CCU
HOME BASE:7200-CCU (ICU plus telemetry) and 7300 (telemetry only). Occasionally 7100 (CT surgery).
TEAM:
2 teams (blue/green or red/yellow), each with: One attending (switches about weekly), 2 senior medicine residents (R2, sometimes R3), 2 interns. There are 5 interns total with one on nights. You may switch teams after you cycle through your night week.
Red/Yellow team: Heart failure patients, cardiogenic shock patients, the patients on this team are generally more sick. (mostly patients on 7200)
Blue/Green team: more the bread and butter STEMI, NSTEMI, UA, post cath, arrythmias, less ICU level patients (mostly patients on 7300)
When you are the long call intern or on night float, you carry a code blue pager.
CALL SCHEDULE:
The schedule is supposed to be similar to MICU but doesn't function as smoothly due to medicine resident clinic days. Each team admits every other day. One of the admitting team's seniors is on overnight. The first 5 days or so everyone comes in to get used to the CCU schedule. Then, theoretically, schedule is: post call, long call (6am-8pm), post call, then off (so every 4th day you should have off). They got better at honoring this schedule so you have more days off than you think.
For post call days you can leave whatever time you finish your floor work, but make sure all your patient responsibilities are completely done before leaving ( ie discharges, notes, family meetings). I would leave most days around 2-3pm, but still answer pages till 5pm.
You will also have one week of night call (7pm-7am) where you and the long call senior for the day are on. Generally for nights, you are responsible for taking care of all the floor patients and responding to the code blues. You should not be admitting patients overnight unless the senior is swamped.
CALL ROOM:
On the 7th floor across from the north elevators. At the end of the hall are two call rooms facing each other. One's for you, the other for your senior. You'll spend most of your time here for nights. During the day, the red/yellow team has a resident work room on 7200 and the blue/ green team has a work room on 7300.
DAYS OFF:
Generally, every 4th day you have off so it ends up being around 6 days off in the month. For long call days it is just you and the senior. For post call days, it is a senior and 2 interns.
TYPICAL ADMITS:
R/O MI, Acute MI, Unstable angina, CHF exacerbation (lot of patients), Afib w/RVR, Syncope, post cath.
TYPICAL DAY:
6am: Arrive and get sign out on any events overnight from the night intern. Then I would go to 7100 unit to get the telemetry events on my patients. Then see pts and write notes. (some attending want notes to be completely done and signed before rounds).
8:30 or 9am: Round with attending, ward work.
2pm: CCU fellow lecture (variable, but 1 to perhaps 2 days per week). The fellow will contact you if there are lectures
2pm onward: Ward work then update list, sign out all patients to on-call intern/senior and leave. Yes, you can leave this early. It is wonderful. You will be expected to answer your pages until the night person gets in.
Long call: Seniors often try to do the morning admits so you can present on rounds. After rounds you and admit until 7. You also carry the code blue pager. Responding to codes is the fun part of this rotation!
**Regarding attending EM conference **: It is OUR protected time so theoretically you should be there every Wednesday. For those days, I would arrive earlier and make sure all my notes are done by 8am. Then tell the senior the plans for your patients, he/she will present your notes on rounds. HOWEVER, this is not possible if conference falls on your long call day though (only the senior is there and it is hard for them to present all the patients and do admissions). On those days, present all your patients first and you might just miss the first hour of conference.
PAPERWORK: (update the handoff on epic everyday so the team and night float intern knows your plans and what "to do" overnight)
- H&P: dot phrase: gsccuhp (change sig)
- Progress notes: .gsccuprog (change sig)
- Orders: see below for assessment and plans for the typical CCU patients. Basic admission orders, and more info below based on cc). Generally at least add BMP and mag q12 hours (it's all about repleting electrolytes this month)
- Discharges: Unlike MICU you DC all of your patients. Use the discharge tab, go through the med rec. Type a discharge summary using the generic epic discharge template. If you update the DC med rec don't forget to go back and refresh it on the DC summary. Generally, these discharge summaries are less painful if you update your CCU course everyday on your progress note so you can copy and paste it into D/C summary when they are ready to go.
- Current Team List: the red/yellow and green/blue CCU lists will be shared with you. Just keep the handoff part updated.
Pearls:
- R/O MI Admits: Use chart review "caridology tab" on epic to look up old stress tests, recent cath, echos , etc. Order cardiac enzymes x3 q8hrs, will need either ETT (treadmill) or dobutamine echo in a.m. (depends on if they are physically able to do treadmill: ask them on admission. It requires very brisk walking for several minutes). Most will get ASA QD, ask senior about starting beta blocker and ACE-I (usually standard on any serious chest pain rule-outs). Start heparin gtt if high suspicion ACS (can use TIMI risk score to assess). Order EKG q am and prn chest pain. Keep most new pts NPO p MN for any possible tests (TEE, ETT, angio).
- Syncope/arrhythmia admits: Monitor on Tele overnight, orthostatics also good to have. May get echo, or tilt table test in a.m. or may set up as outpt. May need carotid U/S, TSH, FT4, UDS. Then EP consult in morning if applicable
- CHF: determine if needs lasix gtt (if EF so low cannot tolerate large lasix boluses, titrate to keep UOP > 100cc/hr, order BMP q 8 to 12 hrs to monitor K), IV lasix, or PO lasix. Daily weights, I&Os, BUN/Cr, TTE if has not had one recently. You must know if it's systolic vs diastolic or mixed and underlying cause (ischemic cardiomyopathy, etc).
- You get what you put into this rotation. Make it clear day 1 to your senior what you expect from this rotation. I told my senior I want to respond to the codes and do any procedures if any come up. He/She made sure I was there to intubate if a patient was crashing and they let me run the codes (once I felt more comfortable).
Stuff to review before starting:
ACLS, eval and treatment of MI and unstable angina, coronary artery anatomy, EKG interpretation, arrhythmias, syncope, anti-arrhythmic meds, CHF treatment, review pressors (they love dobutamine, dopamine, milrinone) You will RARELY use levophed, cardiologists hate it and worsens ischemia.
Assessment and plans for typical CCU admits:
Prognostic Factors
Age >= 65 years
>= 3 Traditional CAD risk factors (family hx of CAD [CAD in male 1st degree relative, father < 55, female 1st degree < 65], HTN, Chol, DM, current smoker)
Documented CAD with >= 50% diameter stenosis
ST-segment deviation
>= 2 Anginal episodes in the past 24 hours
Aspirin use in the past week
Elevated cardiac biomarkers
TIMI Risk Score:
0-2 Low risk
3-4 Intermediate risk
5-7 High risk
# STEMI - (> 2 mm precordial leads or > 1mm other leads)
- Will go to Cath lab, you just do the post care
- PCI or thrombolytics. GP IIb/IIIa inhibitor
- IV heparin gtt
- Aspirin 325 and Plavix (only if stent placed)
- ACEI (captopril 6.25 TID), metoprolol 25 BID, atorvastatin 80
- Trend cardiac enzymes
- Nitroglycerin prn (although if RV infarction don't give anything that decreases preload like nitro, diuretics and vasodilators as RV is thin walled and preload dependent)
- TTE
- Lipid panel, HgbA1c
- bed rest
- EKG in AM
- CXR
- telemetry
- post cath monitoring (groin hematomas, distal pulses. If hypotensive consider retroperitoneal bleed (noncontrast CG) or recurrent ischemia)
- smoking cessation counseling, cardiac diet
# NSTEMI - positive enzymes, no ST elevation
- if critically unstable consider cath, intraortic baloon pump
- consider stress test
- IV heparin gtt
- Aspirin
- ACEI, metoprolol 25 BID, atorvastatin 80
- Trend cardiac enzymes
- Nitroglycerin prn
- TTE
- Lipid panel, HgbA1c
- NPO after MN for possible cath
- bed rest
- EKG in AM
- CXR
- telemetry
# Unstable angina - angina that is new, occurs at rest, more frequent / severe. Negative enzymes
- same as above
# Chest pain-
- Stress test (can't do exercise stress if abnormal EKG (BBB, V paced, ST changes). Dobutamine (beta 1 agonist), adenosine (coronary vasodilator to stress heart)
- stress echo (treadmill if patient tolerant, if can't do dobutamine)
# CHF - systolic vs diastolic, acute on chronic
Etiology: ischemic, dilated, hypertensive, valvular, drug induced?
Exacerbation: diet, no meds, ischemic, thyroid, HTN, arrhythmia, infection, stress, PE
- admit to CCU with telemetry, pulse ox
- IV Lasix with potassium supplementation, BMP q12. If poor diuresis, give thiazide-like metolazone 5 mg 30 minutes before Lasix. If severe volume overload, Lasix bolus then gtt
- ACEI for afterload reduction. Start captopril 3.125 mg q8h and increase dose by dose as BP allows
- Hydralazine 10 mg q6h is good alternative to ACEI if can't tolerate, especially African, class III-IV on max medical therapy
- Beta blocker (Coreg if EF < 35%). Don't start in acute CHF, but continue if pt already taking at home. When stable, start metoprolol 12.5 daily or coreg 3.125 mg BID and titrate up as BP allows (goal metoprolol 200 daily, coreg 25 BID)
- Consider Nitroglycerin gtt to decrease preload (don't need if good diuresis and BP control). When stable, convert to isosorbide dinitrate 10 mg TID
- If hypotensive, dopamine gtt (intermediate dose 2-10 ug/kg/min for beta receptor stimulation).
- IV inotropes if low EF -- dobutamine (beta agonist), milrinone (inodilator, phosphodiesterase inhibitor, reduces filling pressures and vascular resistance)
- aspirin, statin, diet, exercise, smoking cessation, BP / DM control
- ICD mortality benefit for EF < 35%
- more chronic meds: Spironolactone 25 daily if EF < 35%, NYHA III-IV. Digoxin
- morphine PRN for venodilation and dyspnea relief
- 2 gm Na diet, 1.5 L fluid restriction, daily weights, strict I & O
- TTE
- BNP, TSH, EKG, CXR
- should be sent home with Ace-I, unless intolerant
# Syncope
- tele, EKG, TTE, orthostatics, carotid u/s
# Afib
- most common due to CHF, HTN. Also consider EtOH, thyroid, CAD, valve disease, lung disease
- CHADS 2 score. If > 2, need Coumadin
- TTE, TSH, urine tox
- if in RVR, start gtt (diltiazem IV if BP ok, EF normal; esmolol if BP ok, EF low; amiodarone if BP low -- 150 mg bolus first). Avoid close administration of IV beta and calcium blockers = excessive AV node blockade
- telemetry
- if cardioversion planned, need anticoagulation for 3-4 weeks or TEE to exclude LA thrombus
- consider blood alcohol level
# Bradycardia
- Observe if symptomatic. Atropine if symptomatic, have pacers at bedside and call fellow
- atropine at bedside
- pacers in place
​# Heart transplant rejection
- get eccho
- notify fellow or attending
- may have rejection (right heart cath and biopsy)
- look for old reports re: rejeciton (previous score)
FEN/PPX:
- SCDs
- IV fluids
- cardiac diet
Code Status: {code status:20168}