Situation in hospital - what do u do

[sozme]

Case 1


Well I read this thinking, hmm seems like a commonplace scenario.... yet I dont know wtf to do. Im about to graduate later this year and I dont think I would have much of a clue how to handle this... other than: examining and trying to arouse her, and if unsuccessful give Narcan. Hopefully she responds.... If not....... uh then... idk... intubate her? CT scan? CMP??

I mean honestly it seems like a straightforward situation , but I'm sure its more complex than this. So what is the appropriate course of action in a situation like this?
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EDIT: Here is the full prompt and questions -

64-year-old chronic smoker hospitalized for a knee replacement. As part of the orthopedic care protocol, she receives 2 L O2 per nasal cannula and a patient-controlled analgesia pump with morphine postoperatively. Although she initially does well, a rapid response call is made on her on her second postoperative day when the nurses find her unresponsive. Vital signs are normal, as is a blood glucose check done at bedside.

1. What are your immediate orders to the nurse over the phone?
2. What is the most likely diagnosis based on the history? What is the definitive treatment for this problem?
3. Assuming you are the only physician responding, how will your management proceed? (Be detailed and list various contingencies).

SUMMARY

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[VisionaryTics]

I was reading a neat little book called "Resident Readiness - Internal Medicine."
There was this scenario in there, presumably something realistic that would happen on night float.
The scenario was pretty much as follows:

60-something woman who smokes a bazillion packs per day is in hospital for knee replacement. She is placed on 2 L/min LFNC and PCA with morphine post operatively as part of "orthopedic care protocol." Said lady does well initially but at 2:30am, nurse find her unresponsive and rapid response is called. Her vital signs are normal and POC glucose at bedside is also normal. You are the responding intern, what do you do?

Well I read this thinking, hmm seems like a commonplace scenario.... yet I dont know wtf to do. Im about to graduate later this year and I dont think I would have much of a clue how to handle this... other than: examining and trying to arouse her, and if unsuccessful give Narcan. Hopefully she responds.... If not....... uh then... idk... intubate her? CT scan? CMP??

I mean honestly it seems like a straightforward situation , but I'm sure its more complex than this. So what is the appropriate course of action in a situation like this?

Slash cric, initiate cardiopulmonary bypass, Heimlich, emergent hysterography.

What are you learning in med school?

 

[OnePunchBiopsy]

Bedside thoracotomy... works every time.

But seriously, what to do relies on your physical exam when you walk in. Vitals? Airway? GCS? Without seeing/knowing the patient's history there are many directions you could take. Could be anything from a saddle embolus to hyponatremia.

 

[Dr_Rogers_Neighborhood]

Bedside thoracotomy... works every time.

But seriously, what to do relies on your physical exam when you walk in. Vitals? Airway? GCS? Without seeing/knowing the patient's history there are many directions you could take. Could be anything from a saddle embolus to hyponatremia.

Or is it just simply overanalgesia.

 

[Dr_Rogers_Neighborhood]

What you would do chappy is go examine the patient. Do not take nurses word for anything. You always need to run along and have a look for yourself.

Do however ask for vital signs and D-stick on the way, as well as brief history.

In this case, old lady with PCA the most obvious and most likely cause is overanalgesia, and for that you'd use Narcan.

Just for the fun of the exercise, say that doesn't work. Then you'd have to start back at the top, go in and try to arouse her by shouting/pressing on underside of jaw or above the eyebrow (supraorbital) ridge. If her VS show impending arrest, intubate. Even if not, if there is any concern whatever for her ability to protect airway, or adequately ventilate, you'd intubate. Most of the time she would be intubated regardless, except in those extremely rare cases you suspect some underlying problem that is rapidly reversible. For example, person with GCS <8 with acute hypercapnea may respond very quickly to simple BVM, whereas a metabolic encephalopathy not so much.

If glucose is low, you give ampule of D50 (thiamine first if alcoholic or malnourished).
Hypotensive? Might bolus crystalloid (assuming they aren't already volume overloaded)
Tachycardic - EKG, enzymes (would get EKG anyway though)
But no matter what you do as full exam as possible, if shes unarousable to noxious stimuli, then you still need to do dig further. Is she posturing? Does she have pupillary light reflex? Corneal reflex? Does she have papilledema or passive resistance to neck flexion? ? If yes, then immediate non-contrast CT, then LP. If no, still complete other components of the exam.

Other tests that could be ordered in these situations: Stat EKG, ABG, CBC, CMP, Mg2+, phosphate, free ionized calcium, lactate, coagulation panel, troponin. Since she is post-surgical and you know next to nothing about her, maybe TSH/serum free T4. If exam shows any signs of nonconvulsive seizure, then you'd get an EEG.

In reality a lot of this stuff would be handled by a RR team, and the tired ass hospitalist would shot-gun pretty much all that stuff even if the cause was rather obvious.

Also, note how nothing is necessarily "routine." Every situation is unique and requires you to use your brain, not blindly follow an algorithm (or a book in your coat pocket) right off the cliff.

And whatever you do, you'd better see the patient before ordering a bunch of garbage over the phone. You'd be surprised how many times nursing staff will say someone is on death's door only to find them sitting up in bed eating tea and crumpets. The opposite situation also holds, where they don't say someone is sick and they're literally stroking out or already dead. Nurses are great and you'd better not ignore them, but they are very busy and things can slip through the cracks for a lot of reasons.

 

[JamaicanHerb]

The seniors would come and save your ass.

Narcan, ABG, EKG, CMP, CBC, crash cart and get ready to go; this coming from a 4th year that just did his first chest compressions on someone (i know, i literally missed every single opportunity in my old hospital).

 

[Crayola227]

For reals?

I get out my EMRA Top Clinical Problems white coat book

ABCs -
recheck vitals, pulse ox,
"DON'T" coma cocktail - dextrose, O2, naloxone, thiamine
They are getting an EKG even if not tachycardic, they may be having an MI anyway, get troponin
ABG, CMP, CBC, coags, lactate, draw 2 bottles for culture, urinaylsis, wound culture, start broad coverage abx (you don't know enough about this patient, do they have APAP on board post-op [probably] and so they can't mount a fever?),
(remember that a ddimer is worthless as she is post op and your suspicion of PE is quite high at this point)
Have the nurse raise her legs, you haven't defined for me normal for this lady and even if her systolic looks OK at 100, that might be too low to perfuse her brain for consciousness, hang a bag of fluids
You pop all this off on your way over
Rapid Reponse should be called and crash cart
If naloxone was gonna work it should have by now
Do a sternal rub, intubate (if a sternal rub and arterial stab and intubation doesn't rouse her nothing will and she can't protect her airway)
What is baseline MS? Cardiac, neuro, psych, endocrine, renal, infectious hx? You can have a nurse look this up in chart and let you know while you do your thing
Glasgow, any response to pain and is it flex or extension
Examine for signs of head trauma, check pupils, neck stiffness,
Listen to heart and lungs
Rectal
Rest of a coma neuro exam to look for focal deficit, any signs of trauma elsewhere
If focal neural deficit they go for head CT, CXR
Consider FAST scan
Consider TIPS AEIOU - trauma, temp, infxn, psychogenic, stroke, subarachnoid, shock from blood loss, space occupying lesion, alchohol/other drugs (you'd be surprised what patients smuggle in sometimes), electrolytes, endocrine, encephalopathy, insulin, oxygen, opiates, organ failure, uremia
Your exam, chart review and any POC labs, and any response to your interventions above let you eliminate or consider the above more closely and helps guide you if you want to add on the following tests:
Ca, Mg, TSH, ammonia, tox screen or LP

I'm taking an EM approach to this because she could be having an emergency!
The above is complete and systematic in a way that I like, hence why I carry the book.
All of that was on two tiny pages. Keep in mind as you go through the above depending what you find you may skip some elements, you don't have to do all fo the above, but it's nice not FORGET any of the above, and without being an ED doc that does the above assessment enough not to need a book, I like having a book, that said if I didn't have a book, hopefully I can remember the main causes of AMS in elderly and post-op well enough to cover a lot of the above
By god we will find out what is wrong with this lady!

EDIT: my bad. I didn't mean to say FAST exam per se, and in any case is would be closer to the eFAST or extended FAST scan

What I should have said is that there are certain views that can identify some things that that @lymphocyte mentioned, and there's at least two "windows" that can do that

you might be able to see a pericardial effusion, or tamponade, with one of it's views even some findings that suggest a large PE
also, another window can catch stones (I had a patient go down from chole)
it can also catch pneumothorax
there are other things you could look at bedside with it

of course, I mean this if you're stumped otherwise or have high suspicion for these things, but you're likely to use other imaging. Just saying, u/s is a tool in your toolbox

 

[TooMuchResearch]

I was reading a neat little book called "Resident Readiness - Internal Medicine."
There was this scenario in there, presumably something realistic that would happen on night float.
The scenario was pretty much as follows:

60-something woman who smokes a bazillion packs per day is in hospital for knee replacement. She is placed on 2 L/min LFNC and PCA with morphine post operatively as part of "orthopedic care protocol." Said lady does well initially but at 2:30am, nurse find her unresponsive and rapid response is called. Her vital signs are normal and POC glucose at bedside is also normal. You are the responding intern, what do you do?

Well I read this thinking, hmm seems like a commonplace scenario.... yet I dont know wtf to do. Im about to graduate later this year and I dont think I would have much of a clue how to handle this... other than: examining and trying to arouse her, and if unsuccessful give Narcan. Hopefully she responds.... If not....... uh then... idk... intubate her? CT scan? CMP??

I mean honestly it seems like a straightforward situation , but I'm sure its more complex than this. So what is the appropriate course of action in a situation like this?

"she's still breathing and vitals normal? Okay, I'll come see her now."

And just figure the rest out when you get there.

 

[Dr_Rogers_Neighborhood]

The seniors would probably come and save your ass.

Narcan, ABG, EKG, CMP, CBC, crash cart and get ready to go; this coming from a 4th year that just did his first chest compressions on someone (i know, i literally missed every single opportunity in my old hospital).

But you better start thinking of these scenarios beforehand in case they don't. Also, you will one day be the senior, then the end of the line at one point. Residency programs exist out there that still put interns in the ICU at the VA on their first day of residency with the senior available only by phone. It's getting rare, but it definitely does happen.

 

[Dr_Rogers_Neighborhood]

I get out my EMRA Top Clinical Problems white coat book

Is your avatar Starbuck from Battlestar Gallactica?

 

[Crayola227]

Is your avatar Starbuck from Battlestar Gallactica?

Yes it is!!! She is my spirit animal. I won't claim to be as badass as she is, but her and I have quite a bit in common.

 

[cbrons]

Yes it is!!! She is my spirit animal. I won't claim to be as badass as she is, but her and I have quite a bit in common.

She ruined that show.

 

[Crayola227]

She ruined that show.

Fan of the old show or just didn't like where they took the character? No spoilers for the rest of the folk please.

 

[neusu]

What you would do chappy is go examine the patient. Do not take nurses word for anything. You always need to run along and have a look for yourself.

Do however ask for vital signs and D-stick on the way, as well as brief history.

In this case, old lady with PCA the most obvious and most likely cause is overanalgesia, and for that you'd use Narcan.

Just for the fun of the exercise, say that doesn't work. Then you'd have to start back at the top, go in and try to arouse her by shouting/pressing on underside of jaw or above the eyebrow (supraorbital) ridge. If her VS show impending arrest, intubate. Even if not, if there is any concern whatever for her ability to protect airway, or adequately ventilate, you'd intubate. Most of the time she would be intubated regardless, except in those extremely rare cases you suspect some underlying problem that is rapidly reversible. For example, person with GCS <8 with acute hypercapnea may respond very quickly to simple BVM, whereas a metabolic encephalopathy not so much.

If glucose is low, you give ampule of D50 (thiamine first if alcoholic or malnourished).
Hypotensive? Might bolus crystalloid (assuming they aren't already volume overloaded)
Tachycardic - EKG, enzymes (would get EKG anyway though)
But no matter what you do as full exam as possible, if shes unarousable to noxious stimuli, then you still need to do dig further. Is she posturing? Does she have pupillary light reflex? Corneal reflex? Does she have papilledema or passive resistance to neck flexion? ? If yes, then immediate non-contrast CT, then LP. If no, still complete other components of the exam.

Other tests that could be ordered in these situations: Stat EKG, ABG, CBC, CMP, Mg2+, phosphate, free ionized calcium, lactate, coagulation panel, troponin. Since she is post-surgical and you know next to nothing about her, maybe TSH/serum free T4. If exam shows any signs of nonconvulsive seizure, then you'd get an EEG.

In reality a lot of this stuff would be handled by a RR team, and the tired ass hospitalist would shot-gun pretty much all that stuff even if the cause was rather obvious.

Also, note how nothing is necessarily "routine." Every situation is unique and requires you to use your brain, not blindly follow an algorithm (or a book in your coat pocket) right off the cliff.

And whatever you do, you'd better see the patient before ordering a bunch of garbage over the phone. You'd be surprised how many times nursing staff will say someone is on death's door only to find them sitting up in bed eating tea and crumpets. The opposite situation also holds, where they don't say someone is sick and they're literally stroking out or already dead. Nurses are great and you'd better not ignore them, but they are very busy and things can slip through the cracks for a lot of reasons.

I agree with seeing the patient. You need more stimulation than you're describing, a good axillary pinch is the best. The rest of your workup seems appropriate.

 

[lymphocyte]

I was reading a neat little book called "Resident Readiness - Internal Medicine."
There was this scenario in there, presumably something realistic that would happen on night float.
The scenario was pretty much as follows:

60-something woman who smokes a bazillion packs per day is in hospital for knee replacement. She is placed on 2 L/min LFNC and PCA with morphine post operatively as part of "orthopedic care protocol." Said lady does well initially but at 2:30am, nurse find her unresponsive and rapid response is called. Her vital signs are normal and POC glucose at bedside is also normal. You are the responding intern, what do you do?

Well I read this thinking, hmm seems like a commonplace scenario.... yet I dont know wtf to do. Im about to graduate later this year and I dont think I would have much of a clue how to handle this... other than: examining and trying to arouse her, and if unsuccessful give Narcan. Hopefully she responds.... If not....... uh then... idk... intubate her? CT scan? CMP??

I mean honestly it seems like a straightforward situation , but I'm sure its more complex than this. So what is the appropriate course of action in a situation like this?

I disagree with some of the advice above. Why is the new intern intubating? Why not just ventilate with an nasopharyngeal airway? Or a dead-simple LMA at most? And why have the nurse pop the legs up? Why not trade that therapeutically useless maneuver for a diagnostically useful one (like the passive leg raise test)?

For a new intern at a teaching hospital, help is probably on the way (if not, let your resident know immediately after you've done your initial exam and common-sense management). Right now, I'd imagine you basically have three jobs: 1) initiate initial resuscitation as indicated, 2) rule out anything immediately life-threatening and reversible, and 3) organise for the first lot of interventions/tests.

The first pulse to check is your own, and you need a simple, systematic approach. Analysis paralysis and cognitive fixation are major issues here. (Like jumping straight to Narcan... and then... what else?) Have a system so you don't miss silly things. This is what I use (very open to correction or feedback):

ABCDC. Airway, breathing, circulation, disability, and crew-resource management. Look, feel, listen/test, manage for each one. Just circle round those 5 things over and over again in broadening fashion. Treat something immediately life-threatening before moving on. Examination is so key here and will guide everything. There is no one-size fits all solution; but there is a system.

Get the story and then in less than a minute:

Airway. Look for obstruction, oedema (altered mental state can be a sign of anaphylaxis), signs of an unprotected airway, and factors that might make this a difficult to ventilate situation (you don't have to intubate--at least you don't--just ventilate). Feel for tracheal deviation. Listen for wheezes, stridor or rattles. Manage. Crank up the oxygen, slap on the pulse ox, suction if needed, slip in an nasopharyngeal airway with BVM if indicated. Anything immediately life-threatening?

Breathing. Look for tachypnea (RR is a highly sensitive for a PE, just gestalt it), equal chest excursion, diaphoresis, accessory muscles (is this COPDer getting tired?), depth and pattern of breathing (consistent with over-analgesia?), JVP, engorged veins (I've seen one clinically-apparent tamponade s/p cholecystectomy missed initially), chest drains? (are they patent? yes, it's easy to miss the obvious). Feel the chest wall for surgical emphysema or crepitus. Listen for breath sounds bilaterally. Equal air entry? Manage. Check the SpO2. Titrate O2 accordingly or consider a different oxygenation strategy is the sats are abysmal. Try the Narcan. Anything immediately life-threatening?

Circulation. Look at the digits (blue, pink, pale?), if the veins are collapsed, what's going in and out (drugs, drains, bloods, abx, fluids, catheter, whatever--cease whatever you can; check for concealed haemorrhages). Feel if the patient is wet and clammy or warm and well-perfused, what the central cap-refill is, check the BP (narrow or wide PP?), palpate central pulses (bounding or flat?), check the legs for asymmetrical swelling. Listen to the heart. Does the heart sound distant? Murmurs? Rubs? Mange. Check that there's a 14 or 16 gauge cannula in place (much better for volume resuscitation than a central line even). Normal BP is not reassuring, since people can compensate extremely well--until they can't. That's why you have to look at the whole clinical picture. And if you're going to give a fluid challenge, be sure to monitor vitals. This person might not be fluid responsive. Anything immediately life-threatening?

Disability. Now you worry about your neuro stuff (including glucose). The principle is the same, and people have already described a quick exam plus common-sense interventions. Anything immediately life-threatening?

Crew-resource management: Often overlooked. You've done your minute assessment. Now it's time to take control of the team. Point. Be assertive. You, get the ABG and bloods done. You, pop on the FM for this COPD patient or manage the BVM or whatever. You, pop in the 14G cannula. You, get the EKG. You, do X, Y, and Z. Obviously, prioritise based on your clinical exam. And then call your resident.

Reassess. ABCDC. Airway, breathing, circulation, disability, and crew-resource management. Look, feel, listen/test, manage. Keep going and keep thinking but keep going. As you gather more data, you start thinking better. The differentials become more or less likely, and you're being systematic in your approach, and your patient hopefully won't die of something easily reversible, and you can be meaningfully communicative with your resident.

I think the shotgun of tests is pretty routine and in every handbook. I've noticed the better clinicians are systematic in their approach and they see the big picture--which is, initially, to keep air going in and out, and blood going round and round.

 

[Crayola227]

I disagree with some of the advice above. Why is the new intern intubating? Why not just ventilate with an oropharyngeal airway? Or a dead-simple LMA at most?

The point wasn't that the intern is doing the intubation themselves. The point is if the patient is truly not responsive and some simple interventions haven't worked, they can't protect their airway. If a *truly brutal* sternal rub or other arousing manuevers, arterial stab, narcan, haven't got much of a response, that tells me they can't protect their airway. If they vomit, I can't trust they won't inhale it all and choke to death.

Re: LMA http://emedicine.medscape.com/article/82527-overview#a2

Elective ventilation
The laryngeal mask airway (LMA) is an acceptable alternative to mask anesthesia in the operating room. It is often used for short procedures when endotracheal intubation is not necessary.[1]

Difficult airway
After failed intubation, the LMA can be used as a rescue device.

In the case of the patient who cannot be intubated but can be ventilated, the LMA is a good alternative to continued bag-valve-mask ventilation because LMA is easier to maintain over time and it has been shown to decrease, though not eliminate, aspiration risk.[6, 7]

In the case of the patient who cannot be intubated or ventilated, a surgical airway is indicated and should not be delayed. However, if the LMA is at hand, it can easily be attempted quickly, while an assistant simultaneously prepares for cricothyroidotomy.[5] ​

I was taught by ED docs that LMAs and oropharyngeal airways, when they are indicated, is usually when an intubation is needed. They are helpful for those who are not experienced with intubation to ventilate. They are not so much alternatives to intubation but rather rescue devices.
The oropharyngeal airway and LMA should be considered on an emergent basis for ventilation, the hope being you can reverse the inability to protect their airway quickly, or it is used while you prepare to intubate, or if you're having difficulty intubatng. Intubation is definitive control of the airway, and if you don't make them aspirate getting it in, then you have also protected them from major aspiration. Oropharyngeal airway does not do this. LMA does to some extent but not as well as a tube.

You can always take the tube out. If your other interventions work in the meantime, nothing like a tube to wake someone up, and if the patient gets it together enough to rip it out great. (kidding a little here).

And why have the nurse pop the legs up? Why not save that therapeutically useless maneuver for a diagnostically useful maneuver (like the passive leg raise test)?

I don't know what you mean by diagnostically useful manuveur the passive leg raise. Why do you have to "save" it? Do you mean when you're looking for signs of meningitis?

I would argue it's not a therapeutically useless manuveur as I have had more than one ED attending tell me to always try this (assuming no spinal, pelvic, leg trauma) in these cases. Also, I have seen just this simple manuveur bring someone back around. So that's why.

(Like jumping straight to Narcan... and then... what else?) Have a system so you don't miss silly things.

Or course in the post op patient on a PCA you're going to Narcan. That's a given. Period. In this situation, you can't harm them with it, and by giving repeated doses you effectively rule out opiate overdose.

The rest of your strategy is a bit out of order in my opinion.
You did bring up excellent and specific points for things to look for on physical exam.

But what do I know?

 

[ssttrrbbk]

But you better start thinking of these scenarios beforehand in case they don't. Also, you will one day be the senior, then the end of the line at one point. Residency programs exist out there that still put interns in the ICU at the VA on their first day of residency with the senior available only by phone. It's getting rare, but it definitely does happen.

Yeah I was in peds so no icu in first year but my first code was a congenital heart baby and there was something wrong with the pager system. It was me, a nurse, and a crying nursing student for a complete set of chest compressions, HR came up and we stopped for about 30 seconds, and then had to restart 30 seconds later. The next person came into the code midway through the second set. That being said there wasn't a whole lot of diagnostic uncertainty I knew I had to do what I was doing until someone else came in so we had enough people to intubate and draw up drugs. I would have probably tried to utilize the crying nursing student to go to another floor and grab another resident / attending and really initiate a rapid response had I known that the pager system was down and no one else was going to be coming to help for awhile. I was completely unaware that the page didn't go to the code system though. I'm not even sure if the person who called the operator knew. we discussed it after the fact when I realized my code pager NEVER went off. I found out other people didn't get a page either but somehow heard of the code via a nurse on the floor I think. Interestingly this was not my first or last issue with a code pager and it took a few instances for anyone to take it seriously.

 

[cbrons]

Yeah I was in peds so no icu in first year but my first code was a congenital heart baby and there was something wrong with the pager system. It was me, a nurse, and a crying nursing student for a complete set of chest compressions, HR came up and we stopped for about 30 seconds, and then had to restart 30 seconds later. The next person came into the code midway through the second set. That being said there wasn't a whole lot of diagnostic uncertainty I knew I had to do what I was doing until someone else came in so we had enough people to intubate and draw up drugs. I would have probably tried to utilize the crying nursing student to go to another floor and grab another resident / attending and really initiate a rapid response had I known that the pager system was down and no one else was going to be coming to help for awhile. I was completely unaware that the page didn't go to the code system though. I'm not even sure if the person who called the operator knew. we discussed it after the fact when I realized my code pager NEVER went off. I found out other people didn't get a page either but somehow heard of the code via a nurse on the floor I think. Interestingly this was not my first or last issue with a code pager and it took a few instances for anyone to take it seriously.

This is how hundred + million dollar lawsuits happen.
It's funny that the people who run these big hospital systems will often try to squeeze various physician services by paying them a few thousand less every time contract time comes up, but then they allow stuff like this to happen and it ends up costing them tens of millions if not more.

 

[cbrons]

I disagree with some of the advice above. Why is the new intern intubating? Why not just ventilate with an oropharyngeal airway? Or a dead-simple LMA at most? And why have the nurse pop the legs up? Why not trade that therapeutically useless maneuver for a diagnostically useful one (like the passive leg raise test)?

I think you missed the whole point of the exercise. And interns often do intubate on the floor and in the ED during residency (as do CRNAs, CRNA students, RTs, EMT students, etc.). But regardless, these types of exercises aren't meant to be answered with, "Have someone else do everything" or go off half-cocked with various advanced techniques you heard on EMCrit or read on Lifeinthefastlane

For a new intern at a teaching hospital, help is probably on the way (if not, let your resident know immediately after you've done your initial exam and common-sense management).

See above.

The first pulse to check is your own

 

[lymphocyte]

I think you missed the whole point of the exercise. And interns often do intubate on the floor and in the ED during residency (as do CRNAs, CRNA students, RTs, EMT students, etc.). But regardless, these types of exercises aren't meant to be answered with, "Have someone else do everything" or go off half-cocked with various advanced techniques you heard on EMCrit or read on Lifeinthefastlane


See above.

So you're suggesting an intern without help should intubate an unresponsive patient with spontaneous respiration and normal vital signs? Interesting. What was the point of the exercise again?

And there's a difference between assisting ventilation and a crash airway. Even in a crash airway situation, you should do everything you can to maintain oxygenation before having an amatuer go at intubating. Lots of half-cocked strategies are worth reading up on.

 

[cbrons]

So you're suggesting an intern without help should intubate

What you originally said was, "Why in the intern intubating?" to which I responded that interns do in fact perform intubations.

Lots of half-cocked strategies are worth reading up on.

Ya? Try unilaterally doing one of those things in a U.S. hospital as an intern. Your career will be so utterly destroyed, you'll be lucky to do insurance physicals in ****ing rancho cucamonga.

 

[lymphocyte]

What you originally said was, "Why in the intern intubating?" to which I responded that interns do in fact perform intubations.

Ya? Try unilaterally doing one of those things in a U.S. hospital as an intern. You're career will be so utterly destroyed, you'll be lucky to do insurance physicals in ****ing rancho cucamonga.

1) Yes, interns intubate. You're correct. I meant "why is the new intern intubating in this situation"? What was the point of the exercise again?

2) So, intubating as a new intern without resident support is okay in your book, but assisting ventilation with a BVM + PEEP valve isn't? Is that really so controversial? Interesting. You assist ventilation to buy time, until somebody experienced can intubate, or until somebody experienced can supervise you as the new intern. Fair enough about CPAP or BiPAP or an adjunct or a rescue LMA. I'd imagine you'd want to try every strategy to maximise oxygenation, but I certainly don't want to end up in Rancho Cucamonga. And a crash airway is very different from a difficult airway.

 

[cbrons]

1) Yes, interns intubate. You're correct. I meant "why is the new intern intubating in this situation"? What was the point of the exercise again?

2) So, intubating as a new intern without resident support is okay in your book, but assisting ventilation with a BVM + PEEP valve isn't? Is that really so controversial? Interesting. You assist ventilation to buy time, until somebody experienced can intubate, or until somebody experienced can supervise you as the new intern. Fair enough about CPAP or BiPAP or an adjunct or a rescue LMA. I'd imagine you'd want to try every strategy to maximise oxygenation, but I certainly don't want to end up in Rancho Cucamonga. And a crash airway is very different from a difficult airway.

Do you have aspbergers or something? The prompt says "rapid response was called". That means there is support.

The point was to think about a systematic way of handling a situation where you are in charge. Its a mental exercise. And insofar as you addressed the point of the prompt you didnt add anything beyond what others already have

Sent from my SM-N910P using SDN mobile

 

[lymphocyte]

The point wasn't that the intern is doing the intubation themselves. The point is if the patient is truly not responsive and some simple interventions haven't worked, they can't protect their airway. If a *truly brutal* sternal rub or other arousing manuevers, arterial stab, narcan, haven't got much of a response, that tells me they can't protect their airway. If they vomit, I can't trust they won't inhale it all and choke to death.

Re: LMA http://emedicine.medscape.com/article/82527-overview#a2

Elective ventilation
The laryngeal mask airway (LMA) is an acceptable alternative to mask anesthesia in the operating room. It is often used for short procedures when endotracheal intubation is not necessary.[1]

Difficult airway
After failed intubation, the LMA can be used as a rescue device.

In the case of the patient who cannot be intubated but can be ventilated, the LMA is a good alternative to continued bag-valve-mask ventilation because LMA is easier to maintain over time and it has been shown to decrease, though not eliminate, aspiration risk.[6, 7]

In the case of the patient who cannot be intubated or ventilated, a surgical airway is indicated and should not be delayed. However, if the LMA is at hand, it can easily be attempted quickly, while an assistant simultaneously prepares for cricothyroidotomy.[5] ​

I was taught by ED docs that LMAs and oropharyngeal airways, when they are indicated, is usually when an intubation is needed. They are helpful for those who are not experienced with intubation to ventilate. They are not so much alternatives to intubation but rather rescue devices.
The oropharyngeal airway and LMA should be considered on an emergent basis for ventilation, the hope being you can reverse the inability to protect their airway quickly, or it is used while you prepare to intubate, or if you're having difficulty intubatng. Intubation is definitive control of the airway, and if you don't make them aspirate getting it in, then you have also protected them from major aspiration. Oropharyngeal airway does not do this. LMA does to some extent but not as well as a tube.

You can always take the tube out. If your other interventions work in the meantime, nothing like a tube to wake someone up, and if the patient gets it together enough to rip it out great. (kidding a little here).



I don't know what you mean by diagnostically useful manuveur the passive leg raise. Why do you have to "save" it? Do you mean when you're looking for signs of meningitis?

I would argue it's not a therapeutically useless manuveur as I have had more than one ED attending tell me to always try this (assuming no spinal, pelvic, leg trauma) in these cases. Also, I have seen just this simple manuveur bring someone back around. So that's why.



Or course in the post op patient on a PCA you're going to Narcan. That's a given. Period. In this situation, you can't harm them with it, and by giving repeated doses you effectively rule out opiate overdose.

The rest of your strategy is a bit out of order in my opinion.
You did bring up excellent and specific points for things to look for on physical exam.

But what do I know?

That's fine about intubating. But oxygenation, ventilation, and intubation are different things. And oxygenation always takes priority. There aren't too many "must intubate now" airway emergencies if you can maintain oxygenation, although acute, progressive airway compromise like angioedema would definitely be one of them.

The passive leg raise test is a great dynamic measure for fluid responsiveness. But putting the legs up unfortunately doesn't do very much that's haemodynamically helpful. Having the nurses do it for you will probably ruin your chance to test a critical management strategy. This is literally the most recent paper on the topic: http://www.ncbi.nlm.nih.gov/pubmed/27478966

 

[lymphocyte]

Do you have aspbergers or something? The prompt says "rapid response was called". That means there is support.

The point was to think about a systematic way of handling a situation where you are in charge. Its a mental exercise. And insofar as you addressed the point of the prompt you didnt add anything beyond what others already have

Sent from my SM-N910P using SDN mobile

Help is on the way. You're correct. You have about 5 minutes to do something useful. So what's your plan? Other than a pretty routine shotgun of tests you can find in any handbook. The question posed was: "You are the responding intern, what do you do"? I think the best thing to do is to examine the patient yourself in a systematic, management-oriented way.

 

[Dr_Rogers_Neighborhood]

I disagree with some of the advice above. Why is the new intern intubating? Why not just ventilate with an nasopharyngeal airway? Or a dead-simple LMA at most? And why have the nurse pop the legs up? Why not trade that therapeutically useless maneuver for a diagnostically useful one (like the passive leg raise test)?

For a new intern at a teaching hospital, help is probably on the way (if not, let your resident know immediately after you've done your initial exam and common-sense management). Right now, I'd imagine you basically have three jobs: 1) initiate initial resuscitation as indicated, 2) rule out anything immediately life-threatening and reversible, and 3) organise for the first lot of interventions/tests.

The first pulse to check is your own, and you need a simple, systematic approach. Analysis paralysis and cognitive fixation are major issues here. (Like jumping straight to Narcan... and then... what else?) Have a system so you don't miss silly things. This is what I use (very open to correction or feedback):

ABCDC. Airway, breathing, circulation, disability, and crew-resource management. Look, feel, listen/test, manage for each one. Just circle round those 5 things over and over again in broadening fashion. Treat something immediately life-threatening before moving on. Examination is so key here and will guide everything. There is no one-size fits all solution; but there is a system.

Get the story and then in less than a minute:

Airway. Look for obstruction, oedema (altered mental state can be a sign of anaphylaxis), signs of an unprotected airway, and factors that might make this a difficult to ventilate situation (you don't have to intubate--at least you don't--just ventilate). Feel for tracheal deviation. Listen for wheezes, stridor or rattles. Manage. Crank up the oxygen, slap on the pulse ox, suction if needed, slip in an nasopharyngeal airway with BVM if indicated. Anything immediately life-threatening?

Breathing. Look for tachypnea (RR is a highly sensitive for a PE, just gestalt it), equal chest excursion, diaphoresis, accessory muscles (is this COPDer getting tired?), depth and pattern of breathing (consistent with over-analgesia?), JVP, engorged veins (I've seen one clinically-apparent tamponade s/p cholecystectomy missed initially), chest drains? (are they patent? yes, it's easy to miss the obvious). Feel the chest wall for surgical emphysema or crepitus. Listen for breath sounds bilaterally. Equal air entry? Manage. Check the SpO2. Titrate O2 accordingly or consider a different oxygenation strategy is the sats are abysmal. Try the Narcan. Anything immediately life-threatening?

Circulation. This one's fun. Look at the digits (blue, pink, pale?), if the veins are collapsed, what's going in and out (drugs, drains, bloods, abx, fluids, catheter, whatever--cease whatever you can; check for concealed haemorrhages). Feel if the patient is wet and clammy or warm and well-perfused, what the central cap-refill is, check the BP (narrow or wide PP?), palpate central pulses (bounding or flat?), check the legs for asymmetrical swelling. Listen to the heart. Does the heart sound distant? Murmurs? Rubs? Mange. Check that there's a 14 or 16 gauge cannula in place (much better for volume resuscitation than a central line even). Normal BP is not reassuring, since people can compensate extremely well--until they can't. That's why you have to look at the whole clinical picture. And if you're going to give a fluid challenge, be sure to monitor vitals. This person might not be fluid responsive. Anything immediately life-threatening?

Disability. Now you worry about your neuro stuff (including glucose). The principle is the same, and people have already described a quick exam plus common-sense interventions. Anything immediately life-threatening?

Crew-resource management: Often overlooked. You've done your minute assessment. Now it's time to take control of the team. Point. Be assertive. You get the ABG and bloods done. You pop on the FM for this COPD patient or manage the BVM or whatever. You pop in the 14G cannula. You get the EKG. You do X, Y, and Z. Obviously, prioritise based on your clinical exam. And then call your resident.

Reassess. ABCDC. Airway, breathing, circulation, disability, and crew-resource management. Look, feel, listen/test, manage. Keep going and keep thinking but keep going. As you gather more data, you start thinking better. The differentials become more or less likely, and you're being systematic in your approach, and your patient hopefully won't die of something easily reversible, and you can be meaningfully communicative with your resident.

I think the shotgun of tests is pretty routine and in every handbook. I've noticed the better clinicians are systematic in their approach and they see the big picture--which is, initially, to keep air going in and out, and blood going round and round.

Trying to image a resident at rapid response saying, "Get me the ultrasound so I can look at her IVC!!

 

[sozme]

So what I have is:

1. Order patient hooked up to telemetry, EKG, and confirm IV access. Then ask for a brief history over the phone en route to bed side. Also ask about other meds she is taking (i.e. benzos, sleeping pills, etc.).
2. Most likely diagnosis is overanalgesia from PCA. This can be reversed with naloxone.
3. Management:

• Arrive at room, look for anything obvious (posturing, clinical signs of immenent cardiorespiratory failure, i.e. tachypnea, tachycardia, acrocyanosis, use of accessory muscles, etc.). Assuming nothing immediately obvious, try to arouse patient by shouting, sternal rub, axillary pinch, etc. Listen/observe for any vocalization, eye opening, limb movement.
• If still unarousable, start with naloxone 0.4mg, repeated q2mins if no response.
• After about 5-6 rounds, if there is still no response, there is likely another etiology at play. Conduct more thorough examination:
  • Perform funduscopic exam, noting any papilledema.
  • Check pupillary or corneal reflexes.
  • Complete non-neurologic exam, especially any surgical incisions or drainage sites.
• If still non-responsive, with normal vital signs, intubate????
• Address abnormal vital sign(s) and abnormalities on initial eval. as follows:
  • Coma w/ Hypotensive and tachycardia: Bolus 500mL LR or 0.90% NS
  • Coma w/ Febrile hypotension, tachycardia: Same as above, non-contrast CT head, followed by lumbar puncture. Blood cultures, empiric antibiotics (basically empiric sepsis treatment)
  • Coma w/ Desaturation: Immediately BVM. If no improvement, then RSI.
  • Coma w/ Hypoglycemia: Thiamine 100mg, then 1 amp D50.
  • EKG signs of ischemia +/- vital abnormalities: Nitropaste? Rectal aspirin? Not sure at all what the appropriate immediate interventions would be.
  • Any focal neurologic symptoms: non-contrast CT head.
  • Any signs of nonconvulsive seizure: EEG.
• Other tests:
  • Arterial blood gas
  • CBC with differential
  • CMP
  • Serum ionized Ca2+
  • Serum Mg2+
  • Serum phosphate
  • Serum lactate
  • Serum osmolarity
  • PT/INR
  • aPTT
  • Troponin T
  • TSH
  • Serum free T4
  • Non-contrast CT head
  • 2-site blood cultures

Need help with pink colored points. Am I missing some stuff? Thanks for the helpful responses.

 

[cbrons]

That's fine about intubating. But oxygenation, ventilation, and intubation are different things. And oxygenation always takes priority. There aren't too many "must intubate now" airway emergencies if you can maintain oxygenation, although acute, progressive airway compromise like angioedema would definitely be one of them.

A person who has recently become comatose cannot be assumed able to protect their airway.

 

[lymphocyte]

A person who has recently become comatose cannot be assumed able to protect their airway.

Genuine curiosity: as the responding intern, would you 1) oxygenate with whatever strategy until help arrives, 2) stick in the ETT, 3) or stick in a LMA as a temporising measure? Suppose non-responsive but spontaneously breathing with normal vitals. Or suppose desatting. Thank you in advance.

 

[cbrons]

Genuine curiosity: as the responding intern, would you 1) oxygenate with whatever strategy until help arrives, 2) stick in the ETT, 3) or stick in a LMA as a temporising measure? Suppose non-responsive but spontaneously breathing with normal vitals. Or suppose desatting. Thank you in advance.

Supraglottic airways including LMAs are not typically appropriate for people with presumed high aspiration risk.

 

[pulmoblast]

You can always take the tube out.

No you cannot always take the tube out.

nothing like a tube to wake someone up,

The easiest way to have an intern kill someone is hand them a laryngoscope and sux.

I don't know what you mean by diagnostically useful manuveur the passive leg raise. Why do you have to "save" it? Do you mean when you're looking for signs of meningitis?

Passive leg raising is a maneuver to assess for fluid responsiveness. Probable has the highest diagnostic accuracy amongst all static and dynamic measures.

I would argue it's not a therapeutically useless manuveur as I have had more than one ED attending tell me to always try this (assuming no spinal, pelvic, leg trauma) in these cases. Also, I have seen just this simple manuveur bring someone back around. So that's why.

N=1.

PCA you're going to Narcan. That's a given. Period. In this situation, you can't harm them with it, and by giving repeated doses you effectively rule out opiate overdose.

You can harm by Narcan. It's called seizures.

But what do I know?

.




Sent from my iPhone using SDN mobile app

 

[lymphocyte]

Trying to image a resident at rapid response saying, "Get me the ultrasound so I can look at her IVC!!

US for fluid resuscitation actually isn't the best. The evidence is mostly against it. Just do a passive leg raise test or consider the patient in the clinical context based on your exam. When I said "veins are collapsed" I mean literally just looking at the person's veins. You get a feel pretty quickly, and if not--good thing you're looking at a bunch of other factors too.

I think in general people tend to overvalue tests and fancy interventions when a history, brief but systematic exam, and some simple therapeutic/therapeutic maneuvers can get you pretty far. At least within the first few minutes on the scene.

I do think bedside ultrasound will one become a component of every rapid response team. Somebody mentioned doing a FAST. Similar protocols are being developed for medical shock situations.

Seif D, Perera P, Mailhot T, Riley D, Mandavia D. Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol. Crit Care Res Pract. 2012;2012:503254.

 

[Poit]

When do I get to learn what to do in these situations? I just finished 1st year and I haven't a clue what any of you are talking about.

 

[lymphocyte]

Supraglottic airways including LMAs are not typically appropriate for people with presumed high aspiration risk.

Anything specific to this scenario? What would you do?

"GCS 8 = intubate" is a mantra from the trauma literature that's sorta diffused throughout the rest of medicine. And even ATLS now recognises the use of LMAs. The 8th edition says: "There is an established role for the LMA in the management of a patient with a difficult airway, particularly if attempts at tracheal intubation or BVM have failed." The Difficult Airway Course teaches something similar. I just don't think an inexperienced or unsupervised intern should be intubating in this situation, especially without trialing optimum oxygenation strategies, even in a crash airway emergency.

There was an interesting prospective observational study about GCS as it relates to need for intubation in the context of poisoning. All of the patients did just fine (= 0 clinically significant aspiration) with proper positioning, suctioning, or an adjunct airway. The only one that required intubation had a GCS of 12. The decision to intubate is a big one, and it requires clinical judgement that can't replaced by simple rules of thumb.

Duncan R, Thakore S. Decreased Glasgow Coma Scale score does not mandate endotracheal intubation in the emergency department. J Emerg Med. 2009;37(4):451-5.

 

[Crayola227]

JFC people.

I only meant that as the intern you should recognize from the start that this lady being out of it means she can't protect her airway, and you should be worried about aspiration, and the definitive control over the airway is intubation. This does not mean that you do it or decide when it needs to be done, it means that you DO SOMETHING RIGHT NOW TO GET SOMEONE WHO CAN DO ADVANCED AIRWAY MANAGEMENT IN THE ****ING ROOM.

Because it's not you, and if she pukes it can all go downhill pretty ****ing quickly. So no, I'm not too excited to do a damn thing that might make her puke. Don't BVM her if she's breathing and satting comfortably on cannula/mask, that can make her puke too. Obviously if oxygenation is needed this is what you'll do. And when I say you, not you at all. It should be a nurse who can BVM her. If they can't, then you want them to go get someone who can while you do it, so you can be hands free again. A lot of being a doctor isn't doing **** yourself, it's knowing what needs to be done and getting other people to do it.

You're right, as the intern there is plenty for you to do on your own in figuring this out, and you don't have any intubation skills.
In my mind, that means 2 things:
1) I need to do stuff
2) I need someone who can intubate
3) how do I get 1 & 2 done simultaneously?
4) delegate - ask the nurse if RRT intubates, ask them to find you someone who can intubate (you can bark it just like that, and bark it at RRT if they're there already or when they come). You should have made sure you knew exactly what senior and what attending you can call on in emergency and expect a response at the beginning of every shift. If not, have the nurse call the attending of record. Have them call the operator and ask for the attending on call. Have them go get the charge nurse if they're totally useless. The charge nurse will know how to get a doctor who can tube.
5) go about everything else people suggested. I just don't rest easy with an unresponsive patient if I don't have someone on getting someone for airway.

You might rest easier when YOU become the person who can do the airway. Until then, you should be puckered until *that* safety net arrives. Not so puckered you're not doing other stuff, just, someone needs to be on getting someone in the ****ing room.

That's great if you're super-confident in your LMA placement skills are up to par and you're sure it's indicated, great.

Sorry when I said "intubate" I didn't mean it as a verb in the most idiotic manner possible. I meant it as something to think about. And by think about, all of the above is what I have either done myself as an Aug intern, or would do now in a similar situation.

 

[Crayola227]

So what I have is:

1. Order patient hooked up to telemetry, EKG, and confirm IV access. Then ask for a brief history over the phone en route to bed side. Also ask about other meds she is taking (i.e. benzos, sleeping pills, etc.).
2. Most likely diagnosis is overanalgesia from PCA. This can be reversed with naloxone.
3. Management:

• Arrive at room, look for anything obvious (posturing, clinical signs of immenent cardiorespiratory failure, i.e. tachypnea, tachycardia, acrocyanosis, use of accessory muscles, etc.). Assuming nothing immediately obvious, try to arouse patient by shouting, sternal rub, axillary pinch, etc. Listen/observe for any vocalization, eye opening, limb movement.
• If still unarousable, start with naloxone 0.4mg, repeated q2mins if no response.
• After about 5-6 rounds, if there is still no response, there is likely another etiology at play. Conduct more thorough examination:
  • Perform funduscopic exam, noting any papilledema.
  • Check pupillary or corneal reflexes.
  • Complete non-neurologic exam, especially any surgical incisions or drainage sites.
• If still non-responsive, with normal vital signs, intubate????
• Address abnormal vital sign(s) and abnormalities on initial eval. as follows:
  • Coma w/ Hypotensive and tachycardia: Bolus 500mL LR or 0.90% NS
  • Coma w/ Febrile hypotension, tachycardia: Same as above, non-contrast CT head, followed by lumbar puncture. Blood cultures, empiric antibiotics (basically empiric sepsis treatment)
  • Coma w/ Desaturation: Immediately BVM. If no improvement, then RSI.
  • Coma w/ Hypoglycemia: Thiamine 100mg, then 1 amp D50.
  • EKG signs of ischemia +/- vital abnormalities: Nitropaste? Rectal aspirin? Not sure at all what the appropriate immediate interventions would be.
  • Any focal neurologic symptoms: non-contrast CT head.
  • Any signs of nonconvulsive seizure: EEG.
• Other tests:
  • Arterial blood gas
  • CBC with differential
  • CMP
  • Serum ionized Ca2+
  • Serum Mg2+
  • Serum phosphate
  • Serum lactate
  • Serum osmolarity
  • PT/INR
  • aPTT
  • Troponin T
  • TSH
  • Serum free T4
  • Non-contrast CT head
  • 2-site blood cultures

Need help with pink colored points. Am I missing some stuff? Thanks for the helpful responses.

Argh, too many words and it loses something, doesn't it?


My AMA ACLS cards say this is "immediate ED general treatment." Adjust it using common sense for the floor and situation.

OK, so EKG c/w ischemia
"MONA" - this is not an all inclusive treatise with citations on the topic
morphine
oxygen
nitro - determine if this is an inferior MI or not, and don't use morphine unless they're having chest pain that is not relieved with nitro
ASA

It says concurrent ED assessment < 10 min
Most, but not all of it, I consider "common sense" for an intern
Check vitals (vitals are vital!), eval oxygen status
Establish IV access
Brief H&P
Review Fibrinolytic checklist & contraindications
Initial cardiac markers, lytes, coags
Portable CX

There's more to the algorithm than this, but it starts to get more complicated so I won't type it.
Get the AMA ACLS cards on Acute Coronary Syndromes & Stroke. Also Cardiac Arrest, Arrhythmia, And Their Treatment. If I was only allowed 2 resources in the hospital it would be these two.

The only thing beyond doing the above for the immediate moment is if you need to give a beta blocker. If someone is having an emergency, and you're an intern and don't know what to do, that would be the thing I would want the most help with.

If you are using certain tools, assuming you're a qualified and have good common sense, you will not only *not* kill patients, you will be helping keep them alive, and you will be doing they by doing simple things and checkboxing. No one is going to say you majorly ****ed up with the things advised to *think* about, and do the ones that seem like safe bets. You don't have to put every order in. You don't have to intubate someone! Do what you are comfortable with. Apply a strategy, and build on it.

Yeah guys, I never knew what to make of the leg thing. I don't really care. It was something docs told me to do that I didn't think would hurt. If it's worthless it's worthless. When you're an intern, you're going to just have to go with what you know or what you're told. There isn't time to pontificate about how much tylenol to give Mrs. Lenchner.
Save that for noon report.

 

[lymphocyte]

Good case. More please!

 

[Crayola227]

Good case. More please!

I'm glad you deleted that post.

 

[lymphocyte]

I'm glad you deleted that post.

Me too. These case discussions can be fraught. Somebody ventures something helpful and everybody jumps on the one bit that they might disagree with. No bueno for learning. I'm really grateful for everybody that's posted.

 

[Mad Jack]

When do I get to learn what to do in these situations? I just finished 1st year and I haven't a clue what any of you are talking about.

You don't learn this stuff in first year, you learn it during the clinical years and residency.

 

[witzelsucht]

When do I get to learn what to do in these situations? I just finished 1st year and I haven't a clue what any of you are talking about.

A lot of these situations are impossible to understand without knowing where in the Kreb's cycle the CO2 comes off (CO2 is important in evaluating respiratory status), and the branches of the brachial plexus (which controls the arm movement for laryngoscopy and intubation) so if you don't follow the conversation, you probably need to review these basic first year items.

 

[QualityProcess]

A lot of these situations are impossible to understand without knowing where in the Kreb's cycle the CO2 comes off (CO2 is important in evaluating respiratory status), and the branches of the brachial plexus (which controls the arm movement for laryngoscopy and intubation) so if you don't follow the conversation, you probably need to review these basic first year items.

Money post. Ive never managed a code or emergency situation personally but when i do ill make sure to have my wikipedia printout of the krebs cycle ready to reference

 

[Promethean]

Well I read this thinking, hmm seems like a commonplace scenario.... yet I dont know wtf to do. Im about to graduate later this year and I dont think I would have much of a clue how to handle this... other than: examining and trying to arouse her, and if unsuccessful give Narcan. Hopefully she responds.... If not....... uh then... idk... intubate her? CT scan? CMP??

You are at the beginning of your 4th year. There is a reason we aren't licensed to practice upon graduation. You aren't expected to know exactly what to do.

That said, it won't be very long before you are expected to know what to do, and working through exercises like these are how you get there.

At least you are getting some of your "deer in the headlights" moments out of the way through hypothetical scenarios and not at the bedside.

 

[Crayola227]

You don't learn this stuff in first year, you learn it during the clinical years and residency.

Christ, I thought this was a PGY1

I watch a lot of forums and sometimes I miss things. Oops.

 

[Law2Doc]

A lot of these situations are impossible to understand without knowing where in the Kreb's cycle the CO2 comes off ...

Funniest thing I've read here in a while - nice.

You might learn some of this stuff in your sub-I's in med school or if you do any ICU rotations. And you'll learn the basics of intubation in the ACLS course you'll take before residency or if you do an anesthesia rotation. But otherwise you learn on the job as an intern, either during the day or while being closely supervised by seniors on your first few calls. After that it's all on you - seniors may be dealing with other patients so don't count on backup. And if you are at a smaller place don't expect to have access to bedside ultrasound or FAST scans on the floors during a code - you'll have a crash cart and nurses, the ability to call a code, and maybe that's it.

While intubation isn't something you should treat lightly and ought not typically be the first thing in your bag of tricks, protecting the airway is extremely important and it's very likely that at some point in intern year you'll be making the decision to intubate, if not actually doing it yourself. Sometimes you'll be wrong -- I had a colleague who as an intern was preparing to intubate and had an anesthesiologist show up late to the code and literally bat the intubation tube out of his hands. I personally during intern year had to wake up an attending to tell her I had intubated one of her patients who was crashing and she was fine with the intubation but less fine with the waking her up part.

You'll learn what to do in various situations based on exam, vitals, history and labs. What you don't want is to try to learn algorithms in a vacuum as an early med student, when, as mentioned, things like the Krebs cycle are your knowledge base. That's not how medicine is practiced and will inevitably bias you in the wrong direction. Working overnight is partly knowledge, partly a dance. By the end of the intern year you'll be pretty good at keeping people alive, at least until the day team shows up.

 

[sozme]

I personally during intern year had to wake up an attending to tell her I had intubated one of her patients who was crashing and she was fine with the intubation but less fine with the waking her up part.

lol

 

[sozme]

a

 

[sozme]

SUMMARY

Obtain brief history from nurse while on phone – especially inquire about any causative medications (i.e. sedatives, opioids, etc.).

• If on high-dose narcotics (i.e. PCA), then:
  • Naloxone 0.4-2mg IM, repeat q2mins if no initial response [If no response after 10mg, consider other cause]
• If insulin dose recently increased:
  • D50 1 ampule [Administer thiamine 100mg before if alcoholic or malnourished]

Ask for full vital signs, POC glucose, EKG, and confirm IV access. Address abnormalities of above as follows:

• Coma w/ hypotension and tachycardia: Bolus 500mL LR or 0.90% NS
• Coma w/ febrile hypotension, tachycardia: Same as above, non-contrast CT head, followed by lumbar puncture. Blood cultures, empiric antibiotics (basically empiric sepsis treatment)
• Coma w/ desaturation: Immediately BVM - call rapid response. If no improvement, then RSI.
• Coma w/ hypoglycemia: Thiamine 100mg, then 1 amp D50.

Upon arrival at bedside:

• Look for anything obvious (posturing, clinical signs of imminent cardiorespiratory failure, i.e. tachypnea, tachycardia, acrocyanosis, use of accessory muscles, etc.)
• Try to arouse patient by shouting, sternal rub, axillary pinch, etc. Listen/observe for any vocalization, eye opening, limb movement.
• If still not responsive:
  • Inspect fundi (papilledema)
    • If any papilledema or focal neurologic signs: STAT non-contrast CT head.
  • Evaluate pupillary, corneal, and vestibuloocular reflexes
  • Do standard exam (minus voluntary maneuvers) – note CSF rhinorrhea, skin findings, resistance to passive neck flexion (meningismus).
• Other tests to order (STAT):
  • Arterial blood gas
  • CBC with differential
  • CMP
  • Serum ionized Ca2+
  • Serum Mg2+
  • Serum phosphorus
  • Serum lactate
  • Serum osmolarity
  • PT/INR
  • aPTT
  • Troponin T
  • +/- Serum ACTH, serum cortisol, serum renin, serum aldosterone (Addisonian crisis)
  • +/- TSH and serum free T4
  • +/- Blood cultures
  • +/- Peripheral blood smear (DIC, TTP)
  • +/- Serum drug concentrations (for specific causative agents)
  • +/- Non-contrast CT head
    • +/- Follow-up MRI head if coma not explained.
    • +/- Follow-up lumbar puncture if mass lesion excluded.
  • +/- EEG (if exam findings suggestive of nonconvulsive seizure)

Bonus consideration - If Initial hospital presentation was to emergency department:
+/- Urine and serum drug screen (including methanol, ethylene glycol salicylates)
+/- Carboxyhemoglobin level

 

[Promethean]

SUMMARY

Obtain brief history from nurse while on phone – especially inquire about any causative medications (i.e. sedatives, opioids, etc.).

• If on high-dose narcotics (i.e. PCA), then:
  • Naloxone 0.4-2mg IM, repeat q2mins if no initial response [If no response after 10mg, consider other cause]
• If insulin dose recently increased:
  • D50 1 ampule [Administer thiamine 100mg before if alcoholic or malnourished]

Ask for full vital signs, POC glucose, EKG, and confirm IV access. Address abnormalities of above as follows:

• Coma w/ hypotension and tachycardia: Bolus 500mL LR or 0.90% NS
• Coma w/ febrile hypotension, tachycardia: Same as above, non-contrast CT head, followed by lumbar puncture. Blood cultures, empiric antibiotics (basically empiric sepsis treatment)
• Coma w/ desaturation: Immediately BVM - call rapid response. If no improvement, then RSI.
• Coma w/ hypoglycemia: Thiamine 100mg, then 1 amp D50.

Upon arrival at bedside:

• Look for anything obvious (posturing, clinical signs of imminent cardiorespiratory failure, i.e. tachypnea, tachycardia, acrocyanosis, use of accessory muscles, etc.)
• Try to arouse patient by shouting, sternal rub, axillary pinch, etc. Listen/observe for any vocalization, eye opening, limb movement.
• If still not responsive:
  • Inspect fundi (papilledema)
    • If any papilledema or focal neurologic signs: STAT non-contrast CT head.
  • Evaluate pupillary, corneal, and vestibuloocular reflexes
  • Do standard exam (minus voluntary maneuvers) – note CSF rhinorrhea, skin findings, resistance to passive neck flexion (meningismus).
• Other tests to order (STAT):
  • Arterial blood gas
  • CBC with differential
  • CMP
  • Serum ionized Ca2+
  • Serum Mg2+
  • Serum phosphorus
  • Serum lactate
  • Serum osmolarity
  • PT/INR
  • aPTT
  • Troponin T
  • +/- Serum ACTH, serum cortisol, serum renin, serum aldosterone (Addisonian crisis)
  • +/- TSH and serum free T4
  • +/- Blood cultures
  • +/- Peripheral blood smear (DIC, TTP)
  • +/- Serum drug concentrations (for specific causative agents)
  • +/- Non-contrast CT head
    • +/- Follow-up MRI head if coma not explained.
    • +/- Follow-up lumbar puncture if mass lesion excluded.
  • +/- EEG (if exam findings suggestive of nonconvulsive seizure)

Bonus consideration - If Initial hospital presentation was to emergency department:
+/- Urine and serum drug screen (including methanol, ethylene glycol salicylates)
+/- Carboxyhemoglobin level

Nice. Thanks for sharing this.

 

[jdh71]

"Inspect fundi"

Lol