Common Inpatient On-Call Issues

Responding to the Call:

• Assess the patient ASAP

• Have nursing obtain:

  • Full set of vitals

  • Obtain an EKG

  • Consider starting on oxygen

History and Physical:

• Assess for the Serious Six of Chest pain

  • Acute coronary syndrome - "crushing" substernal chest pain, shortness of breath, not reproducible with palpation in a patient with cardiac risk factors. Symptom presentation may be variable - maintain a high clinical suspicion

  • Pericarditis with tamponade - Pleuritic chest pain, tachycardia, tachypnea, hypotension, neck vein enlargement

  • Pulmonary embolism - Pleuritic chest pain, tachycardia, tachypnea, oxygen desaturation, hypercoagulation risk factors

  • Pneumothorax - Pleuritic chest pain, absent lung sounds on one side, tachypnea, oxygen desaturation

  • Aortic dissection - "Tearing" chest pain radiating to back or neck, shortness of breath, blood pressure may be increased or decreased

  • Esophageal rupture - Severe retching or vomiting prior, crepitus may be present, pain may radiate to L shoulder.

• Inspect, palpate, auscultate. Is the pain positional? Quality of pain? Reproducible with palpation?

Labs and Imaging:

• Troponin

• EKG

  • STEMI Criteria:

    • Men <40: >2.5 mm (1 mm = 1 small box) in V2 or V3, >1 mm in any other lead.

    • Men >40: >2.0 mm in V2 or V3, >1 mm in any other lead

    • Women of all ages: >1.5 mm in V2 or V3, >1 mm in any other lead

• CXR

  • Assess for pneumothorax, free air under the diaphragm.

• Close vital sign monitoring

Time-sensitive Interventions:

• STEMI/NSTEMI found on EKG

  • Notify your attending, if STEMI consider calling a Code Blue for cardiopulmonary emergency. Notify cardiology STAT.

  • Medications STAT.

    • Aspirin 325 mg

    • Clopidogrel (Plavix) 300-600 mg PO loading dose OR ticagrelor (Brillinta) 180 mg PO loading dose.

    • Enoxaparin (Lovenox) 1 mg/kg subq q12h OR unfractionated heparin IV loading dose 60 IU/kg (max 4000 IU) followed by initial infusion of 12 IU/kg/hr, titrating per protocol.

    • Oral beta blocker (metoprolol succinate 25-50 mg q6-12h) within the first 24 hours in patients without 1.) Signs of HF, 2.) Evidence of low output state, 3.) Increased risk for cardiogenic shock, or 4.) other contraindications to beta blockade e.g. PR >0.24, 2nd or 3rd degree heart block w/o pacemaker, active asthma or reactive airway disease.

  • Discuss with cardiology transfer for cardiac catheterization and/or other interventional management, if it is within patient's goals.

*DISCLAIMER*: This is an Agitation algorithm I learned and really liked from a Senior ED resident so take its recommendations with a grain of salt. As there is no standardized approach to agitation this is just one possible algorithm you can consider depending on your patient's individual situation. It also is from the perspective of an ED resident so keep this in mind when dealing with agitation on the wards. Obviously before administering any below, you should evaluate the patient and attempt to determine the etiology of pt's agitation. However if deemed more psychogenic, I think it is important to have some go to meds to start with according to the clinical situation.

-Brad Matheus 7/23/2022 1439

MILD ("Disruptive, Uncooperative/Cooperative")

Olanzipine: 5-10mg Dissolving Tabs. (15 min onset and can often last 4-6 hours duration)

Valium (Diazepam): 2-10mg Tabs. Less common option but can be considered.

Moderate ("Aggressive, Combative")

MIX THE TWO MEDS BELOW

Olanzipine 5mg IM (1-2 min onset, can last 6 hours duration)

+

Midazolam 5mg IM (1min onset, can last 30 minutes duration)

Alternative but not used as frequently: The B52

Benadryl 50mg

5 of Haldol

5 of Ativan

Severe ("Danger to others vs. themselves")

Ketamine: 3-5mg/kg IM (Typically 350mg for 70kg) (Onset <5mins and can last 6-8 hours duration.)

Notes: Does not depress respiratory drive unless EXTREMELY High Doses