure that security
is aware
 Ask if they would be interested in organ donation (Contacting Trillium Gift of
Life for every death is now a mandatory step in death pronouncement, even if
family members decline).
  Ask if they would like you to call a chaplain (many hospitals have a chaplain on
call 24 hours/day) or whether there are special rites or practices which should be
observed
 Expressing condolences is appropriate
 Inform the attending physician of the patient death. If the death was expected this can
happen in the morning. If it was unexpected, ensure they know before they arrive in the
morning.
 Ideally call the family physician (and referring institution if applicable) during business
hours to inform them of the death

Documentation:

In the chart:
1. Record the date and time
2. Brief statement of the cause of death
3. Note absence of pulse, spontaneous respirations, pupil response
4. Note whether family present or informed
5. Note discussion pertaining to autopsy and organ donation
6. Note whether attending and/or family physicians were informed
7. Note whether chaplaincy, SW or other services were involved
8. Note any involvement of the coroner

Fill out the death certificate:

 Often times there is a sample on the wards
 It is illegal to produce a duplicate. If someone wants a copy they can photocopy it.
There is to be only one original.
 Cause of death (not mechanism) should be listed
 Immediate Cause – for example Aspiration Pneumonia (not respiratory arrest)
 Antecedent Cause – for example Alzheimer’s Disease
 Contributing Factors – for example Coronary Artery Disease, cigarette smoking

Fill out hospital specific form if required (necessary at UHN, not MSH)
 Indicates:
 Whether autopsy requested by family or required by coroner
 Documentation of contact with Trillium Gift of Life Network
 Second page of this document is a useful resource which outline indications for
mandatory notification of the coroner
 If you are uncertain as to whether a death meets criteria to become a “coroners case”, you
can page the coroner on call through locating and discuss

Phone numbers:
Trillium Gift of Life: 416-363-4438
Coroner’s Office: 416-314-4100
Blood culture results on call

When called about positive blood culture results, this often needs to be acted on immediately because
unless a contaminant, means that the patient is bacteremic, and therefore if not yet very sick, they will be
without appropriate treatment.

Your jobs:
1) Decide whether the patient requires treatment
2) Look at current therapy and decide whether needs changing
3) See the patient and see whether they need to be in a higher intensity area (i.e. are they septic?)

Is it a contaminant?
This is hard to decide based on gram stain, since S. aureus (which needs treatment) and S.
epidermidis (which is usually a contaminant) look the same (gram +ve cocci in clusters)
 CNST (coagulase negative Staph sp.), Gram positive bacilli (corynebacterium and bacillus sp.) are
frequent contaminants.

To help decide if these are contaminants:

 If multiple cultures from different times or sites have the same growth, less likely contaminant.
 If the patient is sick (fever, leukocytiosis with left shift) with positive blood cultures, assume it is real.
 group A streptococci, Strep pneumoniae, Enterococcus, H. influenzae, Enterobacteriaceae,
Bacteroidaceae, Pseudomonas aeruginosa, and Candida species should be treated.
 S. lugdunesis (a rarer CNST) and Corynebacterium jeikeium often cause “true” infections
and need treatment

What should I use? – need to consider

- What is the likely source of infection?

- What is the likely organism based on the source, where the patient is from, comorbidities, screening
swabs (MRSA, ESBL, VRE, etc.)?
- Which antibiotics would cover the bugs I’m concerned about?
- Will the antibiotic I prescribe reach the intended target (route of administration, penetration of organ
system)?
- Are there any contraindications to the antibiotic I want to prescribe (allergies, medication interactions),
do I need to adjust the dose based on renal function, and will my patient take it (compliance, cost,
availability) ?

 For Gram positive infections – Vancomycin 1-1.5g IV q12h is a good empiric choice
 For Gram positive infections in a very sick patient (ICU bound) – consider adding Ancef 1g IV q8h

 For Gram negative infections – more difficult decision:

o If the patient has a positive ESBL swab – Meropenem 1g IV q8h
o Consider the need to cover Pseudomonas – Ceftazidime 1gIV q8h, Cipro 400 mg IV q12h,
Piptazo 4.5g IV q8h, Meropenem (if very sick/ICU bound/consider ID consult) 1gIV q8h.
AND also consider a dose of Tobramycin 5mg/kg IV until speciation is determined
o Otherwise – Ceftriaxone 1-2g IV q12-24h or Piptazo 4.5gIV q8h
 If concerned about anaerobes: Piptazo, Meropenem (if other indications as well) Clindamycin or
Flagyl are good options for the anaerobes (but don’t forget about the aerobes too (i.e. don’t use Flagyl
alone empirically)
SPICE organisms:
Serratia, Providencia, Indole-positive proteus (not mirabilis), Citrobacter, Enterobacter

SPICE are part of the group of bacteria termed “ESBL (extended-spectrum beta lactamase). There are
also other types of ESBL. SPICE organisms have inducible beta lactamases. The induction of the beta
lactamase is caused by "inducing agent" antibiotics. This means that initial c+s may show sensitivity, but
exposure to these antibiotics will lead to the development of resistance.

If you see these bugs, do not use beta lactam (e.g. ceftriaxone, amp, pip-tazo). Need quinolone or
carbapenem. Empiric treatment for a bacteremia caused by these organism should be a carbepenem. For
any bacteremia caused by a SPICE organism or another ESBL, an ID consult is a very good idea. Also
consider calling the microbiology lab to discuss the isolate/resistance pattern.

Some tips/pearls:
1) When in doubt, start antibiotics
2) Start with IV antibiotics
3) Re-culture liberally (prior to Abx if possible)
4) Be very careful with S. aureus, enterococcus. Other “bad actors”: S. anginosus / milleri, Staph.
Lugdunesis (behaves like Staph Aureus), gram negatives like enterobacter, citrobacter
5) If you ever see S. aureus in the urine, it likely came from the blood.
6) If you see a SPICE organism, don’t start a beta lactam.
7) Look for and remove the source- e.g. line, I+D, OR etc.
8) Consider calling for an Infectious disease consult/phone advice