Intern Basics- Part II
Jacobi medical Center
Falls








Assess the patient after the fall
Witnessed or not
Ask the patient about the fall and any injury
Examine the patient with special attention to the
area of injury; examine the head to rule out any
injury to the head
Imaging studies to rule out any fractures
If any change in the mental status from the
baseline is noted, get a head CT
Complete the incident report
Restrains as needed
Altered Mental Status
Confusion, delirium, drowsiness, stupor
 Look for the possible (and obvious) causes:
-medications (opiates, benzodiazepines, other
sedatives)
-metabolic (hypoglycemia, hyponatremia,
hypernatremia, uremia, hypercapnia, hypoxia)
-trauma to the head
-Stroke
-Seizures
-Infections
-Others: hyperthyroidism, liver failure,
Hypertensive encephalopathy

AMS (contd.)

Work up:
-Any acute change in mental status (stupor), call an RRT
(rapid response team), stabilize the patient first. Always
check ABC. Make sure the patient has a working IV line
-Check finger stick glucose to r/o hypoglycemia
-If patient seems unable to protect his airway, then he
probably needs intubation (call RRT if not already called;
ask the nurse to call anesthesia and respiratory
therapist)
-labs: CBC, serum electrolytes, BUN/Cr, ABG
-If any suspicion of infection, check UA and CXR
-Head CT
AMS (contd.)

Management:
-Delirium: Haldol 2-5mg IM can be given
-Underlying cause should be treated. If
patient has been intubated, then will need
to be transferred to the ICU/CCU. Contact
SMR for the transfer.
Insomnia



Antihistamines (benadryl): may cause daytime
sleepiness the next day, avoid in patients with
angina, cardiac arrythmias, BPH, COPD
Benzodiazepine (restoril, ativan): daytime
sleepiness, cause respiratory depression, avoid
in COPD or any underlying lung problems
Newer hypnotics (ambien): fewer side effects,
better tolerated; consider trazodone
Constipation
Causes: functional (most common in the
hospitals), obstruction, medications (most
commonly opioids), neurogenic
 Abdominal x-ray if needed
 Treatment: colace, senna, dulcolax
(bisacodyl), lactulose, enema (tap water,
fleets), disimpaction of stool

Diarrhea
Acute onset: rule out infection
 Check fecal leucocytes, occult blood in
stool, stool culture, C. diff toxin
 Check CBC for leucocytosis
 If any reason to suspect C. Diff infection
and patient appears acutely sick, should
start metronidazole empirically

Heparin drip adjustments






Initial dose
PTT <35
PTT 35-45
PTT 46-70
PTT 70-90
PTT>90
80 U/Kg bolus, then 18U/Kg/hr
80 U/kg bolus, increase drip by 4 U/kg/hr
40 U/kg bolus, increase drip by 2 U/kg/hr
No change in rate
Decrease drip by 2 U/kg/hr
Hold infusion for 1hr, decrease the rate of
drip by 3 U/kg/hr
Death notification






Confirm death: pupils, heart, breathing
Note the official time of death (when you pronounce the
patient)
Notify the family
Call organ donation (If they reject the case, they will give
a case number; also get the name of the person you
speak to)
Write a death note in the EMR and complete the
discharge summary
When the death certificate is ready, the admitting will call
you to get your signature/ finger print (please do that
promptly and do not sign that out)
Sample death note

Called to the bedside by the nurse. Patient
found unresponsive, pupils unreactive, no
spontaneous breathing, no heart sounds.
Pt pronounced dead at 1100am on
07/24/2010. Pt’s son (name) notified.
Called organ donation and spoke with Ms.
X. The case was rejected and the case
number is XXXXX.
Questions??