The Washington Manual Internship Survival Guide (10 page)

•
  Check BP, pulse, respirations, O
₂
saturations, and temperature.

•
  Quickly look at the patient and review the chart.

•
  Take a focused history.

•
  Determine volume status. Review ins and outs over the past few days. Any new medications (e.g., ACE inhibitors, diuretics, NSAIDs, IV contrast dye)?

Focused Examination

•
  General: Does the patient appear sick?

•
  Vitals: Check orthostatics and weight over the past few days.

•
  Cardiovascular: Look for JVD, friction rub, and skin turgor.

•
  Abdomen: Evaluate for ascites or enlarged bladder.

•
  Genitourinary: Check for enlarged prostate.

•
  Extremities: Assess perfusion. Check for asterixis.

Laboratory Data

•
  UA: Look for cells, casts, protein.

•
  Check serum electrolytes and urine electrolytes; calculate FE
_Na
(and/or FE
_urea
if the patient is on diuretics); consider urine eosinophils, ABG, and ECG.

•
  Renal ultrasound should be ordered within 24 hours to rule out hydronephrosis and evaluate the renal system.

Management

•
  The minimum acceptable urine output is 30 mL/h. If flushing the Foley catheter did not help, ask the nurse to change the Foley catheter.

•
  Initial management should be directed at treating life-threatening electrolyte disorders and correcting volume contraction and hypotension. Obtain diagnostic urinary studies before administering diuretics. Don’t forget to adjust drug doses based on glomerular filtration rate.

•
  Calculate the fractional excretion of sodium:

FE
_Na
= (U
_[Na+]
× P
_[Cr]
)/(P
_[Na+]
× U
_[Cr]
) × 100

This equation is most useful with oliguric renal failure but may be helpful in nonoliguric renal failure.

•  FE
_Na
>1% to 2% with oliguria is almost always ATN but can be prerenal with diuretics.

•  FE
_Na
<1% with oliguria is generally prerenal: volume depletion, severe CHF, nephrotic syndrome, NSAID or dye toxicity, sepsis, cyclosporine toxicity, acute glomerulonephritis, and hepatorenal syndrome.

•  Calculate FE
_urea
in nonoliguric renal failure or if diuretics have been given. FE
_urea
<35% is consistent with prerenal state.

•
  If hyperkalemia is suspected, order an ECG and stat serum potassium.

•
  A stat renal consult is required if the patient needs urgent dialysis. Indications for urgent dialysis include
AEIOU
:

•  
A
= Acidemia (pH <7.2)

•  
E
= Electrolyte disorder (e.g., hyperkalemia when unable to manage medically, see Chapter 17, Fluid and Electrolytes)

•  
I
= Intoxication (e.g., alcohol, salicylates, theophylline, lithium)

•  
O
= Overload (e.g., pulmonary edema when unable to manage medically)

•  
U
= Uremia (encephalopathy, pericarditis)

•
  
Prerenal causes
can be initially managed with a small volume challenge, such as 500 mL NS bolus depending on the cardiovascular status of the patient. This can be followed by NS at a set rate. Specific criteria should be given to the nursing staff (i.e., call HO if urine output is <30 mL/h). Alternatively, if congestive heart failure is suspected, the patient may need diuresis. Escalating doses of furosemide can be used, and urine output and daily weights can be assessed. With a fluid challenge, the creatinine level often trends down by the next morning if the cause is prerenal.

•
  
Postrenal causes
can be potentially managed by placing a Foley catheter. If immediate flow is obtained, urethral obstruction is likely. If a Foley cannot be placed due to obstruction, consider a urology consultation.

•
  To prevent
contrast-induced ARF
, euvolemia is essential. Use ½NS or NS at 1 mg/kg/h for 6 to 12 hours before and 6 to 12 hours after the procedure. Due to conflicting study results, the use of acetylcysteine remains controversial in most circumstances.

HEADACHE

•
  What are the patient’s vital signs? How severe is the headache? Has there been a change in consciousness? Are there any new focal CNS symptoms? Has the patient had similar headaches in the past; if so, what precipitates or relieves them?

•
  
If the headache is severe and acute or associated with N/V, changes in vision, other focal CNS findings, fever, or decreased consciousness, the patient should be seen immediately
. Otherwise, inform the nurse you will see the patient shortly.

Major Causes and Types of Headache

•
  Tension

•
  Vascular (migraine, subarachnoid hemorrhage)

•
  Cluster

•
  Drugs

•
  Temporal arteritis

•
  Infectious (meningitis, sinusitis)

•
  Trauma

•
  CVA

•
  Severe hypertension

•
  Mass lesions

Things You Don’t Want to Miss (Call Your Resident)

•
  Meningitis

•
  Subarachnoid hemorrhage or subdural hematoma

•
  Mass lesion associated with herniation

Key History

•
  Check BP, pulse, respirations, O
₂
saturations, and temperature.

•
  Quickly look at the patient and review the chart.

•
  A detailed, well-focused history is the best method for evaluating a headache. Most are tension or migraine type, but more serious conditions need to be ruled out.

Focused Examination

•
  General: Does the patient appear ill or distressed?

•
  HEENT: Look for signs of trauma, pupil size, symmetry, response to light, papilledema, nuchal rigidity, temporal artery tenderness, and sinus tenderness.

•
  Neurologic: Thorough examination is mandatory, including mental status.

Laboratory Data

•
  Consider CBC and ESR if temporal arteritis suspected.

•
  
Head CT
should be considered for:

•  A chronic headache pattern that has changed or a new severe headache occurs.

•  A new headache in a patient older than 50 years.

•  Focal findings on neurologic examination.

•
  
If meningitis is suspected, an LP should be performed
. The performance of a head CT before lumbar puncture is controversial but is generally not required for nonelderly, immunocompetent patients who present without focal neurologic abnormalities, seizures, or diminished level of consciousness.

Management

•
  
The initial goal is to exclude the serious life-threatening conditions
mentioned previously. After such conditions have been excluded, management can focus on symptomatic relief.

•
  For suspected bacterial meningitis, start antibiotics immediately. See Chapter 21, Neurology consult section, for antibiotic choices.

•
  For suspected subdural hematoma or subarachnoid hemorrhage, obtain CT scan. If positive, a neurosurgery consultation should be obtained.

•
  Tension headaches and mild migraines can be treated with acetaminophen 650 to 1,000 mg PO q6h prn or ibuprofen 200 to 600 mg PO q6-8h; consider sumatriptan 25 mg PO for moderate to severe migraine headaches; can repeat 25 to 100 mg q2h for maximum of 200 to 300 mg/d.

•
  Severe migraines may require an opiate. Sumatriptan and ergotamine are usually most effective in the prodromal stage. These agents are contraindicated in patients with angina, uncontrolled hypertension, hemiplegia, or basilar artery migraine.

HYPOTENSION AND HYPERTENSION

HYPOTENSION

•
  What are the patient’s vital signs? Is the patient conscious, confused, or disoriented? What has the patient’s blood pressure been? What was the reason for admission?

•
  
Hypotension requires that you see the patient immediately.

•
  If impending or established shock is suspected, ensure IV access (at least 20G IV) and consider having the patient placed in the Trendelenburg position (i.e., head of bed down). However, use of the head-down position has been significantly challenged as not helpful and potentially harmful.

Major Causes of Hypotension

•
  Cardiogenic (rate or pump problem)

•
  Hypovolemic

•
  Septic shock

•
  Anaphylaxis

Things You Don’t Want to Miss (Call Your Resident)

•
  You will likely want to let your resident know about any patient with significant hypotension.

•
  Shock is inadequate tissue and organ perfusion. This is best assessed by looking at end organs: brain (mental status), heart (chest pain), kidneys (urine output), and skin (cool, clammy).

•
  Shock is a clinical diagnosis defined as an SBP <90, with evidence of inadequate tissue perfusion.

Key History

•
  Check BP (both arms), pulse, respirations, O
₂
saturations, and temperature.

•
  Quickly look at the patient and review chart.

Focused Examination

•
  General: How distressed or sick does the patient look?

•
  Vitals: Repeat now and often. Elevated temperature and hypotension suggest sepsis.

•
  Cardiovascular: Heart rate, JVP, skin temperature, color, and warmth. Capillary refill.

•
  Lungs: Listen for crackles, breath sounds on both sides.

•
  GI: Any evidence of blood loss?

•
  Neurologic: Mentation, symmetric movements.

Laboratory Data

Consider troponins, ECG, ABG, CBC, electrolytes, and CXR.

Management

•
  Examine the ECG and take the pulse yourself. Check BP in both arms. A compensatory sinus tachycardia is an expected appropriate response to hypotension. However, check the ECG to ensure that the patient does not have atrial fibrillation, SVT, or ventricular tachycardia, which may cause hypotension because of decreased diastolic filling. Bradycardia may be seen in autonomic dysfunction or heart block.

•
  Most causes of shock require fluids to normalize the intravascular volume. Use normal saline or lactated Ringer’s. The exception is cardiogenic shock, which may require preload and afterload reduction, inotropic and/or vasopressor support, and transfer to an ICU.

•
  
Hypovolemic, anaphylactic, and septic shock require fluids
. Use boluses of 500 mL to 1 L. If no response, repeat bolus or leave fluids open.

•
  
Anaphylactic shock requires epinephrine
, 0.3 mg IV immediately and repeated every 10 to 15 minutes as required. Epinephrine is the most important component of management. Hydrocortisone, 200 mg IV, and diphenhydramine, 25 mg IV, should also be administered. Diphenhydramine is adjunctive and not first-line treatment. H2 antihistamines probably add little. Glucocorticoids do nothing for the emergent symptoms and take hours to become effective; they are given to prevent prolonged or recurrent anaphylactic reactions.

•
  
In septic shock, IV fluids and antibiotics can resolve the shock
. However, continuing hypotension requires ICU admission for vasopressors.

•
  Cardiogenic shock can be the result of an acute MI or worsening CHF. However, other causes of hypotension and elevated JVP include acute cardiac tamponade, PE, and tension pneumothorax. These always need to be considered.

HYPERTENSION

•
  What are the patient’s vital signs? What has the patient’s blood pressure been? What is the reason for admission? What BP medications has the patient been taking? Does the patient have signs of hypertensive emergency (end-organ damage)?

•
  The rate of rise of the BP and the setting in which the high BP is occurring are more important than the level of BP itself. Elevated blood pressure alone, in the absence of symptoms or new or progressive end-organ damage, rarely requires emergent therapy.

•
  
Hypertensive emergencies require that you see the patient immediately
. Prior to your arrival, make sure the patient has an IV and order an ECG.