NIGHT FLOAT - COMMON CALLS

Contents
1 NGHT FLOAT - COMMON CALLS
1.1 For Starters
1.2 CHEST PAN
1.3 BRADYCARDA
1.4 TACHYCARDA (HR > 100)
1.5 HYPOTENSON
1.6 HYPERTENSON
1.7 FEVER
1.8 LOW URNE OUTPUT
1.9 DYSPNEA
1.10 COMBATVE OR CONFUSED PATENTS
1.11 FALLS
1.12 NSOMNA
1.13 NDGESTON
1.14 PAN MANAGEMENT update
1.15 Nausea
1.16 Constipation
1.17 ntractable Hiccups
1.18 Radiology Tips
1.19 Rash
1.20 V Fluid table
1.21 DEATHS AND DOCUMENTATON
1.22 CV NGHT FLOAT NGHTMARES


CHEST PAIN
1. Ask Ior vital signs on the phone immediately, including O2 sat
(vitasls stable vs. unstable?).
2. Know the context oI the chest pain - take a look at your sign-out
card. Is this worrisome Ior angina or MI? II so, ask nurses to get
EKG during the time it takes you to arrive or at least bring EKG
machine to bedside.
3. Upon arriving in pt's room, look at EKG first (ask Ior prior
EKG Irom chart) or start obtaining the EKG as you're asking
history.
. Directed H&P. This will comprise the bulk oI your diagnostic
workup. You will need to rule out the stuII that will kill you rather
than diagnose deIinitively. The major killers are:
0MI - "pressure" pain associated with SOB, diaphoresis, radiation
to L jaw/arm, N/V, cardiac risk Iactors present, similar to
previous angina?
Aortic dissection - "tearing" pain, radiation to back, unequal
pulses; associated with HTN, smoking.
Pneumothorax COPD, trauma, decreased breath sounds,
hyperresonance, deviation oI trachea away Irom side with
pneumothorax, hypoxia.
PE - dyspnea, hypoxia, A-aO2 gradient, hemoptysis, pleuritic
chest pain.
Other etiologies that are sometimes overlooked include
pericarditis, pneumonia/pleurisy, GERD, PUD, esophageal
spasm, candidiasis, herpes zoster, costochondritis (Tietze's
syndrome), anxiety (a diagnosis oI exclusion).
5 If angina suspected, start O2 by NC and use sublingual NTG
(NTG 0. mg SL q5 min x 3; hold Ior SBP 100). Remember, just
because the CP responds to NTG does not
automatically rule in angina. II ineIIective, but high suspicion, try
other antianginals including:
Nitropaste or consider starting NTG gtt (iI heading toward this
option, call SMR as the patient will most likely will need
transIer to the ICU). (see Sliding Scale: Nitropaste)
00Morphine IV (helps relieve pain and anxiety) 1mg at a time in
little old ladies; 2- mg IV q5 min in a younger man.
00Metoprolol 5 mg IV q5 min x 3 (use with caution in
COPD/asthma).
ASA 325 mg, chew and swallow, iI not already on ASA and no
contraindications
00#emember, if you suspect angina, it is VE# important to
control the pain
. II ongoing CP with signiIicant EKG changes, call the SMR
immediately. You might start heparin /- integrilin as well as a
nitro drip. The SMR should be involved in this decision and come
to see the patient. (Remember, all EKGs done overnight must be
reviewed by SMR). II you do not give integrilin, lovenox (low
molecular weight heparin) is preIerred over regular IV
heparin. Lovenox can`t be given iI pt is obese or has renal Iailure.
Remember to hold Lovenox 12 hrs prior to procedure/surgery.
7. II suspecting dissection, call SMR Ior possible transIer to ICU
to reduce BP ans inotropy with beta-blocker. Arrange Ior
emergent CT scan or echo and call vascular surgery. EKG may
show evidence oI ischemia in RCA distribution iI dissection is
proximal.
. II pneumothorax suspected, get STAT CXR (call X33720) and
when conIirmed call surgery Ior chest tube placement. II tension
pneumothorax, don't wait Ior the CXR! Shove a needle into the
2nd intercostal space at the midclavicular line (on the side with the
pneumo!).
. II !E suspected, get ABG to conIirm hypoxia. Consider V/Q
and anticoagulation.
10. AIter your chest pain assessment, be sure to obtain post-pain
EKG and document the encounter in the patient`s chart.

#ADYCA#DIA
1. Ask yourselI 2 questions:
1. Is the patient symptomatic or hemodynamcially unstable? II
so, get patient in Trendelenberg (Ieet above head) and Iollow
ACLS protocols. Now is a good time to call the resident.
2. Does the ECG show either type II 2
nd
-degree or 3
rd
-degree AV
block? II so, consider trans-cutaneously pacing the patient and prepare
Ior possible transvenous pacer (consult Cardiology)

2. II patient stable and no dangerous AV block on EKG, now is the
time to do a quick chart biopsy and look Ior clues Irom the
patient's med list and admitting diagnoses.
$ome common causes of bradycardia:
Meds -blockers, Ca2-channel blockers, digoxin, amiodarone,
clonidine (remember eye drops)
Cardiac sick sinus, inIerior MI, vasovagal, 2nd or 3rd degree
heart block, junctional rhythm
Other hypothyroidism, increased intracranial pressure
(Cushing's reIlex), nml variant, OSA, hyper-/hypokalemia,
hypothermia
3. In general iI the pt is not symptomatic and this is not a
signiIicant change Irom prior days/nights, then an exhaustive
workup is unnecessary. However, iI your suspicion oI cardiac
disease is high and this is a change Irom prior vitals, then a 12-lead
EKG at the minimum and consider ischemia in at-risk patients.
. Take a focused H&!. Focus on signs and symptoms to
distinguish the above (chest pain, prior MI, straining or other
maneuvers prior to bradycardia, nausea/vomiting, altered mental
status, hypothermia, BP, etc.)
5. II you believe the bradycardia is secondary to meds, be careIul
discontinuing them.
Remember, treat the pt, not the numbers. Stopping rate control
meds could cause a rebound tachycardia and precipitate MI (a bad
thing). However, iI the bradycardia is new and signiIicant, hold all
rate controlling meds and notiIy team in am.
. II you are particularly concerned, write an order Ior Zoll pacer
and atropine (usually 0.5-1 mg) at bedside (just in case.). Call
the SMR. Transcutaneous pacing can be uncomIortable. II there is
time, short-acting analgesics and/or sedatives may be worthwhile
to consider.
7. In asymptomatic patients with bradycardia, the class I
indications Ior pacemakers are as Iollows:
3
rd
-degree AV block with asystole lasting ~ 3 seconds or with escape
rates 0 while awake.
3
rd
-degree or 2
nd
-degree type II AV block in patients with chronic
biIascicular or triIascicular block

TACHYCA#DIA (H# > 100)
1. Is the pt symptomatic or unstable? What`s the BP? II so, Iollow
ACLS protocol, call the SMR and get a crash cart into the room
ASAP.
2. Does this merit investigation, i.e. has the pt been tachycardic all
week and has this been noted in the regular team's progress notes?
3. Obtain an EKG and examine the pt.
. Tachycardias are classiIied according: 1) rate- regular vs
irregular 2) width oI QRS - narrow vs wide (~120ms). They are
listed below with diagnostic clues and treatments. Generally, you
will want to call a resident iI you want to treat, since they may
involve calling a code.

Narrow Q#$, #egular #ate
1. $inus tachycardia
Multiple causes (pain, anxiety, hypoxia, hypovolemia,
myocardial dysIunction, Iever, anemia, meds, pericarditis,
hyperthyroidism, PE, alcohol withdrawal).
Diagnosis rests on upright P waves in II, III, and aVF always
Iollowed by QRS.
Compare EKG with priors, iI available. Maximum HR 220-
age.
Treat the underlying cause.
2. V nodal re-entrant tachycardia (VN#T)
More common than AVRT or AT (below).
Caused by existence oI dual AV pathways with diIIering
reIractory periods with circuit rhythm set oII by PAC.
Dx: look Ior isolated R, pseudo S, or inverted P on ECG. HR
typically 10 20.
Treat with AV nodal block (carotid sinus massage, adenosine, -
blockers, Ca2-channel blockers, digoxin).
3. V re-entrant tachycardia (V#T)
Caused by presence oI accessory pathway causing large circuit
rhythm.
Diagnosis: short RP interval (i.e. RP PR interval), retrograde P
wave.
Treat with AV nodal blocking (see above).
. trial tachycardia (T)
Caused by enhanced automaticity oI atrial tissue or ectopic atrial
pacemaker(s).
Diagnosis: long RP interval (i.e. RP ~ PR). HR typically 250.
Treat with Ca2-channel blocker.
5. trial flutter with regular block
Similar to atrial Iibrillation; usually some heart disease present.
Diagnosis: Ilutter waves in inIerior leads, ventricular rate some
multiple oI 300 5; when the HR is about 150, always
consider atrial Ilutter.
Treat with cardioversion, AV nodal blocking.

Narrow Q#$, Irregular #ate
1. trial fibrillation
Causes: see expanded section in Cardiology.
Diagnosis: no P waves and Ilutter waves in all leads.
Treatment: see expanded section in Cardiology.
2. trial flutter with variable block
OIten diIIicult to distinguish Irom atrial Iibrillation.
Look in inIerior leads Ior Ilutter waves at approximately
300/min. May increase AV block transiently with adenosine
or carotid sinus massage to reveal Ilutter waves.
Treat with AV nodal blocking, cardioversion.
3. ultifocal atrial tachycardia (T)
Caused by multiple ectopic atrial pacemakers; usually associated
with pulmonary disease. Also seen in hypomagnesemia,
hypokalemia.
Look Ior 3 distinct P wave morphologies in the same lead and 3
separate PR intervals
Treat underlying dysIunction.
. requent !Cs

Wide Q#$, #egular #ate
1. Ventricular tachycardia (VT) versus supraventricular
tachycardia ($VT) with aberrancy. Aberrancy reIers to either
dysIunction oI the His-Purkinje system or presence oI an accessory
pathway.
2. Given the seriousness oI VT, in any pt with heart disease with a
wide QRS tachycardia you must assume VT until proven
otherwise.
3. The Brugada criteria (see Cardiology section) is a useIul tool to
distinguish VT Irom SVT with aberrancy.

Wide Q#$, Irregular #ate
1. VT versus atrial fibrillation with aberrancy. Actually, any
condition causing an irregular rate in the presence oI aberrancy
will cause this.
2. Generally treated with cardioversion, either electrical or with
procainamide.

HYPOTENSION
see Hypotension Algorithm
1. o you believe the B! Ask the nurse to repeat the
measurement (or repeat it yourselI).
2. Is it any diIIerent Irom prior values? II the pt usually lives
around 0/0, then the acuity is decreased somewhat.
3. Is the pt symptomatic? You determine this by looking Ior
evidence oI shock (i.e. inadequate tissue perIusion), tachycardia,
tachypnea, pre-renal oliguria, altered mental status, etc. II shock is
present, then evaluation should proceed sooner rather than later.
You should strongly consider calling a resident and preparing Ior
ACLS.
What are the other vital signs?
Is the pt awake or altered?
Is the pt having chest pain?
Has the pt had any urine output over the last shiIt?
Is there any respiratory compromise or wheezing?
. Hypotension can only result Irom low cardiac output (CO) or
low systemic vascular resistance (SVR).
Remember eqs: 1) MAPCO x SVR; COSV x HR; and
SVpreload x contractility; MAP (SBP 2(DBP))/3
Your DDx is extensive but can be generally thought oI in the
Iollowing categories:

A. ow cardiac output Think: COSV x HR; and SVpreload x
contractility
ecreased preload: assess: JVP, volume status, and
consider hypovolemia, tension pneumothorax, PE, tamponade,
RV inIarct, pulmonary hypertension, Hypovolemia (e.g.
bleeding, diuresis, burns, GI losses, third spacing,
pancreatitis)
ecreased contractility: assess: listen Ior gallop,
murmurs, rales and consider myocardial dysIunction, valvular
dysIunction (AS, AI, MR), cardiomyopathy, aortic dissection,
drugs.
Heart rate: look at ECG Ior pathologic tachycardia,
bradycardia and consider arrhythmia, drugs, lytes
B. ow vascular resistance
ecreased $V#: assess: warm extremities, Ilushing;
consider InIection (sepsis), Anaphylaxis, Drugs (vasodilators,
morphine, Demerol), Autonomic dysIunction, e.g. in
diabetics, spinal cord injury/shock), Endocrine (thyroid or
adrenal insuIIiciency)
5. Take a focused H&! and a chart biopsy to R/O the above
diagnoses. Don't Iorget:
I prior heart disease, chest pain, ischemia on EKG
Tamponade pulsus paradoxus, distant heart sounds, JVD,
electrical alternans on EKG
!neumothorax unequal breath sounds, tracheal deviation away
Irom side oI PTx, JVD
!E dyspnea, JVD, hypoxia, RV heave, loud P2
naphylaxis Ilushed skin, urticaria, stridor, wheezing
Bleeding think oI bleeding into retroperitoneum (esp with post
cath pts), abdomen, pancreas, thigh, GI tract
. II pt has shock, act quickly. Some basic steps:
Treatment is aimed at the underlying cause, but almost all cases
call Ior Iluid resuscitation. Get two larger peripheral IV`s
running Normal $aline IV wide open. Squeeze the
bags. Don`t use normal saline or D5W Ior volume
resuscitation in this setting!
$tart O2, put pt in Trendelenberg, draw basic labs (CBC, lytes,
BUN, Cr, glucose, LFTs, blood cultures), ABG; get EKG and
CXR.
Consider Foley to measure urine output.
Consider invasive monitoring (CVP or PA line, arterial line) and
echocardiogram.
7. Other speciIic notes:
Remember that the BP cuII can markedly underestimate BP in low
Ilow states; thereIore, an arterial line can be invaluable Ior better
BP monitoring.
II BP is undetectable, palpate Ior pulses. A palpable Iemoral pulse
indicates systolic blood pressure (SBP) ~ 0 mmHg and a
palpable carotid pulse indicates SBP ~ 0 mmHg.
For tamponade in a post-cardiac pt, notiIy the CV surgeon on-
call. In a medicine pt, most likely will need to be discussed
with the cardiologist on-call.
For pneumothorax, don't wait Ior a CXR. Shove a 1 or 1
gauge needle into the second intercostal space at the
midclavicular line ASAP.
For anaphylaxis, give epi 0.3 mg IV 1:1000 SC/IM q10 min
(diluted dose diIIerent Irom code blue), Benadryl 50 mg IV,
hydrocortisone 100 mg IV
Consider albuterol nebulizers Ior bronchospasm or intubation Ior
respiratory Iailure.
For sepsis, rapid administration oI antibiotics and pressors will
be crucial.
. Above all, stay calm. Crashing pts are scary. Don't try to
manage pts in shock by yourselI.

HYPE#TENSION
High BP is one oI the most common night Iloat calls. One oI your
concerns should be whether this represents a hypertensive
emergency or whether the hypertension reIlects a more serious
underlying process. Most oI the time, nurses are calling (170/0)
only because it`s what was written in the admission orders 'call
MD Ior BP oI. OIten, it does not require thorough evaluation,
but it does require you to think.

1. Do you believe the reading? Take BP yourselI iI in doubt; use
the right size cuII.
2. What is the pt`s normal range?
3. Look at the sign-out and/or a brieI chart biopsy - note the time
course oI hypertension. Has it been constant since admission, or
has it developed suddenly? Did the patient come in with a MI, in
which case you want the BP to be well-controlled, or were they
admitted with something unrelated to BP problems?
. Remember.common problems can cause increased BP - is the
patient anxious or in pain Does that patient have a history oI
HTN? Treat the underlying problem rather than the BP.
Other underlying problems that can cause HTN:
EtOH withdrawal (tachycardia, tremor, conIusion)
Drug overdose (cocaine, amphetamine)
Drug interactions (MAO inhibitors, tricyclics)
Drug withdrawals (-blockers, ACE inhibitors, central alpha
blockers)
Increased intracranial pressure (Cushing's reIlex)
Renal Iailure, renal artery stenosis
Eclampsia, pre-eclampsia (is the patient pregnant?)
Coarctation oI the aorta, aortic dissection (unequal BP in arms?)
Pheochromocytoma (episodic nature; associated with Ilushing,
diaphoresis, tachycardia)
Endocrine (Cushing's syndrome, thyrotoxicosis)
Pain, anxiety (diagnosis oI exclusion)
5. $ome general tips:
Try not to cross classes in the middle oI the night.
II the pt is on an antihypertensive medication, try giving an extra
dose or their usual dose early. II that Iails, try hydralazine
25mg PO or 10mg IV (Iaster).
Be careIul with niIedipine as it can cause an acute decrease in BP
(NEVER use sublingual).
In general, do not write Ior a standing order oI medication - just
one time orders.
NotiIy the primary team in the am, they can then adjust the pt`s
antihypertensive regimen.
. Hypertensive emergency exists when elevated BP is associated
with end-organ damage (brain, eye, heart, kidney). Hypertensive
urgency SBP ~200 or DBP~120 with no end-organ damage. Ask
about and examine:
Brain: headache, conIusion, lethargy
Eye: blurred vision, papilledema, Ilame hemorrhages
Heart: chest pain, SOB, S3, S, EKG strain or ischemic changes
Kidney: low urine output, edema, hematuria
Hypertensive emergencies require admission to the ICU and
rapid reduction oI BP by 25 over -12hrous with IV medications
Your choices include:
Labetolol 20 mg IV q10 min or 0.5-2mg/min iv gtt until BP
down
Nitroglycerin gtt 5 mcg/min, titrate up (use when heart disease
present; causes headache and ICU stay)
Nitroprusside gtt 0.3 mcg/kg/min, titrate up (requires arterial
line BP monitoring & ICU)
7. II no underlying condition, is there a hypertensive urgency (BP
~ 10/120, no end-organ damage)? Bring BP down with short-
acting agent. Suggestions:
Clonidine 0.1 mg po bid
Captopril .25-25 mg po tid (check K, Cr, allergies)
Nitropaste (see Sliding Scales; and can cause Headaches)
Hydralazine 10 mg po and titrate up qh
Avoid short-acting niIedipine (increased mortality)
. $pecial $ituations:
cute CN$ process: In patients with an acute CNS process (i.e.
during/post-CVA), HTN is usually compensatory and should
be permitted as long as the BP is 220/110.
!regnancy: hydralazine and labetaolol are Iirst line
I: beta-blockers and nitrates
ortic dissection: use labetaolol or esmolol; avoid hydralazine
FEVE#
Defined at T>38.5C, 101.3F and in neutruopenic, organ transplant and
dialysis patients, T>38.0C, 100.4F
1. The diIIerential diagnosis is broad:
InIection (lung, heart, brain, urine, sinuses, prostate, abdomen,
skin, lines)
InIlammation (collagen vascular disease, neoplastic disease)
Blood product reaction
Drug Iever (beta-lactam antibiotics, amphotericin and
chemotherapy are Irequent oIIenders)
PE or DVT
Neurologic (spinal cord injury, ICH, seizures, subdural
hematoma)
Endocrine (adrenal insuIIiciency, thryotoxicosis)
Misc (Aspiration, atelectasis, hematoma)
2. Determine whether the pt is stable or unstable (i.e., look at other
vital signs and examine the pt). ESP. Monitor BP and RR;
hypotension~sepsis; tachypnea~early sign oI sepsis. II unstable
and you think an ICU transIer may be in order, call the SMR.
3. Take a Iocused H&P. Remember drug allergies!
. Determine whether additional studies to rule out the above Dx
are indicated (e.g. CXR, U/A w/micro, UCx, sputum Cx).
5. Determine whether BCx have been drawn within 2 hours. II so,
there is generally no need to draw additional cultures.
. II your suspicion oI inIection is high, determine iI antibiotics
should be started. However, it is tricky starting new drugs on pts
unless your signout card speciIically gives you some choices. II
you're unsure, consult the SMR.
. II pt is neutropenic w/Iever - start ceItazidime (Ior pseudomonal
coverage), consider starting vanco Ior gram
coverage. (Neutropenia absolute neutrophil count 500; ANC
WBC* |(PMN/100 band/100)|). Be sure pt has neutropenic
precautions written.


LOW U#INE OUTPUT
1. DO NOT just automatically give Lasix - examine patient Iirst.
Normal UOP is typically at least 0.5 ml/kg/hr. Oliguria is deIined
as UOP 00 ml/day, and anuria is 100 ml/day.
2. First, do you believe the numbers?
iI pt has a Foley, Ilush tubing to make sure it is not clogged.
look Ior daily weights .
3. Examine the pt and assess volume status. Important areas to
examine:
mucous membranes, skin pallor/dryness, edema, complaints oI
thirst
neck veins (to assess CVP), crackles in lungs (pulmonary edema)
bladder palpable on abdominal exam
prostate exam
. Rule out obstructive uropathy by checking a post-void residual
(!V#) by inserting Foley aIter pt voids (important even iI the
nurse says the pt voided a large amount). II volume ~ 200 ml then
leave the Foley in; this indicates signiIicant residual bladder
volume indicating urinary retention. Some reasons Ior urinary
retention include BPH, anticholinergic side-eIIects oI medications
(narcotics, Benadryl, anesthetics, etc.).
5. Renal Iailure is caused by prerenal, renal, and postrenal
causes. Many laboratory indices exist to diIIerentiate these (see
section under #enal) but iI pt is not volume overloaded or
obstructed and has no history oI CHF then a Iluid challenge is
usually appropriate (250 500 ml NS IV bolus). II they respond,
however, your job isn't quite done yet. Do the workup described
under the #enal section.
. II pt is in CHF or is volume overloaded, initiate diuresis.
Though pointless iI NOT truly volume overloaded.
Pts with working kidneys and overaggressive hydration usually
will diurese themselves just by lowering the IV Iluid rate
II in CHF or with symptoms, use Lasix 20 - 0 mg IV (dose
depends on prior use oI Lasix)
II in renal Iailure, may require dialysis. Sometimes people in
renal Iailure can still respond to high dose Lasix while
waiting Ior hemodialysis (10-20 mg IV). II a patient with
declining renal Iunction has a very low urine output, consider
checking the serum potassium level to make sure they are not
hyperkalemic Irom anuria.
DYSPNEA
1. ifferential x (5 major categories oI disease to consider)
A. !ulmonary
PNA - cough, Iever, sputum
Pneumothorax - acute onset, pleuritic CP. Consider in any
intubated pt.
PE - oIten diIIicult to rule in or out by Hx/exam. Consider this
early.
Aspiration - common problem in patients with decreased LOC.
Bronchospasm - can occur in CHF, pneumonia as well as
asthma/COPD
Upper airway obstruction - oIten acute onset, stridor/Iocal
wheezing
ARDS - usually in pts hospitalized with another Dx (e.g. sepsis)
B. Cardiac
MI/ischemia - dyspnea can be an anginal equivalent
CHF - common in elderly pts on IVF, or due to ischemia
Arrhythmia - can cause SOB even without CHF/ischemia
Tamponade - consider when pt has signs oI isolated R heart
Iailure
C. etabolic
Acidosis - pts become tachypneic to blow oII CO2 in
compensation
Sepsis - dyspnea can be an early, non-speciIic sign oI systemic
inIection
D. Hematologic
Anemia - easy to miss this by history/general exam
Methemoglobinemia - rare; consider in pts taking dapsone or
certain other meds with cyanosis/low sat, nl pO2
E. !sychiatric
Anxiety - common, but a diagnosis oI exclusion!
2. Evaluation of the !atient
History: you need to know about the acuity of onset oI dyspnea,
any associated $x (cough, CP, palpitations, Iever), any new
events or meds given (including IV Iluids!) around the time
oI onset, as well as the relevant !H and admitting
diagnosis.
!hysical exam: start with the vitals. You should ask Ior these
(including a sat) as soon as you hear that the pt is
complaining oI SOB; this will help you decide how quickly
you need to respond (and/or call your resident Ior help!). A
good lung exam Ior wheezes, rales, stridor, symmetry oI
breath sounds, as well as a Iull cardiac exam with attention
to JVP, carotids, rate/rhythm, and murmurs or rubs are
crucial. Remember that adventitial lung sounds may be
absent in someone with severe airIlow limitation. Look at the
extremities Ior edema (unilateral vs. bilateral) and perIusion
(cool vs. warm, cap reIill, cyanosis). The mental status is
important because it gives you an idea oI cerebral O2
delivery; iI the pt is mentating poorly, consider intubation Ior
airway protection.
abs/studies: CBC, ABG, ECG, CXR. These basic studies
will give you a great deal oI inIormation, and help you sort
out what might be going on with your pt iI it's not clear Irom
the above. Certainly, in any pt you don't know well, you
should almost always get all oI these.
3. Initial anagement
Oxygen: this should be your initial intervention Ior any pt who is
dyspneic. Even CO2 retainers need O2, and it takes longer
than the Iew minutes you need to evaluate them Ior
signiIicant respiratory depression to develop.
Goal is a PO2 ~ 0, or O2 sat ~ 2. II nasal cannula isn't
doing the trick (max FiO2 is ~0), try a Venti mask
(up to 50), Nonrebreather (70), or high-humidity
mask (0). Remember that RTs are your Iriends; call
early iI you're having any trouble; they can help with
nebs, suction, masks, ABGs.
iuretics: consider Lasix in any pt with history or exam
consistent with CHF (also consider in CV pts - look at pre-op
wt); other processes associated with increased lung water
(pneumonia, ARDS) also improve temporarily with diuresis,
and a single dose oI Lasix is unlikely to do any irreversible
damage.
Y-agonists: pts with wheezing Irom any etiology can beneIit
Irom bronchodilators. Wheezing can occur in many
conditions other than asthma (e.g., CHF, pneumonia).
Assess potential need Ior intubation (see Pulmonary section).
Other: once you have the pt stabilized and the results oI your
initial studies, you can initiate therapy directed at the speciIic
etiology oI the pt's dyspnea.

COMATIVE O# CONFUSED PATIENTS
NOTE: Read the document ,7e of P,tients with Rest7,ints
provided by Patient Care Services handed out early in the
year. See also ltered ental $tatus in the Neurology section.
1. Does the pt have AMS Irom a systemic condition or is he/she
upset over something?
2. II there is any question oI physical injury, call security. No
matter how many years oI commando training you have, it is not
your responsibility to restrain pts in a saIe manner.
Also, pts generally tend to calm down when they are conIronted by
overwhelming numbers oI people who are responsive to their
needs or anxieties.
3. Try to do as much oI an altered mental status workup as you can
(see section under Neurology). II you suspect an underlying reason
Ior the agitation (pain, sundowning, hypoxia, medication), then
obviously treat the underlying reason.
. Medications that are oIten useIul (but remember, cannot be
given as a verbal order; go see the patient and an indication must
be written down i.e. agitation):
Haldol 1-10 mg IV/IM/PO (a very versatile drug with minimal
respiratory and CNS depression; use Ior delirium, not as a
"chemical restraint"), watch Ior Qt prolongation
Ativan 0.5 - 2 mg IV/PO (short halI-liIe), may cause increased
agitation in elderly.
Droperidol 2.5-10 mg IV/IM (iI given IM, wait at least 10-15
min Ior its eIIects). Very eIIective Ior the agitated pt.
5. II you Ieel restraints are needed, there is a Iorm that needs to be
completed speciIying the type oI restraint and the reasons Ior
initiating. Restraint orders must be renewed every 2 hrs.
Generally, try to initiate the least restrictive type oI restraint; aIter
all, would you want to be tied down?
Posey vests prevent pts Irom leaving the bed but leave the arms
and legs Iree.
Four point cloth restraints limit the movement oI arms and legs.
They are more restrictive than Poseys but may be necessary
iI patient is pulling out lines.
Can also try mittens to prevent pulling.
II the pt is especially conIused you may need to request (and
insist upon) a sitter.
FALLS
1. Assess pt Ior any injury. Any Iocality on exam must be worked
up in the appropriate manner (e.g. head CT, plain Iilms,
immobilization, etc.).
In particular, look Ior:
Ecchymoses, abrasions, Iractures, pain, asymmetry, deIormity,
decreased ROM.
Look at head, hands, shoulders, hips, knees, Ieet.
Do a complete neuro exam including gait, strength, and
cerebellar tests.
Mental status testing may be necessary iI pt is conIused or
altered.
2. Try to Iind out the circumstances oI the Iall.
Witnessed? By whom?
Loss oI consciousness (does patient remember hitting the
ground)?
Mechanism (getting out oI bed, going to bathroom, standing up,
turning around, etc.)
Associated symptoms (premontory aura, incontinence, dizziness,
headache, visual symptoms, palpitations, chest pain,
dyspnea)
Preceding actions (coughing, urinating, straining, standing
suddenly)
Past medical history (diabetes, heart disease, CVA, sensory
deIicits, Parkinsonism, arthritis, depression, new
medications, prior Ialls)
3. Broad diIIerential diagnosis.
Neuro: seizures, CVA/TIA, gait disorder, Parkinson's, vertigo,
dementia, normal pressure hydrocephalus, poor
proprioception
Cardiac: arrhythmia, MI, vasovagal, hypovolemia, orthostasis
Meds: sedative/hypnotics, antidepressants, vasodilators, alcohol,
diuretics (requiring Irequent trips to bathroom)
Musculoskeletal: arthritis, pain, deconditioning, weakness
Other: anemia, poor eyesight, dim lighting, room change, bed
rails leIt down, wet Iloor
. REMEBER
COLLECT--hx Irom patient and nurses
ORDER--low threshold to order head CT iI the patient hit their
head, loss consciousness or doesn't remember Ialling. II new
Iocal neuro deIicit, head CT is a must. $erial neuro exams
aIter Iall are important to r/o progressive deIicits Irom head
injury (subdural).
DOCUMENT--write a note indicating hx, all involved, tests
ordered and plan. Fill out an incident report.
INSOMNIA
1. Ask nurse to check pt's allergies.
2. Take brieI hx about patient and admission
3. Keep in mind DiII Dx: psychological (anxiety, grieI), physical
(pain), delirium, inIection, metabolic, polyuria, incontinence, sleep
apnea
. Consider patient:
Young patient--generally start with antihistamine, e.g.
diphenhydramine (Benadryl) 25-50 mg or hydroxyzine
(Atarax or Vistaril) 50-100 mg po qhs prn insomnia. Avoid in
elderly. Watch out Ior anticholinergic side-eIIects (e.g. dry
mouth, blurry vision, urinary retention).
Elederly or iI antihistamine ineIIective Ior young--low dose
trazodone. Sedative doses usually 25-50 mg po qhs prn
although some patients may need up to 100-200 mg. Another
possible choice Ior the elderly is risperdal 1 mg po qhs or
Remeron.
II above ineIIective, benzodiazepines are oIten used next. Most
commonly, medium halI-liIe benzos are used such as
temazepam (Restoril) 15 - 30 mg (Iavorite among the
housestaII) or lorazepam (Ativan) 0.5 - 1 mg po qhs prn
insomnia.
5. edication dosing: no72, vs. e/e7 o7 ci77hotic p,tients
Trazodone: start at 50 mg, max 300 mg. II age ~ 5 or () cirrhosis,
start at 25 mg, max 100 mg.
Ativan: start at 0.5-1.0 mg, max mg. II age ~ 5 or () cirrhosis,
start at 0.25 mg, max 1 mg.
Restoril: start at 15 mg, max 30 mg. II age ~ 5 or () cirrhosis, start
at 7.5 mg, max 15 mg.
. II above measures do not work, evaluate pt Iirst beIore giving
more powerIul sedatives. In ANY patient in whom you think
sedation is potentially dangerous (e.g. end- stage liver disease,
severe COPD) evaluate the patient and consider not treating the
insomnia.

INDIGESTION
Some general principles:
Be careIul, some pts misinterpret angina as indigestion.
Avoid Magnesium-containing products in pts with renal
insuIIiciency or Iailure (i.e MOM). Options Ior renal pts:
Amphogel, Allocaps, Tums.
Standard 1st line treatments include MOM, Mylanta, Maalox,
and Tums. Can also consider starting pts on H2-blocker or
proton pump inhibitor (PPI).
PAIN MANAGEMENT update
#emember: as night float, objective is pain control, especially
in patients with chronic pain; if patient is already on certain
pain meds, just consider giving an early dose or additional dose
before starting new pain meds at night, especially in the
elderly
st line:
NSAIDs be careIul in renal insuIIiciency, GIB (h/o ulcers),
thrombocytopenia
Acetaminophen be careIul in pts with liver problems
2nd line:
Start with low doses.
When ordering narcotics, add hold parameters Ior respiratory rate
10 or somnolence
Narcotics cause constipation! Be sure to monitor BMs and
provide adequate bowel regimens Ior pts who are on pain
meds.
1 - 2 mg po morphine equivalent to:
- Tylenol 3 (30 - 0 min)
- Vicodin (hydrocodone/acetaminophen: onset 1h, peak 5h)
--Vicodin 1 tab po q6hours prn mod pain; 2 tabs po q6 prn severe
pain

rd line
5 mg morphine (cautious in elderly, renal Iailure, and
hypotension)
- Percocet (oxycodone/acetaminophen: onset 1h, peak h)
- Roxicodone (oxycodone)
th line (generally for pts with severe, end-stage diseases)
15 mg morphine
- 15 mg po morphine/5mg IV morphine
- Dilaudid mg po
- Roxanol
Conversion Ratios
Morphine PO/V 3:1
Morphine V/DilaudidV 5:1
Morphine PO/Dilaudid PO 5:1
Morphine PO/Hydrocodone 1:1
Morphine PO/Oxycodone 1.5:1
Morphine PO/Fentanyl V 80:1
Nausea
#ash
R/O drug reaction
R/O anaphylaxis
II routine rash/pruritis
Benadryl 50mg po q hours prn (be careIul in elderly pt
can cause delirum, drowsiness and urinary retention)
Or Atarax 50 mg q prn
Steroids cream: low dose TAC
Ranitidine
Anaphylaxis: angioedema, laryngeal edema, bronchospasm, and
hypotension
Support airway and pressure
Call SMR
Epinephrine 0.3mg 0.5 mg IM oI 1:1000
Epinephrine neb 0.25 ml (1:100)
Benadryl 25-50 mg IM/IV
Ranitidine 50mg IV
Solumedrol 100mg IV q
IV Iluids

IV FIuid tabIe

Put a limit on your V fluids. (Ex: NS at 100cc/hr x 2 L. This
way you don't forget to d/c fluid and put someone in CHF.)
Fluid Na Cl HCO
3
Suga
r
NS
(0.9%)
15
4
15
4

D
5
W

50g
/L
LR 13
0
10
9
28



DEATHS AND DOCUMENTATION
Patients tend to die at night. Basically, just as the unit assistant or
RN Ior a death packet, and Iollow all the instructions on the
paperwork.
1. !ronounce ead: Evaluate the patient and ascertain that
it is the correct patient. There are many ways to pronounce a
death, some Ieel Ior a pulse on the wrist, others listen Ior a
heartbeat with a stethoscope.
2. Notify the next of kin and determine whether the Iamily
would like to view the body prior to transport to the morgue. It
may help the Iamily member to inIorm them that the patient
died peaceIully, etc. It may seem a little awkward at Iirst, but
it is very important to determine iI the Iamily would like an
autopsy. Document the answer on the death certiIicate as well
as your note.
3. ill out the death certificate the cause oI death is
notoriously the most diIIicult. UnIortunately
'cardiopulmonary arrest is not a cause oI death, you must be
more speciIic (e.g. renal Iailure caused by sepsis caused by
sternal wound inIection). This is more oI an art than a science
and requires experience. NotiIy senior iI death was
unexpected.
. Call the coroner if: the cause oI death is unknown, or due
to an accident, homicide, suicide, injury, criminal act, hospital
procedure, poisoning, inpatient 2 hours or occupationally
related (the death packet has this inIormation). II in doubt, call
them and run the case by the department.
5. Call Organ Transplant Hotline Ior EVERY death. Many
will not be a possible candidate, but they must be contacted and
a reIerence number is required in the death packet as well as in
the chart.
. Notify the patient`s !, either by voicemail or email.
7. Write a death note in the chart stating your Iindings, time
oI death, the Iact that you contacted (or are trying to contact)
the immediate Iamily, Iamily`s wishes regarding autopsy and
that you notiIied the primary doctor. In addition, as Night
Float or Cross-Cover, you are expected to dictate the death
pronouncement (since you are the one who pronounced death)
a brieI, STAT (type 10) dictation. The primary intern will
dictate a Iull summary in the morning.

CV NIGHT FLOAT NIGHTMA#ES
Lucky Ior you, in 200, the intern night Iloat intern is no longer
responsible Ior the Iresh post-op cardiac surgery patients. This
section remains just in case. you`ll have post-CV patients in the
ICU some time.
Below are things to think about in evaluating each situation.
1. Hypotension overdiuresed, cardiac tamponade (especially iI
anticoagulated), arrhythmia (rapid a-Iib), bleeding, CHF, sepsis.
Place pt in Trendelenburg, start IVF, check a stat hematocrit, stop
heparin (iI on), get an EKG, STAT pCXR, and call the SMR.
2. Hypertension see section above on hypertension #, but also
think about the possibility that the pt`s pain may not be adequately
controlled.
3. ever common causes include inIection and atelectasis. For
inIection, see CV section. For atelectasis, the patient should be
using the incentive spirometer, though personally I have had RT
administer IPPB with albuterol nebs and Iound it to be quite
eIIective.
. Hypoxemia/shortness of breath usually this is due to Iluid
overload, though some oI these pts also had bad lungs to start with
(restrictive or obstructive lung disease). II acute, you need to rule
out pneumothorax (CXR) and cardiac tamponade (echo),
especially iI the BP is dropping. Be sure to look at the med list,
the day`s I/Os, listen to the lungs Ior rales and the presence oI
breath sounds, check Ior pedal edema, look at the post-op weight
gain (all due to IVF). Give more Lasix iI pt appears to need more
diuresis. Give MSO and nitrates iI the BP can tolerate it, as this
will help open up the lungs. Sit the pt up iI this is CHF and the BP
can tolerate it. Atelectasis is also common post-op and initiating
IPPB (call RT to do this) with albuterol nebs qh can also be
helpIul. Some pts may Ieel SOB due to chest wall incisional
pain. II this is suspected, give pain killers and get rid oI the pain!
5. Chest pain ischemia is rare in post-op pts but it can happen.
Any pt who has CP should get an EKG. II there are signs oI acute
ischemia on the EKG, the CVICU person on-call should be paged
immediately. This pt will likely need to go back to the OR
immediately Ior revascularization. Other common problems are
chest incisional pain and pericarditis. Pericarditis has PR
depression and most oI the time will resolve when the pt is placed
in an upright position. Toradol can be given, but should be avoided
in pts who are at high risk oI bleeding or who have a h/o peptic
ulcer disease.
. rrhythmias most commonly this is a-Iib. II the pt is in
stable condition (O2 sat ~ 0 and not Ialling, SBP ~ 0, awake
and arousable), start with digoxin 0.5 mg IVP. Pt should be placed
on the Merlyn machine Ior monitoring. Give the digoxin at least
hour to work. II there appears to be absolutely no eIIect, the SMR
should be called. II it works, continue the loading oI 0.25 mg IVP
q hrs x 2 and start the pt on 0.25 mg po qd iI kidney Ixn is nml, or
none to 0.125 mg po qd iI kidney Iunction is abnormal. II the pt
appears SOB, diaphoretic, requiring high amounts oI oxygen, has
Ialling BPs, page the SMR and the anesthesiologist Ior a
cardioversion. Consider amiodarone Ior medical cardioversion, iI
the pt is stable. You can push IV diltiazem or IV metoprolol to
achieve temporary rate control.
7. Bleeding (Irom chest tube, sternum, SVG harvest site) the
SMR should be paged Ior all bleeds Irom the chest tube and
sternum. Stop all anticoagulation, type and cross blood, order FFP
iI necessary. Order a stat pCXR. Bleeding Irom the SVG harvest
site is seen every once in a while. Usually this resolves over the
Iirst two days. Kerlexes over the site plus the ACE bandage
wrapped tightly usually is enough to cause enough stasis. II the
bleeding appears to be even more prolonged, page the senior.
. Constipation you will get more calls about this at night than
you can imagine. Start with a Dulcolax suppository and make sure
they are on Colace 250 bid. II that doesn`t work, consider Mg-
citrate, because Fleet`s enemas can be traumatizing and diIIicult to
administer.
. !oor urine output most pts are wet and not dry, so Iirst ask
the nurse to Ilush the Foley catheter, then try a dose oI Lasix iI the
pt is not at pre-op weight. II the pt is near or below pre-op weight,
a small Iluid bolus challenge may be given (250 NS). Warning
sometimes a brisk bleed may be Iirst maniIested by poor UOP, so
iI the pt is on anticoagulation and not responding to your
maneuvers, consider a stat Hct.

TACHYCARDIA
1. Is the patient symptomatic or unstable? If so, follow ACLS
protocols, call a resident and get a crash cart into the room
ASAP.
2. Does this merit investigation, 0 has the patient been
tachycardic all week and has this been noted in the regular
teams progress notes?
3. Obtain an EKG and go to examine the patient.
Tachycardias are classified according to whether they have a
regular rate and whether the QRS on EKG is wide or narrow.
They are listed below with diagnostic clues and treatments.
Generally, you will want to call a resident if you want to treat,
since this may involve calling a code.
Narrow QRS, regular rate
1. Sinus tachycardia
A. Multiple causes (pain, anxiety, hypoxia, hypovolemia,
myocardial dysfunction, fever, anemia, meds, pericarditis,
hyperthyroidism, PE, alcohol withdrawal).
B. Compare EKG with priors, if available. Maximum HR = 220-
age.
C. Treat the underlying cause.
2. AV nodal re-entrant tachycardia (AVNRT): more common than
AVRT or AT (see below)
A. Caused by existence of dual AV pathways with differing
refractory periods, with circuit rhythm set off by PAC.
B. Diagnosis: look for isolated R, pseudo S, or inverted P on EKG.
HR typically 180 l 20.
C. Treat with AV nodal block (carotid sinus massage, adenosine,
blockers, Ca blockers, digoxin).
3. AV re-entrant tachycardia (AVRT)
A. Caused by presence of accessory pathway causing large circuit
rhythm.
B. Diagnosis: short RP interval (0 RP < PR interval), retrograde
P wave.
C. Treat with AV nodal blocking (see above).
4. Atrial tachycardia (AT)
A. Caused by enhanced automaticity of atrial tissue or ectopic
atrial pacemaker(s).
B. Diagnosis: long RP interval (0 RP > PR). HR typically <250.
C. Treat with Ca blocker.
5. Atrial flutter with regular block
A. Similar to atrial fibrillation. Usually some heart disease
present.
B. Diagnosis: flutter waves in inferior leads, ventricular rate
some multiple of 300 l 5. When the HR is about 150, always
consider atrial flutter.
C. Treat with cardioversion, AV nodal blocking.
Narrow QRS, irregular rate
1. Atrial fibrillation. See also expanded section in Cardiology.
A. Causes: see expanded section in Cardiology.
B. Diagnosis: relatively straightforward. Look for absence of P
waves and flutter waves in , leads.
C. Treatment: see expanded section in Cardiology.
2. Atrial flutter with variable block
A. Often difficult to distinguish from atrial fibrillation.
B. Look in inferior leads for flutter waves at approximately 300
per minute. May increase AV block transiently with adenosine or
carotid sinus massage to reveal flutter waves.
C. Treat with AV nodal blocking, cardioversion.
3. Multifocal atrial tachycardia (MAT)
A. Caused by multiple ectopic atrial pacemakers. Usually
associated with pulmonary disease. Also seen in
hypomagnesemia, hypokalemia.
B. Look for three distinct P wave morphologies in the same lead
and three separate PR intervals.
C. Treat underlying dysfunction--verapamil may be useful.
4. Frequent PACs
ide QRS, regular rate
1. Ventricular tachycardia (VT) ;078:8 supraventricular
tachycardia (SVT) with aberrancy. Aberrancy refers to either
dysfunction of the His-Purkinje system or presence of an
accessory pathway.
2. Given the seriousness of VT, in any patient with heart disease
with a wide QRS tachycardia you must assume VT until proven
otherwise. See ACLS section for treatment.
3. The Brugada criteria (see Cardiology section) is a useful tool to
distinguish VT from SVT with aberrancy.
ide QRS, irregular rate
1. VT ;078:8 atrial fibrillation with aberrancy. Actually, any
condition causing an irregular rate in the presence of aberrancy
will cause this.
2. Generally treated with cardioversion, either electrical or with
procainamide.