How do I manage a bradycardic patient?
Your first step is to ask for a full set of vitals, EKG, and assess the patient. While assessing, try to gather relevant history (medications such as digoxin or beta-blockers, CAD, falls, etc.) but your most important assessment piece is to determine if the patient is symptomatic.
When examining the patient, don't forget to assess for:
Mental Status
JVP
Skin temperature
Cyanosis
Capillary refill
Murmurs
Lung crackles and breath sounds
If your patient is hypotensive or symptomatic, you should immediately give IV atropine (0.5 mg to 1 mg push) while you are applying the transcutaneous pacing pads. You can repeat atropine up to 3 mg total. At this point, you should start transcutaneous pacing. You could start this right away, but it hurts and is rough on a conscious patient.
If asymptomatic with an appropriate blood pressure, review the EKG. No further action is needed unless there is a Mobitz II or complete heart block.
Management otherwise focuses on ABCs and treatment of the underlying cause. Differential diagnosis includes:
Digoxin toxicity (Check med list & check a level. Treat with lyte correction +/- digiFab)
Beta-Blocker toxicity (Bolus 50 mcg glucaon, then start a gtt)
Sick Sinus Syndrome
Acute Coronary Syndrome
Hyperkalemia
Hypothyroidism
Hypothermia
How do I handle the acutely seizing patient?
First, STAY CALM. Most seizures remit spontaneously within two minutes!
Next, assess ABCs, get vitals, & optimize the environment. Place patient in a lateral decubitus position, make sure bed railings have pads on, and make sure suction is on and in place.
Your goal is to stop the seizure and make sure to treat the underlying cause.
1. Stopping the Seizure-Always get a blood glucose to make sure hypoglycemia is not the reason! If a serum glucose level cannot be obtained quickly, just give thiamine followed by glucose.
Next, have someone draw up 0.1 mg/kg of lorazepam (max of 4 mg). While you are waiting for this to be drawn, make sure you have an Ambu bag ready because the benzo push could result in respiratory depression and apnea. Give 2 mg of lorazepam slowly & have someone call neurology. If needed, give the remaining 2 mg.
If still seizing, neuro should be able to help recommend further medical management. Make sure to discuss loading of antiepileptics after and further management with neurology.
2. Treat the Underlying Cause- Many things can cause a seizure:
Infection
Metabolic (including Hypoglycemia, Hyponatremia, and Delirium tremens)
CVA
Structural/Malignancy
Trauma
Iatrogenic
Therefore, consider the following workup:
Blood glucose
CMP, calcium, magnesium, phosphorous
ABG
Urine, serum tox screen
Can check a prolactin after a seizure to confirm it was a true seizure
Once seizure is complete: consider CToH
How do I handle an acutely febrile patient?
A fever is defined as a temperature of >38C (100.4F). This should be present for more than one hour in non-neutropenic, non-immunocompromised patients.
When dealing with fever, first ask for a full set of vitals over the phone as well as the reason for admission. (You will approach a patient just admitted with pneumonia much differently than a patient with AML getting induction chemotherapy). You can also ask about infectious symptoms (i.e. cough/sputum/SOB, CP, dysuria, diarrhea, etc.). Don't forget to ask about recent surgery, any wounds, PE/DVT risk factors, blood transfusions, etc.
On exam, don't forget to interpret those vitals. Look at mental status and for agitation or lethargy. Rule out intracranial infections: look for photophobia, neck stiffness, etc.Make sure patient is not septic: evaluate skin temp and color, pulse pressure, perfusion. Look for sources, including wounds, rashes, cellulitis, DVT, line infections. This includes a good lung exam.
Workup is largely based on the results of your history and physical. Consider:
2 complete sets of Blood Cultures, including peripheral culture and culture from each lumen of central lines.
UA with Urine Culture
CXR
If neuro signs, consider LP
If liver history, diagnostic paracentesis
Management depends on your examination: If the patient is stable, make the diagnosis before starting antibiotics. If your patient is unstable or very high risk, grab cultures and then treat. Don’t forget to assess for sepsis and treat with volume as appropriate!
If you can, focus your antibiotic choices based on suspected infection:
CNS: Ceftriaxone/Vancomycin, consider Ampicillin if risk factors for listeria
Aspiration: Cover for anaerobes (clindamycin)
GU: Fluoroquinolones, bactrim, amp/gent
Skin: Think community-acquired MRSA: clindamycin to start, vancomycin if sick or at risk for hospital-acquired MRSA
GI: Fluoroquinolones, metronidazole, Zosyn
Lines: Vancomycin
Neutropenic Fever: Cefepime
References:
MKSAP17. “Seizures and Epilepsy”.
Schacter, SC. “Evaluation and management of the first seizure in adults” from UptoDate. 08/2019.
MKSAP 17 Visual Dx
Dinarello, CA. “Pathophysiology and treatment of fever in adults”. UptoDate. 09/2018.
Freifeld AG, Bow EJ, Sepkowitz KA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the infectious diseases society of america. Clin Infect Dis 2011; 52:e56.
“Part 7: Adult Advanced Cardiovascular Life Support.” Mark S. Link, Chair, Lauren C. Berkow, Peter J. Kudenchuk, Henry R. Halperin, Erik P. Hess, Vivek K. Moitra, Robert W. Neumar, Brian J. O’Neil, James H. Paxton, Scott M. Silvers, Roger D. White, Demetris Yannopoulos, and Michael W. Donnino
Soar et al. “European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support”. Resuscitation 2015. 95. 100-147.
Neumar et al. “Part 8: Adult Advanced Cardiovascular Life Support”. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122:S729–S767
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