Case Approach:

A Resident Guide to Internal

Medicine at UH Case Medical
Center and the Cleveland VA

2015-2016

“The physicians are the natural attorneys of the poor, and

social problems fall to a large extent within their jurisdiction.”
-Rudolf Virchow

001
Program Directors Department of Medicine 33970 Weisman
K. Armitage: 31552 House Staff Pager Roster 2014-2015 33306 Ratnoff
C. Harwell: 36564 ALPHABETICAL Order 33559 Eckel
Ambulatory Chief: 31529 440-562-0509 ORANGE MED 33726 Naff
S. Singh: 440-562-0026 440-562-0491 WHITE MED 32605 Hellerstein
VAMC Chief: 31533 440-562-0502 GREEN MED 32654 Wearn
R. Mourad: 440-562-2465 440-562-0456 BLUE MED 32661 Carpenter
UHCMC Chief Res: 31250 OnCall Pager Douglas Moore :30224 32299 Dworken
Quality Chief: 36644 H Bhavsar 35129 DACR/NACR: 30512
PACS: 35030
Pager Last Name First Name Pager Last Name First Name Pager Last Name First Name

31318 Abdel Rahman Mohamed 33785 Fong Vincent 31815 Nayak Ashwini
31329 Abdul Rahman Rania 36561 Garner Will 38743 Ndubuizu Obinna
30570 Ade Timothy 36556 George Tiffany 31816 Ndum Ogechukwu
33387 Agwu Ogechi 37554 Ghosh Sohini 31595 Newman Tessa
30345 Alabdulkader Assim 35086 Gollamudi Jahnavi 38613 Olasokan Olapeju
39979 Alahmadi Asrar 31585 Graham John 37751 Patel Namrata
30163 Alajali Wissam 36503 Guzman Christina 38797 Patterson Andrew
33658 Aljorayid Abdullah 31663 Hambley Bryan 37317 Peluso Christopher
33481 Al-Kindi Sadeer 33077 Hannah William 37891 Pensiero Amanda
39833 Almasoud Abdullah 37780 Harris Andrew 39287 Poynton Emily
39650 Alotaibi Mona 39499 Hlatshwayo Mati 38567 Prabhakar Dhivya
31340 Alquraini Hussain 37772 Ho Won Jin 38560 Pruthi Dafina
37282 Alsalem Ahmed 37769 Hornick John 38557 Raj Rohit
39947 Alsallom Faisal 36495 Horstman Gabrielle 38575 Rali Aniket
36471 Al-Shathri Ziyad 37759 Hull Leland 35994 Riaz Anum
39866 Alyahya Mossaed 37764 Igboeli Blessing 32134 Richards Sindhu R.
32053 Banks Matthew 37784 Iovleva Alina 35902 Rios Nancy
35859 Barrero Ortiz Andres 37217 Iyer Arun 35781 Rizvi Macym
32030 Barrett Terry 31685 James Christine 35051 Robertson Leanna Marie
37757 Batt Courtney 36587 Jandali Bouchra 31452 Roh Justin
33712 Baydoun Atallah 31699 Jhawar Nupur 38568 Romero Rachel
32018 Berg Michael 37451 Johnson Angela 32008 Sabeh Mohamed
31394 Betbadal Anthony 37351 Jonna James 38573 Sadik Jacob
31899 Bogorodskaya Milana 31711 Kellie Lesley 36023 Selfridge Jennifer

36140 Borinsky Elliott 37788 Khalid Khadieja 32017 Serhal Maya

35945 Bou-Abboud Carine 37522 Khanna Akriti 35658 Shah Ruchi
36109 Bowen Ted 37792 Khetan Aditya 32019 Shah Shenil
36164 Brady Elise Bonnema
36992 Khoury Katia 32023 Shaniuk Paul
36489 Buch Niranjani 36562 Kim Chang 38571 Sharma Rishi
36344 Budnick Susan 31730 Kim Stephanie 35715 Si Xin
36108 Burns Charles 38019 Kleinman Sara 35617 Smith Kimone
36379 Campbell Timica 31734 Koo Patrick 38530 Srivastava Neetika
36492 Chami Ahmad 35503 Kunkel Matthew 38455 Stehouwer Nathan
36199 Chan Megan 31760 Lee Rose 32034 Sullivan John
31424 Chen Dhruti Patel 32755 Lin Paul 38519 Summers Nathan
31450 Christopher Bridgette 31767 Linder Kathleen 38525 Szeto Brandon
36347 Coletta Paul 31771 Linz Christopher 38476 Thakker Prashanth
36415 Couturier Spencer 37329 Lundgrin Erika 32049 Thomas David
31480 Danawala Sejal 31403 Lyles Galina B. 38482 Thorton Gabriel
36184 Das Alvin 32371 Ma Vincent 32063 Tripathi Priyam
31481 Davis Georgia 31780 Madan Shivanshu 35833 Trotter Ashley
31487 Davitkov Perica 37183 Makani Amber 32079 Tuckerman Jason
36330 Dean Chad 32198 Mansoor Emad 35597 Uppal Saurav
36260 Dedhia Nikita 36211 Matto Faisal 32458 Volpe Peter
31488 Demachkie Perihan 31800 Michal Stephanie 35812 Wang Han
36345 Dhatt Roppa 31583 Miller Carlyann 33069 Wentworth Ashley
36384 Diamond Akiva 33106 Miranda Alexander 31258 Wetzel Lindsey
36403 Dickey Trisha 31461 Moini Megan 35958 Yasinow Scott
31742 Drescher Cassandra 31641 Moria Yosra 36398 Younes Ahmad
39370 Duncan Phillicia 37805 Morris Stephen 35832 Zachariah Robin
36152 Durchholz Christina 33101 Morrison Justin 36024 Zande Jonathon
36535 Faramarzalian Ali 36945 Nadeem Fahd 35944 Zhang Andrew
33778 Fatehchand Anodika 31303 Natu Ashwinee 38460 Zhou Ning

002
003
 Table of Contents:

2-3 Resident Pagers by Name, Poster

4 Table of Contents
5 Introduction
6-7 Block Schedule Dates, Residency Calendar
8 Pager Info
9-11 VA Tips and Tricks, CPRS
12-16 Notes, Presentations, Workflow
17 Admission Rules
18-21 DACR/NACR Reference Sheets and Checklist
22-28 Common Night Float Issues (Falls, Hyperglycemia, CP, SOB)
29-32 Radiology
33-40 Eckel/Nephrology and Electrolytes
41-53 Hellerstein/Cardiology and CICU
54-66 Pulmonology/MICU
67-75 Rheumatology
76-84 Ratnoff and Weisman/Hematology and Oncology
85-96 Carpenter/ID
97-104 Dworken/GI
106-109 Endocrinology and DKA
110-112 Palliative Care and End of Life
113-116 Toxicology
117-120 Procedures
121-122 Can I add that on?
123 Best On Call Food Options
124-125 Common Numbers VA and UH Numbers

004
Welcome to Case Western Internal Medicine. We’re glad you’re here. A hallmark of this
residency program is continuous improvement. From Dr. Salata, Dr. Bonomo, and Dr.
Armitage on down, we’re a great place which is always striving to be better. This book is
an effort in that spirit, and it represents a first attempt to give interns a guide in
practicing medicine at Case Medical Center (UH) and the Wade Park VA. This is not meant
as a reference book (the Oxford manuals, Pocket Medicine, and Washington Manual are
detailed references and there is no need to repeat their work). This book attempts to
connect the most common issues on ward and ICU medicine with the nuances of how to
make things happen for your patients at UH and the VA.

This guide is meant to be an evolving document. As such, your recommendations are vital
to maximizing its utility. If you see something wrong, let us know. If something should be
added or removed, we would love your suggestions. To make a suggestion, email
casechiefs@gmail.com with the subject: “Intern Book.”

Lastly, while this book is meant to help guide you through some of the most common
issues in ward medicine, it is no replacement for talking through an issue with a senior
resident. At UH there is always a DACR, MICU and CICU resident, and usually your senior
resident in house during the day. At night, the NACR, MICU, and CICU residents are
always around as well. At the VA, there is always a MICU resident, cardiology resident,
and at least 1 senior ward or night float resident. We love looking at ECGs, calculating
acid/base, and even interpreting ANA panels.

Once again, welcome and good luck. This is a program we love, and we’re glad you’re a
part of it now.

Sincerely,
The Case Western Internal Medicine Senior Residents

Contributors:

Dhruti Chen
Bryan Hambley
Patrick Koo
Katie Linder
Shiv Madan
Greg Nizialek
Andreea Popa
Nathan Stehouwer
Jason Tuckerman

Special thanks to all the individuals who reviewed sections of this book, including Cassie
Kovach, Nathan Summers, Prashanth Thakker, Carine BouAbboud, Jacob Sadik, Jack
Hornick, Peter Volpe, Megan Chan, Akriti Khanna, Akiva Diamond, Amanda Pensiero,
Ruchi Shah, Ashley Wentworth, Paul Lin, and Will Hannah
005
 2015-2016 Block Schedule

Block Intern Resident

Block 1A July1-July 12 July 1-July14
Block 1B July 13-July 26 July 15-July 28
Block 2A July 27-Aug 9 July 29-Aug 11
Block 2B Aug 10-Aug 23 Aug 12-Aug25
Block 3A Aug 24-Sept 6 Aug 26-Sept 8
Block 3B Sept 7-Sept 20 Sept 9-Sept 22
Block 4A Sept 21-Oct 4 Sept 23-Oct 6
Block 4B Oct 5-Oct 18 Oct 7-Oct 20
Block 5A Oct 19-Nov 1 Oct 21-Nov 3
Block 5B Nov 2-Nov15 Nov 4-Nov 17
Block 6A Nov 16-Nov 29 Nov 18-Dec 1
Block 6B Nov 30-Dec 13 Dec 2- Dec 15
Block 7A Dec 14- Dec 27 Dec 16-Dec 30
Block 7B Dec 28-Jan 10 Dec 31-Jan 12
Block 8A Jan 11-Jan 24 Jan 13-Jan 26
Block 8B Jan 25-Feb 7 Jan 27-Feb 9
Block 9A Feb 8-Feb 21 Feb 10-Feb 23
Block 9B Feb 22-Mar 6 Feb 24-Mar 8
Block 10A Mar 7-Mar 20 Mar 9-Mar 22
Block 10B Mar 21-Apr 3 Mar 23-Apr 5
Block 11A Apr 4-Apr 17 Apr 6-Apr 19
Block 11B Apr 18-May 1 Apr 20-May 3
Block 12A May 2-May 15 May 4-May 17
Block 12B May 16-May 29 May 18-May 31
Block 13A May 30-June 12 June 1-June 14
Block 13B June 13-June 23 June 15-June 30
Block Zero June 24-June 30(OFF!!!) -

Holidays:
Thanksgiving: Nov 26-29 (Thur-Sun)
Christmas Dec 24-27 (Thur-Sun)
New Years Dec 31-Jan 3 (Thur-Sun)

*Note: Block 7B senior residents switch on Thur Dec 31st rather than Wed Dec 30th
to fit with the holiday schedule.

006
 Annual Residency Calendar
July
PGY-3’s: Start Your FCVS/Ohio/DEA Credentialling (must have Step 3 score)

August
Fellowship interviews (Late Aug-Early Nov)

September
Grand Rounds begins weekly
Agre Society begins monthly (great food, friends, and some of the most outstanding researchers
at Case Western)
Intraining Exam

October
Interview Season Begins- Monday and Thursday Noon Lunches@ UHCMC and Dinners Sunday
and Wednesday

November
Thanksgiving Holiday

December
Recruitment continues- Noon Lunches@ UHCMC and Dinners
Fellowship Match Day (One of our biggest celebrations of the year)
Christmas and New Years Holidays

January
Recruitment continues- Noon Lunches@ UHCMC and Dinners

February
Morale Week

March
Residency Match Results

May
Department of Medicine Research Day
Bronson’s Day (interns go to a daytime Indians game)
Housestaff Spring Dinner- 4TH Thursday of the Month

June
Future PGY 3 and PGY 2 Retreat
Spring Picnic-First Thursday of the month.
New Intern Orientation
ERAS Fellowship Application process opens
Block Zero: Last week in June. Vacation for outgoing interns, required coverage for PGY-2s and
PGY-3s.

007
 Sending Pages

At UH:
1. Dial “222”
2. Wait for long beep, enter 5 digit pager number
3. Wait for a series of beeps, then enter your extension, followed by a “*” and then your
pager number (the * and your pager tells the other team it’s a physician calling, and they
answer quicker)
4. Wait for short beeps, and then hang up.
If you make a mistake when entering your extension you enter you can hit “*” three times
and start over.
From outside the hospital including the VA: 216-207-7244; then follow the above
directions.

At the VA:
-VA pagers are a 4 digit number. Some consult services (ID, surgery services…) have a set
VA pager, others have a UH pager which may alternate with the resident/fellow on the
service.

1. To page a VA pager, dial 9-440-562-xxxx (enter the 4 digit pager for the xxxx)
2. Enter your number followed by * and then your pager, followed by #
3. If you’re paging a UH pager, it’s 9-207-7244 as above, then the 5 digit UH pager
followed by the same system as above. Even when paging a UH pager, if you enter
your 4 digit extension they’ll know it’s a VA number you’re paging them to.

To find out who is on call

- Go to the VA intranet homepage, select Clinical References -> On-call schedule
- https://vaww.v10.r03.portal.va.gov/sites/cleveland/oncalls/default.aspx

Save these numbers to your phone:

Answering pages at UH: 216-844-5344 then the extension you were paged to. This allows
you to bypass the operator.
Answering pages at the VA: (216)791-3800 then enter the 4 digit extension you were
paged to.
Paging a UH pager: (216)-207-7244

For a frequently updated google doc of UH pagers and extensions tinyurl.com/uhpagers

is a document created by a neurology resident. Usually faster than calling the floor or
operator, and common consult pagers are usually up to date (however services that
change residents/fellows daily will still need to be found through the operator). The VA
intranet is useful as well, as your resident how to log onto it.
008
 Basic Tips and Tricks at the VA

Noon conferences that have food (subject to change!)

Monday, Thursday, Friday (Tuesday = Grand Rounds teleconferenced from UH,
Wednesday = VA M&M)

Getting blood draws urgently:

PCU (2D) nurses can draw labs.
4a and 4b: “Labs on demand” order is how to get urgent labs drawn. This includes blood
cultures.
*You cannot order “timed” labs for non pre-scheduled draw times. If you need something
drawn at 1am, you have to have night float intern order labs on demand at midnight.

CPRS note writing shortcuts

Getting labs and vitals:
Templates  Objects  Wajeehs multi-use objects
For labs not included in WMUO, you can copy-paste them. Coversheetbottom L corner
Recent Lab Results  double click  highlight control+C (right click will not do
anything) control +v in your note.
Forced note templates: H&Ps and progress notes have required boxes. Some of them are
actually not required to start the note fully. You can type a few letters to make the box
happy and then submit.
*Save without signature is a good way to start work and then return to finish later!*
Filtering notes: select “all signed notes”. Two methods:
Highlight medicine notes: Right click custom view  bottom box “where either of”
[x]title [x]subject contain: “medicine”
Show all filtered notes at once (or find notes from another service): select “all signed
notes”. A top box will appear with titles/dates of notes. You can sort by note title, and
therefore find all the Cardiothoracic notes, etc. once you have created your medicine
filter, you can see all the medicine notes only in that box. If you right click again and
choose a new date range it’ll show you unfiltered notes and you can look at that top box
and sort by alphabetical note title.

Add a printer: The first time you sign on to a computer you have to install the printer for
your account on that computer. StartSettingsprinters and faxesadd printer
connect to this printer  \\vhaclefpc1\cle-medw## (number will be labeled on the
printer)

PARKING
You can park in both lots for free. If you want to park in the visitors’ lot, you “have to” get
a parking pass from the police office, but they usually only check in the mornings during
weekdays (ie. Before 9am). If you want to park in the employee lot across the street from
E105 at a time other than in the morning, then you need to get a swipe card. In the
mornings, the gate arms are always up. In the visitors lot, must park on the roof (ensures
our patients have covered parking).

009
Inpatient
Ordering C Diff
Laboratory Quick Orders… -> Inpatient Labs -> All other inpatients -> Clostridium
Difficile
Ordering cytology (ie. On pleural fluid)
Laboratory Quick Orders… -> Pathology Specimen Orders (under Anatomic Pathology) ->
Non GYN Cytopathology -> Cytology Non Gyn Fluids
Consulting Pharmacy to manage the Vanc levels
- Consults -> Standard Consults -> Wade Park Consults -> Inpatient -> W Pharmacy
Consults Inpt -> W Pharmacy Inpt
Type and Screen
- Go through the menu as if you are ordering blood, but don’t actually order blood,
only select the type and screen.
Suicide precaution
Add new order -> suicide/hostile behavior precautions

Outpatient
Ordering Outpatient labs to be done in a future date
Laboratory Quick Orders… -> Outpatient Labs.
Select the appropriate labs.
Scheduling an appointment for your patient in the future for patient you didn’t see
today
From CPRS, go to Tools -> CMT Task Tracker. The first time you do this, you might have
to get authorization.
Select the patient and attention the secretary for your color team in the comments
section.

Scheduling an appointment/checking out patients you see today.

Webpage to see the status of your patient, ie. If they have been checked in or not. Also,
the webpage to check out a patient when you are finished and to schedule a f/u
appointment.

010
https://vhacleapp3.v10.med.va.gov/Cleveland/PatientAppointment/Doctor.aspx
Alternatively, you can go to Tools -> More… -> Patient Appt Check-In
To mail a letter to your patients with results
Normally you would mail your patients a letter with results if the results are normal and
do not warrant a telephone call. Create a new note called: “PATIENT RESULTS LETTER”
and select which lab results you want to mail. When you sign the note, it will
automatically print and get mailed to the patient.
Renal duplex
Consults-> wade park -> surgery -> vascular lab -> click continue -> select renal duplex
*similar format for other vascular labs studies
To forward your alerts to someone
- To forward individually, just click on the alerts and select forward
- If you are going to be away from the VA and want all alerts automatically
forwarded, go to select Tools menu -> Options -> Notifications tab -> Surrogate
Settings button

011
 Admission Orders

UH:
1. First, if the patient not yet listed as on the floor, change the category of orders to
“Pre-Admit on Hold” (a drop down option under ‘session type’ once you enter the
order screen).
2. Start with the “Admission Order Set CMC”. This will have your basic admission dx,
DVT ppx (if desired), vitals, diet, and even IVF and labs if you prefer to place them
within the order set. If you’re entering as pre-admit, click the box telling the RN to
release the orders on arrival to the floor.
3. Complete the medication reconciliation. There is no substitute for talking with the
patient or their family. Doing this right and entering orders through this may take
some time, but getting this right on admission will make discharging much easier.
4. Order any additional medications and imaging you want for your patient.
5. Labs can be ordered to recur daily by clicking the “Repeat” tab in the bottom left
and next to the ‘floor to collect’ tab. If there’s a central line, including PICC and
Mediport, it’s “Floor to collect first AM draw”, if no central line then it’s “Lab to
Collect.” For “Range of Repetition” usually start with 5 or 6 days (if your patient is
in house longer, they may no longer need daily labs). Remember not every patient
needs daily labs, and many labs (coags, LFTs) are rarely needed on a daily basis.

VA:
1. The main difference at the VA is that there are many more admission order sets.
Some work for all patients, some are specific (alcohol withdrawal, NSTEMI…). Talk
with your senior about which order set fits your patient.
2. Reconcile home meds. This is much easier at the VA, highlight the home meds you
want to continue inpatient and then select the “transfer to inpatient” option.
3. Other orders: imaging, diet, new meds for their reason for hospitalization.
4. Remember, if you want to draw troponins to rule out MI in your patient, you need
to call 5573 and ensure they are going to a PCU bed. 4B may soon house a few low
risk CP patients and draw troponins. When that occurs, if a troponin returns
positive the patient should be transferred to the PCU. If you’re concerned enough
to have the patient on a heparin drip, always send them to the PCU.

The History and Physical

Whether at the VA or UH, your patient needs an HPI that accurately assesses their history
and why they came to the hospital, with a clear plan on what your team will do for the
patient.

1) A History of the reason the patient came to the hospital. Many residents use the first
sentence to include important past medical history, but don’t feel obliged to include every
detail here (that will come later). If the patient is here for chest pain, you can tell us “A 54
year old man with PMH of DM II, CAS, LAD PCI x2, who presents with exertional chest
pain.” Then go in to the patient’s description of the pain. Pick your approach, “FAR
COLDER” is one (Frequency, Associated symp, Radiation, Character, Onset, Location,
012
Duration, Exacerbating, Relieving). After you describe the chief complaint, you’ll have
some suspicions. End the HPI by asking the patient some guided questions (did this
happen before your last heart attack? Did you have leg pain and swelling prior to the
chest pain and shortness of breath?...). Other residents should have an idea of your
differential diagnosis based upon the questions you ask.
2)Past Med Hx/Surg Hx
3)Meds (Can cut and paste from your carefully done medication reconciliation)
4)Review of systems (often covered in HPI, add anything else here then say 12 point ROS
complete for the bean counters)
5)Social: smoking/drugs/sexual/living situation/etoh is a start, add add’l pertinent info
6)Allergies
7)Vitals and Physical Exam
8)Labs/Imaging/Studies
9)Assessment and Plan: First give us your differential for the main chief complaint. Then
make a problem based plan. If they are here for chest pain start with that. If they have
diabetes and their insulin will need adjusted while NPO for a cath, add that as another
problem. Chronic issues which are not active can be brief.

10)End every note with prophylaxis and code status (if DNR, ensure this order was
entered into the EMR, at the VA this requires a “DNR Note”)

Oral Presentations:
-For the initial HPI, be able to talk fluidly about why the patient is here and describe their
chief complaint. It’s fine to read their history/meds…
-For the regular morning rounds, have vitals (we need numbers, not ‘stable’), labs if they
are back, and all study results and consult recs from the previous day. Start with
overnight events and vitals, quickly hit your exam (pertinents and anything that
changed). Your assessment is a synthesis of all the information to describe what you
think is causing the patient’s difficulties. Then move quickly to the plan. We’re a program
based on autonomy, have a plan for the day and if it makes sense for your patient that’s
usually what we’ll do.
-We are not a malignant program. Rounds are not about pimping on random facts. The
most important thing is to be able to enter a discussion about what is happening
with your patient and the best next step for their care.

Progress Notes
In the era of duty hours, almost every hospital has a nightfloat based system. These
physicians do not know your patients. Think of your progress notes as updates to the
nightfloat about what happened to your patient that day and what you’re actively doing.
SOAP
S: subjective, update on chief complaint and tell us about any new complaints
O: Vitals, then exam, then labs/imaging/culture data/other studies. Old imaging reports
don’t need listed on every progress note.
A/P: Assessment (first line is the identifier, then paragraph about where you are with
diagnostic and treatment plan for the patient’s chief complaint). The last sentence or two
of your assessment should start with the word “Today” and clearly tell covering
013
physicians ‘Today Mr Jones had a coronary angiogram with PCI to his left circ” or “a liver
biopsy.” If a plan is in place for tomorrow (heart cath?) say it here. Keeping this format
makes it easier for the covering team overnight if your patient is crashing, they can
quickly discover if your patient had a procedure that may drastically alter the differential
(post cath tamponade? Post liver biopsy hemorrhage....).
The plan is again problem based. Some residents like to keep it updated with every detail
for every problem (even non active problems). Others focus on a short description of
changes and progress. Both approaches are fine. The most important thing is to ensure
your plan is up to date. Don’t be the resident that describes the patient as on day 2 of
vancomycin for 3 straight days, or anticipates a renal biopsy which happened 4 days ago.
The last line of every progress note should be the code status (again, if DNR or DNI,
ensure this order has been placed).

Discharge Tips
1. Do the med rec the day before you plan discharge, that way you can discuss
medications on rounds and address any issues. When you preround on the patient
the day of planned discharge, ask if they need any refills and what pharmacy they
want you to e-script it to. Asking this preemptively will save you from going back
multiple times to send another script.
2. Start discharge planning day 1.
3. Plan appropriate follow up with primary care, and if a specific specialty follow up
is needed due to issues during the hospitalization (such as Rheum for new SLE
diagnosis) make that f/u as well.
UH: If you order “Physician Appointment Post Discharge” 1-2 business days
prior to discharge, staff will make these appointments for you at UH, and even add
them to the discharge profile.
VA: Goes through the outpatient consults tabs.

4. Discharge Med Rec

UH: the med rec is a program through the med tabs.
VA: you need to adjust your patient’s outpatient medication list to what you’d like
it to be on homegoing (add any new inpatient meds you’d like the patient to
continue). Then use the CPRS ‘Anticipated Discharge’ note to let pharmacy know
you’re planning on discharging the patient and to take a look at your med list.
They’ll frequently call with issues (if a med isn’t available, interacts with another
med…). Get this in and then give them an hour. After they say they’re good with it
you can move on to the discharge instructions.

5. Discharge Instructions
UH: The Discharge Profile is where you give diet recs, plan PICC line care, list
follow up. If the patient will need facility placement or home care, this is where
those orders go.
VA: The Discharge Instructions note is where the analogous guidance goes.

6. Discharge Summary

014
 UH: The discharge summary is a type of note, and will include some prepopulated
information along with a text box for your summary.
VA: The discharge summary is a special note that appears in a different tab. Some
components are prepopulated, but the general idea is the same. As briefly as
possible you want to communicate to the outpatient physician why the patient
came, what you did, and what you learned. In simple COPD/atypical chest pain
type admissions this can be very brief, as little as 2-3 sentences. For patients with
more issues it will be longer, but remember you don’t have to communicate every
wrong idea you had or study you ordered, use the information you now know to
judge what is pertinent for the outpatient team to know. A quick email to the PCP is
always helpful. All antibiotics should have stop dates.
As a rule discharge summaries done the day of discharge take half the time
because all the information is fresh in your mind.
There are lots of dispo issues which are best learned in person from your senior resident.
Ask them, they’ve done it before and can help save you time.

Daily workflow
“COLD SAND:
AM: PM:
Consults Signout
Orders AM Labs
Labs Note
Discharges Diet

Tips for an Effective Night Float Signout

A good signout should be concise, include only pertinent data, and give a covering
resident a snapshot of the patient’s current clinical status.
1.) Basics that should be included:
a. Identifying information: Name, room, MRN, Age
b. Diagnosis (or working ddx), Pertinent PMHx
c. Brief summary (keep it concise)
d. Tasks for overnight, pertinent issues, guidance for foreseeable situations
e. Is the patient SICK, ICU aware, etc.

2.) Be specific and include parameters:

a. Rather than… follow up on In/Outs  at 9pm, give 40mg IV Lasix if < net -
500cc
b. Rather than… transfuse if Hb is low  Give 2units pRBCs for Hb<7

3.) Try to think ahead about pertinent possible issues:

a. Include recent procedures and any possible adverse outcomes. Eg, ERCP
today, please assess if abdominal pain for post-ERCP pancreatitis.

015
 b. Include appropriate antibiotic coverage if you are watching for an
infection. Eg, Concerned for HCAP. If febrile, get blood cultures, CXR and start
vanc and zosyn.
c. Include things to avoid! Eg, Avoid benzos…Don’t reculture if febrile…Don’t
draw troponins.

4.) Pertinent FYIs:

a. Include FYIs that could be useful. Eg, Neuro exams if abnormal…Pt has
history of HIT… If MICU is aware of patient, may crash
Ways to minimize calls for your peers:
- Don’t forget to update the diet orders if necessary before leaving.
- Include PRN orders for medications (anti-hypertensives, pain meds, etc) when you
admit a patient
- Tell the patient in advance if you are holding/changing home medications. This upsets
patients and often prompts calls to the covering resident.
- Don’t forget bowel regimens for patients getting narcotics. 3am calls for constipation
happen!
- Double check orders are in! If you ask them to follow up on an evening RFP, make sure
it’s ordered.

016
 Admission Rules

• Long call – 3 patients by 7 PM

• Only 1 after 6 PM, 2 after 5 PM
• Medium call – 2 patients by 4 PM
• Short Call:
• UH: 2 Patients (nightfloat admission or ICU transfer) by noon
• VA: 2 Patients (nightfloat or ICU transfer) by 1PM

• Cycle: Long Medium Short HAPPY!

• UH:
• 10 patient cap per intern on all UH ward rotations EXCEPT Ratnoff and
Weisman which cap at 8 (rolling cap, meaning an afternoon discharge opens
up a long or medium admission slot)
• Short call day will cap at 8 (based on number of patients you start with in
AM; not rolling). AI/intern pair cap at 10.
• Teams with 2 Residents: AI/Intern or Intern/Intern paired on same call
schedule cap at 12, except Ratnoff/Weisman where it’s 10.
• With 1 Senior Resident: AI/Intern Pair and Intern/Intern Pair are capped at
10 and 8 (no increase)
• VA:
• Cap = 8 patients per intern all days, Rolling Cap for Long/Medium
• AI/Intern Pair and Intern/Intern Pair cap at 10 (team cap=20)

• Special Circumstances
• Hellerstein, Ratnoff, and Weisman Short will only get 1 patient
• No Eckel Short Admissions
• No team gets weekend short call admissions
• AIs can get new admissions on short call (and increase long call to 4)
• 2 senior time in early months may increase team cap.

*During busy periods or when your team’s attending wants to admit a specific patient to
the team, senior residents should be open to “flexing” on these patients when their team
is capped. It’s paid, it helps the nightfloat, and it keeps patients on the team that will
provide the best care. A win-win-win.

Bouncebacks: Patients do better on teams that know them. Bouncebacks go by team,

even if the intern or resident who worked with them initially if off. If a patient returns
within 48 hours of discharge or MICU transfer, the patient will be a bounceback to the
team and does not count as a new admission. These patients are often our sickest and
keeping them on the same team is a top priority in order to improve the quality of their
care.

017
 DACR/NACR Reference

Medical Nurse Practitioners (35642):

• Preferred Patient: Private pts, elderly with placement/social issues or those many
non-specific, complex general medical problems.
• No ACS rule outs, but syncope on tele is ok. No sickle cell patients or patients that
will need procedures
• 1st priority for early admissions, patients must be on the floor by 5pm
• Have a staff cap of 18 weekdays, 15 weekends.
• On Saturday and Sunday only take nightfloat admissions. Sunday is off for NP’s but
covered by hospitalist-will take night float admits
• Can take ICU transfers that are non-tele
Fang Service [37566] :
• Moonlighting fellows overnight and during the weekend- if they are established
patients of a heart failure attending or Dr. Effron they should be admitted by Fang
or go to their service in the morning.
Hospitalist B pager 36387 and C pager 37166 and D pager 32508:
• Patients without complex social issues and quick turnover. No PRIVATES.
• They have a cap of 12. One pt after 5 and none after 6.
• Cannot take ICU Transfers that have been in the unit >48 hours.
• Can take non-complicated sickle cell patients NOT ON SEIDMAN. If it is a busy
heme-onc night, can put sickle cell on Tower with plan to give to Hospitalists in
AM.
Berger Team pager 36599:
• Heme-onc pts with less complex issues.
• Can admit NF or new patients. Evening hospitalist will admit new. Evening and
overnight coverage may be increasing this year…
Medicine Teams:
• Naff LK 20/Wearn LK 20
-Gen med of all varieties.
• Dworken LK55
-GI cases (luminal); Take established liver patients to a cap of 4 IF approved by
hepatologist who will be primary attending on record
Carpenter Tower 8
-All HIV pts should be on Carpenter – if pt has HIV+ESRD, use your judgment
• Eckel LK 50
-Chronic ESRD on dialysis (if Eckel full, try to flex and put on the team the next day);
-Pts with ARF in ICU followed by renal consult should go to other teams.
-Family Medicine + ESRD go to Eckel -- no exceptions
• Ratnoff (S3) /Weisman (S4)
-Pts with known heme/onc disease followed in SCC. Pts with newly diagnosed cancer
with bx proven diagnosis.
-Some sickle cell pts can go to Gen Med or Hospitalists if Ratnoff/Weisman is full-
need to ask for beds on Tower/LK when this happens

018
 -Bone Marrow Transplant pts go to BMT service (call the fellow 31252) during the
day; staff patients overnight with the fellow

• Geriatrics
-Cap of 8, max of 3 new patients per day
-Target admits are geriatric disorders: falls, polypharmacy, dementia related
admissions
• Hellerstein T5
-All patients with a UH cardiologist and a cardiac issue go to Hellerstein
-Chest Pain, HF patients, CICU transfers; avoid patients with complicated medical
issues who just happen to need telemetry

RULES FOR OTHER SERVICES:

Family Medicine (35111): Ask ED to contact FM for all Bolwell FM patients.
We should not be giving them complex cardiac patients or any complex patient that
is not a Bolwell pt.
- When they are full, NF admits the overflow and then these pts should go to
Family Medicine in the morning. Need to call in the morning and see if
Family Medicine can take their patients back.
- Generally non-Bolwell FP are to go to the Hospitalist service or appropriate
service
- All ESRD (even FP) go to Eckel
For the services below, if the patient truly belongs on their service (the main issue is
neuro or surgical or orthopedic), repeat after me, “We will be happy to take the patient as
long as the ATTENDING does not want to accept the patient.” – THEY HAVE TO CALL THE
ATTENDING AND THE ATTENDING HAS TO REFUSE BEFORE WE ACCEPT. Their note
should specify the name of the attending with whom they spoke.
Neurology:
- Insist that all seizures be seen by neurology before assignment made in ED
Transplant Surgery Day 38447 or Night/Weekend 31330:
- All pts with kidney transplant <1 month MUST go to transplant surgery
- All pts with kidney transplant <1 year, pancreas, liver transplant should go to
transplant surgery service, on a case-by-case basis at discretion of IM transplant
attending (if the patient is on more than steroids for immunosuppression, they should go
to transplant medicine)
- Always call the IM transplant attending if there is a question- they make the call
General Surgery:
- Insist that all SBO and other surgical cases be seen by surgery in ED before assignment
is made – these should go to surgery. If resident refuses, we will take the patient if their
ATTENDING also refuses.
Orthopedic Surgery:
- If pt has orthopedic issue + complex medical issues (e.g. DKA, COPD exacerbation) that
would otherwise be admitted to medicine, then admit to medicine with ortho consult
- If orthopedic issues but stable medical issues, then admit to ortho, but medicine consult
manages all medical issues – see them for “co-management” and see them in a timely
fashion
019
Pregnant patients:
- Pt < 20 weeks – admit to medicine
- Pt > 20 weeks – admit to OB/GYN
EMERGENCY DEPARTMENT ISSUES:
- Call admitting (72400) to coordinate proper bed assignments based on geographic
localization
- Pts can be moved to floor without assignment, pts can be assigned without a bed
- Check on ED board often
- If a pt is a Vet and wants to go to VA, call VA transfer center during day and M.O.D.
(x4433) at night
MEDICINE CONSULT ISSUES:
- When a consult is called overnight, see the pt in a timely fashion and leave at least a
preliminary note (‘full consult to follow’)
- Ortho (or any service) does not need to have question, we co-manage medical issues &
enter relevant orders (same for GU, etc.)
- Pager 31067 is the Code White Nurse- please respond immediately to all level 2 code
whites

Admitting: 26054, 72400 Use the phone to keep in contact with admitting at all times:
Geo LOC!

ER: 43722; 48330

Medical NP Pager: 35642
Medical NP #s: 28418, 28417
Fang pager: 37566
Berger pager: 36599
CHARGE: 32575
CCLHD: 33116
ALHD: 37436
Family Medicine Pager: 35111
UH Chief: p31250; Phone 43621
Dr Armitage: p31552

020
 NACR AM Checklist

Resident NF Checklist:
 Run list with NF team
 Get updated list from NACR (do not use your previous version)
 Assign all housestaff patients and highlight or cross out patient when report
given
 Follow-up with Chief to ensure Fang patients have not been reassigned to
Hellerstein
 Run list with NACR to ensure all housestaff patients assigned

NACR Checklist:
 5AM: obtain intern census from NF interns and write on automated board
printout
 Look on amion to see if any short call Med/Peds interns have clinic and
cross off of automated board (cannot get new patients)
 Copy patients who have not arrived to hospital (from OSH) to book but take
off NACR list
 Run list with NF team twice
 Print out updated list (2 copies for NF residents, 2 copies for Chief)
 Make sure book is updated with all overnight admissions and color in the
box for patients who have been assigned a team. Leave OSH transfers who
have not arrive uncolored (to be assigned when they arrive)
 Run list with NF residents to ensure all housestaff patients have been
assigned
 Add team pagers to the NACR List
 At 8:00 am, the hospitalist will call you to discuss their patients. Write the
assignments (B, C, D) next to hospitalist on the NACR sheet
 Copy all housestaff assignments to today’s automated board
 Fax yesterday’s automated board and today’s NACR sheet to all floors
 When you signout to DACR, make sure they know about new flex patients

Chief Checklist:
 Run list twice with team
 Highlight list for MNP and Berger
 Call Fang to ask about admissions. If they are full, assign to Hellerstein and
update NACR and resident NFs
 If a renal transplant patient was admitted, contact tx team
 If liver patient admitted to Dworken, make sure liver attending accepts
 Add patients to Flex board
 Add patients to each team list
 Go over H&P with medical student

021
 NIGHT FLOAT ISSUES

Congratulations! You’re now on night float (or as we like to think of it, the Wild West of
medicine). You’ll betaking care of 4-5 medicine teams with patients, who will have plenty
of issues in the middle of the night. We’ve tried to compile some of the more common
calls you might get in order to make things a little easier. Don’t forget the NACR or PGY-2
NF are there for assistance.
A fundamental rule is that if you see a patient or change management in a meaningful
way, you should document your reasoning in a clinical event note. This will be
immensely helpful to the day team.

Logistics
- Hours 7p-7a, There will be 2 NF Residents and the NACR (UH) or One NF Resident
(VA)
- Meet in Blue team room (VA) or Tower 5 (UH)
- Signout at 7p and then throughout the night depending on when Long Call finishes.
- Up to you how to split the teams. Generally for a two person NF team, a good split
would be Lakeside (Wearn, Naff, Dworkin, Eckle, Geri) vs. Seidman/Tower (Ratnoff,
Berger, Weissman, Hellerstein, Carpenter).
- You *may* be called to admit patients on busy nights.

General Suggestions on surviving NF

- Biggest issue is to keep organized. Up to you what system helps you to keep
organized.
- Remember to get your senior’s contact info. Don’t hesitate to contact them if you
have questions or feel you need more help!
- Sunday nights there should be pizza in the resident lounge (Lakeside 6th floor)
- In any emergency, first thing to ask is VITAL SIGNS. They are vital for a reason.
This will tell you if the situation is urgent and help direct your next steps of action.
- Help your colleagues get out on time. If your colleagues are swamped, see if, for
example, they can sign out the team to you, so they can just focus on their new
patients.

“Mr. A is acting altered…”

Altered mental status is one of the most common reasons you may be called overnight.
The key to figuring out what to do about it is to figure out the most likely cause (or
causes!) of AMS. Vital signs first, then go through an approach.

We have found “TIPSAEIOU” to be a helpful mnemonic, but feel free to use

your own.

022
T - trauma, toxins
I - insulin (hypo- or hyperglycemia)
P - psychiatric, polypharmacy, pain meds
S - stroke, subdural hematoma, seizures
A - alcohol
E - electrolytes(sodium, calcium), encephalopathy (hepatic)
I - infection
O - oxygen (hypoxia, hypercapnea)
U - uremia

Given that these are your likely possibilities, consider obtaining the following:
• POC blood glucose (the RN can do this for you)
• arterial blood gas
• neurologic exam
• repeat labs including CBC, RFP, lactate (if you think this is indicated)
• blood cultures (if you suspect infection as cause of decompensation)

Ask yourself the following questions:

• is the patient so altered that they cannot protect their airway? (if yes, call Code
White and consider MICU transfer)
• is the patient hemodynamically unstable? (if yes, call Code White and consider MICU
transfer)
• does the patient have new neurologic deficits? (if yes, call BAT team and neurology
will come to your aid at UH). At the VA, activate stroke protocol in CPRS if concerned.
• Has the patient had any medications recently that may cause alterations?
• *BAT and Code White are at UH. At the VA you can call an MNR, but the most
important thing at both hospitals is to talk with the night resident and ICU resident for
the best next steps in caring for your patient.

“Ms. B has a fever.”

In any case of a new fever, it is important to consider infectious etiologies as well as any
non- infectious causes of fever.

Keep in mind:
• fever is defined as a T of 38C over at least one hour, or T of 38.3C once. It is
usually reasonable to recheck T in another hour
Once patient is febrile, you should think to yourself - is this an infection?
• at nighttime, it is SAFER to assume a fever is infectious. Day team can always
narrow antibiotics!
• however, if you feel strongly that this is a non-infectious fever (perhaps patient has
another reason to have a fever, e.g. VTE, lymphoma and appears otherwise well) it
is reasonable to check on the patient in another hour or so and make sure they are
doing well
• DO NOT give any antibiotics without collecting blood cultures (as well as urine and
sputum if possible). If you can’t get access for blood cultures and are suspicious of
infection, go ahead and treat.
023
• IF you choose to give antibiotics, start broad and the team can narrow later.
• If the patient is already on antibiotics, you can consider broadening the spectrum.
• Check med list if you’re concerned for NMS or serotonin syndrome.
• See neutropenic fever section in H/O chapter
• Always check allergies before new abx

Treat fever with acetaminophen if patient is symptomatic OR if fever is dangerously

high, e.g. >40C.

“So Mr. C had a blood sugar of 450 on their bedtime blood glucose check; how
much insulin do you want me to give?”

Typically, patients with DM will have blood sugars checked before meals (for the sliding
scale to be administered) and before bedtime. Since it is common to give patients less
insulin on admission (in order to protect patients from hypoglycemia), patients will often
have higher blood sugars while inpatient.

All sliding scales at UH and the VA max out at 400. If a patient’s blood glucose is >400,
the RN is asked to call the physician to verify dose.

Keep in mind the greatest risk to your patients in the hospital is hypoglycemia, not
hyperglycemia. For most type 2 diabetics who are getting ready for bed and not eating
any more, they don’t need additional insulin for glucose <350 (they need the day team to
titrate their long acting). If it’s >350, determine a single short acting dose based on the
patient’s daytime use. Remember, sliding scale may grossly underdose a long term type 2
diabetic, but may overdose a type 1 diabetic. Know your patient.
Don’t forget to tell the day team the readings so they can adjust the long acting.

024
“Ms. D is complaining of chest pain.”

Chest pain is one of the most concerning calls you may get as a night float intern! The
good news is that a good percentage of the chest pain that occurs in the hospital is
non-cardiac.

Regardless, the following steps should be taken to ensure you don’t miss anything:
• collect a FULL set of vitals
• ask the bedside RN to get a 12-lead ECG (this may have been done for you already)
• obtain an old ECG (this can be done in physician portal tab on left under
cardiovascular system or vista imaging by clicking the ECG tab, or can be done by
looking in the paper chart)

When you see the patient:

• obtain a history of when symptoms started and with what activity; if patient was
walking to the restroom when pain started, you may be more concerned than if
patient was laying flat after eating.
• find out if patient has ever had this pain before. Is this the pain they had that
brought them to the hospital?
• full cardiac exam INCLUDING cardiac auscultation, assessment of JVP, palpation of the
chest wall

If ECG or exam is concerning, discuss with NF senior or with the NACR; they can assist
you in triaging the patient.

You can send a troponin and an AMI panel if you have a suspicion that chest pain is
cardiac. It will likely not influence your overall management since it will take time to
return and since troponin will not increase after acute event for several hours. At the
VA, you will have to move the patient to the PCU to trend troponins. (One time draw
can be done by M&R RN or by labs on demand.)
4B and 5A may soon allow troponins and low risk chest pain.

CARDIAC NON-CARDIAC

stable angina musculoskeletal chest pain

acute coronary syndrome costochondritis
- unstable angina GERD
- NSTEMI lung pathology
- STEMI - PNA
- Dissection - pleuritis
- Pericarditis - PE
cardiac tamponade - Pneumothorax
cardiac vasospasm - Esoph Rupture

025
“Mr. E fell.”

Falls are unfortunately more common in the hospital than we’d like them to be. When
called to assess someone post-fall consider the following:
• how did the fall happen? was it mechanical, or did patient have a seizure or a
syncopal event?
• did patient hit head?
• did patient lose consciousness?
• was patient on anticoagulation?

Post-fall, it is appropriate to conduct a full neuro exam to assess for focal deficits. It
is appropriate to get imaging of the head (non-contrast CT) if patient was on
anticoagulation, if patient hit head, or if patient had loss of consciousness.
The VA has a “Post Fall Assessment” note. At UH use a clinical event note.

“Ms. H is feeling short of breath.”

Acute shortness of breath is another complaint that is nerve-wracking to get in the

middle of the night. First, get a full set of vitals. Is the patient subjectively short of
breath, or are they actually desatting? The big 3 tests of dyspnea: ECG, ABG, and
portable CXR.

If patient is desatting, start oxygen:

NC oxygen —> ventimask —> nonrebreather* —> NIPPV* —> intubation*

Consider ICU transfer for starred options. Remember CPAP

for hypoxia and BiPAP for hypercapnea (more complex than
this, but beyond the scope of this book).

Pulmonary causes of SOB: Pnthx, obstructive (COPD/Asthma/foreign body),

Aspiration, Pulm HTN, ILD, Effusion, DAH, PE, PNA
Cardiovascular causes of SOB: CHF, MI, tamponade/myopericarditis, arrhythmia
Non-Cardio/Pulm causes: Anemia, metabolic acidosis, carboxy/sulph/met-Hgb,
diaphragmatic paralysis (ALS?), Abdominal HTN.

Additional tests to consider: CBC, RFP, D-dimer, CT PE, troponin, BNP

“Mrs. F’s blood pressure is 201/130.”

Hypertension can be either a primary problem mandating hospitalization or can be

secondary to underlying medical conditions. Try to assess why your patient is
acutely hypertensive. Is there a stimulus that can be treated (e.g. pain/discomfort,
anxiety)? Did patient take AM antihypertensives
026 or did they miss these medications
for some reason?

Severe hypertension comes in 2 “flavors”:

• HTN urgency: BP >180 systolic or >120 diastolic WITHOUT end organ damage
• HTN emergency: BP >180 systolic or >120 diastolic with evidence of end organ
damage. Examples of end organ damage might include papilledema, chest pain,
troponin leak, dizziness, altered mental status.
BP should be lowered no more than 25% acutely in order to maintain cerebral
perfusion.

Oral agents are appropriate to use in cases of hypertensive urgency, but not in
hypertensive emergency. Commonly used one-time agents include:
• hydralazine - arteriolar vasodilator, can be given q8h. Beware reflex tachycardia!
Starting dose is often 10mg PO, but this is usually too little and dose can be
increased to as high as 100mg PO tid. IV hydralazine is rarely indicated as it can
cause precipitous drops in BP.
• labetalol - mixed alpha/beta blocker. Start with 100mg PO
• You can give patients their AM medications early if needed!

Commonly used IV agents for HTN emergency include:

• nitroglycerin
• nitroprusside
• nicardipine
These agents are restricted to MICU/CICU and should not be started without
appropriate level of care.

Note at the VA patients need to be in the PCU for IV antihypertensive administration.

“Mr. G is having a lot of pain and he doesn’t have anything ordered.”

Often patients will have some PRN pain meds written but this isn’t enough to treat
their acute pain. First, assess the patient’s pain. Is pain musculoskeletal? Is it
neuropathic? Is it similar to pain that brought them in to the hospital?

Sometimes team will try to restrict certain pain medications (particularly if

concern for narcotic abuse) so check your signout to make sure that the team has
not restricted your arsenal.

027
medication give for caution with dose

acetaminophen mild pain liver dysfunction (2g daily 650mg PO q6h prn; 1g
max in cirrhosis, 3g daily IV q12h prn (IV form
max for normal liver available at VA only)
function)

ibuprofen (NSAIDs) mild to moderate pain, renal or liver failure (could 400-600mg PO q6h prn;
MSK pain precipitate HRS), heart consider prophy PPI
failure, GI bleeding

ketorolac moderate pain, MSK GI bleeding. cannot use 30mg IV q6h (15mg for
pain for >5 days and cannot renal dosing); consider
use while other NSAID prophy PPI
ordered.

tramadol moderate pain Liver and renal failure 50mg PO q6h prn (q12h
(contraindicated in Child C) for renal failure and
cirrhosis
oxycodone moderate to severe pain - 5mg PO q4-6h prn

morphine severe pain renal failure (renally 2mg IV q4h prn,

excreted) increase as tolerated

dilaudid severe pain - start at 0.2-0.4mg IVPB

q3h, increase as
needed

028
 Radiology

Diagnostic Radiology
The department of radiology performs a wide variety of studies such as radiographs, CTs,
MRIs, ultrasounds, fluoroscopic studies, PET scans, and other nuclear medicine studies.
Give radiology a clinical scenario or question and they will provide a more specific read.
M-F 8am to 5pm studies will be read by the individual subdepartments within the
department of radiology. After 5pm on weekdays and on weekends the in-house
Junior Radiology resident (X-rays and CTs) on call can be reached at 32494 and the
Senior Resident (Ultrasound and MRI) can be reached at 32495.
At the VA, after hours radiology reads (after 5PM and on weekends) are available
by calling Valor at 1 800-773-9812.

The American College of Radiology maintains a large database of evidence based

recommendations on the appropriateness of various diagnostic tests broken down by
symptom. These can be found online at ACR.org, click the “Appropriateness Criteria” tab
under “Quality and Safety.”

Specific tips-

Head imaging
- Basic head CTs should be ordered without contrast.
- Brain MRI’s are considerably more sensitive and specific for all types of brain pathology
with the exception of acute hemorrhage. Specify your indication in orders as much as
possible as the exact sequences run will be selected by a radiologist depending on the
indication. In general, any evaluation of a mass requires Gadolinium contrast.

Chest imaging
- CT to exclude Pulmonary embolism requires IV contrast
- CT of chest for other indications generally benefits from IV contrast, but the lung
parenchyma can be evaluated for nodules and masses without should contrast be
contraindicated. There are almost no indications for CT Chest requiring both with and
without contrast.

Abdominal imaging
-Plain radiographs of the abdomen (KUBs) have limited sensitivity for many types of
intraabdominal pathology and a negative KUB does not rule out serious intra abdominal
pathology. Order erect views if you wish to exclude a large volume of free air.
- IV contrast benefits most general CTs of the abdomen. Exceptions include evaluation of
kidney stones and evaluation of intraabdominal or retroperitoneal hemorrhages.
029
- There are several dedicated CT studies of the abdomen including Triple phase liver,
Triple phase kidney, and Triple phase adrenal CTs. These are special protocols to
evaluate masses within these organs and should be specified if required. CT urograms are
also dedicated CTs of the kidneys, ureters, and bladder that administer a higher dose of
radiation and should be specified if required.
- Oral contrast may be positive or negative contrast and is generally decided by the
radiology department. If you have a strong preference for positive oral contrast, include
this in the order. Oral contrast is useful for bowel pathology
- MRI of the liver, pancreas, or kidneys should generally be performed with Gadolinium
Contrast

Caution with Contrast

Contrast induced nephropathy- IV contrast used in diagnostic CTs, angiograms, and

cardiac catheterizations can cause a generally reversible type of acute kidney injury
referred to as contrast induced nephropathy. The largest risk factor for CIN is low GFR at
the time of contrast administration. In patients with very low GFRs who are not on
dialysis, IV contrast may not be appropriate. IV hydration for patients with borderline
GFRs may reduce the risk of contrast induced nephropathy.

Nephrogenic Systemic Fibrosis- IV gadolinum contrast used in diagnostic MRIs can cause
a severe fibrosing disorder in patients with preexisting renal failure. While uncommon
(~400 cases are reported in the literature) NSF is a life threatening condition. Gadolinum
contrast should be avoided in patients with a GFR less than 30. If gadolinium is necessary
in a patient with such a low GFR, dialysis should be considered within hours following
imaging to reduce the risk of NSF (and done 3 straight days thereafter, discuss with
nephrology before the MRI).

Interventional Radiology (Specific for UH, some may apply to VA)

The department of interventional radiology performs a wide variety of procedures using
various methods of image guidance such as ultrasound, fluoroscopy, and CT.

Procedures performed
-Basic image guided procedures such as paracentesis, thoracentesis, and lumbar
punctures
-Ultrasound or CT guided biopsies, drain placements, nephrostomy tube
placements/exchanges, and pleurx catheters.
-Various vascular procedures such as IVC filter placements, vascular embolizations for GI
or other bleeds, TIPS, etc.

030
-Vascular access such as temporary dialysis catheters, tunneled lines such as tunneled
PICCs, dialysis catheters, hickman catheters, and mediports. At the VA tunneled lines are
outsourced and require a travel consult.
-Dedicated PICC nurses place PICC’s and Midline catheters, but not on weekends.

Ordering procedures- At UH, for any questions regarding IR procedures from M-F
7am-5pm contact the interventional radiology nurse coordinator at ex 48290. After
hours and on weekends the senior radiology resident on call can be reached at pgr
32495 and is the contact person for all interventional procedures.
- Lumbar punctures, thoracentesis, and paracentesis orders can be found in the
EMR-
- In the order, try to include whether the procedure is to be diagnostic (only a
small amount of fluid to be removed for analysis) or therapeutic (a larger
volume removed to relieve symptoms).
- Specify the required laboratory studies as certain labs require specific
collection methods. Flow cytometry, cytology, and pH for body fluids
generally require special handling.

- The general order for most other IR procedures is the “Angio Consult for Body”
order in UH Care
- Include the specifics for exactly what procedure you wish performed in the
special instructions section. Ex. Clarify the lesion you wish biopsied, the
fluid collection you wish drained, or what size line you want placed.

- PICC’s and Midline catheters can be ordered in the EMR under the PICC Midline
Placement CMC/Ahuja Order Set. Always order flushes for Midline/PICC.

Procedures checklist- Depending on the procedure, IR will have certain preprocedural

requirements. If you anticipate your patient will require a procedure done by IR the next
morning this list can expedite the process and make sure the IR department will be able to
attend to your patient.

- NPO after midnight- Many IR procedures are performed under conscious sedation
using fentanyl and versed administered by the IR department requiring that the
patient be NPO to reduce the risk of aspiration. If you anticipate your patient will
require general anesthesia, arrangements will need to be made with the
department of Anesthesia, which depending on the urgency, has taken up to
several days to coordinate.
- INR and Platelet counts- In general, INR <1.7 and PLT >50,000 will be acceptable
for any radiology based procedure, but the necessary levels are somewhat
031
 dependent on the attending radiologist performing the procedure and upon the
specific bleeding risk of the procedure. Fresh Frozen Plasma or Platelets, ordered
from the blood bank, may be required depending on these specifics. Often, these
will be ordered by the primary team, but administered by the radiology
department.
- Remember, patients who have an elevated INR due to Coumadin or other
anticoagulation are at a higher bleeding risk than patients with liver disease
causing an elevated INR. Talk with radiology, be sure to differentiate between
Coumadin patients and cirrhosis to avoid unnecessary blood product exposure
(they may still want FFP in cirrhosis for a para, and the team doing the procedure
ultimately makes that call).
- Stopping Anticoagulants and Antiplatelets- Patients on warfarin with a therapeutic
or elevated INR may require FFP prior to the procedure. Heparin drips and other
IV anticoagulants will need to be stopped 4-6 hours prior to many procedures.
Depending on the risk of the procedure, clopidogrel or newer oral anticoagulants
may need to be stopped several days in advance of a nonurgent procedure. The VA
often wants 5-7 days off aspirin/clopidogrel and urgent procedures may require
attending to attending discussion.
- Consent- Consent will be obtained by the radiology department. If the patient is
un-consentable, the radiology department will require contact information for the
POA or next of kin. Providing this information in the order may spare you a phone-
call.
- GFR/Renal Function Labs- Some Vascular procedures, such as IVC filter
placements and GI bleed embolizations, involve the use of IV or arterial iodinated
contrast.
- Head CT for Lumbar Punctures- In general the department of radiology will
require a recent head CT before performing an LP on any patient with impaired
mental status, focal neurological deficits, papilledema, new seizure, or impaired
cellular immunity due to the risk of herniation.

032
 Top 5 Eckel(Nephrology) Admissions

Eckel Basics:
-2 Residents, 4 Interns
-Interns get happy day off

For all admissions the first line of the assessment should be:
“ESRD due to_________, on HD days, at location, via access (nephrologist is ___________, dry
weight is ___________).”

1. Fever during dialysis/infection:

Most likely etiologies of infection – sepsis from line infection!!! Must check all access sites,
when they last had tunneled catheter replaced, etc.
1. Draw cultures peripherally and from dialysis access site (only dialysis RN can do
this).
2. Other causes include pneumonia (HCAP), skin and soft tissue, joint, C diff,
endocarditis.
3. Review recent blood and other cultures. MIC creep with vancomycin is real and
may change the empiric gram positive coverage you start.

Treatment:
1. Use IV antibiotics to cover gram positives for line infection, especially MRSA!
2. If patient has catheter and cultures return positive for pathogen, it must come out
and have “line holiday” for two days prior to re-insertion of new catheter.
3. Culture results with CONS (coagulase neg staph) is often not a contaminant and
must be treated though can often be treated with IV antibiotics and not require
catheter change (talk with ID).
4. Staph and some other organisms require workup for endocarditis/seeding of other
sites (TTE? TEE? MRI for back pain?). Staph aureus in the blood should have an ID
consult.
5. ESRD Vanc dosing: 20mg/kg load followed by 10mg/kg after HD
6. ESRD Pip/tazo dosing: 2.25gm q8h for HCAP, 2.25gm q12h otherwise

2. Shortness of breath due to fluid overload:

Most likely etiology of shortness of breath – fluid overload, interdialytic weight gain. You
can check their weight after last dialysis session in dialysis sheets (call HD unit for this
info) and compare to today’s weight. Most patients have a known “dry weight” (ask the
patient, if they don’t know ask their HD center). Also consider other ddx including acute
hypertensive urgency and flash pulmonary edema, CAD and ischemia (remember more
than 25% of HD patients experience sudden cardiac death).

033
Treatment: if significant weight gain and symptoms, must get dialyzed to get fluid off. If
they have access, call the HD unit (41585) or coordinating nurse (Melissa) to set up HD in
the dialysis unit or in patient’s room if later in evening. If they don’t have access decide if
it’s urgent (hypoxia, tachypnea…). If so, need to go to unit for access and HD. If not, IR in
AM for temporary line (tunneled?) and HD after.
-Few patients make enough urine for diuretics to give significant benefit, but ask them
about urine output and you can try. If GFR<30 HCTZ doesn’t work.
-Afterload reduction for HTN (hydralazine, ACE/ARB if ESRD with normal K)

3. Missed dialysis/hyperkalemia

Most likely etiology of hyperkalemia – usually cause is ineffective elimination (in HD

patients, missed/incomplete HD sessions) or excessive intake (dietary), sometimes
medication induced (think ACEI, NSAIDs, Bactrim). Make sure sample is not hemolyzed
(most common causes of hemolysis is drawing labs via small bore peripheral IV,
traumatizing the cells)! You should be worried with K above 5.3, very worried if K>5.8
with ECG change (peaked T waves, small p waves, increased PR interval, and widening
QRS from baseline). Notably, ECG changes are less sensitive in ESRD.

Treatment: temporary measures including shifting potassium into cells (insulin/D50),

stabilizing cardiac membraines (calcium gluconate or calcium choloride buy you 30-60
minutes). More long acting measures include elimination through hemodialysis (acutely,
especially if ECG changes and high K) or kayexalate to bind potassium in GI tract (should
be used for low levels of hyperkalemia without ECG changes if HD is not readily
available).
On Sundays, HD unit is closed and patients needing urgent HD need MICU tx.

4. No vascular access for HD

Most likely etiology – patient had clotted graft/catheter. There are three types of HD
access that we see primarily:
1) fistula (ideal, less complications, less likely to thrombose or get infected),
2) AV graft (artificial material is used to create access, higher risk of thrombosis and
infection)
3) Central venous catheter with two lumens (tunneled catheters are used for long term
access to reduce risk of infection, other complication includes stenosis and thrombosis).

Treatment: determine when the access was last used, whether it is working at all (talk to
the dialysis center nurse about this, they are immensely helpful!). Examine the fistula for
thrill/bruit or aneurysm (which may need to be repaired). Imaging of AV graft to evaluate
for thrombosis and declottication, vascular surgery usually does this (talk with vascular
the day a nonfunctioning graft/fistula is admitted, in some cases time is essential).
Remember it takes months for a fistula to become functional, plan for the interim as well.
-At UH, Body Angiography Consult for IR for tunneled HD line. Tell them where you want
it.
034
-At the VA, talk with IR, requires planning (and often begging). Tunneled lines are
outsourced.
-If it’s urgent, transfer to MICU at either VA or UH for line and HD.

5. Chest pain + ESRD

Most likely etiology – just like in any other patient, you should be worried about MI,
arrhythmia, PNA. But in ESRD patients, be more worried!! These patients have
significantly higher cardiovascular mortality and any chest pain syndrome should be
taken seriously. Get an ECG, CXR, troponin (if appropriate) and low threshold to monitor
closely on telemetry. Remember ESRD doesn’t cause positive troponins, just lowers their
clearance.
See Cards section on chest pain for more details.

Common ESRD inpatient problems/pages:

Hypertension in AM before dialysis –

Remember these patients are often fluid overloaded and have elevated BP at baseline. BP
before dialysis days tends to be higher, you can look back at their prior admissions/notes
and see the trend. Give the morning medications, make sure they are getting dialyzed
early and having fluid removed. If in the interim BP is >200/100, use PO hydralazine or
PO clonidine (caution with IV hydral for precipitous drops, if needed start with 5 IV).
Make sure you follow up after giving the medications and re-assess the patient for
symptoms.

Hyperkalemia on AM labs –
Is it real or hemolysis? How high is the potassium? Is it higher than 5.8-6.0? Get an ECG,
follow up on next HD session and give calcium/gluconate, insulin/D50 and kayexalate if
HD will not be done urgently. Place patient on telemetry. If there is urgent HD required,
patient may need MICU transfer.

Hypokalemia on AM labs in ESRD –

Remember ESRD patients do not excrete potassium normally unless they make some
amount of urine. So be wary of repleting K as you would in a patient with normal renal
function. In general, if K>3.4, do nothing. If K<3.4 and patient known to have diarrheal
illness, cardiac arrhythmia, etc then replete about half as much as you would for normal
renal function and recheck! Remember, labs drawn in the hours after HD can show
inaccurate hypokalemia as body reaches new equilibrium. Redraw >6 hours later to
confirm a post-HD patient is truly hypokalemic.

Unable to get AM labs –

Many of our patients with ESRD have difficult vascular access from years of attempted
access, inflammatory states leading to venous stenosis, fistulas on multiple extremities. If
labs are not urgent and patient is stable, they can get labs when they go to dialysis unit. If
urgent, consider arterial stick for full panel. If prolonged access issue, patient may need
035
PICC, but this should be discussed with nephrologist as it is placing them at higher risk
for stenotic vessels which may limit future HD access (if you can get away with a midline
instead of PICC, do it).

Acute hypotension, bleeding, sepsis requiring fluid resuscitation –

Patients with ESRD are used to large fluid shifts, however in setting of acute sepsis, large
bleed or hypotension they may require IVF acutely. The major risk of IVF is pulmonary
edema in this population. Start with small IVF bolus (500mL) and monitor clinical status
closely, confirm code status (are they okay with intubation if needed), discuss whether
they still make urine (and would respond to loop diuretic therapy). If blood product
transfusion planned, try to coordinate during HD sessions.

ELECTROLYTES

Hypocalcemia: Long QT, wide QRS, parasthesia, confusion, tetany,

seizures. Remember to correct for low albumin (add 0.8 to calcium for
every 1 decrease in albumin below 4). Remember alkalosis causes
calcium to bind with albumin, causing real hypocalcemia.

Oral Replacement:
Calcium Carbonate tablet 1250–2500 mg (500–1000 mg elemental
calcium) PO TID–QID Recheck serum calcium or ionized serum calcium
daily
Parenteral(IV) Replacement:
Serum Ca(i) Level Calcium GLUCONATE

0.85 – 1 2 grams Calcium Gluconate IV in 100 mL of D5W or NS over 1

hour

< 0.85 3 grams Calcium Gluconate IV in 100 mL of D5W or NS over 2

hours
May repeat serum level 2 hours after the infusion complete. Repeat replacement
boluses as needed.

• Maximum concentration: No maximum concentration; may be given

undiluted in emergency situations
• Maximum infusion rate: Calcium Gluconate 200 mg/min; Calcium Chloride
100 mg/min (in emergency situations)
• Rapid calcium infusions may cause vasodilation, hypotension, bradycardia, cardiac
arrhythmias, syncope, and cardiac arrest.
• Extravasation of calcium can cause serious tissue irritation and necrosis.
Immediately discontinue administration if observed.
• If hypocalcemia and hypomagnesemia coexist, magnesium should be corrected
to avoid accumulation of calcium in muscle cells.
036
• Hyperphosphatemia should also be corrected prior to administering
calcium
Hypercalcemia:

I Signs: "Stones, moans, groans, with psychic overtones"

•Renal: polyuria (that’s why they’re always dehydrated), nephrolithiasis, renal
failure
•GI: nausea, vomiting, constipation
•Neuro: weakness, confusion, coma
•EKG: shortened QT

II Mechanism:
1)increased bone resorption 2)increased GI absorption 3)decreased renal
excretion.

III Etiology:
1. Primary hyperparathyroidism: 85% adenoma, 14% hyperplasia, 1% carcinoma
2. Malignancy:
 PTHrP-mediated: especially with renal tumors and squamous cell carcinomas:
lung, head/neck, esophageal, bladder, ovarian
 Osteoclast Activating Factor: multiple myeloma, lymphoma, leukemia, some solid
tumor mets (e.g. breast cancer)
3. Granulomatous disease: sarcoidosis, fungal, TB (increased 25-OH Vit D)
4. Vitamin D toxicity
5. Milk-alkali syndrome
6. Thiazide diuretics
7. Hyperthyroidism (T3 increases osteoclast activity)
8. Adrenal Insufficiency (Addison’s)
9. Immobilization
10. Familial hypocalciuric hypercalcemia
11. Lithium
12. Estrogens and anti-estrogens
13. Aluminum intoxication

IV: Workup
90% due to hyperparathyroidism or malignancy. Initial labs: Ca, Phos, albumin,
ionized Ca, alkaline phosphatase, PTH.
If PTH appropriate: send TSH, Vit D 1,25, Vit D 25, PTHrP, SPEP/UPEP, cancer
screening, LDH, beta-2-microglobulin.
If PTH inappropriate: it’s either primary hyperparathyroidism or FHH (urinary
calcium can help dx the very rare FHH)

V: Treatment
1. IVF volume resuscitation: at least 3-4L in first 24 hours
2. IV lasix after volume repleted (urine Na and Cl > 90). Keep I =O.
3. Calcitonin: 4-8u SQ/IM q6-12hr. Works within hours, but weak effect (1-3
037
 mg/dL) that wanes after 2-3 days.
4. Pamidronate: 90mg IV over 24hr (for Ca>13.5) or zolindronic acid 4mg once.
Treatment of choice in hypercalcemia of malignancy. Side effects include decreased
Mg and phos and low grade temperature.
5. Caution with bisphosphonates in renal failure.

-The cancer may be metastatic, but don’t determine your patient’s functional status until
their calcium has normalized (they may be able to tolerate more aggressive therapy than
you first think when they’re acutely hypercalcemic).

Hypomagnesaemia: lethargy, confusion, arrhythmias

Oral Replacement (may cause diarrhea):
1. Magnesium Oxide tablet 400–800 mg PO daily
2. Milk of Magnesium (magnesium hydroxide) 24% concentrate suspension10 mL
= 1001 mg of elemental magnesium (82 mEq)

Parenteral Replacement:
Serum Level Magnesium Sulfate
(mg/dL)
1 – 1.5 2 gm Magnesium Sulfate IV in 100 mL of D5W or NS over 2
hours (2 gm =16.2 meq)
<1 4 gm Magnesium Sulfate IV in 250 mL of D5W or NS over 4
hours (4gm = 32.4 meq)
*** In patients with renal insufficiency (creatinine clearance < 50 mL/min) use 50% or
less of the suggested dose.
In patient with cardiac risks for arrhythmia, may be more aggressive (slight
overcorrection safer than sustained level <1).

• Oral therapy is not usually adequate to replace mag<1.5 mg/dL).

• Serum magnesium concentrations may be elevated for 1-2 days following an
infusion, because it can take up to 48 hours for the magnesium to fully
redistribute into body tissues.
• Serum magnesium levels correlate poorly with total body store
Hypermagnesemia:
1.Rarely a clinical problem unless serum mag > 4mg/dL
2. Severe symptoms include: areflexia, hypotension, bradycardia, asystole, heart block
3. If severe, 1 amp calcium gluconate over 10 minutes. May need calcium gluconate
infusion or HD depending on setting.
-Remember at UH, RFP does not include a serum magnesium level (order separately, ok
to add on)

Hypophosphatemia:
• Alcoholics and malnourished at risk. Also critically ill burn/sepsis/cirrhosis patients.
Refeeding syndrome is when insulin shifts phos into cells. Hypophos is usually less
clinically worrisome than other electrolyte disorders.
Oral Replacement:
038
 • Neutraphos packet 1-2 PO TID–QID
• K-Phos (250mg tab= 75mL solution)

• Parenteral Replacement:
Serum Level SODIUM or POTASSIUM Phosphate
(mg/dL)
21 mmol SODIUM Phosphate IV in 250 mL of NS or D5W
1 – 1.9 over 6 hours or
21 mmol POTASSIUM Phosphate IV in 250 mL of D5W or NS over 6
hours
30 mmol SODIUM Phosphate IV in 250 mL of NS or D5W
<1 over 8 hours or
30 mmol POTASSIUM Phosphate IV in 250 mL of D5W or NS over 8
h
*** In patients with renal insufficiency (creatinine clearance < 50 mL/min) use
sodium phosphate and 50% or less of the suggested dose.

Hyperphosphatemia:
• Think: Renal failure, tumor lysis, iatrogenic replacement, rhabdo
• Can cause calcifications if severe.
• Treatment: CaCO3 (tums) 1000mg tid with meals or calcium acetate (PhosLo)
667mg tid with meals bind phos in the gut to prevent absorption. If calcium is
low use sevelamer.

Hypokalemia
• Causes: Diarrhea, vomiting, alkalosis, renal losses (diuresis,
mineralocorticoid excess, RTA I/2), hypomag
• Look for EKG changes: T wave flattening, A fib, NSVT, U wave V4-6
• As above, supplement ESRD/CKD patients cautiously.
Strategy:
1. Replete Mag first
2. Know how far you’re behind:
Potassium Level (in meq/L) mEq of repletion for a 0.1 increase in KCl
2.0-2.5 40-50
2.5-3 30
3.0-3.5 10-20
3.5-4.0 10
*Caution, levels within hours of dialysis may be falsely low while body equilibrates.
-And if you’re continuing diuresis, they’ll continue to lose more.

3. Make a plan: The downside of PO is upset stomach (pills probably better

tolerated than terrible tasting liquid/powder, though if they have an NG these
are good options). The downside of IV is if given through a peripheral IV it’s
painful, and must be given slowly regardless (10mEq per hour max through

039
 peripheral, 20mEq max via central line)
4. Set a goal: >4.0 in a cardiac patient, >3.5 in noncardiac

Hyperkalemia: See above (meds similar in ESRD/non ESRD). If DKA, see DKA-specific
section

040
 Cardiology
Hellerstein
The inpatient team that is staffed by a Cardiology attending. Most of the patients admitted
to the service present with typical or atypical chest pain that physicians in the ED feel
need to be ruled out for potential acute coronary syndrome. Other patient categories
include heart failure exacerbations with fluid overload, valvular diseases (especially
patients who are planning to undergo transcatheter aortic valve replacement), and those
with heart rhythm disturbances like atrial fibrillation or atrial flutter. Many patients are
admitted overnight by the NF residents or are transferred from the CICU after
undergoing invasive procedures such as percutaneous intervention.

Team Structure: 1 attending, 2 senior residents, 4 interns

Cap: 10 patients per intern
Admission Guidelines: Short – 1NF or CICU transfer prior to 1PM (none if clinic or on the
weekend); Medium – 2 admissions prior to 4PM; Long – 3 admissions prior to 7PM; Pre-
call – no admissions and off Fri-Mon

CICU
Team Structure: 1 attending, 1 Cardiology Fellow, 4 day Senior Residents, 1 night Senior
Resident, 2 Interns
Cap: No Cap – max 20 beds in the CICU
Call Structure:
Q4 28h call
On call: admissions from 7am-7am. Daytime admitting help from interns and nighttime
admitting help from trading off with the night resident.
Post Call: round on your patients, finish you work, and go home.
Helper: Cross cover, stay till after afternoon rounds
Interns: Daytime admitting 1-2 patients with SR every other day. Follow these patients.
Should not carry more than 4.

041
Data Interpretation Fundamentals
ECGs – always check patient name, date, gain
Rate - Slow <60; Fast >100
--- pathologic or physiologic?

Rhythm - regular or irregular

Axis – Look at I, II
- Normal: -30° to +100°
o I, II all +
- Left: -30° to -90°
Source: Harrisons 18th
o I +; II neg vs isoelect
Edition
- Right: +100° to +180°
o I, II

Waves:
P: atrial depolarization
Right Atrial Enlargement – high amplitude II, positive net deflection V1
Left Atrial Enlargement – wide P-wave II; negative net deflection V1
Normal – equal biphasic V1; 1x1 box in II
*** if negative deflection in V1, HIGH LIKELIHOOD for lead misplacement

QRS: ventricular depolarization – width indicates ventricular synchrony

 RBBB
o QRS >120
o rSR’ (bunny ears) in V1, V2

 LBBB
o QRS >120
o Notched, slurred R wave in I, aVL, V5, V6
o Deep S waves in V1, V2
o Prolonged time to peak R wave in V5, V6

 Also to Diagnose LVH – Sokolow-Lyon System

o SV1 + RV5 >35 little boxes
o RaVL > 11 little boxes
Source: Harrisons 18th Edition
T: ventricular depolarization
- May be inverted in areas of ischemia suggestive of subendocardial ischemia or
NSTEMI; CANNOT reliably localize an artery based on T wave abnormalities alone
- Wellen’s T Waves – deeply inverted biphasic T waves in V2, V3 – highly specific for
critical stenosis in the LAD. Patients may be asymptomatic at time of ECG but are
at high risk for anterior MI in the ensuing days to weeks

U: not always present; can appear in hypokalemia

042
Intervals:
PR – normal 120-200 ms
QRS - <100-120ms
QTc < 440ms
ST – Elevation in right clinical context suggests acute complete occlusion and necessitates
emergent revascularization

Area of ECG Leads Related Artery

Infarction
Inferior II, III, aVF RCA or posterolateral branch LCx
Anterior V2-V4 LAD or 1st Diag
Lateral I, aVL, V5, V6 LCx
True Posterior Tall R wave in V1 Posterolateral branch LCx or PDA of
RCA
Septal V1-V3 LAD or 1st Diag
Anterolateral I, aVL, V2-V6 Prox Diag
Inferolateral II, III, aVF, I, aVL, V5, V6 Prox Cx; large RCA if R Dominant

** ST ELEVATION DOES NOT NECESSARILY MEAN ISCHEMIA

DDx includes – normal variant, LVH, LBBB, acute pericarditis, hyperkalemia, Brugada
Syndrome, PE, immediately after DCCV, Prinzmetal Angina
*** 90% of health young men have a concave ST elevation of 1-3mm in V2

TP – high variability; use this segment to determine isoelectric line

Coronary Angiography (sometimes called left heart cath):

Useful tool to diagnose extent of coronary disease and deliver percutaneous
interventions
 Usually Femoral vs Radial Access

Indications:
- Known or suspected CAD – persistent angina despite medical treatment, high risk
criteria on noninvasive testing, patients resuscitated after sudden cardiac death,
patients who have had >30 sec of monomorphic VT or <30 sec of polymorphic VT
- Nonspecific Chest Pain w/ high risk features on noninvasive testing
- Unstable Angina/NSTEMI – refractory angina, hemodynamic or electrical
instability, or high risk for MACE
- STEMI – primary rescue PCI, cardiogenic shock who are candidates for PCI
- Suspected Abrupt closure or in-stent thrombosis after PCI

Relative Contraindications
- Coagulopathy
- Uncontrolled HTN
- Pregnancy
- Renal Failure

043
 - ** contrast allergy is NOT a contraindication – patient can be prepped with
sterioids and antihistamine therapy
Risk of Major Complications is 1-2% - includes death, MI, stroke, bleeding, contrast
reaction – operator dependent and lower risk at tertiary care centers

Views:
Identifying View
RAO vs LAO (R Anterior Oblique vs L Anterior Oblique)
- If spine and catheter are to the right of the image, LAO
Cranial Vs Caudal
- If diaphragm can be seen, likely cranial view
Anteroposterior (AP) - Visualize Left main ostium; distal RCA bifurcation
RAO Caudal – best view for prox/mid LCx and Distal LAD
LAO Caudal – Left Main, prox LAD and prox LCx
RAO Cranial – mid/distal LAD, distal LCx; mid RCA and PDA
LAO Cranial – mid/distal LAD, diags, prox LCx; ostial/prox RCA

Interpretations:
- Presence of acute thrombus vs ulceration
- TIMI flow pre- and post-intervention
Echocardiography:
3 BASIC VIEWS ALL INTERNISTS SHOULD KNOW
Parasternal Long Axis (PLAX) – left sternum between 3rd and 5th intercostal spaces

Parasternal Short Axis (PSAX) Source: Harrison’s 18th Edition

- Probe location same as PLAX, but rotated 90 degrees and public access images
- Shows cross sections of LV walls at level of AV, MV, and mid
ventricle

044
Apical 4 Chamber
- Probe at LV apex max impulse

For More Info, please check out:

https://web.stanford.edu/group/ccm_echocardio/cgi-
bin/mediawiki/index.php/Parasternal_long_axis_view
(Also a source for above images)

Right Heart Cath Interpretation

*** Right heart catheterization means measuring pressures on the right side of the heart
with the intention of understanding the volume status of the patient. It is NOT the
evaluation of the right coronary artery***
In cardiogenic shock, lab may leave Swan in for CICU to use for management.

Common Parameters w/ Normal Values

Right Atrial Pressure (RAP) – same as your JVP – 1-5mm Hg
Pulm Artery Pressure (PAP) – ~25/10 mm Hg
Pulm Capillary Wedge Pressure (PCWP) – represents left atrial pressure – 4-12 mm Hg

Cardiac Output (CO) – calculated from Fick Equation

Cardiac Index (CI) – CO/Body Surface Area

In the CICU, cardiogenic shock patients will frequently have CI of <2.0; the goal will
be to guide therapy to a CI >2.4
045
Systemic Vascular Resistance (SVR) - 700-1600 woods units
(MAP – CVP) / CO
Pulmonary Vascular Resistance (PVR) – 20-120 woods units
(PAP – PCWP) / CO

Chest Pain
Mr. Wellen is a 54 y/o gentleman presents with 8 hours of midsternal chest pain. His ECG
was negative. What’s the Differential??? Be broad and think by organ systems.

Cardiac – Angina, MI, Pericarditis

Vascular – Aortic Dissection, PE, Pulm HTN
Pulmonary – Pleuritis/PNA, Pneumothorax, Bronchitis
GI – GERD, Peptic Ulcer, Gallbladder, Cholecystitis, Pancreatitis
MSK – Costochondritis, Cervical Disc Disease, Trauma, Muscle Strain
ID – Herpes Zoster
Psych – Panic disorder, anxiety

What to do?
1st ---- is the patient hemodynamically stable?
NO  Ask for HELP, assess for STEMI, Massive PE, Aortic Dissection, Cardiac Tamponade,
Tension Pneumothorax, PE.

YES 
History + Phys Exam (HIGH YIELD)
- Reproducibility w/ palpation, exertion?
- Prolonged pain at rest or minimal exercise in the last 12 hours?
- Assc w/ nausea, diaphoresis? Radiating to left arm or neck?
- Similar to any previous MIs?
- Improves with rest? Improves with nitro?

ECG + CXR (HIGH YIELD) --- r/o PNTX, STEMI; check for pericarditis
 If + ECG changes, check cardiac biomarkers (Troponins, CKMB)
o ST changes >1 little box or TWI >3 little boxes in 3 or more limb leads or 4
or more precordial leads?
 Widened mediastinum on CXR, consider aortic dissection – CT Angio vs MRI vs TEE
 Pulm Infiltrate – consider PNA, lung abscess, empyema

High Suspicion for Coronary Ischemia  Patient Story + ECG changes + Biomarkers
1. Admit to telemetry
2. Bed rest
3. Make NPO for a stress test or cardiac catheterization the following day
4. Oxygen
5. EKG on admission and in the morning
6. Labs – troponin q8, CBC, CMP, coags, lipid profile, HgA1c
7. Aspirin 325mg x1 and then 81mg by mouth daily
8. Sublingual Nitroglycerin vs nitro paste vs nitroglycerin drip
046
9. Metoprolol Tartrate (as long as patient is not in decompensated heart failure). Start
q6h and titrate to HR 60.
10. Atorvastatin 80mg PO daily – check LFTs

Acute Coronary Syndromes

Unstable Angina / NSTEMI
- Continue Aspirin, Beta Blockade, Statin, Nitrates as above
- Initiate Anticoagulation with Heparin gtt with a bolus
- Antiplatelet – usually clopidogrel 600mg x1 dose followed by 75mg by mouth
every day thereafter (some cardiologists prefer ticagrelor)
- Refer for cardiac catheterization for further evaluation and possible intervention

STEMI
- In appropriate clinical setting and significant ST elevations in contiguous leads 
ACTIVATE CATH LAB; usually done by outside hospital ED or our ED

Post STEMI Complications

- LV Free Wall Rupture – chest pain, SOB, hypotension, cardiogenic shock
- VSD – usually assc w/ new harsh thrill on examination (3-7 days post)
- Papillary muscle rupture – abrupt SOB, pulm edema, hypotension
- Cardiogenic Shock
- LV Aneurysm (several weeks post)
- Early Pericarditis
- Delayed Pericarditis (Dressler’s Syndrome)
- Arrhythmias

RV Infarction:
Clinical triad of --- hypotension, clear lung fields, elevated JVD
Perform a Right Sided ECG
Treatment – Fluids, fluids, fluids --- need to maintain RV preload
Reduce RV afterload
Provide inotropic support if needed (dobutamine)
Revascularization w/ PCI

Heart Failure
Mrs. Ganz is a 52 year old lady who presents with a 3 week history of gradual increased
SOB, 15 pound weight gain, abdominal distension and lower extremity swelling.

What to do?
History
- Ask about orthopnea, PND, cough, chest pain, dizziness, lightheadness, palpitations
- How much weight gain? Is there a previously known dry weight?
- Compliance to home medications – especially diuretics? Dietary habits and salt
intake?

047
 - Try to pin down exercise capacity specifically in terms of activities and judge NYHA
classification
o Class I – symptoms with fairly significant activity, well compensated
o Class II – symptoms at moderate activity
o Class III – symptoms at minimal activity (<1 block flat, <1 flight stairs)
o Class IV – symptoms at rest
- Ask about family history, personal hx of coronary disease, hx of illicit drug use
(cocaine)

Phys Exam:
- GOTTA CHECK THE NECK VEINS!
- Heart Sounds - is there an S3? Remember to listen for KEN-TU-CKY
- Monitor leg swelling and check weights daily as a supplemental measure of body
volume
- Pulm: differentiate RV vs LV and RV failure.

Heart Failure can largely be categorized as such:

- Systolic vs diastolic (EF <35%)
- Ischemic vs Nonischemic
o Ischemic Etiology – treatment should include strategies that target
revascularization (CABG/PCI) vs medical therapy w/ statins, anti-platelet
agents
o Non-ischemic –hyper/hypothyroidism, autoimmune etiology, HIV
 Infiltrative Cardiomyopathies – sarcoidosis, amyloid,
hemochromatosis

HF Meds
- Beta Blockers – only 3 beta blockers have shown mortality benefit in patients with
HF and reduced EF
o Metoprolol Succinate (Toprol XL – long acting);
 Metoprolol Tartrate is short acting – q6 to q12; daily dose to not
exceed 400mg
o Carvedilol (concomitant α1 antagonism w/ antihypertensive effect)
o Bisoprolol
- ACE-I / ARB
o Lisinopril most commonly used
o Can use captopril q8 dosing for shorter length titration. Conversion is 1mg
lisinopril for every 5mg of daily captopril. For example, patient on 12.5mg
captopril q8h converts to about 7.5mg lisinopril daily.
- Nitrates + Hydralazine
o Consider in patients w/ in whom ACE/ARB are contraindicated, i.e. acute
renal failure, angioedema
- Loop Diuretics (Conversion Chart Below)

048
Drug Initial Oral PO IV Onset Peak Duration
Dose (PO) Bioavail Equivalents Equivalents (hrs) (hrs) (hrs)
Furosemide 20mg 10- 80mg 40mg 0.5 1 6
100%
Bumetanide 0.5mg 80- 1mg 1mg 0.5 1 4-6
100%
Torsemide 20mg 80- 20mg 20mg 0.5 1 6-8
100%
Ethacrynic 25mg 80- 50mg 50mg 0.5 1 6-8
Acid 100%

- Spironolactone – aldosterone antagonist

o Monitor potassium levels especially if patient is on supplemental K
o Improves mortality in patients w/ reduced EF (NYHA III/IV)

- Digoxin – negative dromotrope and positive inotrope

o Need to watch for digoxin toxicity
o Improved symptoms, no mortality benefit

Ms. G starts developing respiratory distress and pulse ox shows him satting 84% on RA.
What to do?
Ask for help! Check vital signs, assess for flash pulm edema?
- Provide supplemental O2 – talk with MICU resident, senior resident. At UH
consider code white if you think they need MICU tx.
- STAT IV Lasix – usually start with 40mg IV x1 but can adjust dose based on
patient’s home meds
- obtain an ABG, ECG, CXR
- if hypertensive with suspicion for flash edema, start IV Nitroglycerin drip
- Full set of labs
- Consider transfer to CICU for further monitoring, diuresis, and potential PA
catheter guided therapies with inotropes and vasodilators

Arrhythmias
Mr. Brugada and his brother come see you in the office. His brother states he witnessed
the patient pass out at home. This has happened 3 times in the last 6 months and last
time Mr. B had complained of palpitations just before passing out. Symptoms resolved
within a minute. The patient appears comfortable and denies any current chest pain or
trouble breathing. Vital signs in the office reveal a BP of 125/83 and a pulse of 146.

What to do?? Get an ECG!!!!!

Ask Yourself 3 Questions –

1) Fast or Slow?
2) Regular or Irregular?
3) Narrow or Wide QRS?

These 3 questions will narrow your differential diagnosis quickly and efficiently!
049
Narrow Complex, Fast
- Atrial Fibrillation – irregular, no p-waves
- Atrial Tachycardia – emperor of the SVTs – any p-wave morphology, can be
regular or irregular
- Multifocal Atrial Tachycardia – various p-wave morphologies usually in patients
with concomitant pulmonary disease
- Atrial Flutter – “sawtooth” – usually regular, reentrant
- AVNRT - Regular, usually no P waves (atrial depol simultaneous with vent depol)
- AVRT – Regular, because circuit is longer than AVNRT may see P waves after QRS

Wide Complex, Fast

- Ventricular Tachycardia – monomorphic or polymorphic; shock if
hemodynamically unstable, otherwise can treat medically with amiodarone,
lidocaine, etc.
- Torsades De Pointes – a subset of polymorphic VT; can be assc w/ electrolyte
abnormalities --- low Mg or from an “R on T” phenomenon in patients w/
prolonged QT
o Check the drugs; Consider congenital electrical disturbances
- VFib
o Complete degeneration of the ventricular electrical conduction system
o Irregular, no organized rhythms
- SVT w/ aberrancy
o Any of the narrow complex rhythms now traveling via an accessory pathway
leading to early ventricular preexcitation and a wide complex on ECG

Narrow Complex, Slow

- 2nd degree, 3rd degree heart block
o 2nd degree – Mobitz I vs Mobitz II
o 3rd degree – complete discordance between atrial and ventricular
depolarization
- Sinus bradycardia – a sick sinus node but at a rate that is still faster than that of
the intrinsic AV node pacemaker cells
- Ventricular escape rhythm – HR usually 20-40
- Junctional Rhythm – HR usually ~40; can be accelerated junctional 40-80

Diagnosis and Treatment:

Unstable Patients
For all patients, ALWAYS determine if they are hemodynamically stable. If NOT, this is #1
priority. For fast heart rates, place pads and prepare for cardioversion. For slow heart
rates, place pads and prepare for potential cutaneous pacing and may need to activate
cath lab for placement of a temporary pacemaker.

Stable Patients
Fast Narrow Complex
050
 - Obtain an ECG; may need to use adenosine push while monitoring patient on a
rhythm strip – this will attempt to slow the rhythm and allow you to identify it
- Afib – metoprolol IV vs PO, diltiazem, amiodarone, digoxin (BP may limit BB/CCB)
- Aflutter – tremendously difficult to control – best treatment is cardioversion
o For both Afib/Aflutter, the patient must be anticoagulated for at least 4
weeks or have a TEE documented absence of intra-atrial clot
- Atrial Tachycardia – beta blockade vs centrally-acting calcium channel blockers
- AVNRT/AVRT – any AV nodal blocking agent should successfully terminate the
reentrant circuit (adenosine usually more effective, have continuous EKG so EP can
evaluate later)

Fast Wide Complex

- VT – amiodarone 150mg IV bolus followed by amiodarone drip
o Can Also use lidocaine and esmolol drips if patient continuing to have
breakthrough VT
o If patient develops VT storm despite medical therapy, can activate cath lab
for placement of Intraaortic Balloon Pump for mechanical assistance
- Torsades –
o Check and Replete Electrolytes, Give Mag 2gm over 1 min, can repeat q5-
15minutes. May require DCCV (particularly if degenerates to V fib)
o Treatment should also focus on narrowing QT – can use isoproterenol drip
vs ensuring that patients AV nodal blockers are stopped
o *** at this time, must be sure that this is NOT polymorphic VT from an
ischemic etiology!! Especially if starting isoproterenol which will increase
O2 demand.

Slow Rhythms
- Ensure that no AV nodal blocking agents are being administered
- If bradycardia or heart block persists, patient will need a pacemaker placed for
definitive therapy
-
BONUS POINTS!
Brugada Syndrome – a sodium channelopathy first described in 1992 by the Brugada
brothers resulting in a significant cause of death in young males particularly in Southeast
Asia. Appears to have autosominal dominant inheritance. ST segment elevations >2mm in
V1-V3 followed by a neg T wave is called the Brugada Sign. Diagnosis is made when this
finding is assc w/ documented VFib, polymorphic VT, family hx of sudden cardiac death
<45 yrs, inducibility of VT during an EP study, syncope, or nocturnal agonal respiration.

Implantable Cardiac Devices

Permanent Pacemaker (PPM) --- FOR SLOW RHYTHMS
- Indications: symptomatic bradycardia, symptomatic chronotropic incompetence,
Mobitz 2 heart block; 3rd degree heart block
- Any episodes of asystole >3 seconds; any escape rhythm <40 bpm
- Patients may have episodes of bradycardia after an MI

051
 o Bradycardia after posterior MI usually resolves spontaneously; usually
persists after anterior MI as this is a marker of a large territory exposed to
ischemia
- Types of PPMs
o Single Chamber – lead in 1 chamber (usually RV). VVI – ventricle
sensed/paced; can be in RA  A-sensed, A-paced
o Dual Chamber – 1 lead in RA, 2nd lead in RV – A-sensed, V-paced; allows for A-V
synchronization --- DDDR (dual chambers pace, dual chambers sensed, dual
response)
o Biventricular PM – 3 Leads! – one lead in RA, one in RV, and one in coronary sinus
that paces LV

Implantable Cardioverter-Defibrillator (ICD) – FOR FAST RHYTHMS - **all ICDs have

pacemakers as well
- Indications – primary, secondary
o Primary
 Heart failure w/ EF <35% in Non-ischemic cardiomyopathy
 Patients w/ ischemic cardiomyopathy who are at least 40 days post-
MI and have persistent reduced EF <35% on optimal medical tx
 Patient’s w/ prolonged QT and family hx of sudden cardiac death –
e.g., Brugada syndrome
 Cardiac Resynchronization Therapy (CRT) for patients with EF <35%
and those with wide complex on ECG
o Secondary – survivors of cardiac arrest from Vfib or sustained VT
 patients w/ syncopal events who have inducible VT during EP studies

Common Device Issues

1. Failure to Sense – intrinsic rhythm is not detected by the PM; as a result, pacing is
inappropriate – usually from lead dislodgement/fracture or programming errors
2. Failure to Pace – occurs with oversensing; inappropriate signals are sensed resulting in
inappoproate pauses
3. Failure to Capture – no evidence of depolarization despite a pacing spike being
delivered (no QRS after pacing spike). Sensing is intact. If occurs shortly after initial
implant, likely from lead dislodgement or perforation. If occurs weeks/months later, then
due to lead maturation issues with possible structural injury to the lead insulation or
conductor.

Mrs. Naxos is 67 year old lady who underwent elective placement of a dual chamber PPM
yesterday by the EP service. She is being monitored in the CICU and the EP fellow
requests that you manage care going forth. You visit Mrs. N in the morning – the pocket
site looks good and her vitals are stable. How do you assess the new device? What to do?
1. Need a CXR after the procedure and 2 view CXR the morning after to ensure no
progressing pneumothorax and proper placement of leads. Also need to assess for any
enlargement in cardiac silhouette that could suggest hemopericardium.
2. Always obtain an ECG after device implantation and the morning to ensure that the
device is sensing and pacing appropriately.
052
3. If a temporary pacing wire is in place, it’s important to check the capture threshold
and the intrinsic rhythm of the patient. The capture threshold can be adjusted with a
device at the bedside – the cardiology fellow will show you how to do this!

Crucial Cardiovascular Physical Exam Techniques:

JVP
- Relax patient, remove pillows, ensure a well-lit room
- Look for a bifid pulsation (first “a” wave, then “v” wave) and see if it moves as you
alter the head of the bed
- Press on the RUQ and assess for change in pulsation – hepatojugular reflux
- Identify the highest point of pulsation and measure vertical distance from the angle
of Louis
o Angle of Louis – sternal angle – junction of manubrium and sternum -- 5cm
H2O from the center of the left atrium
** KEY Venous Pulsation Findings**
Cannon A wave – large initial pulsation that occurs when RA contracts against
closed tricuspid valve. Occurs intermittently during conditions with AV
dissociation – VT, complete heart block
Kussmaul Sign – neck veins rise during inspiration – a sign of pericardial tamponade

Pulsus Paradoxus – a drop in SBP >10mm Hg with inspiration

- Check BP w/ manual cuff – inflate at least 20mm Hg above the pressure at which
radial pulse disappears
- Deflate slowly until you hear any sounds (intermittently regardless if these
correspond with heart rate) and record highest SBP
- Continue to deflate slowly until you hear sounds with every heart beat – difference
between these two pressures is the “pulsus”
- During inspiration, intrathoracic pressure decreases and right heart filling
increases. In tamponade, the increased RV blood exerts force on the
interventricular septum causing a left sided bulge and reduced systemic stroke
volume and a resulting significant (>10mm Hg) drop in SBP.

Heart Sounds and Murmurs

S3 – after S2, low pitch, assc w/ volume overload in CHF – left lat decub at cardiac apex
S4 – before S1, atrial gallop – blood being forced into a stiff, hypertrophic LV
Mitral Regurg – holosytolic murmur at apex; similar to TR (at LLSB)
Aortic Stenosis – systolic crescendo/decrescendo w/ radiation to carotids at RUSB
Aortic Regurg – diastolic decrescendo murmur
Mitral Stenosis – mid diastolic soft rumbling murmur w/ OPENING SNAP
Rub – scratching, creaking, high pitch usually at beginning and end of diastole assc w/
pericarditis

053
 UH MICU Tips and Time Savers

1. Rounds generally start at 8 am with CXR and imaging rounds at the back.
2. Unit coverage: You can leave the unit, just let team know how to reach you and
how long you will be gone.
3. Resident/Intern Schedule: Hanging up next to a computer terminal in back
of unit. Please write you days off so the NP’s can help figure out who may need
help with coverage on your days off.
4. Privacy/Dignity: Keep curtain shut when examining patients.
5. Isolation: Need to wash hands prior to entering patients room and when
coming out. Pay attention to isolation signs outside of rooms!
6. Kathy and Rachel NP’s are here four -10hour days – when not here their
patients have to be covered by the residents. Their role is to take patients with
known diagnosis and predictable course. They perform H&P’s, physical exams,
diagnosis, write notes, call consultants and manage day/day issues. If needed
they can help place dobhoffs, a-lines & femoral lines. They are discharge planning
experts.
7. Respiratory therapy: at least one assigned to the unit at all times. Only
Respiratory therapy, the Attending or Fellow may make ventilatory changes.
8. Charge Nurse: knows about bed availability, status on incoming pts….
9. Social Work – is available to assist with any and all social work issues. Call
early, these discharges can get complicated.
10. Nutritional support should usually be started within 24 hrs of admission.
Dietician is available for assistance with tubefeeds/TPN.
11. Pharm D: Andreea Popa 31503 is available to help with medication dosing
and availability.
12. Keep side rails up at all times unless pt is alert and oriented and allowed to
walk around.
13. Document DNAR discussions in the chart and place order. Make sure you
include added limitations. Discuss advanced directive with all admissions.
14. The unit is a Family Centered Care Unit – frequently family members will
attend rounds. We encourage frequent family meetings and updates to keep
them abreast of changes. During an arrest, the family is asked if they want to
stay in the room. A staff member will stay at their side to support them and
answer questions. Visiting hrs are 24/7 for immediate family. Other visitors are
invited between 11am and 7pm. Communication is KEY to appropriate goal
setting.
15. We work as a team. The RNs are outstanding teammates. If a MICU RN asks you
to assess a patient, assess the patient. If they are concerned about something, go
with them to the bedside. A MICU RN expressing concern about a patient more
than once in a day is a highly specific sign of a patient who is about to
decompsensate without attention.
16. Workflow: Most days in the unit you will have 3 or fewer patients to cover as an
intern. Beware, prerounding well on a MICU patient takes 30-60 minutes per
patient. Have a discussion with the RN every morning. Look at all new imaging,
labs, vitals. Know vent settings, drip rates. Be prepared for a detailed systems
054
 based presentation on rounds. Notes should be detailed and fully updated,
delete outdated information. Transfer notes should be updated daily if patient is
to leave the unit. Unless you are the post-call resident, no intern or resident
should leave the unit prior to 4PM on any day. Even if you are done with your
work, there is always activity, procedures, learning to be done in the ICU.
Moreover, the on call team is busy, and taking your sign out early is one more
task for them.
17. W.O.W.s (workstation on wheels) need to be plugged in when not in use.
The battery is only good for 2hrs and if it completely discharges, it will not
charge up completely, making for a miserable day.
18. Days off: Precall day for senior residents Fri-Mon, Helper day for interns
Fri-Mon
19. Patients in the unit are everyone’s responsibility. Whether you are
covering for a day or just covering while your team gets lunch, we take
responsibility for any active issue on any patient in the unit.
Orders:
1. EMR: Please be sure to place order for Admission with Pulmonary Critical
Care as the service. Complete the medication reconciliation on admission.
2. EMR: Medications: Please order medications that need to be given at a specific
time ie: antibiotics, as “time specific” and not “stat”. If you just order it BID or
even q 8 hrs it may not get given in a timely fashion.
3. Every patient needs some form of DVT prophylaxis (SCDS count)and if they
are on a vent, GI prophylaxis (PPI?).
4. Radiology tests: Place as STAT orders, include specific suspicion so radiology
can comment on this.
5. CXR’s-need to be ordered daily on all ET intubated patients. Once pt is
considered chronic, stable, do not need to order daily CXR’s (if trach).
6. STAT orders: Verbally notify the nurse what they need to do (med or labs).
7. Daily Labs : Order floor to collect (all labs are floor to collect in unit).
8. Transfers out: Need to place EMR order to transfer out, notify nurse and the
secretary to get a bed, and update orders (ie. Stop all ICU type orders). Page
DACR 30512 (or call 67121)to let them know about the patient. Give verbal
report to team accepting the patient. If not done by the time you leave, sign out
that report still needs to be called.
9. Palliative Care Service: available to help with difficult
patients/families/siutations.
10. Ethics Consult: available when pts unable to make own decisions, if they have
no family, and for ethical dilemmas
11. Keep track of how long a line has been in, what the site is looking like and
daily ask yourself if you still need it-if you don’t need it remove it. (Remember,
new dialysis patients will need some form of access before removing any other
access).
12. Trachs- fresh tracheostomy is performed bedside by ENT (for most patients).
Sutures need to be in place for 5 days, then ENT can remove them. Therefore a pt
needs to stay in the unit until the sutures get removed.
Ventilator patients: Daily wake up assessments (turning off sedation/narcotics)
055
should be done on all patients once O2 requirements <55%, PEEP < 10, reason for
intubation identified and treatments started. While awake, patients should be assessed
for delirium using the CAM ICU score and weaning parameters obtained, if
appropriate. If weaning trial done, know the NIF and RSBI for rounds. It is helpful to
remind the bedside nurse/RT to do this assessment after 8am in the morning

056
 UNIVERSITY HOSPITALS OF CLEVELAND CASE MEDICAL CENTER
*Clinical Risk Factors for infection with Pseudomonas in CAP: Structural lung disease (brochiectasis), or repeated exacerbations of severe COPD leading to frequent

Presence of risk factors for HCAP :hospitalization for 2 days or more in the preceding 90 days; residence in a nursing home or an extended care facility; home infusion

MICU INITIAL EMPIRICAL ADULT IV ANTIBIOTIC THERAPY

tazobactam, Acyclovir, Aztreonam, Ciprofloxacin, Cefepime, Metronidazole, Ceftazidime, Meropenem and Vancomycin will need dosage adjustment for renal disfunction.

INFECTION LIKELY
EMPIRIC THERAPY
Tobramycin and gentamicin dosing should be individualized based on diagnosis and renal function. Round Vancomycin dose to the nearest 250 mg. Piperacillin/

SOURCE / SETTING PATHOGENS

Ceftriaxone 1 gm daily + Azithromycin 500 mg daily OR
Community S. pneumoniae,
Ceftriaxone 1 gm daily + Levofloxacin 750 mg IV daily Medical Intensive
*If Pseudomonas suspected: Piperacillin/tazobactam 4.5 gm q 6 hrs+ Levofloxacin 750 mg daily
Care Unit
Acquired Legionella, H.
Pneumonia influenzae, PCN allergy: substitute Piperacillin/tazobactam with Aztreonam 2 gm q 8 hrs
(ICU) Mycoplasma,
Chlamydia
If recent positive culture for Pseudomonas, or recent fluoroquinolone use, or if severe sepsis,
septic shock: consider adding Tobramycin SEPSIS Resource
For severe CAP ADD: Vancomycin 15 mg/kg q 8-12 hours
2015
S. pneumoniae, Andreea Popa, Pharm.D. BCPS
Hospital Acquired, Legionella, H. Piperacillin/tazobactam 4.5 gm q 6 hrs
Keith Armitage MD
Ventilator- influenzae, MSSA PCN allergy: Cefepime 2 gm q 8 hrs OR Meropenem 1gm q 8 hrs, based on allergy severity
associated and P. aeruginosa, If recent positive culture for MDR GNR, or severe sepsis/septic shock: consider adding Tobramycin Constantine Tsigrelis MD
Healthcare- Anaerobes,
If HCAP and patient resides in community: add Levofloxacin or Azithromycin (Legionella Edited by: Mariana Petrozzi M.D.
associated Enterobacteriaceae,
Acinetobacter sp., coverage)
Pneumonia
MRSA To all regimens ADD: Vancomycin 15 mg/kg q 8-12 hours (MRSA coverage) Sepsis: Infection, documented or
suspected and some of the following
Piperacillin/tazobactam 4.5 gm q 6 hrs OR
Enterobacteriaceae, , Fever (>38.3 ºC)
PCN allergy: Cefepime 2 gm q 8 hrs OR Meropenem 1gm q 8 hrs, based on allergy severity Hypothermia (core temperature <36 ºC)
P. aeruginosa, General
Neutropenic Fever Streptococcus sp.,
If recent positive culture for MDR GNR, or if severe sepsis/septic shock, or if current positive HR > 90/min-1 or more than 2SD above the normal for age
variables
MRSA, MRSE blood culture for GNR: consider adding Tobramycin Tachypnea
Altered mental status
To all regimens ADD: Vancomycin 15 mg/kg q 8-12 hours (MRSA coverage) Significant edema or positive fluid balance (>20 mL/kg/ 24 hrs)
Hyperglycemia (BG >140 mg/dL) in the absence of diabetes
Enterobacteriaceae, , Community acquired: Ceftriaxone 1 gm daily; PCN allergy: Aztreonam 1 gm q 8 hrs
Enterococcus Hospital acquired: Piperacillin/tazobactam 3.375 gm q 6 hrs
Urinary Tract E. coli, K. Leukocytosis (WBC count > 12,000 mcL-1)

057
Infections pneumoniae, P. PCN allergy: Cefepime 2 gm q12 hrs OR Aztreonam 1 gm q 8 hrs based on allergy severity Inflamm.
Leukopenia (WBC count <4000 mcL-1)
If severe sepsis/septic shock, or current positive blood culture for GNR: consider adding Normal WBC count with > 10% immature forms
aeruginosa, variables
Plasma C-reactive protein > 2 SD above normal
Enterococcus Gentamicin Plasma procalcitonin > 2 SD above normal
Enterobacteriaceae, , Piperacillin/tazobactam 3.375 gm q 6 hrs OR
Intra-Abdominal P. aeruginosa,
PCN allergy: Cefepime 2 gm q 12hrs + Metronidazole 500 mg q 8 hrs OR Hemo- Arterial hypotension (SBP<90 mmHg , MAP <70 mmHg , or an
Infections Enterococcus,
Meropenem 1 gm q 8 hrs based on allergy severity

therapy, chronic dialysis, home wound care, family member with MDRs
Anaerobes dynamic SBP decrease >40 mm Hg in adults or less than 2 SD below
variables normal for age)
Vascular Catheter- Staphylococcus sp. Vancomycin 15 mg/kg q 8-12 + Piperacillin/tazobactam 3.375 gm q 6 hrs
Related (MRSA), PCN allergy: substitute Piperacillin/tazobactam with Cefepime 2 gm q12 hrs OR Arterial hypoxemia (PaO2/FiO2 < 300)
Infections Enterococcus Aztreonam 1 gm q 8 hrs based on allergy severity Acute oliguria (urine output <0.5 mL/kg/hr for at least 2 hours
despite adequate fluid resuscitation)
Organ
Creatinine increase >0.5 mg/dL

steroid and/or antibiotic use, and prior antibiotic therapy.

Cellulitis/Limb Streptococcus sp.,
Start with: Vancomycin 15 mg/kg q 8-12 hours until MRSA ruled out and then narrow coverage dysfxn.
Infections Staphylococcus sp. Coagulation abnormalities (INR>1.5 or aPTT>60s)
variables
(MRSA) using: Nafcillin 2 gm q 4 hrs OR Cefazollin 1 gm q 8 hrs Ileus (absent bowel sounds)
(Normal Hosts)
Thrombocytopenia (platelet count <100,000 mcL-1)
Piperacillin/tazobactam 3.375 gm q 6 hrs OR Hyperbilirubinemia (plasma total bilirubin > 4 mg/dL)
Diabetic/PVD limb Enterobacteriaceae, , PCN allergy: Cefepime 2 gm q 12 hrs + Metronidazole 500 mg q 6 hrs OR Meropenem 1 gm
P. aeruginosa, Tissue
infections and
Enterococcus,
q 8 hrs based on allergy severity Hyperlactetemia (>1 mmol/L)
perfusion
cellulitis Anaerobes ADD Clindamycin 600 mg q 8 hrs for necrotizing fasciitis Decreased capillary refill or mottling
variables
To all regimens ADD: Vancomycin 15 mg/kg q 8-12 hours (MRSA coverage)
Severe Sepsis: sepsis induced tissue
Community Give with or just before the 1st dose of antibiotics for suspected/known pneumococcal meningitis: hypoperfusion or organ dysfunction
acquired: S. Dexamethasone 0.15mg/kg IV q6 hrs x 2-4 days
pneumoniae, N. Community acquired:
Sepsis induced hypotension
Meningitidis, Listeria, Ceftriaxone 2 g q 12 hrs + Vancomycin 15 mg/kg q 8-12 hrs; Lactate above upper limits laboratory normal
Meningitis/ H. influenzae (If > 50 yo and suspect Listeria add Ampicillin 2 gm q 4 hrs) UO <0.5mL/kg/hr for more than 2 hours despite adequate fluid resuscitation
Encephalitis Hospital acquired, ALI with PaO2/FiO2 < 250 in the absence of pneumonia as infection source
Post procedure: Acyclovir 10 mg/kg (use IBW if obese) q 8 hrs (if suspected viral encephalitis) ALI with PaO2/FiO2 <200 in the presence of pneumonia as infection source
S.aureus, Hospital acquired, Post procedure: Creatinine >2 mg/dL
P.aeruginosa, Vancomycin 15 mg/kg q 12 hrs +( Ceftazidime 2 gm q 8 OR Cefepime 2 gm q 8 hrs Platelet count < 100,000 mcL-1
Enterobacteriaceae, OR Meropenem 2 gm q 8 hrs) Coagulopaty (INR >1.5)
C. difficile Septic Shock: sepsis induced hypotension
Diarrhea
Clostridium difficile Vancomycin 125 mg PO q 6 hrs (if ileus, toxic megacolon add IV metronidazole +/- rectal vancomycin
persisting despite adequate fluid
 Hemodynamic Support of Adult Patient with Severe Sepsis and Septic Shock Surviving Sepsis Campaign Bundles Guidelines for Management of
SEPSIS with Hypotension or signs of
TO BE COMPLETED WITHIN 3 HOURS Severe Sepsis and Septic Shock
Hypoperfusion 1) Measure lactate level
- SBP<90mmHg - Change in mental status 2) Obtain blood cultures prior to administration of antibiotics
- MAP<65 mmHg - ¯Urine Output (UO) 3) Administer broad spectrum antibiotics Initial resusci- MAP ≥ 65 mm Hg, urine output ≥ 0.5 mL/kg/hr, CVP of 8-12 mm Hg (12-15
4) Administer 30 mL/kg crystalloid for hypotension or lactate ≥ 4 tation mm Hg in MV patients), Central venous or mixed venous oxygen saturation 70%
- ¯ SBP > 40 mmHg -↑ Lactate > 4 mmol/L
mmol/L or 65% , normalize lactate
TO BE COMPLETED WITHIN 6 HOURS Fluids 1. Crystalloids are the initial fluids of choice; albumin should be used only when
5) Apply vasopressors (for hypotension that does not respond to initial patients require substantial amounts of crystalloids
ICU Admission fluid resuscitation) to maintain a MAP ≥ 65 mmHg 2. Hydroxyethyl starches should not be used
• Arterial Cannula; 6) In the event of persistent arterial hypotension despite volume 3. Use fluid challenges of 30 mL/kg crystalloid
• Establish resuscitation goals 4. Fluid challenges as long as there is hemodynamic improvement based on
resuscitation (septic shock) or initial lactate ≥ 4 mmol/L reassess
-Clinical Endpoints: BP, HR, UO, skin perfusion, mental status dynamic ( change in pulse pressure, stroke volume variation) or static (arterial
volume status and tissue perfusion and document findings as EITHER:
-Indices of perfusion: lactate, mixed or central venous oxygen saturation pressure, heart rate) variables.
- Focused exam (after initial fluid resuscitation) by licensed independ-
ent practitioner ( vital signs, cardiopulmonary, capillary refill, pulse Vasopressors 1. Norepinephrine (NE) is the first choice vasopressor
and skin findings) and Inotropes 2. Epinephrine (added to and potentially substituted for NE) when an additional
- OR TWO OF THE FOLLOWING: Measure CVP, Measure agent is needed
FLUID Therapy ScvO2, bedside cardiovascular ultrasound, dynamic assessment of 3. Low dose vasopressin can be added to NE with intent of either raising MAP or
Crystalloids or Colloids titrated to clinical endpoints fluid responsiveness with passive leg raise or fluid challenge decreasing NE dose
Maintain Hb 7-9 g/dL 4. Low dose vasopressin is not recommended as single initial vasopressor; higher
doses only recommended as salvage
Adjunctive Therapies 5. Dopamine as an alternative to NE only in highly selective patients ( low risk of
tachyarrhythmias and absolute or relative bradycardia)
Blood 1. Once tissue perfusion resolved and in the absence of : 6. Phenylephrine is NOT recommended in the treatment of septic shock except:
BP at goal? Products myocardial ischemia, severe hypoxemia, acute hemor- when NE is associated with serious arrhythmias or CO is known
(one attempt, if fails move to next step) rhage and ischemic heart disease, red blood cell transfu- to be high and BP persistently low - salvage therapy
sion should occur only when Hg < 7.0 g/dL to taget Hg 7. A trial of dobutamine up to 20 mcg/kg/min +/- vasopressor in the presence of
NO 7.0-9.0 g/dL myocardial dysfunction or ongoing signs of hypoperfusion
2. Administer platelets when < 10,000/ mm3 in the Source control
Consider invasive hemodynamic NO absence of apparent bleeding, when < 20,000/ mm3 if
1. Administration of effective intravenous antimicrobials within the FIRST
monitoring and antibiotics HOUR of r ecognition of septic shock and sever e sepsis without septic shock.
significant risk of bleeding
• Central Venous Pressure (CVP) 2. Initial empiric anti-infective therapy (see table) of one or more drugs that have
3. Higher counts ≥ 50,000/mm3 are advised for active activity against all likely pathogens and that penetrate in adequate concentrations
bleeding , surgery or invasive procedures into tissues presumed to be the source of infection
3. Reassess antimicrobial regimen daily for potential de-escalation, to optimize
Glucose 1. Maintain blood glucose 140-180 mg/dL with insulin efficacy, prevent resistance, and avoid toxicity
Control using unit algorithm 4. Combination therapy for neutropenic patients with severe sepsis and for
Adequate filling pressure? patients with difficult to treat multi drug resistant pathogens ( A cinetobacter and

058
Pseudomonas spp.)
YES Mechanical 1. Target a tidal volume of 6ml/kg IBW in patients with 5. Empiric combination should not be administered for > 3-5 days: deescalate to
Ventilation sepsis induced ARDS most appropriate single therapy as soon as susceptibilities known
2. Maintain inspiratory plateau pressure to <30 cmH 2O 6. Duration of therapy : 7-10 days ; longer courses in patients with slow clinical
YES
VASOPRESSOR Therapy 3. Use PEEP to avoid alveolar collapse response, undrainable foci, bacteremia with S.aureus
Norepinephrine as the first choice
Epinephrine added when an additional agent is needed Steroids
Titrate to MAP ≥ 65 mmHg Renal Intermittent hemodialysis and CVVH are considered 1. Do not use IV hydrocortisone to treat adult septic shock if adequate fluid
Replace- equivalent; CVVH offers easier management in HD (hydrocortisone resuscitation and vasopressor therapy are able to restore hemodynamic stability
ment unstable patients 50 mg IV q 6 ) 2. If hyemodynamic stability not achievable use IV hydrocortisone alone at a
total daily dose of 200 mg via intermittent dosing or continuous infusion
Bicarbonate Do not use for purpose of improving hemodynamics or 3. ACTH stimulation test is not recommended to identify septic shock patients
Adequate CO Therapy reducing vasopressor requirements in patients with who should receive treatment with IV hydrocortisone
hypoperfusion induced lactic acidemia with pH>7.15 4. Taper the IV hydrocortisone dose when vasopressors are no longer required
NO
Consider replacement dose STEROIDS
RECEPTOR ACTIVITY HEMODYNAMIC EFFECTS
in vasopressor refractory septic shock YES Inotropic Therapy AGENT
patients Dobutamine (preffered) 1 2 1 2 DA1 V1 MAP CO SVR HR PCWP
DOPAMINE (mcg/kg/min)
0 0 + 0 ++++ 0 0 0 0  0
1-3
0/+ 0 ++++ 0/+ ++++ 0   0  0
3-10
BP at goal? 10-20
+++ 0 ++++ 0/+ 0 0     
NO
EPINEPHRINE (mcg/kg/min)
++ 0 ++ +++ 0 0   0  0
0.01-0.05
+++ +++ +++ +++ 0 0     
Refractory septic shock >0.05
-Vassopressin 0.03 units/min may be added to NE
NOREPINEPHRINE (mcg/kg/min)
with anticipation of an effect equal to NE alone ++++ +++ ++ 0/+ 0 0     
YES 0.05-0.5
PHENYLEPHRINE (mcg/kg/min)
++++ 0 0 0 0 0    ¯ 
0.1-4
VASOPRESSIN (units/min) 0 0 0 0 0 ++++     
0.03
Adequate perfusion? NO DOBUTAMINE (mcg/kg/min) + 0 ++++ ++ 0 0 ↑ ↑ 0/↓ 0/↑ ↓
Establish re-evaluation interval (q15-30 min) 2- 10
++ 0 ++++ +++ 0 0 ↓/↑ ↑ ↓ ↑↑ ↓
Aggressive titration of fluids and vasopressorsto > 10 – 20
YES
maintain established goals of resuscitation based
MILRINONE (mcg/kg/min)
on clinical endpoints and indices of perfusion 0 0 0 0 0 0 0/↓/↑ ↑ ↓ ↑↑ ↓
0.375 – 0.75
Notice: Readers are encouraged to confirm the information contained herein with other resources. Dellinger RP et al. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock, 2012. Crit Care Med 2013
12
Andreea Popa, PharmD, BCPS
Critical Care Clinical Pharmacist
Liz Hohner, PharmD Candidate
P A I N , A G I TAT I O N , D E L I R I U M A N D P A R A LY S I S
MEDICAL INTENSIVE CARE UNIT
Barr J, Fraser GL, Puntillo K, Ely EW, et al. Clinical practice guidelines for the management of pain,
agitation and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41:263-306.
Key Guideline Recommendations
Pain
• Preferred assessment tools for pain in ICU patients
− Self-report of pain preferred
Assess
− Behavioral pain scale (BPS 3-12)
− Vital signs alone should not be used
• Non-neuropathic pain: IV opioids +/- non-opioid analgesia
Treat
• Neuropathic pain: gabapentin or carbamazepine + IV opioids
• Pre-procedural analgesia +/- non-pharmacologic interventions
Prevent
• Treat pain first, then sedate

059
Agitation
• RASS (-5 to +4) is the preferred assessment tool for depth and quality of
sedation
• If using neuromuscular blocking agents, objective measures of brain
Assess function* should be used as an adjunct to subjective sedation assess-
ments.
• EEG monitoring to detect non-convulsive seizure activity and to titrate
electrosuppressive medications for burst suppression in patients who
known or suspected seizures
• Target lightest level of sedation possible
• Implement daily sedation interruption
• Use analgesia-first sedation
• Non-BZD for sedation (propofol or dexmedeomidine) are preferred,
Treat unless EtOH or BZD withdrawal is suspected
• Management
− Undersedated (RASS > 0): assess / treat pain then sedatives PRN
− Oversedated: hold sedatives until at target then restart at 50% of pre-
vious dose
• Consider daily spontaneous breathing trials, early mobility and exercise
when patients at goal sedation level (unless contraindicated)
Prevent
• EEG monitoring if patient is at risk for seizures or burst suppression ther-
apy is indicated for increased ICP
*auditory evoked potentials, bispectral index, narcotrend index, patient state index or state entropy
2 11
Delirium
Neuromuscular Blocking Agents
• Preferred assessment tools for delirium in ICU patients
Assess
− CAM-ICU (+ or - )
• Treat pain as needed
• Reorient patients, familiarize surroundings, use patient’s eyeglasses or
hearing aids
• Pharmacologic treatment
− Avoid BZD unless suspect EtOH / BZD withdrawal
Treat
− Avoid rivastigmine
− Atypical antipsychotics might reduce the duration of delirium
− Avoid antipsychotics if at risk for QTc prolongation
• If sedation is required in delirious ICU patients, use dexmedetomidine
for sedation, unless delirium is related to EtOH / BZD withdrawal
• Identify delirium risk factors: pre-existing dementia, HTN, history of
EtOH abuse, high severity of illness, coma, BZD use
• Avoid BZD use in those at risk for delirium
• Do not use antipsychotics prophylactically to prevent delirium
Prevent
• Mobilize and exercise patients early
• Promote sleep: control light, noise, cluster patient care activities, de-
crease nocturnal stimuli
• Restart baseline psychiatric meds if indicated

060
Sedation and Delirium Assessment Tools
Richmond Agitation-Sedation Scale (RASS)
+4 Combative Combative, violent, immediate danger to self
+3 Very agitated Pulls or removes tube(s) or catheters(s); aggressive
+2 Agitated Frequent non-purposeful movement, fights ventilator
Anxious, apprehensive but movements are not aggressive
+1 Restless
or vigorous
0 Alert and calm
Not fully alert, but has sustained awakening to voice (eye
-1 Drowsy
opening & contact >10 sec)
-2 Light sedation Briefly awakens to voice (eye opening and contact <10 sec)
-3 Moderate sedation Movement or eye opening to voice (but no contact)
No response to voice, but movement or eye opening to
-4 Deep sedation
stimulation
-5 Unarousable No response to voice or physical stimulation
Sessler, et al. Am J Repir Crit Care Med 2002, 166; 1338-1334.
Ely, et al. JAMA 2003; 286: 2983-2991
10 3
Sedation and Delirium Assessments: A Two Step Approach
Delirium in the ICU
Step One: Sedation Assessment (RASS)
Delirium is associated with increased mortality, prolonged ICU and
If RASS is –4 or –5, then Stop & Reassess patient at later time
hospital length of stay and development of post-ICU cognitive impair-
If RASS is above –3 through +4 then Proceed to Step 2
ment in adult ICU patients.
Incidence of Delirium Prevention Step Two: Delirium Assessment (CAM-ICU)
(hypoactive, hyperactive, mixed) • Optimize ICU environment
Feature 1: Acute onset of mental
• 80% of mechanically ventilated patients • Early mobilization
status changes or a fluctuating course
• 25% of hospitalized patients with chronic • Do not disturb normal sleep
medical conditions • Avoid benzodiazepines And
• 40% HIV patients • Limit dopaminergics, GABA-
• 50% post-operative patients agonists and anticholinger- Feature 2: Inattention
• 81.7% ICU survivors gics And
Risk Factors • Analgesia first “sedation”
• • Use of alpha-2 agonists Feature 3: Disorganized Feature 4: Altered Level
Pre-existing dementia Or
(dexmedtomidine) Thinking of Consciousness
• Hypertension
• History of alcoholism
• Prophylactic pharmacologic = Delirium
prevention is NOT recom-
• High severity of illness at baseline mended Ely. JAMA 2001; 286: 2703-2710.
• Coma Ely. Crit Care Med 2001; 29: 1370-1379.
• Benzodiazepine use Copyright © 2002, E. Wesley, Ely, MD, MPH and Vanderbilt University, all rights reserved
Feature 1: Acute Onset or
Feature 2: Inattention
Treatment of ICU Delirium Fluctuating Course
• There is not sufficient evidence to determine if haloperidol reduces the duration of Positive if either question is answered yes. Positive if ASE score is less than 8.

061
delirium in adult ICU patients. Is there an acute change from mental status Assess using the Attention Screening
• Atypical antipsychotics, such as quetiapine, may reduce the duration of delirium baseline? Examination (ASE) – Letters or Pic-
in ICU patients, however they have no impact on mortality or length of ICU stay. Did the patient’s mental status fluctuate during the tures. Attempt ASE Letters first. If patient
past 24 hrs as evidenced by fluctuation of is able to perform this test and the score is
• Antipsychoitcs should be avoided in patients are risk for QT prolongation. sedation scale (RASS), GCS or previous delir- clear, record the score and move to Fea-
Haloperidol (Haldol) Quetiapine (Seroquel) ium assessment? ture 3. If patient is unable to perform this
• MOA: Blocks dopaminergic receptors in • MOA: Blocks dopaminergic and test or the score is unclear, perform the
Feature 3: Disorganized Thinking ASE Pictures. If you perform both tests,
the brain; also has some alpha-blocking serotinergic receptors in the brain
use the ASE Pictures results to score the
and anticholinergic effects and also has histamine-blocking Positive if the combined (Questions + Com- Feature.
• Repeat bolus doses every 30 min until and alpha-blocking effects. mand) score is less than 4. ASE Letters: Auditory / Random Letter
calm and then administer 25% of the • In a small prospective, randomized, Yes/No Questions: Use either Set A or B, alter- “A” Test
maximum dose ever 6 hours  double-blind, patients who were nate on consecutive days if necessary. Directions: Say to the patient “I am going
Set A to read you a series of 10 letters. When-
− Mild agitation: 0.5-2 mg IV  being treated with haloperidol for
Will a stone float on water? ever you hear the letter ‘A’, indicate by
− Moderate agitation: 2-5 mg IV  delirium and additionally received Are there fish in the sea? squeezing my hand.” Read letters from
quetiapine had a reduced duration
− Severe agitation: 10-20 mg IV of delirium.
Does one pound weigh more than two pounds? the following list in a normal tone: S A V E
Can you use a hammer to pound a nail? AHAART
Ziprasidone (Zyprexa) − Quetiapine: 50 mg q 12 hrs and Set B Scoring: Errors are counted when patient
Will a leaf float on water? fails to squeeze on the letter “A” and when
• MOA: Blocks dopaminergic, serotiner- could be increased by 50 mg
Are there elephants in the sea?
every 24 hrs if needed up to patient squeezes on any letter other than
gic, alpha-1 and cholinergic receptors Do two pounds weigh more than one pound?
200 mg q 12 hrs “A”.
• In a small, randomized, double-blind, Can you use a hammer to cut wood? ASE Pictures: Visual / Picture Recogni-
treatment of delirium with either halop- − Patients could receive IV halop- Score: Patient earns 1 point for each correct tion - Directions and scoring are located
eridol, ziprasidone or placebo resulted eridol 1-10 mg q 2 hrs PRN answer out of 4. on picture packet.
in a similar number of days alive without • More conservative dosing of Command: Say to patient: “Hold up this many Feature 4: Altered Level of
quetiapine starting at 12.5-25 mg fingers” (examiner holds two fingers in front of the
delirium or coma. Consciousness
patient) “Now do the same thing with the other
− Haloperidol 5 mg q 6-12 hrs vs. q 12 hours may be appropriate. hand” (not repeating the number of fingers). Positive if patient’s current level of
Ziprasidone 40 mg q 6-12 hrs Score: Patient earns 1 point if able to success- consciousness is anything other than
fully complete the entire command. alert (RASS other than “0” at time of
assessment).
4 9
Propofol:
Pain in the ICU • MOA: CNS depression by agonism of GABA and blockade of NMDA receptors
Causes of Pain • General anesthetic with sedative / hypnotic properties but no analgesia
• Limited positioning at rest, endotracheal tube, post-operative / post- • Produced less amnesia than midazolam in comparative studies
procedural pain • Predictable time to sedation and recovery
Incidence of Pain in the ICU • Studies comparing propofol with midazolam showed shorter time to extubation
• In patients discharged from the ICU but remaining in the hospital, 82% with propofol.Has been used to sedate neurosurgical patients to reduce ele-
remember pain or discomfort associated with ET tube and 77% remem- vated ICP, decrease cerebral blood flow and metabolism
bered experiencing moderate to severe pain during their ICU stay. Pharmacokinetics Adverse Effects
• Six months after discharge, 38% of patient still recalled pain as their most • Onset: 30 sec after bolus • Strong respiratory depressant
traumatic ICU memory and 18% were at risk for development of PTSD. • Duration 3-10 min • Hypotension (dose-related)
Opioids are first line for management of pain. • Vd: extremely lipophillic with a large Vd • Longer recovery after > 12 hr infusion
• All available opioids when titrated to similar pain intensity endpoints are leads to accumulation with high doses, • Hyperlipidemia, TGs (10% so bean oil)
equally effective. Agent selection is based on pharmacological properties prolonged infusions and obese patients • Risk of infection
and potential for adverse drug reactions • Protein bound: 97.9% • Infusion related (administer centrally)
• MOA: opioids bind Mu, Kappa and Delta receptors in CNS • Initial t ½: 2-8 min • Propofol syndrome (hypotension, pan-
• Opioid Class Adverse Effects • Terminal t ½: 300-700 min creatitis, brady cardia, lactic acidosis,
− Potent respiratory depression (dose-dependent) • No changes in kinetics with renal or rhabdomyolysis, renal failure)
hepatic dysfunction
− Hypotension and vasodilation
− Decreased intestinal motility (dose-dependent) Benzodiazepines:
− Histamine release (morphine) Lorazepam (Ativan), Midazolam (Versed), Diazepam (Valium)
• MOA: bind GABA receptors in CNS and increase affinity for GABA
Active Onset of Duration of
Drug Elim t ½ • Dose dependent sedation / amnesia
Metabolite Action effect
• Do not provide any analgesia, although does have opioid sparing effects by

062
Fentanyl No 1-2 min 2-4 hr 0.5-1 hr moderation of anticipatory pain response
Morphine Yes 5-10 min 3-4 hr 2-4 hr • Highly protein bound and hepatically metabolized
• Durations of action are dependent on lipid solubility, volume of distribution,
Hydromorphone No 5-15 min 2-3 hr 2-6 hr protein binding and elimination half-life
Fentanyl Morphine Hydromorphone • Active metabolites may prolong duration and elimination
• Preferred for • Accumulation with hepatic/ • Similar duration − 1-hydroxymidazolam is renally eliminated and accumulates in renal failure
hemodynamically renal impairment of action to mor- • Propylene glycol toxicity (diluent IV lorazepam) with high doses (>10 mg/hr)
unstable patient • Only use in hemodynamically phine, however it • Drug interactions
• 50-100x more po- stable patients has no active − Enhanced elimination: cimetidine, erythromycin, isoniazid, ketoconazole,
tent than morphine • Can cause venodilation metabolite metoprolol, and propranolol
• 7000x more lipo- (direct effect, histamine re- • Not associated − Reduced elimination: rifampin and theophylline
philic than mor- lease, neural medication) and with histamine
Active Receptor Lipid Onset of
phine hypotension release Drug
Metabolite Affinity Solubility
Elim t ½
Action
• Accumulates dur- 0.44 1.54
1-4 hr
ing prolonged ad- Midazolam a1-OH mida- (up to 11)
2-5 min
2.23 0.71
ministration zolam
9.57 1.00 20-70 hr
Adjunctive pain medications can be used to reduce opioid requirements Diazepam Desmethyldi- 2-5 min
5.58 0.79 36-90 hr
and to reduce incidence and severity of opioid related side effects. azepam
• For neuropathic pain: gabapentin or carbamazepine in addition to iv Lorazepam None 1.64 0.48 8-15 hr 15-20 min
opioids can be considered for treatment Short term: 3-12 hr
• For non-neuropathic pain: IV acetaminophen and NSAIDS can be used in Propofol None n/a n/a Long term: 1-2 min
50+-18.6hr
addition to opioids
Dexmede-
None n/a n/a 1.8-3.1 hr 5-10 min
tomidine
8 5
Starting Starting
Drug Intermittent IV dosing
bolus infusion
Sedation in the ICU Fentanyl 25-50 mcg
25-50 mcg q 0.5-1 hr
25 mcg/hr
Optimizing Sedation and Analgesia Indications for Sedation 0.35-0.5 mcg/kg q 0.5-1 hr
Morphine 2-4 mg 2-4 mg q 2 hr 2 mg/hr
• Prior to initiation of sedation / analgesia, • Improve tolerance of entotracheal Hydromor-
differentiate between anxiety, pain and / tube and mechanical ventilation 0.4mg 0.2-0.6 mg q 2 hr —
phone
or delirium and treat reversible causes • Suppress spontaneous ventilation to
prior to initiation of sedation and analge- lower airway pressures Drug Onset Elim t ½ Dosing
sia. • Reduce oxygen consumption
• Protocol driven with lighter sedation target • Decrease stress response associ- IV Acetamino- 5-10 1000 mg q 6 hr
• Analgesia first approach or analgesia- 2 hr
ated with procedures phen min Max: 4 g/day
based sedation • Allow sleep in uncomfortable envi-
• Use non-BZD sedatives when possible ronment Initial: 100 mg TID
• Employ “co-sedation” • Treat EtOH / substance abuse with- PO Gabapentin N/A 5-7 hr Maintenance: 900-3600 mg/day in 3
• Perform daily interruptions of sedation drawal divided doses
• Delirium prevention • Prevent self-extubation
Initial 25-65 Initial: 50-100mg BID
Dexmedetomidine (Precedex ®) PO Car-
4-5 hr hrs then 12- Maintenance: 100-200 mg q 4-6hr
• Highly selective alpha-2 adenroreceptor agonist that produces sedation, anx- bamazepine IR
17 hr Max: 1200 mg/day
iolysis and partial analgesia by central binding at the locus ceruleus and spi-
nal cord
• Boluses are associated with hypotension 30 mg then 15-30 mg q 6 hr
IV Ketorolac 10 min 2.4-8.6 hr
− Start infusion at 0.2 mcg/kg/HOUR and titrate to desired level of sedation Max: 120 mg/day x 5 days
every 20-30 min
− Onset of action without bolus: 20-30 min IV Acetamino- • IV achieves higher plasma levels compared to PO result-

063
• FDA Indication: use as a sedative for patients undergoing mechanical ventila- phen ing in higher CNS levels, superior analgesic effects and
tion in the ICU and as a sedative prior to and / or during surgical or other pro- longer duration of effect
cedures of non-intubated patients • Avoids first pass metabolism: lower hepatic exposure
• Patients are sedated when undisturbed and arouse with gentle stimulation • Efficacy data: post-operative pain vs. placebo and as ef-
− “cooperative sedation” fective as 30 mg of ketorolac or 10 mg morphine
• In comparative studies, dexmedetomidine was shown to provide better seda- • Potential opioid sparing effect
tion than lorazepam and equivalent sedation to midazolam and propofol. Ad- NSAIDs • Avoid NSAIDs in the following patients: renal dysfunc-
ditionally, dexmedetomidine was associated with decreased mechanical ven- tion, GI bleeding, platelet abnormalities, concomitant
tilation days and hospital length of stay compared to midazolam and equiva- ACE-inhibitor therapy, CHF, cirrhosis, asthma
lent ventilation days and hospital length of stay compared to propofol. • Contraindicated for treatment of perioperative pain in
• Adverse effects: significant hypotension and bradycardia CABG
• Use caution: heart block, EF<30%, liver failure, hypovolemia and hypotension
Gabapentin • Common side effects: sedation, confusion, dizziness,
Intermittent IV Dose Infusion Dose Range ataxia
0.2-1.4 mcg/kg/HOUR • Adjust dose in patients with renal failure
Dexmedetomidine — • Abrupt d/c associated with drug withdrawal syndrome and
Max reported 2.5 mcg/kg/hr
seizures
5-10 mcg/kg/min
Propofol —
Do not bolus Car- • Side effects: (common) nystagmus, dizziness, diploplia,
1-2 mg q 0.5-2 hr 2 mg/hr
bamazepine lightheadedness, lethargy; (rare) aplastic anemia, agranu-
Midazolam locytosis, Stevens-Johnson syndrome, toxic epidermal
0.02-0.08 mg/kg q 0.5-2 hr 0.04-0.2 mg/kg/hr
necrolysis with HLA-B1502 gene
Diazepam 0.03-0.1 mg/kg q 0.5-6 hr —
• Multiple drug interactions due to hepatic enzyme induc-
0.5-2 mg q 2-6 hr 1 mg/hr tion.
Lorazepam
0.02-0.06 mg/kg q 2-6 hr 0.01-0.1 mg/kg/hr
 6

064
7
I. Specific Agents
 Norepinephrine
 Combined α and β agonist (α > β) , more potent than dopamine
 MAP, SVR
 Little effect CO/Ci or PCWP; Increased HR
 Increased UOP due to increased perfusion
 It does not worsen, and it can improve tissue oxygenation in septic
shock patients
 Adverse effects
_ Tachyarrhythmias
_ In the context of hypovolemia there is increased vascular
resistance and renal ischemia
 DOC in septic shock
 Wide dosage range: 0.2 – 1.3 mcg/kg/min; the highest dose reported:
3.3 mcg/kg/min (most pts stop responding far earlier)
 Vasopressin

 Potent vasoconstrictor (acts on vascular V1 receptors when blood

pressure compromised)
_ It has limited effect in normal subjects, but there is a marked
increase in BP when sympathetic nerve function is impaired
_ More potent than Phenylephrine and Norepinephrine
_ Effective in acidosis/hypoxia
_ Used in small studies in patients with refractory septic shock
_ Other effects: Na+ and H2O retention, cortisol production
2

 SBP, MAP, SVR

 May  renal output (increased perfusion pressure, hydrostatic

pressure).
 PCWP or oxygenation were not adversely affected (reports)
 Vasopressin administration increases effectiveness of simultaneous
catecholamine therapy and may allow for weaning and eventual
catecholamine discontinuation
 Vasopressin levels increase during early septic shock and decrease
over time to below normal -> vasopressin deficiency during late
septic shock
 Dosage range: 0.01 – 0.1 units/min (average: 0.04 units/min)
 Adverse effects
_ In patients with CAD -> Increase in myocardial oxygen
consumption -> may precipitate an MI
_ Impairment of blood flow to splanchnic system, stress ulcers,
bowel ileus and malabsorption

 Dopamine
 Precursor of norepinephrine and epinephrine (conversion might be
impaired in shock states)

065
  CO/Ci (improves ventricular contractility and HR), MAP, SVR
 Dose dependent adrenergic effects

 At low doses acts on the DA1 receptors causing renal vasodilatation.

This dose response relationship has not been confirmed in critically ill
patients (“renal dose dopamine”)
 Adverse effects
_ Tachyarrhythmias
_ PCWP (pulmonary vasoconstriction), increase in pulmonary shunt
 There is limited improvement when going beyond the 20 mcg/kg/min
dose
 Dobutamine
 Synthetic cathecolamine selective for β1, mild β2 and vascular α1
activity-> positive inotrope without vasoconstriction
  in CO/Ci is greater than with dopamine
 No effect on DA receptors
 The increased contractility leads to reflex reduction in sympathetic
tone -> SVR
 Used to increase CO/Ci in septic and cardiogenic shock patients

 Phenylephrine
 Pure α1 agonist
 MAP, SVR

 Does not impair Ci, PSWP

 Reflex bradycardia has been reported, usually no change in HR
 Limited studies in septic shock patients
 It can cause severe peripheral vasoconstriction

 Epinephrine
 Combined α and β agonist
  MAP, Ci, SVR, HR

 Used as last resort

 Adverse effects
_ Tachyarrhythmias
_ Severe vasoconstriction of splachnic and renal beds
_ Increases regional and systemic lactate concentrations

Andreea E. Popa, Pharm.D. Critical Care Clinical Pharmacist

066
 Rheumatology
Lab testing
In general, remember that rheumatologic diagnosis relies more on history and physical
than lab tests. A patient with a very low pretest probability and a positive test still has a
low posttest of probability of having the disease of interest.

ANA: can be obtained as a screen where perinuclear staining is visualized using

immunoflorescence, OR a panel of specific antibodies. Generally the screening
visualization test has fewer false positives but gives less detailed or specific information.
At UH: This can be ordered as screen only (ANA without reflex ENA), screen with
reflex to panel (ANA with reflex ENA), or screen + panel (ANA with automatic ENA).
Generally you will be ordering the screen with reflex to panel (ANA with reflex
ANA). Only order the screen with automatic panel in situations where you have a VERY
high pretest probability – typically you will only be doing this at rheum’s
recommendation.
At the VA: this comes as ANA multiplex only (no staining, specific antibiodies
only). This means you get a panel of ~12 antibodies WITHOUT the screening stain test.
The panel alone has at least one positive antibody in >20% of the women in the general
population, a number which increases with age to 40-50% by age 65 – be careful about
ordering about this in older patients with symptoms of fibromyalgia as you are likely to
get a false positive and end up incorrectly diagnosing the patient as lupus!

ESR/CRP
Sensitive and nonspecific.
-CRP can be ordered as standard assay reported in mg/dL (useful for assessing gross
abnormalities of inflammation in rheum patients) and the high sensitivity assay reported
in mg/L (useful in coronary risk assessment). At UH, ordering CRP will order the
standard assay (mg/dL) but at VA ordering CRP orders the high sensitivity assay in mg/L,
so remember to divide your result by 10 before interpretation (a CRP of 10 at the VA is
normal!)
-ESR: Upper limit of normal can be estimated by Age/2 in men, and (Age+10)/2 in
women.

ANCA (anti-neutrophil cytoplasmic antibody) : Can be useful in assessing suspected

vasculitis. As with ANA you typically will order the ANCA as an immunofluorescence
assay (sensitive, not specific) and if positive will give you the staining pattern (p for
perinuclear, c for cytoplasmic). ELISA can also be performed for the specific targets of
interest, PR3 (proteinase 3) and MPO (myeloperoxidase), and these may be ordered to
follow up a positive ANCA. Rheumatology may have you order the ANCA along with the
specific antibodies (anti-PR3 and anti-MPO) in patients with a very high pretest
probability of vasculitis.
-C-ANCA is when staining is noted more prominently in cytoplasm; this is more
commonly (but not exclusively) associated with PR3, and more commonly associated
with GPA (Wegener’s)

067
-P-ANCA is a pattern of perinuclear staining, more commonly associated (but again not
exclusively) with MPO. More commonly associated with MPA (microscopic polyangiitis)
and Churg Strauss.

RF and anti-CCP
Tested in suspected RA and can be helpful in differentiating RA and psoriatic arthritis or
other conditions. Up to 20% of patients with RA are seronegative (negative for both
antibodies.) Seronegative RA tends to be limited to joint involvement, and has fewer
systemic effects.
RF is an IgM specific for Fc portion of IgG. Titers can correlate with disease activity. Can
also be positive in diseases such as connective tissue disease, B cell lymphomas, chronic
Hep C and SBE.
Anti-CCP more specific than RF and portends a worse prognosis.

Complement levels (C3, C4)

In the context of rheumatology, most useful for assessing activity of glomerulonephritis
in SLE, in which levels will be low. Low generally in diseases where immune complexes
are being formed, including Sjogren’s, mixed cryoglobulinemia, and MPGN.

Rheumatologic emergencies and urgent clinical situations

C-spine instability in patients with RA: consider urgent C-spine imaging (MRI with GAD
preferred) and urgent Spine surgery consult in patients with RA or
spondyloarthropathies who develop neurologic symptoms; may be associated with
atlantoaxial instability/subluxation resulting in cord compression

Scleroderma renal crisis: Consider in a patient with systemic sclerosis (usually recently
diagnosed) with acute onset of renal failure without hx of CKD. Assocated with abrupt
onset of HTN. UA normal. Associated with MAHA and sometimes difficult to differentiate
from TTP/HUS. Pathophysiology related to infrarenal renal artery stenosis. Treat with
captopril as first-line, but monitor creatinine closely.

Pulmonary-renal disease -> can be rapidly progressive. Differential includes GPA, MPA,
endocarditis, Churg-Strauss, Goodpasture’s. Send ANCA and anti-GBM. Initial lab workup
should include ANA, HIV, LFTs, C3/C4, UA, hepatitis panel to exclude other causes. Low
threshold for tissue biopsy and early initiation of immunosuppressive therapy.

Visual loss with Giant Cell Arteritis (Temporal Arteritis) – consider in older patient
(particularly with history of polymyalgia rheumatic) with visual loss and headaches, jaw
claudication, fevers or elevated inflammatory markers. Dx with temporal artery biopsy
and treat with pulse solumedrol if visual loss present.

HLH/MAS: Consider in critically ill patients with unexplained fevers, rash,

lymphadenopathy. Labs notable for cytopenias and profoundly elevated ferritin. CRP
elevated but ESR may be low. Consider macrophage activation syndrome in young adult

068
with hx of juvenile idiopathic arthritis or Adult Still’s. Consult rheum and hem/onc for
consideration of bone marrow biopsy.

Gout management in primary care

Gout occurs due to an immune reaction to urate deposits (tophi.) Uric acid precipitates at
levels greater than 6.8mg/dL at body temperature, and closer to 6 at the temperature of
the extremities. Therefore while uric acid level is >6mg/dL, the patient is in positive
crystal balance. Goal of therapy should be to maintain uric acid <6mg/dL while
preventing flares.

You can manage gout as a primary care physician! Treat with allopurinol - start 100mg
daily x 2 weeks to assess allergic response and avoid precipitating gout flare by dropping
uric acid level too quickly. Then begin to titrate up to achieve goal uric acid level.
Allopurinol dosing is no longer based on renal function. In 1-2% of patients who are
allergic to allopurinol, use febuxostat.

Treat with colchicine 0.6-1.2 mg daily to prevent flares until uric acid <6 for 6-9 months,
then trial weaning off – may need to resume if patient has recurrent flares. Currently at
the VA colchicine can only be ordered by rheumatology, but this will change once
colchicine goes back off patent.

Acute flare: Treat with colchicine 1.2mg followed by another 0.6mg 1 hour later. Use
NSAIDS such as indomethacin along with colchicine to treat acute flares.

Pseudogout (calcium pyrophosphate deposition disease, CPPD) is managed similarly

except for uric acid lowering. Use colchicine or NSAIDS for flare prophylaxis; prednisone
may be used for flares.

Osteoarthritis management in primary care

Osteoarthritis management: no pharm tx to prevent progression, therapy is aimed at

reducing symptoms and disability.

Mild disease: weight loss, exercise, knee braces, PT, acetaminophen, NSAIDS if failure of
acetaminophen or evidence of inflammatory disease, topical NSAIDS (voltaren cream),
capsaicin cream

Moderate or refractory disease: In addition to above therapies: can trial injection of

triamcinolone (40mg for large joints) -> does not halt progression, leads to median 3
weeks of symptom reduction. In patients with failure of above therapies can refer to
rheumatology for trial of intraarticular hyaluronans (Euflexxa) though data do not
necessarily show strong benefit.

069
Severe disease: cautious use of opioids; consider pain management referral; refer to
orthopedics for consideration of joint replacement

070
A classification schema with common presentations of rheumatologic disease:

Seronegative spondyloarthritis: common features include involvement of axial

skeleton, enthesitis (inflammation at tendon insertion site), uveitis, association with
HLA B27, asymmetric peripheral disease. Documentation of HLA-B27 positivity can be
supportive but is extremely nonspecific. Elevated inflammatory markers but by
definition no specific antibodies.
Ankylosing IBD associated
Psoriatic Arthritis Reactive Arthritis
Spondylitis spondyloarthritis
Can be similar to RA but Clinically
involves DIP, may have asymmetric, mono indistinguishable
morning
prominent axial or oligoarthritis in from AS except for
stiffness, SI
involvement, dactylitis, large joints 1-4 wks associated IBD. May
tendernes,
typical rash of psoriasis after GU or GI not correlate with
enthesitis
but arthritis may precede infection activity of intestinal
dermatologic disease disease!

071
Connective tissue disease: Common features include arthritis/arthralgias, can cause overlap syndromes
(also referred to as MCTD, mixed connective tissue disease, associated with anti-RNP)
SLE Systemic Sclerosis, Sjogren's Polymyositis and RA
Scleroderma, CREST dermatomyositis
Most Constitiutional Characteristic is dry eyes, dry Middle age, PIP and MCP
common symptoms, Rash (malar thickened, sclerotic mouth, presents with without DIP
sx rash, discoid lupus, skin leading to parotid progressive involvement.
photosensitivity), progressive enlargement, proximal muscle Also wrists,
arthritis but arthralgias immobility and arthritis, weakness. knees, ankles,
more common, disability. Spectrum of interstitial Dermatomyositis MTPs, C-spine.
glomerulonephritis, disorders - limited nephritis, associated with Associated with
serositis (pleural and cutaneous systemic serositis, gottron's papules pleural disease,
pericardial), verrucous sclerosis, cutaneous increased (over PIP and interstitial lung
endocarditis (libman- with systemic lymphoprolife MCP) and disease. Felty
sacks), symptoms, CREST rative heliotrope rash syndrome =
thromboembolism syndrome (Calcinosis disorders neutropenia,
associated with cutis, Raynaud RA,
antiphospholipid phenomenon, splenomegaly
antibody, wide Esophageal
spectrum of CNS and dysmotility,
peripheral neurologic Sclerodactyly, and
manifestations, Telangiectasia).
keratoconjunctivitis Systemic symptoms
sicca, cytopenias, include ILD,
lymphadenopathy and pulmonary vascular
splenomegaly. disease, renovascular
disease, pericardial or
myocardial
involvement

Common anemia, anti-centromere ANA, +RF, elevated CK, Anemia,

Lab thrombocytopenia, (limited cutaneous anti-SSA, anti- aldolase, AST. Rheumatoid
findings leukolymphopenia, low scleroderma), anti-SCL SSB +ANA typical, Factor (titer
complement, elevated 70 (diffuse systemic occasionally +RF. correlates with
inflammatory markers. sclerosis). Anti-Jo disease
+ ANA with variety of associated but activity), anti-
other + autoantibodies usually negative. CCP (correlates
inc to dsDNA, Smith, Dx testing with more
Ro, La, histone, RNP, includes EMG severe disease)
ribosomal. False + and muscle
VDRL. biopsy.

072
 SLE Systemic Sclerosis, Sjogren's Polymyositis and RA
Scleroderma, CREST dermatomyositis

Tx NSAIDS, steroids, Treatment based on NSAIDS, steroids, Steroids,

hydroxychloroquine; organ involvement; steroids; give methotrexate or methotrexate is
cyclophosphomide for SKIN: eye drops and azathioprine, the workhorse,
acute major organ immunosuppressive supportive care cyclophosphamide, leflunomide, can
involvement (CNS, renal); therapy not very for sicca IVIG use sulfasalazine.
MMF or 6MP for effective for skin symptoms. Biologics
nephritis, MTX for joint thickening. MTX or MMF Immunosuppre (etanercept,
disease to start. Pruritis may be sive therapy adalimumab,
tx with steroids, depending on infliximab)
antihistamines, systemic typically added if
capsaicin, phototherapy. involvement. methotrexate
RENAL: ACEi. LUNG: Hydroxychloroq does not
cyclophosphamide, pulm uine for mild eradicate
vasodilators. JOINT: arthralgias, symptoms.
steroids, MTX for Rituximab
hydroxychloroquine, refractory increasingly used
MTX. GI: promotility symptoms. for refractory
agents, PPI Biologics if disease
severe

073
 Vasculitis: Common features include rash (classically palpable purpuric rash, can be variable),
common renal involvement, high degrees of inflammation.

Small Vessel
Vasculitis
GPA Henoch
from RA,
(Wegener's) Churg Strauss Schonlein Cryoglobulinemia
SLE, or
and MPA Purpura
Sjogren's

Accelerating Associated with

Pulm, renal, Hematuria,
asthma/atopy in Distal arteritis lymphoproliferative
ENT Vasculitis rash
adulthood, with digital disorders or chronic
involvement. on lower
eventually ischemia, HCV. Symptoms
Common Initial lab extremities, Abd
followed by livedo consistent with
symptoms workup should pain, orchitis,
vasculitic reticularis, small vessel
and include ANCA, Arthralgias/Arthr
symptoms purpuric rash. vasculitis including
associations as well as ANA, itis. Typically in
including lung, Pericarditis, renal involvement,
HIV, LFTs, children but can
skin, kidneys, mesenteric arthralgias,
C3/C4, UA, be seen in
neurologic systems ischemia vasculitic rashes,
hepatitis panel younger adults
and others. neuropathy

cryoglobulins (must
ANCA+ in 90% peripheral
be taken to lab
(typically C- eosinophilia,
hematuria, immediately to
Lab findings ANCA in GPA, elevated IgE, P-
proteinuria avoid false
P-ANCA in ANCA against MPO
negative), +RF, dec
MPA) but can be C-ANCA
C4 with normal C3
Biopsy from
affected tissue;
Biopsy in
differentiating clinical, biopsy and
Dx characteristic Clinical
factor is LACK labs are supportive
clinical context
of granulomas
in MPA

Steroids, Supportive,
steroids, Most important
cyclophospham steroids only for
cyclophospha treat underlying
ide. Bactrim to persistent or
Steroids, mide, treat disease; can use
Tx prevent severe
cyclophosphamide underlying steroids, others for
respiratory proteinuria or
connective significant organ
infections for renal
tissue disease involvement
GPA impairment

074
Vasculitis medium
small and medium large vessel
continued vessel
Behcet's PAN GCA Takayasu

Constitutional More
(fevers, weight common in
loss), purpuric young Asian
oral and genital ulcers are classic, headache, visual
rash or livido women.
Common may also have variety of systemic loss, jaw
reticularis, GI, Constitutional
symptoms involvement including derm and claudication.
renal, symptoms
and optho involvement. Associated Very commonly
arthralgias/art follwed by
associations with Middle Eastern and associated with
hritis, myalgias, aortitis and
South/Central Asian ethinicities polymyalgia
peripheral other large
neuropathy, central
orchitis arteries.

leukocytosis,
increased ESR,
associated with elevated ESR and elevated ESR,
Lab findings HLA B51 associated.
HBV, CRP CRP
occasionally p-
ANCA

Clinical; biopsy,
angiography
Clinical, bx of ulcers can be temporal artery vascular
Dx can be
helpful bx imaging
supportive or
confirmatory

Steroids,
cyclophospham
azathioprine, colchicine, steroids, ide. Antiviral steroids, MTX,
Tx Steroids
other DMARDS therapy if antiplatelets
associated with
HBV

075
 Hematology/Oncology (Ratnoff/Weisman)

Ratnoff and Weisman are the Heme/Onc services. Ratnoff is staffed by an oncology
attending, Weisman by a hospitalist. The service is a mix of direct admit from heme/onc
clinics, ED, and outside hospital transfers. Many of the straightforward patients (admit
for chemo, symptom control…) go to the Berger hospitalist/NP service, so the resident
teams are left with patients who are often quite sick and bouncing between the floor and
MICU.

Team Structure: 1 attending, 1 senior resident, 2 interns. Occasional AI/MS3

Cap: 8 patients per intern (lower than other UH services), team cap increases with AI
Admission guidelines: Short: 2 NF’s or ICU transfers prior to 1PM (none if clinic, off
during weekend). Medium: 2 admissions prior to 4PM. Long: 3 by 7PM.
Namesakes: In 1974 Oscar Ratnoff warned in the Annals of Internal Medicine that new
pooled factor from many donors was associated with increased rates of hepatitis in
hemophilia patients, and that the explosion in pooled factor over cryoprecipitate could
cause significant harms. Again at the precipice of the HIV epidemic, he warned that
explosive rates of HIV in hemophiliacs (>50% by 1984) was related to the pooled factor,
and pleaded with industry and the CDC to use hepatitis B screening before accepting
blood and plasma donations. Far ahead of his time, and swimming against the tide of
huge corporate interests, he was ridiculed and ignored. By the 1990s, when the science
finally became obvious to all, northern Ohio had some of the lowest rates of hepatitis and
HIV among hemophiliacs in the country.
As a fellow at Case Western, Russell Weisman worked with an OB/GYN fellow to define
hemolysis as a critical component of the HELLP syndrome in pregnant women.

Febrile Neutropenia: ANC<500 and T>38.0x1 hr (or >38.3 once). (Both UH and VA list
ANC, but you need to use the multiplier 1000: 1.3 at the VA is actually 1300. If in doubt,
multiply WBC by percent neutrophils.
1.Culture. 2 sets of blood cultures STAT (at least 1 from every port and central line, and
one additional peripheral. The second is vital, will tell you if Coag Neg Staph is a
contaminant and tell you if line is infected and needs removed), UA/UCx. If making
sputum, cx it. If diarrhea, cx and send for C diff.
2. Source? Get a CXR (2 view). Push on the belly (neutropenic enterocolitis? sick pts can
develop cholecystitis even if they came in for something else).
3. Get a complete set of vital signs. Is the patient still stable on the floor? Could the fever
be from something else (these pts often get PEs and some PEs present with fever)
4. Cover Broadly: Staph, pseudomonas both in play here. Options: Vancomycin is
sometimes needed for MRSA (if allergic or hx of resistance, daptomycin), our patients
often have enough MRSA risks to buy them a couple days of vanc until the source
becomes clear but this isn’t always needed. Most important is broad coverage with an
gram negative/antipsuedomonal agent (piperacillin/tazobactam, cefepime all work
here…if penicillin allergic meropenem has less cross reactivity and aztreonam is safe but
you start to lose pseudomonas). If you’re thinking about gentamicin or other
aminoglycosides you should run the case by a senior resident. If the patient is either in

076
the MICU or looks like they’re heading there, add antifungals (micafungin, not
fluconazole). If stable and febrile after 5 days, consider voriconazole.
5. In the VA there is a neutropenic order set (will have diet, precautions, abx options,
some culture orders. Check that everything you want is ordered). At UH it’s individual
orders for neutropenic diet and neutropenic precautions.. At the VA all CBC’s have a diff,
at UH you need to specify the lab with a differential.
6. Was the patient already on abx? If so ensure they are on appropriate coverage as
above. Still resend cultures (may have better chance of catching transient bacteremia
during fever).
7. Check past cultures to ensure the above applies to your patient (in CPRS under labs
check the micro section for recent bugs, at UH use portal to look at recent
blood/urine/sputum cultures). Adjust abx as needed.
New neutropenic fever will significantly alter the day team’s work, if you are covering the
patient as a NF write a clinical event note .

Sickle Cell Admission: At UH use Portal to look at the most recent heme note and to see
if the patient has a care path (if so it will be near the top of portal). Use OAARS to check
narcotic use and if patient is filling with multiple providers/systems. The most
challenging aspect of admitting a patient with sickle cell disease is that routine
admissions and life threatening admissions both often involve pain.
Fluids
• hypovolemic: Normal Saline @ 300 - 500 mls/hr until patient is euvolemic.
• euvolemic: D5W1/2NS at 75-125 ml/hr or consider oral rehydration alone if they’re
tolerating
Laboratory/Radiology
All patients on admission:
• CBC, retic, LDH, CMP, CRP, ua, Women: urine beta-HCG
• Some patients on admission: blood culture, urine culture, CXR
• If % of Hgb S subtypes needed (severe crisis, considering exchange transfusion)
order “hemoglobin identification” at UH and “hemoglobin electrophoresis” at VA
• Use labs drawn on a clinic day as baseline, not labs during their last hospitalization
Transfusions
• Transfuse PRBC’s if the Hgb drops >2 g below baseline.
• Transfuse PRBC’s for symptomatic anemia i.e. shortness of breath, dyspnea on
exertion or orthostasis. Sickle cell crisis is NOT a symptom of anemia.
• Many patients chronically have Hgb around 8. Hgb<7 is not necessarily an
indication to transfuse, but Hgb<5.5 probably is.
• Never transfuse to >10
Pain Medications
• All narcotic bolus doses should be given as IVPB (unless Carepath says differently).
IV push narcotics give a euphoric high but not better overall pain control. Use
outpt and previous admission dosing to judge how much the patient needs.
• If there is no IV access, analgesics may be given IM or SQ.
• If the patient is on chronic long acting narcotics, continue the same.
• If no contraindications to NSAID such as renal dysfunction, GI bleed, PUD or GERD
may add ketorolac 30 mg IV every 6 hrs x a maximum of 5 day.
077
 • If pain not relieved with frequent PRN doses, transition to PCA. Avoid a basal dose.
Respiratory
• Incentive spirometry at bedside. Atelectasis and areas of hypoxia are dangerous in
these patients. No O2 unless O2 sat<92%
Ancillary Medications
• Tylenol for fever >38 C.
• For itching: diphenhydramine 25-50 mg po every 4-6 hrs or hydroxyzine 25-50 mg
every 6 hours. No IV Benadryl unless extreme circumstances.
Chronic Care
• Ferritin concentration if not drawn in the previous 12 months
• Echocardiogram if concern for acute chest or active cardiomyopathy (otherwise TTE
done during crisis of little outpt use)
• Pneumococcal, meningococcal and influenza vaccinations if not previously given
Hydrea and Exjade
• useful to know creat stable (for exjade) and neutrophils and retics/hgb aren’t
unstable (hydrea). If Hgb<9 and Retic<100K, hold hydrea. If it’s unclear, ok to hold
for 1st day or 2 of admission, the important thing is to discuss a discharge plan with
the hematology fellow.
Acute Chest
• Hypoxia, chest pain, and new CXR infiltrate. Type and Screen, give O2, and talk
with Heme and transfusion medicine about exchange transfusion and if pt needs
MICU (may need line, closer monitoring, etc…). Control their pain.
• Admission CXR may be normal is patients who subsequently develop Acute Chest
• If Hgb<8, can use simple transfusion to bridge to exchange transfusion while
waiting a MICU bed. Doesn’t remove the Hgb S, but does decrease percentage.

078
 So you’re the intern on Weisman call. You’ve just admitted what you thought was an
uncomplicated patient with pain crisis with your resident. The resident is gone and the
routine labs you sent just come back, but they look off. Moreover, you’ve just gone back in to
see the patient and that HR of 91 has creeped up to 108 and they just don’t look as good
anymore. Here’s an approach to getting your patient what they need.

Red flags for acute concern: Risk for acute crash:

Hgb>2 gram below bsln 1. See patient with senior
RR>22 or SaO2<92% resident (DACR/NACR if your
New CXR infiltrate resident is gone)
Worst HA of life (SCD prone to SAH) 2. Type and Screen, control pain,
Localized new LUQ pain (spln sequest, life ensure good IV access.
threatening) 3. Consider urgent heme
Fever consult, MICU, exchange
“They just look sicker” transfusion, stat imaging
(discuss these with resident
and/or fellow)

Signs of physiologic problems:

Hgb>1 gram below bsln
ALT>2x bsln Talk about labs with your resident or
Absolute Retic>500k another senior, make a plan. Decide if
LDH>1.5xbsln fluids/transfusion/abx indicated.
WBC>1.5x bsln Heme will need to see while
Creat>1.5 x bsln inpatient.
PLT 50% < bsln

Signs of heavy disease burden:

Acute Chest in last 2 mo
Hx CVA
These are chronically very sick
TRV>3 on TTE
patients. Consider heme consult with
Pts on Hydrea/Exjade
your resident if indicated.
Care Path not working

The Sickle Cell fellow’s pager is 32390.

079
Anticoagulation: The most frequent issues
DVT ppx: 1) decide if the patient really needs it (if younger, expecting short hospital stay,
walking…can avoid) 2)what to use (no lovenox in renal failure) 3)if there are any
reasons not to use injectable AC (GIB? PLT<50? …just because an order set says AC is a
good idea doesn’t mean it’s a good idea). Your main options are heparin SC 5000 q8 and
lovenox 40mg daily. UH you must use the DVT risk order set (usually as part of
admission, can just click ‘other’ for risk score to get 3 risk points and open up all your
options)

Therapeutic: lots of options beyond the scope of this guide. Know why they are on it and
if they will need changed for some procedure (biopsy, coronary angio, other surg or IR
procedure…) and how to plan for it (does Coumadin need held? Reversed? Will they need
a heparin drip to bridge or are they ok off AC for a few days?). The issue will boil down to
1)why are they anticoagulated? And 2)Why do we need to hold AC?

New Start/Bridging: Start with the indication (new PE needs AC more urgently than
chronic A fib with CHADS=2). Decide if patient needs 1)Immediate AC with IV or
injectable followed by maintenance oral AC. 2)new oral AC without injectable
(rivaroxaban?). If you’ve decided to use a heparin drip to start Coumadin on a patient
with new anticoagulation indication:
• 1) Start both heparin gtt and Coumadin 5mg oral daily
• 2)when INR>2 for 2 days, stop heparin gtt
• 3)discharge on Coumadin single agent with AC clinic f/u (see below)
A modified outpatient version of this can be done with enoxaparin, but insurance and
approvals often get in the way

Coumadin clinic:
• At VA it’s easy: go to “Consults” in CPRS, click the indication boxes. Done.
• At UH, my friend you are about to start a long journey. 1)Go to Residency Website,
under UH resources print the Anticoagulation Clinic form. 2)Fill out this form
3)Find out which outpatient MD the patient will follow up with for AC 4)Fax the
form to that provider for their signature 5)They fax it back (in theory) 6)Fax it to
the AC Clinic for an appointment
If this weren’t enough, you’ll need an attending to be responsible between discharge and
first AC appointment. If the outpt provider says no, ask your attending.

GI ppx: If hx of UGIB, PUD, or other risk factors, ensure on GI ppx (daily PPI)

Hypercoagulability (this workup is often unnecessary inipatient, but if you’ve decided

your patient needs it a few things to remember):
1) Prior to Heparin: Draw an extra blue top tube prior to starting heparin since
heparin will interfere with assays for antithrombin III and the lupus anticoagulant.
Protein C, S, anticardiolipin antibodies, homocysteine, prothrombin and Factor V
Leiden mutations can be sent on pts on heparin.
080
 2) Prior to Coumadin: Note that Proteins C + S are vitamin K dependent factors and
will thus be lowered by warfarin therapy.
3) DNA-based tests (Factor V Leiden and Prothrombin 20210 mutation) can be done
anytime.
4) Repeat abnormal tests in the future to document an accurate diagnosis.
5) Not every positive test is a diagnosis: keep in mind thrombosis itself (along with
post op or severe liver disease) can decrease AT III, PC, PS. If the workup needs to
start inpatient that’s fine, but most of these patient should have follow up with a
hematologist as outpatients.

The Anemia Workup (low production vs destruction vs sequestration)

Start with some useful labs (CBC with diff, retic, LDH, type and screen, CMP to look at bili
and for AKI of TTP, ferritin, iron studies).
-Haptoglobin is ultrasensitive for hemolysis but not specific, LDH is more useful
-Ferritin is an acute phase reactant, but only elevates with good iron stores. Harrison’s
says over 200 and it’s not iron deficiency. Others use slightly higher or lower numbers.
Essentially, once you’re much over 150-200, it’s not iron deficiency.

Low Retics:
Low MCV Fe def Thalass- ACD Sideroblastic
emia
MCV wnl Acute Hemolysis ACD Liver Sidero- Hypothyroid MDS Aplastic
Bleed Disease blastic
High B12 Folate def Drug Liver Disease Hypothyroid MDS
MCV def (hydrea
?,
Dilantin
?)

High Retics:
Elevated AIHA MAHA PNH Sickle Spur G6PD
LDH/Bili Cell/Hemoglobin- cell/HS/
opathy HE
Normal Subacu Splenic Liver Sequestration
LDH/Bili te Sequestrat
Bleed ion
-Spleen and Liver sequestration may also have elevated LDH/Bili, though often not as
dramatic as would be see in hemolytic crisis.

081
Getting a peripheral smear at UH and the VA
Look at the Smear (schistocytes for TTP, blasts?, hypersegmented neutrophils…):
At UH: Call heme tech at 45244 and ask for a peripheral smear on your patient. An hour
later, go to 5th floor of Humphrey Building, turn left and lab door code is 13799*. Middle
right is the heme tech station, they have a table with “slides for Docs”. Grab your patient’s
slides and go look in the heme path room, back left. Take a senior resident the first time
to show you around.
At VA: Call 4085, ask for smear to be made. Go to basement on elevators between 4A and
4B, turn away from atrium side of hospital, you’ll see sign for lab. Ask at entrance for
hematology lab (it’s the 3rd door on right in hall). Find a tech to show you the slides, there
are two microscopes in the lab.

-If you see several schistocytes per high powered field and TTP is on differential,
remember the motto “Don’t let the sun set on TTP”. Wake up a hematology fellow.

The Tumor Lysis Watchguard

The idea behind tumor lysis syndrome is that killing large number of cancer cells releases
large stores of intracellular ions and metabolites, which can be toxic in large quantities.
Since it’s cell death that’s the cause, we worry particularly about high grade and highly
chemosensitive malignancies (think leukemia, particularly with high WBC count, and
high grade lymphomas). While it’s mostly liquids we think about, this is why tumor
burden and chemosensitivity guide us and we often see small cell lung cancer patients
admitted for tumor lysis observation.
The Players:
1. Uric Acid-arthralgia, renal toxicity
2. Hyperkalemia-often earliest sign of TLS. Weakness and cardiotoxicity
3. Hyperphosphatemia-causes hypocalcemia
4. Hypocalcemia-parasthesias and tetany, may progress to AMS, szr, arrhythmia

Goals: 1)Prevent 2)Recognize and treat quickly

Prophylaxis: 1)start IVF (NS), if no CHF using 200/hr starting prior to chemo (increase to
meet UOP goal). 2)allopurinol 200mg BID if normal renal fx
Note: alkalinization of urine to maximize uric acid excretion is no longer routine, but may
be recommended by a consultant

Labs/Monitoring: BID RFP, phos, ionized calcium, uric acid, LDH, PT/PTT (DIC risk in
these patients), urine output (keep it >100 cc/hr in avg adult, Pession 2011)
Treatment: Increasing uric acid, potassium, hyperphos, hypocalcemia as above all
indicate prevention failed. Rasburicase can rapidly lower uric acid, but is incredibly
expensive. In some situations (like runaway hyperkalemia) patients may need MICU
transfer and temporary HD. If it comes to rasburicase and/or HD discuss with your senior
resident and the heme fellow.
Source: Oxford Handbook of Clinical Haematology, ACP Resident Guide

082
Transfusions: Components, and troubleshooting
The trend is towards less is more regarding transfusions, so decide if it’s really time to
transfuse.
The tools:
1) PRBC-most plasma removed (1 unit should increase Hgb 1 g/dl)
-Leukoreduced: WBC removed, less antigenic. Use in cancer patients when you
think they may need multiple transfusions, or pts with prior fevers with
transfusion.
-Washed: even fewer WBC, indications as above, more expensive
-Irradiated: stem cells killed, lower GvHD risk
-CMV negative: use in CMV negative pre or post-transplant patients(organ or BMT)

2)Platelets (a ‘6-pack’ is outdated terminology, we now use a single donor apheresis

unit which should increase PLT 30-60k)

3)FFP: contains all factors (rapid warfarin correction, bleeding liver failure).
Remember, many coag factors in FFP have ½ life <12 h (V, VII, VIII, protein C), so
don’t load a nonbleeding patient with FFP this afternoon for a procedure that will be
done tomorrow.

4)Cryoprecipitate-factor VIII, factor XIII vW factor, fibrinogen. Use in DIC, ask

transfusion medicine for help with dosing.

Transfusion Reactions:
Acute Hemolytic Reaction: Fever with hemodynamic changes (usually rapid), heat
along vein being transfused: think ABO incompatability. Stop the transfusion, send blood
and patient samples to lab. Given Tylenol, Benadryl, methylprednisolone (125mg IV x1).
Send LDH, smear, coombs, CBC.

Delayed Hemolytic Reaction: fever, hemolysis, poor incremetation. Ab from prior

transfusion/pregnancy (too weak to be detected in pretransfusion testing), when PRBC
with antigen are transfused, hemolysis occurs. Send pt and transfusion samples as above
(especially Coombs/DAT). Tx more supportive, tylenol for the fever and Benadryl if
itching from the bilirubin. Often undiagnosed as it can occurs days or even weeks later
and slowly.

Fever without other vital sign changes: usually due to self reaction against donor WBC.
Tx with tyenol and Benadryl. Unless protocol mandates stopping transfusion, keep it
going and monitor patient.

Allergic/itching: may also include laryngeal edema. Caused by reaction to foreign

plasma proteins. Tx with benadryl, methylprednisolone.

083
Allergic/anaphylaxis: Rare but potentially deadly. Epinephrine IM, methylprednisolone
125mg IV, Benadryl IV, 1L NS. Call ENT for airway evaluation if indicated. If true
anaphylaxis, MICU.

TRALI: Shortness of breath, developing pulm edema on CXR. Supportive care, which may
mean MICU if severe. TRALI is often mistaken for CHF (if your patient has grade 1 or 2
diastolic dysfunction and is now on a ventimask after 1-2 units, consider TRALI rather
than HFPEF).
Source: University of Michigan Department of Pathology and Oxford Handbook of Clinical Haematology

HIT
Pretest Probability (“The 4 T’s of HIT):
1. Thrombocytopenia (>50% decrease, and still >20k)
2. Timing: Occurs 5-10d after starting heparin, earlier if exposure in last 3 mo.
3. Thrombosis: new thrombus, or skin necrosis at site of SC injection
4. Other: is there another reason for decreasing plt? Sepsis? Drug?

Workup: Anti-PF4 is sensitive, but less specific. Comes back early, if negative you can stop
bivalrudin/argatroban (unless pretest probability stratospheric). Seratonin Release
Assay just as sensitive but more specific, takes longer to come back.

Treatment: If pretest probability moderate to high, stop the heparin, and start bivalrudin
or argatroban (if renal failure, use argatroban)

Cause: IgG Ab attacks multimolecular PF4/heparin complexes.

Facts: Incidence higher with heparin than enoxaparin. Incidence greater in surgical
patients.
Sources: Oxford Handbook of Clinical Haematology, Ortel TL. Hematology Am Soc Hematol Educ Program. 2009;225-232.

084
Your first day on:!
CARPENTER SERVICE!
!
Carpenter is the infectious disease service. All* HIV patients are admitted to Carpenter. The
service also carries patients with complicated infections (epidural abscess, severe sepsis, FUO)
and occasionally general medicine patients with “an ID bent”.!
!
*exception: HIV patients who also have cancer or ESRD may go to Ratnoff/Weisman or Eckel service (depending on
which issue their chief complaint is related to). These patients will be followed by the Carpenter attending on service,

!Team structure: 1 attending, 0-1 fellows, 1 senior, 2 interns, occasionally

NOT the ID fellows. !

1-2 AI, usually 1 MS3!

Team cap: 20 patients !
Admission guidelines: 2 patients on short (by 12PM, must be NF or MICU
transfer), 2 patients on medium by 4 PM, 3 patients on long by 7 PM!
Namesake: C.J. Carpenter, former chief of medicine and infectious disease
guru. Still practicing at Brown University. Dr. Salata was his last chief
resident!!
!
General pearls:!
- look up vitals as you normally would, but keep in mind to look for the Tmax!
- report back on all cultures on morning rounds!
- know DAY of antibiotics (e.g. “day 5 of planned 7 day course”) and put a stop date in your
daily note so you don’t forget when antibiotics need to stop!
- consider narrowing antibiotics ASAP!
!
NEED TO KNOW TOPICS:!
!
SIRS/SEPSIS!
!
SIRS: 2/4 “SIRS criteria”!
• T > 38°C or T < 36°C!
• HR > 90 bpm!
• RR > 20 or PaCO2 < 32mmHg!
• WBC > 12,000/mm3 or WBC < 4,000/mm3 or bands > 10%!
Note: you can have SIRS criteria without an infectious etiology! Common examples include
pancreatitis, VTE, cholecystitis. !
!
SEPSIS: SIRS + suspected source of infection!
Check the following to evaluate for infection (in addition to your physical exam):!
• CXR!
• urinalysis (and urine culture)!
• blood cultures!
• consider CT a/p for intraabdominal infection!
• consider Cdiff PCR for concurrent diarrhea!
!
SEVERE SEPSIS: Sepsis + new end organ damage!
Examples of end organ damage include:!
• AKI !

085
 • troponinemia!
• lactic acidosis!
• hyperbilirubinemia!
!
SEPTIC SHOCK: severe sepsis + hypotension not responsive to adequate fluid resuscitation !
Continue to bolus fluids as long as patient can tolerate; would consider adequate challenge at
least 2-3L of NS or LR. If patient is in septic shock, consideration should be made for MICU
transfer. !
!
MULTI ORGAN DYSFUNCTION SYNDROME (MODS):!
Shock leading to organ failure. Patient should be in the MICU by this point. !
!
TREATMENT OF SEPSIS:!
• Early UA/UCx, BCx, SpCx (if applicable), fluid cultures e.g. ascites (if applicable)!
• OBTAIN CULTURES BEFORE ANTIBIOTICS!
• Early administration of broad spectrum antibiotics!
• Follow cultures and narrow antibiotics as needed!
• Aggressive fluid resuscitation!
• Aggressive monitoring (at least frequent VS, could consider CVC if in ICU)!
• Could consider vasopressor agents (in ICU) if BP is not responsive to fluids!
• Goals of care!
• See MICU section for further information on the treatment of septic shock!
!
COMMON ID CLINICAL SYNDROMES!
!
MENINGITIS:!
Presentation: fever, headache, nuchal rigidity (+Kernig and +Brudzinski signs), AMS (with
concurrent encephalitis)!
!
Etiology: S. pneumoniae, N. meningitidis, Listeria (in elderly), enteroviruses!
!
Diagnosis: lumbar puncture!
!
bacterial viral fungal/TB

opening high normal or

pressure slightly elev

glucose very low normal normal to

low

protein high normal/ high

high
WBC 1000-500 10-500, 10-500,
0, PMNs lymphocytic lymphocytic
!
Treatment:!
bacterial meningitis: CTX 2g IV q12h + vancomycin 15mg/kg IV q8h for trough 15-20 +
dexamethasone 0.15 mg/kg IV q6h +/- ampicillin 2g q4h (depending on risk for listeriosis)!
• CTX will cover S. pneumoniae and N. meningitidis!

086
 • vancomycin will cover CTX-resistant S. pneumonia (rare, but consequences of untreated
infection would be devastating!
• dexamethasone improves survival in S. pneumo meningitis!
• ampicillin will cover for listeria in older patients!
• COULD ALSO CONSIDER acyclovir if patient has signs of encephalopathy, as HSV
encephalitis is treatable!
viral meningitis: supportive care!
!
SSTI/CELLULITIS: !
presentation: erythema, edema, pain, +/- fever!
!
etiology: usually streptococcal, although staph is also common skin flora. In special
circumstances (e.g. diabetes) can also be gram negative rods (Pseudomonas)!
!
diagnosis: physical exam, CBC. Consider obtaining XR of affected extremity if you have a
consideration of necrotizing fasciitis (bacteria and air in the fascial plane) as this is a surgical
emergency. !
NOTE wound cultures are only useful to determine presence of MRSA. Otherwise, likely
polymicrobial and will reflect skin flora.!
!
treatment: !
for MSSA/strep: IV: cefazolin or nafcillin. PO: cephalexin or dicloxacillin!
for MRSA: IV: vancomycin. PO: bactrim, doxycycline/minocycline, clindamycin!
for necr fasciitis: STAT surgical consult!
!
NOTE with newer depot-formulation antimicrobials (dalbavancin, oritavancin) management of
SSTI will change substantially in the next few years!!


PNEUMONIA:!
presentation: fever, cough, purulent sputum, hypoxia, infiltrate on CXR!
!
Note: community acquired PNA (CAP) is a distinct clinical entity from health care associated
PNA (HCAP). PNA is defined as HCAP if a patient has been admitted to an acute care hospital
or in contact with health care facility (dialysis, SNF) within the last 90 days.!
!
etiology: !
CAP: S. pneumoniae, Mycoplasma spp., viral; less likely Legionella!
HCAP: S. pneumo, S. aureus, GNR (Klebsiella spp., P. aeruginosa, etc.), Legionella!
!
diagnosis: CXR, BCx, SpCx, urine legionella antigen (only picks up serotype 1), S. pneumo
urine antigen!
!
treatment:!
outpatient: azithromycin monotherapy or respiratory fluoroquinolone; length of treatment until
afebrile x3d!
inpatient CAP: CTX 1g q24h + azithromycin 500mg x1 (then 250mg x5d)!
inpatient HCAP: vancomycin 1-1.5g q12h + pipercillin/tazobactam 4.5g q6h +/- azithromycin (if
patient had been outpatient and has high risk Legionella infection). Consider aztreonam or
carbapenem if patient has PCN allergy.!
If PCN allergy is anaphylaxis, don't use carbapenem due to
2-5% cross reactivity.

087


UTI/PYELONEPHRITIS:!
presentation: fevers, dysuria, urinary frequency, AMS (in elderly). + CVA tenderness, abd pain,
flank pain in pyelonephritis.!
!
etiology: !
typically Enterobactereciae incl. E. coli, Klebsiella spp., S. saprophyticus!
note that in patients with chronic foley, anything goes!!
pyelo most commonly ascending in nature!
!
diagnosis: UA (WBC elevated WITHOUT significant elevation in squamous epithelial cells, as
this indicates unclean catch), UCx, BCx, renal u/s if concern for hydronephrosis, CT a/p if
concern for complicated pyeloneophritis, renal capsular abscess!
!
treatment: !
uncomplicated UTI (female): Bactrim x3d or ciprofloxacin x3d (note our institution’s E. coli has a
lot of cipro resistance) or nitrofurantoin x5d!
complicated UTI (male/female): therapy targeted towards etiologic agent, 10-14d course!
pyelonephritis: amoxicillin/clav or ciprofloxacin targeted towards etiologic agent, 14d course!
asymptomatic bacteriuria: DO NOT TREAT!


INTRAABDOMINAL (DIVERTICULITIS, PERFORATED VISCERA):!
presentation: abdominal pain, +/- rebound/guarding, fevers!
!
etiology: Enterobactereciae (E. coli most common), anaerobes e.g. B. fragilis!
!
diagnosis: CT a/p with contrast, consider abd u/s for appendicitis depending on clinical
presentation!
!
treatment: typically pip/tazo at least initially (good GNR coverage as well as covering B. fragilis).
Can narrow ABx depending on culture data. BEWARE giving just cipro/metronidazole given our
antibiogram.!
!
ENDOCARDITIS:!
presentation: may present either acutely or subacutely. Acute: fever, new valvular insufficiency
(new murmur, fluid overload), embolic disease. Subacute: B symptoms!
!
etiology: !
diagnosis: 2 sets of blood cultures should be taken from SEPARATE sites e.g. one from each
arm. Ideal to also have temporally separated blood cultures (30 min apart) but this is not usually
feasible in clinical practice.!
!
In addition to BCx, patient should have CXR (to assess for septic emboli), EKG (evaluate for
structural disease and make special note of the PR interval, which can prolong with valve root
abscess), TTE (if negative TEE should be pursued. !
!
Duke criteria are used to determine diagnosis:!
• Definite diagnosis is made with either 2 major criteria met, OR 1 major and 3 minor criteria
met, OR 5 minor criteria met, OR + culture obtained pathologically from endocardial mass.!

088
• Endocarditis is possible if either 1 major and 1 minor criteria are met OR if 3 minor criteria are
met.!
!
MAJOR CRITERIA MINOR CRITERIA

+ blood culture from typical organism (viridans predisposing factor (known cardiac
Strep, S. aureus, S. bovis, HACEK, Enterococcus) structural disease, known IVDU)
in 2 separate cultures OR + culture for atypical
organism with 2 separate cultures 12 hours apart
OR + Coxiella IgG/culture

evidence of endocardial involvement on fever > 38°C

echocardiography

evidence of embolus e.g. arterial emboli,

pulmonary septic emboli, Janeway
lesions, conjunctival hemorrhage

immunological problems e.g.

glomerulonephritis, Osler’s nodes, Roth
spots, +RF

microbiologic evidence (e.g. single +

culture or atypical infection) that does
not meet major criteria
!
treatment:!
native valve: treatment tailored to etiologic agent. For MSSA/Strep viridans, typically patient will
be placed on Blactam (nafcillin or cefazolin). Gentamicin is used for synergy with enterococcal
endocarditis and in tricuspid valve endocarditis. CTX often used for GN endocarditis.!
prosthetic valve: vancomycin or nafcillin (depending on whether organism is MR or MS). Gent
added for synergy.!
!
Surgical c/s should be obtained early if patient has evidence of severe heart failure, evidence of
septic emboli (to the chest or brain), valve root abscess, S. aureus infection in prosthetic valve. !
!
C. DIFFICILE COLITIS:!
presentation: fevers, abdominal pain, diffuse diarrhea (especially if past exposure to antibiotics)!
!
etiology: C. difficile… obviously. Antibiotics kill normal gut flora and leave C. diff to repopulate
the bowel. Most common antibiotics to cause CDI: #1 cephalosporins, #2 fluoroquinolones, #3
clindamycin.!
!
diagnosis: C. difficile PCR. Samples can be tested once weekly; if the patient has had a
negative test within the last 7 days, new sample will be rejected unless you make a compelling
case to the lab. Consider getting KUB to assess for megacolon.!
!
treatment: Metronidazole 500mg tid is agent of choice for first case and for first relapse. PO
vancomycin* 125mg-250mg q6h is agent of choice for “severe” CDI (hypoalbuminemia, WBC >
15K, abdominal distention). Could consider fidaxomycin or fecal transplant for refractory
disease.!
!
089
*DO NOT use IV vancomycin in the treatment of C. difficile. IV formulation does not penetrate into the bowel.!
!
ANTIBIOTICS!

090
 Cefepime doesn't
cover anaerobes.

!
091
!
Antibiotics that cover MRSA:!
1. vancomycin!
+: commonly used -: renally dosed, bacteriostatic, “vanc creep” ✓: CBC, RFP!
2. daptomycin!
+: once daily dosing -: inactivated by lung surfactant ✓: CK (rhabdo), CBC, RFP!
3. ceftaroline!
+: broad spectrum (basically CTX + MRSA) -: ID only ✓: CBC (cytopenias after prolonged use)!
4. tigecycline!
+: uncommonly used, will cover resistant GNRs also -: does not cover “3Ps” - Pseudomonas,
Proteus, Providentia, no urine coverage, low blood concentrations ✓: CBC, RFP!
5. linezolid (+ tedizolid)!
+: IV and PO, easy dosing -: bacteriostatic ✓: CBC (cytopenias after prolonged use >7d)!
6. TMP/SMX!
+: PO -: ✓: (G6PD)!
7. doxycycline/minocycline!
+: PO -: photosensitivity ✓: -!
8. clindamycin!
+: PO -: tastes bad, evolving resistance ✓: -!
!
!
!
HIV ISSUES!
!
AIDS is defined as HIV+ status with either CD4 < 200 OR HIV+ status with an AIDS-defining
illness.

!
Common AIDS-defining illnesses include:!
• invasive candidiasis!
• disseminated cryptococcosis!
• Kaposi’s sarcoma!
• Burkitt’s lymphoma!
• invasive cervical cancer!
• Pneumocystis pneumonia!
• disseminated mycobacterial infection!
• Toxoplasma encephalitis!
• HIV wasting syndrome!
!
The recommendation at this time regarding HAART in patients who are HIV+ is that all patients
should be offered antiretroviral therapy. The recommendation is strongest for patients who have
a CD4 count of < 350. Patients with exceedingly high viral load or those who are pregnant
should be started on HAART more urgently.!

!
Before starting HAART, it should be confirmed that patient does not have any opportunistic
infection. Once patient’s immune status improves, they are at risk of Immune Reconstitution
Inflammatory Syndrome (IRIS), in which their now restored immune system vigorously attacks
an infection which had previously gone unnoticed. If patient has an underlying OI, that should
usually be treated before HAART is initiated.!

!
092
When presenting a patient with HIV disease, you should know current CD4 and viral load, nadir
of CD4, whether they have had any opportunistic infections, and current antiretroviral regimen.!
!
Also, when you admit a patient to Carpenter with HIV disease, you should contact the SIU
(Special Immunology Unit) to obtain the patient’s face sheet. This sheet discusses the patient’s
primary care history, history of HAART, any OIs, all CD4/VL data, etc.!
!
ANTIRETROVIRALS!
!
All currently used combinations of antiretrovirals are in combination to block the development of
resistance. !
!
Types of antiretroviral agents:!
NRTI (nucleoside reverse transcriptase inhibitor): essentially a “fake” nucleoside base; when it
is integrated via reverse transcriptase enzyme, DNA synthesis stops as there is no moiety to
hook another base to. Thus HIV DNA is not created from RNA, decreasing viral load.!
NNRTI (non-nucleoside reverse transcriptase inhibitor): agents that bind directly to the active
site of the RT enzyme, thus not allowing creation of HIV DNA. !
PI (protease inhibitor): agents that bind to viral proteases, thus blocking creation of infectious
virions!
INSTI (integrase strand transfer inhibitor): blocks integrase enzyme, which is required for entry
of viral DNA into human cell!
entry inhibitor: blocks formation of gp120 complex which allows entry of HIV into the cell. NOTE
maraviroc, the only example in this class, only works in patients who have CCR5 coreceptor, so
tropism testing must be completed prior to initiation of this agent!
!
The optimal antiretroviral therapy for a treatment-naive patient consists of 2 NRTIs and a third
“other” drug from one of the other 3 classes.!
!
Common regimens include:!
• efaverenz (NNRTI) / tenofovir (NRTI) / emtricitabine (NRTI)!aka Truvada
• atazanavir (PI) / ritonavir (booster for PI) / tenofovir / emtricitabine!
• darunavir (PI) / ritonavir / tenofovir / emtricitabine!
• dolutegravir (INSTI) / tenofovir / emtricitabine!
!
As patients’ virus becomes more resistant, patients may require more complex regimens. !
!
!
!
!
!
!
!
!
!
!
!
!
!

093
PRIMARY PROPHYLAXIS FOR PATIENTS WITH HIV DISEASE!
!
ORGANISM PROPHYLAX AT WITH OR UNTIL
(PREFERRED)

PCP CD4 < 200 OR Bactrim 1 DS daily dapsone, CD4 > 200 for 3
(PneumoCystis history of (could consider atovaquone, months
Pneumonia) oropharyngeal Bactrim 1 DS inhaled
candidiasis MWF) pentamidine

Toxoplasmosis CD4 < 100 (if Bactrim 1 DS daily dapsone/ CD4 > 200 for 3
Toxoplasma IgG+) (could consider pyrimethamine + months
Bactrim 1 DS leukovorin
MWF)

M. avium CD4 < 50 azithromycin clarithromycin CD4 > 100 for 3

complex 1200mg weekly weekly, rifabutin months

Histoplasmosis CD4 < 150 if high itraconazole - CD4 > 150 for 6
exposure risk or 200mg daily months
living in hyper-
endemic area
Primary prophylaxis is not warranted for cryptococcal infection given lack of survival benefit.
Primary prophylaxis is not warranted for CMV given cost and lack of survival benefit.!
!
All HIV + patients should also maintain UTD vaccinations.!
!
!
!

094
 University Hospitals Case Medical Center
Antimicrobial Susceptibility of Gram-Negative Bacilli 2014
UHCMC Adult Patients
Beta-lactams
Agents predominantly
Mono-
Aminoglycosides Quinolones used for urinary tract
Penicillins Cephalosporins bactam
Carbapenems infections

sulfamethoxazole
Trimethoprim-
Nitrofurantoin
Ciprofloxacin

Levofloxacin

Tetracycline
Amoxicillin-

Tobramycin
Meropenem
Ceftazidime
tazobactam

Cefuroxime

Ceftriaxone
clavulanate

Gentamicin
Cefotaxime

Aztreonam

Ertapenem
Pipercillin-
Ampicillin

Imipenem
Cefepime
Cefazolin

Amikacin
Susceptible breakpoint (ug/ml) 8 8 16 8 8 8 8 8 8 8 4 4 2 4 4 16 1 2 4 32 2
No.
Percentage of strains inhibited at susceptible breakpoint
tested
Acinetobacter baumanii 95 - - 39 - - - - 37 38 - 38 41 - 44 53 51 38 40 39 - -

095
Citrobacter freundii 173 10 - 90 8 -* -* -* -* 97 85 98 97 97 96 94 100 91 94 84 99 84
Citrobacter koseri 118 1 - 100 98 83 100 100 100 100 99 100 100 100 97 100 100 99 99 98 65 99
Enterobacter aerogenes 142 5 - 86 9 -* -* -* -* 96 89 97 97 98 99 98 99 97 97 91 21 99
Enterobacter cloacae 283 4 - 80 4 -* -* -* -* 93 74 98 98 99 97 97 100 94 96 85 25 85
Escherichia coli 5707 55 85 97 87 91 94 94 94 95 94 100 100 100 92 92 100 80 81 78 97 78
Klebsiella oxytoca 195 6 88 86 47 80 94 89 93 94 88 100 100 100 96 97 100 92 94 88 87 91
Klebsiella pneumoniae 1421 4 89 92 87 84 90 90 90 90 89 96 96 96 94 91 97 88 90 82 47 86
Morganella morganii 84 3 7 98 5 7 86 92 88 95 88 99 100 99 91 91 100 69 75 45 0 74
Proteus mirabilis 519 84 98 99 96 99 99 99 99 99 94 100 100 100 95 95 100 82 87 1 1 86
Pseudomonas
aeruginosa 652 - - 94 - - - - 91 90 77 88 89 - 80 94 95 76 75 - - -
Serratia marcescens 119 0 - 69 0 -* -* -* -* 98 85 98 99 99 97 90 98 93 98 10 - 94
Stenotrophomonas
maltophilia 149 - - - - - - - 39 - - - - - - 11 21 26 88 - - 87
*Resistance to second and third generation cephalosporins may develop during therapy with these agents
 University Hospitals Case Medical Center
Antimicrobial Susceptibility of Gram Positives 2014
UHCMC Adult Patients
Agents predominantly
Beta-lactams Macrolides Aminoglycosides Quinolones used for urinary tract
infections

sulfamethoxazole
Trimethoprim-

Nitrofurantoin
Erythromycin

Ciprofloxacin

Levofloxacin

Moxifloxacin
Vancomycin

Clindamycin

Tetracycline
Daptomycin
Ceftriaxone
Penicillin G

Gentamicin

Gentamicin
Amoxicillin

Oxacillin a
Ampicillin

Linezolid

Synergyb
c d
Susceptible breakpoint (ug/ml) 0.1 / 8 2 0.5/1 2 2/4 4 4 0.5 0.5 4 - 1 2 1 2 4 32
No. tested Percentage of strains inhibited at susceptible breakpoint
Staphylococcus aureus 3139 12 12 - - 58 100 100 100 37 60 97 - 60 67 79 96 92 99

096
Coagulase neg staphylococci 1073 12 12 - - 46 100 100 99 33 60 78 - 47 48 59 58 82 99
Enterococcus faecalise 1090 100 99 - - - 97 100 100 21 - - 72 66 72 - - 24 99
Enterococcus faeciume 207 11 10 - - - 27 93 99 3 - - 82 8 10 - - 15 51
Streptococcus pneumoniae 72 - 53/92f 82 85/94g - 100 - - 47 75 - - - 100 100 74 - -
a
Staphylococci that are oxacillin resistant are resistant to all b-lactam agents, including penicillins, b-lactam/b-lactamase inhibitor combinations, carbapenems and
cephalosporins with the exception of ceftaroline
b
For penicillin- and vancomycin-susceptible strains, synergy can be achieved with gentamicin provided strains do not have high-level gentamicin-resistance.
c
Staphylococcus aureus/Enterococcus breakpoints
d
Staphylococcus aureus /other Gram-positive breakpoints
e
Enterococcus species are intrinsically resistant to cephalosporins, macrolides and trimethoprim-sulfamethoxazole.
f
Susceptibility at meningitis (< 0.06 ug/mL) and non-meningitis (< 2 ug/mL) breakpoints
g
Susceptibility at meningitis (<0.5 ug/mL)/non-meningitis (<1 ug/mL) breakpoints
 Gastroenterology/Dworken
Gastrointestinal Bleeding
1.Key Historical Elements
1. Upper vs. lower GI bleeding – Upper (Epigastric pain, N/V, hematemesis, coffee
ground emesis, melena) vs. Lower (hematochezia, bright red blood per rectum,
diarrhea)
*Exceptions to rule: If unstable, hematochezia may sign of brisk UGIB.
Melena can also be from LGIB (distal small bowel, R sided colonic).
2.General historical elements- duration, # of episodes, prior GIB,
asp/NSAID/plavix/Coumadin use, alcohol use, s/s of hypovolemia
3.Focused history to determine etiology (e.g. PUD (NSAID/alc use/H.pylori),
Mallory-Weiss (retching, vomiting prior to hematemesis), diverticular (painless
hematochezia), etc.
4. Prior endoscopy? Obtain reports!
5.Rule out oropharyngeal source of bleeding or epistaxis
2. Key Exam Findings-
1. Vitals- Assess degree of hypovolemia (tachycardia, blood pressure, orthostatics).
2.Perform your own rectal (assess for hemorrhoids, anal fissures, color of stool)
3.Labs
1.STAT CBC (compare H/H to baseline), RFP (BUN/Cr in 30s suggests UGIB), LFTs,
coags, type/screen. Note: H/H may be normal or only slightly decreased in first
24h prior to equilibration).
4.Management
1. Stabilize/resuscitate- Keep NPO, place 2 large bore IVs (18 gauge), start IVF
(typically NS, if hypotensive or orthostatic, bolus 1L (or 250-500cc if HF or ESRD),
repeat until vitals normalize then place on maintenance IVF
*If remains unstable despite IVF MICU.
2.Transfuse- Hgb goal around 7 for UGIB, may shoot for >8 in CAD. Transfuse as
needed (1 unit pRBC should increase Hgb by 1). Consider higher transfusion goal
in patients with CAD. O-neg if emergent. Monitor H/H q6-q8h until stable.
3.Reverse coagulopathy-
1. If INR elevated, give FFP (typically 2-4 units initially) and/or Vitamin K as
needed (Vit K more effective in Coumadin patients than cirrhosis)
2. Hold NSAIDs, antiplatelet, anticoagulation if possible. Exceptions exist
however (recent cardiac stents, mechanical heart valves, etc and will need
individual consideration of risk/benefits). .
4.NG lavage – Controversial, unclear overall clinical benefit, misses 18% of UGIB
5.Medications:
1. Acid suppression- If suspect actively bleeding peptic ulcer, STAT PPI
80mg IV x1 followed by PPI drip at 8mg/hr. In other cases of acute UGIB,
can use PPI IV 40mg BID.
2. Cirrhotic patients
1. Suspected variceal bleeding: Octreotide 50 ug IV x1 then 50ug/h,
PPI drip as above, and antibiotics (see below)

097
 2.Antibiotics –Start Ceftriaxone IV (or other abx prophyaxis) in all
cirrhotic patients with GI bleeding (decreases infectious
complications)
4.Consult GI – If patient stable, no need for emergent GI consultation overnight. If
unstable, transfer to MICU and GI may perform emergent endoscopy in the unit.
Parameters for endoscopy: INR <1.5 and platelets >50k. Give add’l FFP or
platelets as needed in preparation

Approach to cirrhotic patients

1. Important background information for each patient
1.Etiology of cirrhosis (e.g. 2/2 alcohol, viral hepatitis, autoimmune, metabolic,
NAFLD, etc)
2.Child Pugh Class (find criteria online), MELD score (calculator online)
3. Known complications from cirrhosis (1. Ascites (?on diuretics, ?requires LVP), 2.
History of spontaneous bacterial peritonitis (SBP) (?on antibiotics for SBP
prophylaxis), 3. History of gastroesophageal varices (grade, date of last EGD, ?on
nonselective beta blockade if applicable, ?prior band ligation)
4. History of hepatic encephalopathy (HSE) (?on lactulose and/or rifaximin), 5.
History of hepatorenal syndrome
5. General information (Hepatologist information, date of last HCC screening, date
of last EGD (varices screening), ?currently being evaluated for transplant)
2.Compensated or decompensated?
1. Signs for decompensated cirrhosis include hepatic encephalopathy, ascites,
jaundice, GI/variceal bleeding
2. If decompensated, must evaluate possible inciting factors (details below).
2.Common problems encountered in cirrhotic patients
1. Ascites
1. Typically treated with salt restriction and combination of lasix and
spironolactone (typically 40mg and 100mg daiy or equal proportions of
this).
2.Refractory ascites (either diuretic resistant or diuretic intolerant (AKI,
hyponatremia, potassium abnormalities with diuretics).
3. If admitting cirrhotic patient with gross signs of volume overload
(worsening LE edema, ascites)
1. Evaluate reason for decompensation (compliance with sodium
restriction, medication compliance, signs for infection (blood culture
x2, u/a, ucx, CXR, diagnostic paracentesis to rule out SBP).
2. Start/continue/increase diuretic regimen of lasix and
spironolactone and uptitrate as renal function and sodium tolerate.
3. If diuretic resistant or intolerant, may require large volume
paracentesis (LVP)
2. Spontaneous bacterial peritonitis
1. Presentation: Abdominal pain, fevers, chills, encephalopathy but can be
asymptomatic as well
2. Must rule out SBP in cirrhotic patients with ascites that present with
abdominal pain, fever, s/s infection, hepatic encephalopathy.
098
 *No one will ever fault you for performing a diagnostic paracentesis
to rule out SBP but they certainly will if you don’t when it is indicated.
Ask a senior to assist you with this.
3. Diagnosis – ascitic neutrophil count of >250cells/uL. Ensure to send
ascitic fluid for gram stain, culture in addition to cell count and differential
when performing dx paracentesis as well as blood cultures x2, etc for
infectious workup.
4. Treatment of SBP – 1. Ceftriaxone IV + IV albumin 1.5g/kg at time of
diagnosis and 1g/kg on day 3. If clinically not improving, repeat
paracentesis on day 3 to assess for appropriate decrease in ascitic
neutrophic count (success = >25-50% decrease).
5. SBP prophylaxis needed if history of SBP or if ascitic fluid total protein <1.
Can use Cipro, norfloxacin, bactrim.
3. Hepatic Encephalopathy
1. Diagnosis- It is a clinical diagnosis of encephalopathy + asterixis. Do not
check ammonia as it has poor sensitivity and no role in diagnosis.
2.Evaluation- Evaluate for possible precipitants:
1. Medication compliance (check with family members if patient was
taking lactulose and/or rifaximin and how many BMs they were
having each day (need 2-3 BMs ideally)
2. GI bleeding
3.Infection – Check blood cultures x2, urinalysis, urine culture, CXR,
sputum culture, perform diagnostic paracentesis to rule out SBP (very
important)
4. Offending substances/medications – Most commonly alcohol, drug
use, narcotics, benzodiazepines.
5. Azotemia – Follow up renal function panel for BUN and Cr
6. Hypoxia, hypo/hypervolemia, hypo/hyperkalemia
3. Treatment
1. Treat underlying precipitants (e.g. treat SBP if present, hold
offending medications like narcotics/benzos, etc).
2. Start lactulose and titrate to 3-4 bowel movements per day (may
start q2h until first BM, then QID or more PRN). May had rifxaimin
550mg PO BID if needed. If obtunded, NG or rectal.
3. Will need to discharge on lactulose +/- rifaximin for secondary
prevention
4. GI bleeding
1. Evaluation of GI bleeding as per GI bleeding section
2. *Take extra caution in cirrhotic patients with acute upper GI bleeds.
Variceal bleeding is a serious complication which patients can
decompensate suddenly and severely from. Thus, patients with suspected
variceal bleeding are often monitored/managed in the MICU. Prior to
transfer, please ensure they have good IV access, are on adequate IV fluids,
PPI drip, octreotide drip, antibiotics for SBP prophylaxis as above and
ensure GI is aware.

099
 3. Patients with variceal bleeding or medium to large varices on variceal
screening will need to be on nonselective beta blockers, titrated to HR. They
also may need esophageal band ligation in future.
5. Acute kidney injury
1. Evaluation - Evaluate AKI in cirrhotic patients as you would in any other
patient (evaluate volume status, NSAID use, recent contrast exposure, check
u/a, ucx, urine electrolytes, renal ultrasound, etc).
2. Management – Hold diuretics, trial of volume expansion with albumin
3. Hepatorenal syndrome is on the differential but other etiologies for acute
kidney injury are usually the culprit so evaluate common causes first
6. General tips: 1. Tylenol is not absolutely contraindicated in patients with
cirrhosis. In non-alcoholic patients, can use up to 2g/day. However, would avoid
in alcoholic patients. 2. Avoid narcotics, benzodiazepines, sleeping aides (ambien,
benadryl) as not to precipitate HSE. 3. Avoid NSAIDs.

Approach to elevated LFTs: Assess the pattern of liver injury

a. 1. Hepatocellular: Mainly elevations in ALT and AST
i. 1. Degree of elevation is important.
1. AST, ALT >1000s severe viral hepatitis, drug induced liver
injury, ischemia, Wilson’s, autoimmune hepatitis
2. Workup:
a. 1. Viral hepatitis workup (Acute hepatitis panel +/- CMV,
EBV, HSV, VZV)
b. 2.Autoimmune hepatitis workup: ANA, anti smooth
muscle antibody (ASMA), anti-liver kidney antibody
(anti-LKM)
c. 3.Wilson’s workup: ceruloplasmin
d. 4.Vascular etiologies: RUQ ultrasound with Doppler
e. 5.Drug workup: Tox screen, alcohol, tylenol level
ii. 2. Clues:
1. AST/ALT >2:1 suggests alcoholic hepatitis, cirrhosis
b. 2. Cholestatic: Elevated alk phos and bilirubin +/- aminotransferases
i. 1. First step: determine if ductal dilation is present (RUQ u/s or CT)
1. Ductal dilation present suggests biliary obstruction-
a. 1. DDx includes choledocholithiasis, pancreatic cancer,
sclerosing cholangitis, cholangiocarcinoma
2. No ductal dilation:
a. 1. DDx is decompensated cirrhosis, hepatitis, medication
induced, sepsis
c. 3. Isolated hyperbilirubinemia: Elevated bilirubin, normal alk phos and
aminotransferase
i. 1. Conjugated hyperbilirubinemia Check RUQ u/s
ii. 2.Unconjugated hyperbilirubinemia Assess for hemolysis
(peripheral smear, LDH, haptoglobin)

Approach to nausea /vomiting

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1. Approach – best to describe by chronicity and presence of abdominal pain
a. 1. Acute or chronic?. Abdominal pain?,
b. 2. Vomiting of undigested food eaten hours earlier? (suggests gastric
obstruction or gastroparesis)
c. 3. Abdominal distension or feculent vomitus? (suggests obstruction of small
intestine)
d. 4. Abd pain history (radiates to back, increases with PO intake? (pancreatitis
vs. biliary colic)
e. 5. Recent changes in medications, motion sickness, new/bad foods,
diarrhea? (infectious gastroenteritis, food poisoning), hx GIB? (UGIB can
cause N/V), recent surgeries (postop ileus)

2. Etiologies of acute N/V

a. 1. Acute onset with severe abdominal pain serious illness potentially with
surgical intervention. EXCLUDE SURGICAL DISORDERS.
i. 1. GI obstruction (acute abd series/KUB, CT)
ii. 2. Mesenteric ischemia (CT/CT angiography)
iii. 3. Pancreatitis (lipase +/- CT)
iv. 4. Biliary colic (CT, RUQ u/s)
v. 5. Conditions cause peritonitis (e.g. appendicitis or perforated viscus)
(CT)
vi. 6. Cardiac – acute ischemia
b. 2. Acute onset of N/V without abdominal pain DDx: Medications, Motion
sickness, food poisoning, infectious gastroenteritis, hepatitis, upper GI
bleeding, postoperative ileus, acute CNS disease
3. Etiologies of chronic or recurrent N/V
a. 1. Chronic with abdominal pain 
i. 1. GI disorders that result in partial or intermittent obstruction of
stomach or small intestine
b. 2. Chronic N/V without abdominal pain 
i. 1. Disorders that impair gastric emptying or small intestine motility
ii. 2. Non-GI causes: Medications, pregnancy, intracerebral disorders,
cardiac disease, endocrine disease, labryrinth disorders, psychiatric
disease (bulimia), functional disorders
4. Diagnosis (review meds, CBC/RFP/LFTs/lipase/amylase/GGT/imaging +/-
additional studies including acute abd series (upright), CT, EGD/enterography, GI
motility (emptying), head CT/MRI
1. Acute without abdominal pain - Most cases of acute vomiting without
abdominal pain are self limited and require no evaluation
a. 1. Medication related sx and pregnancy should be excluded
b. 2. Severe vomiting – obtain serum electrolytes
c. 3. Hyperglycemia may cause acute gastroparesis
d. 4. Increased liver chemistries or pancreatitc enzymes suggest
hepatobiliary or pancreatic disease
2. Acute N/V with abdominal pain –

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 a. 1. Obtain abdominal plain radiographs or CT – look for GI
obstruction, perforated viscus, pancreaticobiliary disease
3. Chronic N/V of uncertain cause – distinguish structural GI disorders, GI
motility disorders, and non-GI disorders
a. 1. EGD, enterography, abdominal cross sectional imaging, GI
motility studies, head CT/MRI may be indicated
5. Treatment
a. Address underlying cause, treat symptomatically with anti-emetics

Approach to a patient with inflammatory bowel disease

1.Characterize the IBD
1.Ulcerative colitis (classify by location: proctitis, L sided, or pancolitis)
2.Crohn’s disease (comment on prior complications: 1.Perianal disease
(fissures/fistulas/perirectal abscess), 2. stricturing disease, 3. fistulas (perianal,
enteroenteric, rectovaginal, enterovesicular, enterocutaneous), 4. Abscess, 5.
Malabsorption (resulting in gallstones, calcium oxalate kidney stones, vit D
deficiency)
3.Prior treatment history (e.g. UC: mesalamine, 6 mercaptopurine/azathioprine;
CD: 6MP/AZA, anti-TNF alpha, MTX). Why prior treatments failed (unsuccessful
vs. inability to tolerate, etc).
4.Prior imaging and endoscopy
2.History
1.Abd pain, N/V, fevers, hematochezia, # of BMs (diarrhea vs.
constipation/obstipation)
2.Severity of flare- # BMs/day, systemic toxicity symptoms, ?tolerating PO, weight
loss, obstructive symptoms
3.Extracolonic symptoms- rashes, ulcers, eye pain, CP, joint pains
3.Management of acute flare
1.Labs – CBC, RFP, LFTs, ESR/CRP, stool studies (C diff, stool culture, fecal
leukocytes), +/- evaluation for vitamin deficiencies in Crohn’s (Fe, B12, folate if
anemic; consider vit D)
2.Imaging – consider CT A/P initially. May need MR or CT enterography in CD
patients to further evaluate disease
3.Rule out infection (stool studies) before treating with immunosuppressants
and/or biologics
4.Acute flare treatment (goal to reduce remission quickly): Depends on severity of
flare but typically use steroids (PO 40mg prednisone if moderate, IV steroids if
severe). Unless systemic signs for infection, typically do not need antibiotics;
exception is perianal disease in Crohn’s disease (Cipro/Flagyl or Augmentin). Pain
control, NPO until patient improves.
1.If fails steroids, may require infliximab, etc (always check PPD, hep B/C
prior to starting)
5.Assess for complications:
1.UC – Toxic megacolon (Dx with KUB, colon dilation >6cm on KUB, systemic
toxicity, risk of perforation, tx with IV steroids and broad spectrum
antibiotics, surgery if fails to improve 48-72h
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 2.CD – 1. Abscess (perianal - abx, call colorectal for possible I/D, abd
abscess-tender abd mass, SIRS criteria), 2. Stricture
(constipation/obstipation, can lead to SBO), 3. Fistulas
6.Consider endoscopic evaluation to restage disease or to further evaluate

Approach to acute pancreatitis

1.Sx: Epigastric pain, N/V, radiation to back, assoc with food (often fatty) intake
2.Diagnosis: Elevated lipase (more specific than amylase; can have false + in renal failure,
DKA), CT A/P (helps but not required for dx)
3.Evaluate etiology: Most commonly 2/2 alcohol and gallstones (make up >70% of cases),
but assess for offending medications, hx malignancy (obstructive), metabolic
(hypertriglyceridemia, hypercalcemia), recent ERCP, trauma, family hx pancreatitis,
autoimmune pancreatitis
4.Tx:
1. Supportive
1. IVF (careful in systolic heart failure or ESRD patients)
2. Pain control (typically need IV, then transition to PO).
2.Assess for complications:
1.Organ failure – renal, respiratory failure, shock (higher mortality)
2.Acute fluid collection- common, no treatment needed
3.Pseudocyst- no tx needed acutely as most resolve spontaneously, if sx
persists 4-6 weeks or if large (>6cm), need drainage (usually via
cystgastrostomy (GI) but IR (percutaneous) or surgical drainage also
sometimes considered)
4.Sterile pancreatic necrosis- supportive care, use of empiric antibiotics
(theoretically to prevent converstion to infected necrosis) is controversial
and not routinely used; however may be reasonable if SIRS criteria/signs for
infection/hemodynamic instability are present.
5.Infected pancreatic necrosis: Carbopenems are usually abx of choice.
Usually no intervention needed in acute setting (allow for organization of
necrosis).
6.Pancreatic abscess- Abx and CT guided drainage
7.Ascites or pleural effusion: 2/2 disrupted pancreatic duct, may require
ERCP and pancreatic duct stenting

103
HBV Serology Interpretation
HBsAg Anti-HBc Anti-HBc Anti-HBs What it means
Total IgM
Neg Neg Neg Neg Never exposed
Neg Neg Neg Positive Vaccinated

104
Neg Positive Neg Positive Immunity (past
infection)
Positive Positive Positive Neg Acute HBV
Positive Positive Neg Neg Chronic HBV
Neg Positive Neg Neg “Isolated Core”
*variable
etiology
 Endocrine

DKA
-Predominantly with failure to produce insulin rather than with insulin resistance (this is
why type 1 diabetics are much more prone to DKA)

Diagnosis-Look for type 1 DM with AMS, dehydration, nausea/vomiting. Often have

glucose in 400-600 range with AGMA (glucose can be even lower in some cases). Send
serum ketones (‘beta hydroxybutyrate serum’ or “ketones serum’ at UH). Pts often have
AKI 2/2 dehydration.

Etiology- Rule out the presence of a 2nd issue that needs addressed. MI, infection, alcohol
or drug intoxication, new steroid use, type 1 DM with missed insulin. Get CBC, RFP, phos,
mg, LFT, lipase, lactate, ABG, EKG and utox, consider CXR/UA.

Anion gap is Na-(Cl + Bicarb). Most don’t use potassium anymore, those who do just
change their ‘normal’ range. Since when discussing a gap most assume you didn’t use
potassium it’s easiest just to avoid.
Tips:
1) Albumin drives the gap (it’s a negatively charged protein). If albumin is low, your
‘normal’ gap should decrease 3 for each g/dL decline in albumin. If albumin is 3, expect a
gap of 9 rather than 12.
2) Don’t correct the sodium for hyperglycemia when calculating the gap (this will
erroneously show most severely hyperglycemic patients with AGMA). Glucose draws
water into the serum, diluting both sodium and bicab/chloride levels. As glucose goes
down, the water goes back into the cells and Na/Cl/bicarb all rise.

HHS
-Very high sugars (>600) in patients with no ketoacidosis. Serum osmolarity elevated
(often >350).
-Often have AMS, usually DM2.
-REMEMBER, glucose is a great diuretic. These patients are often profoundly dehydrated
(that’s why they’re hyperosmolar). 2L bolused is a start. Most will need 3 or more liters in
their first 3-4 hours. Unless severe HF or ESRD, don’t under-resuscitate these patients.
Fluids are the gold standard and bring down glucose some on their own.
- ICU versus floor: Unlike DKA, these patients can often be managed on the floor with
initial fluid bolus and 10U IV push regular insulin in the ED/UCC, then subcu short acting
based upon that response on the floor (adding long acting once you have an idea of their
needs). If hemodynamically unstable, very high serum osm, or the sugars just aren’t
responding to your insulin, consider ICU and gtt (active insulin drips are not safe on the
floor at either UH or the VA). Keep the fluids going and bring the sugars down gradually.
Replete electrolytes.
-As with DKA, ensure there is no other cause of HHS (MI, infection…). Blaming a patient
who missed insulin is common, but sometimes it’s not the real cause.

105
 GUIDELINES FOR THE MANAGEMENT OF ADULT PATIENTS WITH DIABETIC KETOACIDOSIS
Start IV fluids: 1-2 L of 0.9% NaCl/hr (15-20 mL/kg/hr) x 1
hour
±
INSULIN
#
IV Fluids BOLUS POTASSIUM*
Insulin Regular
0.15 units/kg IV
Hypovolemic shock < 3.3 mEq/L 3.3 - 5 mEq/L > 5 mEq/L
Mild hypotension
(administer 0.9% NaCl)
or normal Continuous Infusion
Follow the fluid
(Euvolemia) Insulin Regular
resuscitation guidelines
0.1 units/kg/hr IV
(max:8 units/hr) PO4 >1.5 PO4 >1.5 PO4 >1.5
Evaluate corrected serum Na YES YES YES
(for each 100 mg/dL glucose
>100 mg/dL, add 1.6 mEq) If BG did not fall by NO
If BG falls > 50 40 mEq KCl IV NO 20 mEq KCl lV NO No KCl
50 mg/dL within the
mg/dL within one
first hour, double
hour and BG >250
the insulin rate
Serum Na High or mg/dL continue hourly until BG falls
Serum Na Low insulin at the 15 mmL KPO4 IV
¶ ¶
Normal

106
15 mmL KPO4 IV ¶
(start with 200cc/hr NS, by 50 mg/dL or BG 15 mmL NaPO4 IV
(0.45% NaCl at 4-14 mL/ same rate 20 mEq K) and 20 (20 mEq K)
adjust for hydration <250 mg/dL.
kg/hr depending on mEq KCl IV
status)
hydration state)
*Potassium (in renal failure patients individualize care)
If initial K < 3.3 mEq/L, replete before initiating insulin infusion
If potassium levels are critically low additional doses of KCl might be needed
Serum glucose reaches 250 mg/dL Maximum infusion rate: 20 mEq/hr
*Change the fluids to 5%dextrose Maximum concentration: PERIPHERAL line = 0.08 mEq/mL (ex: 20 mEq in 250 mL)
with 0.45% NaCl at 150-250 mL/hr CENTRAL line = 0.4 mEq/mL (ex: 40 mEq in 100 mL)
¶
*Reduce the insulin infusion rate by Phosphorus (in renal failure patients individualize care)
one half Maximum infusion rate: 7.5 mmol/hr
Stop insulin infusion when:
*Patient is tolerating at least a full liquid diet STANDARD LABORATORY ASSESSMENT
*Anion Gap normalizes Plasma glucose
*Maintenance insulin therapy has been initiated Basic metabolic panel
Insulin infusion should be continued for 1-2 hours after SC insulin (calculated anion gap and effective osmolality)
is administered Phosphorous, magnesium
Beta-hydroxybutyrate
Complete urinalysis with urine ketones by dipstick
±
For dosing insulin use Ideal Body Weight Diabetes Care 27;S94102, 2004. Arterial blood gas
Complete blood count with differential
#
Individualize the treatment of patients with underlying renal failure, and/or heart failure. Electrocardiography
Capillary glucose Q1h
BMP, Phos, mag, Q4h x3 then q6h as long as needed
Diabetes Management in the inpatient (not an exhaustive list, just the high points)

Admitting:
PO Meds: If they’re on metformin, just hold it initally(it’s difficult to know who will need
IV contast, but if patient chilling on floor could restart if planned to d/c on it). NPO
patients should not be on sulfonylureas. Other oral hypoglycemic agents should be held
in the NPH or sick patients, but can frequently be continued.

Insulin: Insulin: Except for patients with low insulin requirements (<25 units/day) generally
~50% of daily insulin should be given as basal (NPH or lantus) and ~50% as short acting.
Basal-bolus results in better glycemic control than sliding scale insulin (SSI), but runs a risk of
hypoglycemia if you do not actively titrate insulin doses on a daily basis! Always ask patients
how much insulin they are taking as the med list is notoriously inaccurate for dosing.

Long acting insulin should not be entirely stopped, even in NPO patients. In patients who are
likely to eat, CONTINUE mealtime bolus insulin and continue to titrate. If NPO or likely not
to eat, HOLD bolus short acting insulin and decrease the long acting to 50-70% of home dose
and have SSI (sliding scale insulin) as a correction factor. Patients on 70/30 at home should not
be continued on this if they’ll be NPO or eating very little.

Short acting insulin should be continued if eating, but make sure to adjust for the amount that
patients are eating in hospital. Make sure to specify in order to HOLD if not eating a meal.

SSI: The protocols are poor quality, but it’s what we have. At the VA the SSI dosing is easy
to change, more difficult at UH. Most dosing will overdose a type 1 diabetic and
underdose an insulin resistant long-term type 2 diabetic. Remember always, lows are
more dangerous than highs. A call about a patient going to bed with a sugar of 295 is not
a huge problem. A call about a patient going to bed with a glucose of 45 is a HUGE
problem. Not every diabetic needs a sliding scale, but every diabetic needs the
‘hypoglycemia order set’. For type I diabetics, use the customizable sliding scale with
doses specific for their needs.

Active management: Often times a patient is not eating well and their long acting is cut in
half on admission with addition of sliding scale. This is fine, but each day if the patient is
eating roughly the same and blood sugars are above 200, fold ½ of the previous day’s
sliding scale use into their long acting, moving it towards their home regimen (if they’re
on lantus 10 qhs and used 12 of SSI the day before, try 16 of lantus tonight).

Steroids: We all know they increase sugars, often we’re caught chasing sugars with
increased insulin. Remember when the steroids stop the sugars drop and the insulin
should drop to pre-steroid levels. When in doubt go low on the insulin and let them ride
high for a day or two while you get the proper dose figured out. Expect the steroid effect
on hyperglycemia to last for at least 24 and max 48 hours after last dose of
prednisone/dexamethasone.

107
Discharging: Metformin is the hospitalist’s enemy and the PCP’s friend. Don’t forget to
restart the metformin unless there is new renal failure. Decide if anything happened
during the stay (poor DM control, new steroids, worsening renal failure…) that should
change their home insulin regimen. If not, don’t make dramatic adjustments to their
PCP’s regimen. Throw the PCP a bone and order an A1c while they’re in house to give
them a head start at the next visit.
Always give metformin with meals to minimize GI side effects.

Hyperthyroid
-Classic sweating, tremor, tachycardia, diarrhea symptoms. If the TSH is low proceed to
Total and Free T4 (remember pregnancy and women on contraceptive have increased
total T4)
-If TSH down but FT4 is normal consider sick euthyroid in our inpatients at UH and the
VA.
-With low TSH and high FT4, hx, exam, an radioactive iodine uptake scan will usually
guide the answer (Graves has diffusely high uptake, subacute thyroiditis often painful,
Jod-Basedow associated with iodine or amiodarone, toxic multinodular goiter has
multiple nodules on uptake…)
-Receiving IV contrast will affect the result of uptake scan-usually avoid in inpatients.
-Beta blockers (all help the symptoms, propranolol has the best evidence for also
decreasing T4->T3 conversion)
-Propylthiouracil, methimazole, radioactive iodine are options based on diagnosis and
patient needs. If at this point, talk with endocrine.
-Thyroid Storm: hyper-T acutely after sickness or stress. It’s a cause of fever, tachy,
hypotension, AMS and is often initially misdiagnosed as sepsis. Tx includes starting with
propranolol and PTU, then iodine, and often the addition of steroids. If you think it’s true
thryroid storm endocrine should see the patient soon.
-In the Unit: remember high dose steroids and dopamine/dobutamine all decrease TSH

Hypothyroidism
-Symptoms: fatigue, hyporeflexia, wt gain, slow speech.
-Myxedema coma involves nonpitting skin thickening and progressive mental status loss.
TSH often>100

-Diagnosis: Both at UH and the VA, start with TSH and then get TF4 and FT4 =. In primary
(Hashimoto’s, iodine deficiency, surgical) think high TSH and low FT4, though T3 may be
normal in iodine deficiency. In secondary (pituitary failure) TSH will also be low.

-Treatment: start low (25 or 50mcg) and gradually increase with levothyroxine (watch
out for tachycardia and increased cardiac demand in those with heart disease). In
myxedema coma you’re too far behind to use oral levothyroxine alone, call endocrine and
prepare for IV levothyroxine.

Remember: IV levothyroxine is half the PO dose

108
How to conduct a Cosyntropin Stim Test (looking for adrenal insufficiency)
1.No utility in chronic steroid use (axis is suppressed). Stop acute steroids at least 24
hours prior. Decadron is an option which doesn’t interfere with the test.
2. Draw a random early AM cortisol. If it’s more than 12 it’s not adrenal insufficiency
unless patient under severe stress.
3. Given parenteral cosyntropin 0.25mg
4. Draw cortisol and ACTH levels at baseline before cosyntropin and cortisol at 30 and 60
minutes after cosyntropin (if 2 sticks is difficult, just get one after 45-60 minutes)

-If serum cortisol is over 18, it’s not adrenal insufficiency. The most challenging part is
coordinating with nursing. Talk with the RN and find out when a good time for their
schedule is, then explain exactly how it needs to be done.

109
 Palliative Care

1. Pain management
a. Basics
i. Perform a complete assessment of the pain. Pain scale 0-10,
Functional pain scale 0-5.
ii. WHO pain pyramid: Non-pharmacologic pain management -> add
non-opioid-> add mild opioid-> add strong opioid-> add
interventional pain management
iii. WHO 3 step model: Step 1 mild pain= Aspirin, Acetaminophen,
NSAIDs, + Adjuvants, Step 2 moderate pain= ASA/Acet + codeine/
hydrocodone/ oxycodone, Tramadol, low-dose oxycodone, +
Adjuvants, Step 3 severe pain= Morphine, Oxycodone, Dilaudid,
Fentanyl, + Nonopioid analgesics, + Adjuvants
iv. Always start a bowel regimen if opiates are initiated*
v. Manage side effects
vi. Re-assess and adjust as necessary, always add hold for sedation
when ordering opiates.
vii. Call Palliative Care for help/advice x35614. They’re always happy to
help.
b. Opioid Conversions:
i. Starting long acting opiate (for morphine and oxycodone): Add total
doses of breakthrough opiate given in 24h and divide into 2 (q12h) or
3 (q8h), given as an extended release formulation.
ii. Rescue dose: 10% of total daily (24h) dose given as an immediate
release formulation q2h prn if possible otherwise q3h prn. If
breakthrough dose does not last long enough, increase the dose.
iii. Opioid adjustments: If > 5 breakthrough doses given in 24h with no
improvement in symptoms add ½ the breakthrough to tomorrow’s
long acting.
iv. Changing to another oral opioid: Calculate total daily dose of opioid
(ER + IR) convert using conversion chart and reduce by 25-50% for
incomplete cross tolerance, prescribe as indicated.
v. Changing from PO to IV: Calculate total daily dose, convert to IV
formulation (if not keeping to the same opiate then adjust for
incomplete cross tolerance), divide by 24h to get hourly rate or by
whatever increment to give (by 6 if giving q4h, by 24 and then again
by 10 if giving q6minutes on a PCA).

110
 vi. Conversion chart: From Ohio Pain Initiative Card

Fentanyl Dosing Based Upon 24 Hour Morphine Requirements

Oral 24-hour Morphine use Fentanyl patch dosing

30-59mg 12.5ug
60-134mg 25ug
135-224mg 50ug
225-314mg 75ug
314-404mg 100ug

2. Giving Bad News:

a. Know the patient and their chart: Get to know more about them through
their SH (family, hobbies, pets, what makes them tick?), FH (how did their
family members die? Good deaths?), ask about HCPOA in the SH, the more
you normalize it the more normal it becomes to the patients and their
families.
b. SPIKES mnemonic: Setup be prepared and go in with a plan, Perception
find out what the patient/family knows/understands, Invitation find out
how much they want to know, Knowledge using layman words, explain the
situation, allowing the information to sink in and sitting in the silence that
comes afterwards, Empathize say something nice but resist the temptation
111
 to make things better by giving false promises/hope,
Summarize/Strategize summarize information given, delineate next steps
and ensure that everyone understands and is on the same page.
c. Remember, physicians speak too much. Allow the patient/family to express
themselves
d. Document interaction: who was there, what was discussed, what decisions
were made

*At UH don’t forget the “End of Life Order Set” for patients expected to die
imminently. From secretions to anxiety, it reminds you of things we don’t
usually think about in other patients.

*Keep in mind at UH, that you don’t have to ask every item in the “additional
limitations” order set to every family. We can assume a family that doesn’t want
added medications or aggressive treatment doesn’t want vasopressors,
procedures, intubation. Keep in mind that going through long lists of limitations
with families can be traumatic as they see each question as another decision
point. Understand the patient’s condition and wishes, and place an order
consistent with those. If you’re changing the code status write about the
discussion in your note, or write a separate clinical event note.

112
 Toxicology: Good Drugs Gone Bad

Poison control is available 24/7 at (800) 222-1222. Do not hesitate to contact them if you
are suspicious of overdose.

ACETAMINOPHEN:

Acetaminophen is one of the most common drugs you will see overused, mainly because
it is available over the counter. As such, patients often underestimate the amount of
damage it can do. The recommended amount of acetaminophen daily is 3g in the normal
patient (2g in patients with cirrhosis). Don’t forget to include acetaminophen from
combination drugs like Percocet when calculating daily total.

Pathophysiology is as follows:
• STAGE I (0.5-24 hours after ingestion): Patients may have nausea, vomiting, lethargy.
Labs normal.
• STAGE II (24-72 hours after ingestion): Symptoms improve, but patients start to have
rising transaminases. Patients may develop RUQ pain and coagulopathy as liver begins
to fail.
• STAGE III (72-96 hours after ingestion): LFTs peak, typically with AST/ALT in the tens
of thousands. Patients are jaundiced, coagulopathic, encephalopathic, hypoglycemic,
may have lactic acidosis.
• STAGE IV (days to weeks after ingestion): Liver begins to recover in surviving patients.

Management:
• start by obtaining a serum acetaminophen level. Using this level, you can plot patients’
risk of toxicity using the Rumack-Matthew nomogram. Patients should be treated if they
fall above the treatment line.
• other indications for treatment include single dose >7.5g, unknown ingestion time and
APAP level >10, any concurrent liver dysfunction.
• if patient presents within 4 hours of ingestion, will benefit from PO activated charcoal
administration (1 g/kg, max 50g) unless patient is at high risk of aspiration. There is no
clinical benefit to intubating patients only to give activated charcoal.
• If patient falls above treatment line, administer N-acetylcysteine (mechanism of action
is not clear, but NAC is thought to replete hepatic glutathione stores).
• IV and PO treatments available
• If patient has any liver dysfunction, they should be treated with IV therapy.
• IV —> 150mg/kg loading dose over 60min, then 50 mg/kg over 4 hours, then
100mg/kg over 16 hours
• PO —> 140mg/kg loading dose, then 70mg/kg PO q4h for a total of 17 doses
• Note there is an order set in the EMR that can make these orders easy!
• Consider EARLY hepatology consultation as patients may progress to fulminant hepatic
failure and require transplant evaluation!

113
TOXIC ALCOHOLS:

Namely ethylene glycol and methanol, toxic alcohol ingestions can be life threatening.
These are typically ingested either as intentional overdose or by accident (during
moonshining process).

Methanol and ethylene glycol are not themselves harmful; it is their metabolites that are
toxic. Methanol is broken down to formic acid and ethylene glycol is broken down to
glycolate, glycoxylate and oxalate.

Presentation:
• patients will usually present with profound anion gap metabolic acidosis.
• formic acid (methanol metabolite) affects the retina, so patients may have blurry vision.
Afferent pupillary defect is ominous sign.
• ethylene glycol toxicity can manifest as flank pain or abdominal pain.
• patients may have a lactic acidosis but lactate level is not sufficient to cause such
profound acidosis

Evaluation:
• ethylene glycol and methanol levels (these are in EMR as “volatile alcohols” and are
actually sent to Akron for processing!)
114
• serum and urine tox to eval for coingestion
• blood alcohol level (concurrent ethanol ingestion slows metabolism of EG and
methanol)
• serum osm to calculate osmolal gap :
• Calculated Posm = (2 x plasma [Na]) + [glucose]/18 + [BUN]/2.8
• osm gap = calculated Posm - measured Posm
• normal Osm gap is <10; if >10, there is an additional osmolyte contributing

Treatment:
• administer fomepizole (blocks EtOH dehydrogenase, which creates toxic metabolites):
15 mg/kg loading dose x1, then 10 mg/kg q12h x4, then 15 mg/kg q12h until toxic
alcohol level is <20 and patient is asymptomatic (increase dose if patient is on dialysis)
• patient should undergo either hemodialysis or CVVH to clear parent compound from
the blood
• folic acid, thiamine, pyridoxine to aid in the elimination of toxic metabolites
• Nephrology consult

ETOH:

Often the issue with alcohol ingestion isn’t the ingestion itself- it’s what comes after the
ingestion stops. Alcohol withdrawal can be life threatening. Alcohol is a depressant
which causes an up-regulation of norepinephrine receptors, when patients stop drinking
they experience an adrenergic surge which leads to withdrawal symptoms.

Minor withdrawal symptoms occur within the first 24-48 hours and include
tremulousness, anxiety, GI upset and headache.

Withdrawal seizures can occur from 12-48 hours after the last drink. They are often
singular. Patients can also have alcoholic hallucinosis from 12-48 hours after the last
drink; again, alcoholic hallucinosis is not synonymous with DTs.

DTs, or delirium tremens, is the most concerning manifestation of alcohol withdrawal. It

is characterized by hemodynamic instability (tachycardia, hypotension) in the setting of
acute cessation from alcohol. Patients develop DTs up to 96 hours from their last drink.
Mortality is as high as 5%.

In order to prevent alcohol withdrawal on the inpatient setting, patients with risk factors
for withdrawal are placed on a CIWA protocol. This nursing-administered questionnaire
attempts to measure patient’s symptoms of withdrawal and allows for early treatment of
withdrawal symptoms with prophylactic benzodiazepines.

There are three main pharmacologic choices for starting a patient on a CIWA protocol:
• diazepam protocol - typically first line agent because it has a long half life and will self-
taper.
• lorazepam protocol - use this instead of diazepam if patient is elderly (>65) or if patient
has synthetic liver dysfunction (INR >1.3)
115
• phenobarbital protocol - best for use if a patient has concurrent alcohol and benzo
abuse; giving phenobarbital instead of a benzo removes any benefit to self-reporting
symptoms

Ordering a CIWA protocol allows the bedside nurse to give medications for symptoms, so
often it will just happen without you even knowing. However, if patient has a CIWA >20,
they may benefit from transfer to MICU for closer monitoring. In this case it is often
helpful to take the CIWA score yourself to verify the score. Moreover, if you suspect a
patient is starting to withdraw from alcohol, give them a dose of benzo regardless of their
CIWA score (don’t fall behind early withdrawal).

Other issues in the alcohol withdrawal admission:

1. Vitamins (thiamine, folate)
2. Electrolytes (magnesium and potassium are often very low)
3. HTN (clonidine 0.1mg PRN SBP>170 and beta blockers like metoprolol 25mg
q6h are common choices)
4. Fluids (may be dehydrated and need boluses, otherwise maintenance D5 1/2NS
at 125/hr)
5. Don’t forget these patients are prone to traumatic falls (CT head?), other
intoxications (utox).
6. If you suspect meningitis in an alcoholic, cover listeria with ampicillin (along
with other meningitis abx).

116
 Procedures
Case Western is an internal medicine program, not a pre-fellowship observership.
Every resident should be able to triage, diagnose, and treat the acutely sick medical
patient. This means central lines when your patient needs one, paracentesis when your
patient needs one, and lumbar punctures to diagnose meningitis rather than ‘treat
empirically’. Occasionally we do thoracentesis with VA attendings or Pulm fellows, but
these are less common and won’t be covered here. The NEJM videos are free online and
are an excellent way to prep for any procedure.

Before all procedures:

1. Are you signed off? (See myevaluations.com for requirements). If not, find
someone who is to supervise (co-resident, fellow, chief resident…)
2. At the VA floor procedures need an attending/chief resident for the poke (most
common with paras, just ask). Dr. Lopresti is a great thoracentesis teacher at
the VA, as are the MICU fellows.
3. Consent: Paper forms at UH, paper or (preferred) computer at the VA. If the
patient cannot consent, call the family and have a coresident hear their consent
and cosign the form. Crashing patients needing urgent procedures do not need
consent, don’t delay an emergent procedure in the MICU/CICU for consent.
Unless you have reason to believe they would not want it, stabilize the patient
then talk with family.
4. Equipment: Kits for floor procedures (paras, thoras, LPs…) are in clean utility
rooms, as are gloves and gowns. In the units they are in designated places, ask
your resident. Ultrasound should be used for all procedures (except LPs): paras
to see the fluid and avoid bowel, thoras to identify lung parenchyma or
loculated effusions, central lines because watching the needle enter the vessel is
the best way to protect your patient.
5. Tell the patient’s RN you’re doing the procedure.
6. Time out, say their name/DOB, say what you’re doing.
7. Put chucks under any area that might get fluid, have respect for the RN who
cleaned the bed to begin with.

After all procedures:

1. Clean up your supplies and the patient. If it’s sharp it goes in the sharps,
whether it was used or not. The janitor doesn’t know which needle was used
when they get stuck.
2. Tell the RN you’re done.
3. Send all the labeled samples with order recs to the lab.
4. Write a procedure note (at UH ask your resident for their procedure dot
phrases)

Central Venous Line

1. Sites: Internal Jugular vs Femoral (subclavian less common)
2. Types: Small Bore Triple Lumen vs Dialysis vs Cordis
3. The easiest way to gather the kit your first time is to have your resident show you
where it’s at. Most kits come with most necessary equipment, though gloves, 4x4’s,
117
 ultrasound probe covers, and often gowns are needed separately at both UH and
the VA. The UH trialysis catheters often come without lidocaine (some have it
taped to the kit, but these tubes often fall off), so the RN will need to get some for
your use. Saline flushes may be included but extra are often helpful.
4. Take a quick ultrasound look at the vessel, ensure you can visualize it and
compress it. Make sure there are no clots that should change your site.
5. Arrange the room, get your kit in a position where it can be reached with a single
movement. Position your ultrasound screen for easy visibility. Move things that are
in the way (ventilators may need moved, IV poles…). Gown up and set up your kit,
flushing and locking the ports of the catheter.
6. Position your patient. For IJ, place the patient in trendelenberg, turn head slightly
away from side of access. For the femoral approach, place the patient flat and if
abdominal fat is an issue use pressure dressing to tape it down (it’ll save you time
later). If your patient has respiratory distress and is not intubated, wait till you are
ready to introduce the finder needle to drop bed (will need assistant to do this). Or
if the patient is very altered or in distress, consider intubating prior to placing line.
7. Prep the area (usually chlorhexadine) at least twice. Quick circle from in to out.
8. Apply sterile drape.
9. Clean once more with chlorhexadine.
10. Apply subcutaneous lidocaine (think placing a PPD), then apply some up to a
centimeter down. Aspirate before injecting.
11. Have assistant hand you the ultrasound probe with gel, place sterile sheath. Apply
more gel to the outside and use the rubber bands to lock the gel around the head of
the probe.
12. Find the target vessel with the ultrasound, if unsure ask a colleague. Insert the
introducer needle, aspirating while advancing. Ensure angle is >45 degrees so that
the ultrasound will let you watch the needle enter the vein. Once flow is
established, remove the syringe from the needle.
13. At this point, various methods are possible to ensure accurate venous placement. A
short set of tubing can be attached to the needle and observed that there is no
arterial pulsation. Placing your finger over the end to feel is another method. Some
institutions even hook up the needle to an A-line kit setup to see the waveform
(excessive, but in special circumstances might be useful).
14. Insert the guidewire through the needle. Once the needle is in the vein, never let go
of the wire at any point, there is plenty of extra length to avoid both letting go of
the guidewire and also keeping your fingers clear of the needle when removing.
15. Visualize the guidewire in the vein using ultrasound.
16. Make a small incision next to the guidewire. Do not cut the guidewire.
17. Dilate the soft tissue with the dilator over the guidewire (for HD and Cordis, dilate
with both dilators).
18. Thread the catheter over the guidewire, remove the guidewire in short strokes
until in comes out the distal port and then insert the catheter into the skin. Thread
the catheter to its desired position and remove the guidewire.
19. Secure the catheter with suture.
20. Aspirate all ports and flush with saline, locking and capping each.
21. Apply sterile dressing.
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 22. Order STAT CXR if IJ. If you did the line, stay until you’ve seen the image and told
the RN the line is good to use.

Paracentesis (diagnostic or therapeutic)

1.Paracentesis kits are in each clean utility room. Vacutainers are usually available,
but are often in short supply. Have gauze, gloves, gown, mask, chlorhex prep. Instead of
kit, an 18-20 gauge needle can be used for quick diagnostic taps.
2. Have patient void.
3. Lay patient at 15-20 degrees.
4. Use ultrasounds to visualize ascites in RLQ or LLQ. Avoid superficial blood vessels
(come to think of it, avoid all blood vessels). Remember, patients with ascites often also
have hepatosplenomegaly, avoid upper quadrants.
5. Arrange room, position ultrasound.
5. Chlorhex the area.
6. Apply sterile drape.
7. Chlorhex again
8. Use assistant to help get sterile probe cover on and find area again.
9. Use lidocaine to inject along area of expected needle course (aspirate before each
injection).
10. Pull skin up slightly so hole in skin does not match entry site to ascites (avoid lots
of leakage when done).
11. Insert needle (90 degree angle with skin, parallel to the floor).
12. Withdraw fluid. If diagnostic fill all 4 tubes (easily done with one piston syringe,
need multiple regular syringes if not using a kit)
13. If therapeutic, set up kit to either drain to gravity or via vacutainer (ask your
resident, better seen than written).
14. Remove needle, clean area, apply 4x4. Tell the patient to expect some leakage.
15. If therapeutic, decide if your patient meets criteria for albumin to avoid post
procedure hypotension.

Labs: Cell count and diff, total protein, albumin, glucose, LDH, gram stain and culture.
Occasionally, will need AFB (TB eval) or cytology (need lots of fluid for cytology). Print
the recs for the studies you need. At the VA, take sample and recs to basement when
you’re done. At UH, small containers can be sent by tube to the lab. Labels on all samples,
send recs with them.

Lumbar Puncture
1. Theoretically patients without neuro signs don’t need a CT prior to LP, in practice
it’s often difficult to fully examine a patient with concern for meningitis and a CT
head is usually indicated prior to LP(noncontrasted).
2. Obtain LP kit, chlorhexadine, gloves, facemasks, gowns. Lidocaine is in most of the
kits at the VA and UH.
3. We usually use the lateral decubitus position. Have the patient positioned on the
bed with their knees pulled towards their chest (an assistant may need to help).
4. Palpate the vertebra at the level of the iliac crest. Identify the intervertebral space.
(Better seen than described)
119
 5. Cleanse the area with chlorhexadine.
6. Put on sterile gear, open the kit, place the sterile drape over the area.
7. Inject lidocaine in area to be instrumented.
8. Insert needle at 90 degree angle with skin. Advance in general direction of
umbilicus> you’ll either hit bone (at that point, redirect) or feel a pop as you enter
the subarachnoid space.
9. Obtain opening pressure if desired.
10. Collect spinal fluid in the kit’s tubes.
11. Withdraw needle and clean site. Tell patient to lay flat as much as possible for
several hours.
12. Label the tubes and send to lab with order requisitions.

Common LP Labs: Tube 1: Cell count and diff Tube 2: glucose, protein (and VDRL/FTA
test if suspicious for neurosyphilis) Tube 3: Culture, AFB for TB eval if suspicious Tube 4:
Repeat cell count and diff (particularly helpful if initial tube has lots of RBCs)

*Thoracentesis and arterial lines are best learned by doing with an experienced person.
Do the things listed for all procedures and then learn directly from them their approach.

120
Can I add that on?

Test Add-on Within Add-On To

A1c 5 days Lavender (CBC)
Albumin 5 days Red/Green (RFP)
Aluminum level SEND OUT TEST
Amylase 5 days Red/Green(RFP
ANA 5 days Red-gray serum separator tube
B12 48 hours Red(RFP)
Basic Metabolic Panel 48 hours Red/Green(RFP)
O
Blood lead level 5 days Green/Lavender (CBC)
NT-proBNP 3 days Red (RFP)
CBC 36 hours Lavender (CBC)
Complete Metabolic 48 hours Red/Green (RFP)
Complement (C3/C4) 5 days Red/Green(RFP)
CRP 5 days Red/Green(RFP)
Cyclosporine level 5 days Lavender (CBC)
D-dimer 4 hours Blue (Coag)
Drug screen 5 days Red(RFP)
ESR 24 hours Lavender (CBC)
Ferritin 5 days Red/Green(RFP)
Fibrinogen 4 hours Blue (Coag)
Folic acid level 2 days Red(RFP)
G-6-PD 48 hours Lavender (CBC)
Haptoglobin 5 days Red/Lavender/Green(RFP)
HCG 5 days Red/Green(RFP)
HCV Genotype SEND OUT TEST Red/Lavender(RFP)
HCV RNA/PCR 72 hours Red/Lavender(RFP)
Hemoglobin 5 days Lavender(CBC)
identification
Hepatic Function 72 hours Red/Green
Hepatitis panel 3 days Red(RFP)
HIV antibody 5 days Red(RFP)
HIV viral load (by 5 days Lavender(CBC)
AmpliPrep TaqMan)
Immunoglobulins 5 days Red(RFP)
Ionized Calcium No add-on
Iron panel 5 days Red (RFP)
Lactate Can’t add on
Lipase 5 days Red(RFP)
Lipid Panel 5 days Red/Green
Lithium Level 48 hours Red (RFP)
Lupus anticoagulant 4 hours Blue(Coag)
(DRVVT)
Lymphocyte surface 72 hours -heparin green top vacutainer, syringe
markers with heparin, lavender or ACD yellow
for bone marrow or peripheral blood

121
 -sterile vials containing RPMI1640 or
viral media for surgical specimens

-sterile container for peritoneal,

pleural, spinal, synovial etc samples
Magnesium 5 days Red/Green (RFP)
Osmolality, serum 5 days Red(RFP)
Potassium 5 days Red/Green (RFP)
Prealbumin 5 days Red/Green (RFP)
Protein C and S 4 hours Blue (Coag)
PSA 48 hours Red (RFP)
PT 24 hours Blue (Coag)
PTT 4 hours Blue (Coag)
Renal function panel 48 hours Red/Green(RFP)
Reticulocyte count 36 hours Lavender (CBC)
Rheumatoid Factor 5 days Red (RFP)
Rubella titer 3 days Red(RFP)
Serum Protein 5 days Red (RFP)
electrophoresis
TCA Levels 5 days Red(RFP)
Testosterone 48 hours Red(RFP)
TSH 5 days Red/Green(RFP)
Total T3 2 days Red (RFP)
Free T4 5 days Red/Green(RFP)
Transferrin 5 days Red (RFP)
Troponin 2 days Red/Green (RFP)
Type and Cross No add-on
Type and Screen No add-on
Uric Acid 5 days Red/Green (RFP)

122
 On Campus Food
1.Wolfgang
-Great quality, moderate expense, can use ID badge/on call cash
-extension 63830 (call ahead and pick up to make it quicker)
-Closes at 7PM
2.Cafeteria
-closes at 8PM, average quality, ID badge/on call accepted
3.Einsteins (in atrium)
-open until 2AM weekdays only (not open weekends)
-latest option in the hospital for coffee/bagels/snacks

On Call Food Delivery

1. Delivermefood.com
-Lots of options, particularly before 9PM.
-Tree country bistro, Café Tandoor, Mad Greek all solid options
-bit more expensive and takes 45-60 minutes

2. Jimmy Johns
-(216) 231-5300
-fast, cheap, filling
-if you’ve ordered from them before, make sure they know if you’ve switched
hospitals (they associate your phone number with the last location where they
delivered to you)

3. Indian Flame
-(216) 791-5555
-sharable (one entrée serves 2), affordable, average quality

*Chipotle, Panera, Qdoba, Starbucks are all walkable in University Circle, but do not
deliver

VA: Le Café Du Lounge

-24 hours
-2nd floor by the PCU
-Finest free cheese sticks and Shasta this side of Paris

Coffee:
Starbucks on Euclid by Seidman Cancer Center
Cafeteria
Java Jive in Bolwell
Resident Lounge has free coffee in both hospitals

123
 VA Medical Center Important Phones/Pagers
Call 216-791-3800 plus 4-digit extension listed below (p) = Pager
CONSULTS HOME CARE/PLACEMENT CLINICS
Anesthesia x 4948/x5120 Home Anticoagulation x5366
Dental x4356 Oxygen x4785/(440) 562-0768(p) Arthritis x5365
Dermatology (440) 562-8588(p) Geriatrics x 5267 Audiology x4090
Endocrinology 30113(p) Cardiology/EP/ Pacemaker x5365
HPBC (Judy Slivika) x4577 Dental x4344/45
ENT (on call) 30115 (p)
CBPC(Diane Pulphus) x4587 Dermatology x4452
Hem/Onc (440) 562-2036(p)
CBPC(fax) (216) 707-5920 Diabetes Teaching x4597
HIV nurse(Jan Briggs) (440) 562-0517(p)
Infectious Disease Paging University Hospitals CMC
(440) 562-8667(p) ENT x4452
GI x5257/58/59
Neurology 31317 (p)
Nephrology Dial 9-1-216-207-7244
(440) 562-8626(p)
GU x4491
Then the 5 digit pager. Gynecology x3425/3724
Neurosurgery (on call) 30170 (p)
Hepatitis C x5365
Opthomology (on call) 30598 (p)
PHARMACY Hypertension x3413
Podiatry (440) 562-8693(p)
x5400/x5485 Lipid x4884/x4379
Psychiatry Consult(on call) (440) 562-2194(p) Medicine Firm A & B x5600
Discharge pharmacy x3632
Psychiatry Cons. & Liason (440) 562-2219(p)
Non-Formulary Pager (440) 562-2149(p) Mental Health & Addiction x4724/x4725
Skin Care (Terry Langdon) (440) 562-2113(p)Satellite Pharm for 3A,3B, 5a x4877/(440)562-1238(p) Nephrology x5365
Surgery (Cardiothoracic) (440) 562-1492(p) Sat Pharm for MICU, PCU, 5b x5478/(440) 562-1187(p) Neurology x5654
Surgery (General) (440) 562-1778(p) Hematology/Oncology x3897
CARDIOLOGY SERVICES
Surgery (Vascular) (440) 562-1777(p) Optometry x5430/x5445
CAT Echocardiogram
x4725 x4859, x4904
Cardiac Cath Main x4857 Orthopedics x5433
38848/31650
Cardiac Cath Reading Room x4880 Occupational Therapy 4131/4149/4150
RESIDENCY AFFAIRS Stress Tests x4867/x4855 Physical Therapy 4142/4141/4137
ECG technician x4870/(440) 562-2354(p) Podiatry x4452
Resident Program Office x6537 EP nurse practitioner (440) 562-0552 (p) Pulmonary/Sleep Med x5365
VA Medicine Chief Resident 5034, 31533 (p) Cardiology team pager (440) 562-0361 (p) Scheduling x3044
Ambulatory Chief Resident 5034, 31529 (p) Smoking Cessation x5733
PULMONARY SERVICES
LABS Speech Pathology x4090/x4092
Pulmonary Function Testing x4754
MEDICAL RECORDS, FAXES
Blood Bank x4083 Respiratory Therapist(Wards) x4753/(440) 562-1544(p)
Blood Gas/Drugs x4061 Respiratory Therapist (MICU) (440) 562-1158(p) Record Control x5232
Sleep Lab x4762 Dictations:x839,7676, #1,99999,1,thenSSN
Automated Chemistry x5897
Chemistry x4058 PROCEDURE LABS/ SERVICES Transcriptions: 839,x 7698 / 7326
Coagulation x4086 Dialysis Fax Medicine (216) 231-3289
x5181/x5182
Fax ICU (216) 231-3463
Cytology x5142 EEG x 5232
Fax Urgent Care (216) 421-3008
Hematology x4085 EMG Lab x4154
Medical records x5392
Histology x4064 Endoscopy Lab x 5258/x5259/x5238
Medical records fax (216) 231-3295
Mircrobiology x4042 HIV Testing Coordinator x4773/(440) 562-0517(p)
Morgue x4055 Geri Rehab NP x4020/(440) 562-0924(p) ADMITTING & LOGISTICS
Pathology x4030 Prosthetics x4212 Bed Control x5358, x5648
Phlebotomy x4077 Rehab Medicine x 4153/x4123 Escort x5095
Urinalysis x4072 Vascular Lab x4423/x5650/x5654 Police x4207/x4208
SOCIAL WORK Supply (SPD) x5288
RADIOLOGY
Kelly Murray (b/g) x4229 Travel x 3061/5362
Main/Scheduling x4301 Heather Loomis (o/w) x4238 Travel (after hours) x4441
CT x 4323/x3393 Simone Ray (5a/b) x5712 Nursing supervisor pager (440) 562-1157
File Room x4316/x4317 Denise Green (renal) x4248/(440) 562-8686(p) CPRS Help Desk 839, x6685
Radiation Therapy x3361/3370 Earlie Williams (supervisor) x4262/(440) 562-0870(p) WARDS
Ultrasound x3755 Miranda Payton (Palliative) x4258/(440) 562-1491(p)
Ward PCU x5041
MRI x3355 DISCHARGE PLANNERS x5042

Nuclear Medicine x5200 Tammy Magill-Babyak (b/g) x3039/p0033 x5044
Angiography x5585 Marvelyn McKee (o/w) x5447/p0042 Ward 5A x5054
WORK/CALL ROOM Maya Hopkins (until 7 p.m.) p0313 Ward 5b (Geri Rehab) x5051
Kimberly Williams (PCU) x3729 MICU/CICU x5040/x5039
Blue x6162/x6163 SICU 5060/4958/4955
TEAM PAGERS
Green x4758/x4774
Orange x4814/x4824 Orange (440) 562-0509 (p)
124 (440) 562-0491 (p)
MISCELLANOUS
White x5823/x5829 White
Green (440) 562-0502 (p)
MICU/CICU/PCU x4552/3401/4380
Blue (440) 562-0456 (p)
Cards 4772
SP21089(5/11)
 UNIVERSITY HOSPITALS OF CLEVELAND—216-844-1000 PHONE NUMBERS
CONSULT PAGERS COMMAND AND CONTROL CLINICS
Anesthesia-Code Pager 30189 Program Director Pager 31552(p) Appointment scheduling 48500
35213 UH Chief Resident 43621, 31250(p) Cardiology Scheduling 43800
Cardiology Fellow pager Med/Peds Chief Resident 38455(p) Douglas Moore Clinic 43400
Dermatology 31426 Deena Segal 42562 ElderHealth 46300
Endocrine 30113 Barb Bonfiglio 43308, 43811 Heart Failure Clinic 45518
ENT 30115 43951
UHHS HOSPITALS
30385/31650
Bedford Medical Center 440-735-3900 MISCELLANEOUS NUMBERS
Heme 31251
Onc 38947 Brown Memorial Hospital 440-593-1131 Admitting 26054/41673/43702
HIV 35268 Geauga Regional Hospital 440-269-6000 OR/Anesthesia scheduling 42270
ID 31285 Heather Hill 440-285-4040 (for radiology studies w/ sedation)
32747/31650 Memorial Hospital of Geneva 440-466-1141 Broviac scheduling hotline 45346
Neurology 30116 Mercy Medical Center 330-489-1000 DACR/NACR – phone 67121 30512(p)
Neurosurgery 30153 Richmond Heights Hospital 440-585-6500 Direct Dial-In to UH 844-5344
Ob/GYN 30554 Southwest General Hospital 440-816-8000 Emergency Room 43722
Ophthalmology 35251 St. John’s West Shore Hosp 440-835-8000 Flex Pager 31855
Pain service-Anesthesia 35879
St. Vincent’s Charity Hosp 216-861-6200 Home Team 4-HOME
Pulmonary Fellow pager
University Hospitals 216-844-1000 IV/PICC line team 30278(p)
Psychiatry 30164
RADIOLOGY Medical Records 43561
32390
Macdonald 4th Floor 41640
Urology 30125 Switchboard/ Control 43062,43063,43064
Wound Care (Becky Roberts) 30417 Angiography NACR/DACR 67121
44945
Nutrition Therapy 41860
LABS/ PHARMACY Body CT 44940
PCOSS Help Desk 43327
Triage 4-LABS (45227) Head CT 47051,26221,28836
Physical Therapy 27053(RBC), 28246, 45200
ABG/Blood Bank 41788/42800 Image Library 47680
Police 4HELP (44357)
Chemistry/Toxicology 45216 MRI 47750
Respiratory Therapy Coordinator 30510(p)
Hematology 45244 Nuclear Medicine 43101
Risk Management 35626(p)
Coagulation 45008 Nuclear Medicine Reading Room 26097
Social Worker On-Call 35138(p)
Microbiology 43482 PET scanner 43107
Virology 43483 PACS pager Speech Therapy 45778
35030(p)
Pathology: Autopsy 41836 Radiation Oncology Transfer Center 41111
43103
Cytology 41803 Radiology Junior Resident 45224/32494(p) UH Pagers (from inside) 222, then dial pager#
Surgical 41817 UH Pagers (from outside) 464-8410
Radiology Specialty Resident 32495(p)
Urinalysis 48481 VA Tie line 203, then dial extension
Radiology scheduling 41700
Inpatient Pharmacy 42016 TEAM PAGERS AND PHONES
Ultrasound scheduling 43186
Bolwell Pharmacy 47270
University Imaging (Bolwell) 47170 Carpenter 32661
Antibiotic approval 30316(p)
IR 48290 Eckel 33559
ICUS, WARDS, ORs
PROCEDURE LABS Hellerstein 32605
CICU 42125 Mather OR 42260 Naff 33726, ph 166253
MICU 42130 Tower (flr#) 420#0 Cardiac Catheterization 43155
Ratnoff 33306
SICU 42120 Lakeside (div#) 415## GI/Endoscopy 51110
Wearn 32654, ph 166288
NSU 42140 Nursing Sup 30515(p) Echocardiography 43824
Weisman 33970
Dialysis 41585 ICU Nrsng 35500(p) ECG 45518
32299
FAX MACHINES Electrophysiology 42333
FLEX 31855
Scheduling 43155
DOM 48216 Lakeside 60 41563 CCLHD 33116
Tower (flr#) Res lounge (216) EEG 43199
Berger 36599
420#4 983-3075 EMG 41923
Geriatrics 39385
Lakeside 20 41521 CICU 42112 Pulmonary Function125Testing 51097/51095
Lakeside 40 41523 MICU 42113 Vascular Lab 48082
Lakeside 50 41223 Dialysis 48975