PGY1 Survival Skills
PGY1 Survival Skills
PGY1 Survival Skills
What can be dealt with over the phone most of the time?
-Sedatives (be careful)
-Glycemic control issues (unless v. low or v. high)
-Laxatives
-minor electrolyte issues
These are only a guide; judgement call. When in doubt, see the pt! If someone asks you to see
the pt, see them, even if seems trivial
Tips:
-Tachycardia, tachypnea often mean patient is sicker than they may seem
-Low threshold to get ECG, CXR
-ABG’s, lactate for severe dyspnea, hypotension
On Call: Approach to the Abnormal Vital Sign
Paul Szmitko, CMR SMH 2008-9. Updated by Luke Devine 2009
Stable/Asymptomatic Unstable/Symptomatic
1. Determine why the nurse called/what they are 1. Does the nurse need to call a code?
concerned about 2. See patient immediately to asses
2. Ensure the other vitals are stable 3. Once the patient is seen, do you need to call a code?
3. Ask for an ECG If so, follow the tachycardia with pulse algorithm.
4. Generally if >110/min or new tachycardia, should Perform immediate synchronized cardioversion if
assess patient unstable, establish iv access, get rhythm strip.
Stable/Asymptomatic Unstable/Symptomatic
1. Determine why the nurse called/what they are 1. Does the nurse need to call a code?
concerned about 2. See patient immediately to asses
2. Ensure the other vitals are stable 3. Once the patient is seen, do you need to call a code? If
3. Ask for an ECG so, follow the bradycardia with pulse algorithm. Prepare
4. Generally if <45/min or new bradycardia, should for transcutaneous pacing, establish iv access, consider
assess patient even if asymptomatic. atropine while awaiting pacer and start dopamine (2-10
ug/kg/min) if pacing ineffective, get rhythm strip.
- If patient unstable, transcutaneous followed by transvenous pacing +/- dopamine infusion (may be given
peripherally)
- If stable, observe and monitor with atropine at the bedside and search for underlying etiology
- any offending medications? – consider holding them or decreasing the dose; check digoxin level if on
digoxin
- metabolic derangement? – assess for hypoxia, sepsis
- evidence for increased ICP?
- evidence for sick sinus syndrome? – paroxysms of sinus brady and atrial tachyarrhythmias
- nature of AV block? – first degree (PR>0.2s), second degree (Mobitz 1 or Wenckebach progressive PR
prolongation until not conducted; Mobitz II – occasional or repetitive blocked impulses without PR
prolongation), or third degree (complete)
- call cardiology for Mobitz II or third degree AV block which may require transvenous pacing and monitoring in
CCU
Abnormal Blood Pressure
Stable/Asymptomatic Symptomatic
1. Determine why the nurse called/what they are 1. See patient immediately to assess if it is indeed a
concerned about hypertensive emergency
2. Ensure the other vitals are stable 2. What are the symptoms experienced and is there any
3. Ask for repeat in 5 minutes with patient at rest and BP indication of acute target-organ damage?
in both arms
4. Generally if sBP>190 or dBP>110 or new Hypertensive Emergency: marked increase in BP,
hypertension, should assess patient and consider usually >180/120, with acute target-organ damage:
treatment - CNS: papilledema, encephalopathy, hemorrhagic or
ischemic stroke
Patient Assessment (minimum) - CVS: ACS, CHF, aortic dissection
1. Why was the patient admitted? Was it for this reason? - Renal: proteinuria, hematuria, acute renal failure
2. Ensure patient does not have any symptoms secondary - hematologic: microangiopathic hemolytic anemia
to HTN (see symptomatic section)
3. Repeat the vitals yourself to confirm – ensure BP and If any of the above are present, need to treat BP, with iv
pulses done in both arms agents, to bring down the MAP, where the MAP = [(2 x
4. PEx – mental status, fundoscopy if able, cardiac, resp, dBP) + sBP)/3], by no more than 25% which will
peripheral pulses, gross neuro +/- other systems as require a monitored setting such as an ICU/CCU
appropriate - you also need to address the target-organ damage (will
5. Investigations – guided based on clinical picture likely need to consult other services)
6. Is my patient safe to stay on medicine? Is this their
normal pattern, an urgency or an emergency? Does Management (iv agents acutely – not a complete list)
cardiology or the ICU need to be called? 1. Labetalol – 20 mg iv bolus over 2 min followed by
0.5-2mg/min iv infusion; acts in 5-10 minutes; good for
Management most except if acute heart failure
- most commonly seen in chronic hypertensive patient 2. sodium nitroprusside – 0.25-10 ug/kg/min iv infusion;
who is experiencing pain, missed their morning meds for acts immediately and wears off within 1-2 min, good in
a procedure/NPO, EtOH withdrawal most cases; caution with high ICP and azotemia
- may consider giving scheduled medication somewhat 3. Hydralazine – 10-20mg iv q 30 min; onset within 10-
earlier, increasing their regular BP medication dose 20min; good in eclampsia
slightly, do nothing if asymptomatic and isolated 4. Nitroglycerin iv – 10-200 ug/min; onset within 5 min;
increase in BP (can recheck BP in a few minutes to an especially useful when coronary ischemia
hour to see if it goes down and ask patient to report any 5. Phentolamine 5-15mg iv bolus prn; onset 1-2 min;
symptoms to nursing staff) and let team know in am useful in catecholamine excess states
- initiating treatment best done by the medicine team,
though I like starting with low dose CCB (Norvasc
2.5mg), ACEi if indicated in patient and no
contraindications (perindopril 2-4mg), or nitrodur
0.4mg/hr overnight with team to reassess in am
Stable/Asymptomatic Symptomatic
1. Determine why the nurse called/what they are 1. See patient immediately to assess if the patient is
concerned about experiencing some form of shock
2. Ensure the other vitals are stable 2. What are the symptoms experienced and is there any
3. Ask for repeat in 5 minutes with patient at rest and BP indication of etiology?
in both arms
4. Generally if sBP<90 or new hypotension, should Patient Assessment (minimum)
assess patient Same as for stable patient. Consider checking for pulsus
paradoxus
Patient Assessment (minimum)
1. Why was the patient admitted? Was it for this reason? Types of Shock:
2. Any relevant info from signover, any new drugs, 1. Hypovolemic – Hemorrhage-induced (GI bleed,
transfusions? ruptured aneurysm, hemorrhagic pancreatitis, etc) or
3. Ensure patient does not have any symptoms secondary Fluid-loss induced (vomiting, diarrhea, aggressive
to hypotension (change in mental status, presyncope, diuresis, third space losses as in pancreatitis)
CP, CHF, peripheral shut down) - due to decreased preload, systemic vascular resistance
3. Repeat the vitals yourself to confirm – ensure done in (SVR) typically increased
both arms, postural vitals; if patient has AFib, automatic 2. Cardiogenic – may be secondary to cardiomyopathies
BP not reliable such as massive MI, arrhythmias, mechanical causes
4. PEx – mental status, JVP, cardiac, resp, peripheral such as acute AR, extracardiac causes such as massive
pulses, gross neuro +/- pulsus paradox, urine output and PE or tamponade; consequence of cardiac pump failure
other systems as appropriate resulting in decreased cardiac output
5. Investigations – guided based on clinical picture, 3. Distributive (vasodilatory) – sepsis, SIRS,
often need ECG and/or CXR, CBC, lytes, Cr, Lactate, anaphylaxis, neurogenic shock after spinal cord injury);
trop, CK, ?liver enz, coags (?DIC), consider cultures consequence of severely decreased SVR
6. Is my patient safe to stay on the medicine floor? Is
this their normal pattern? Does the ICU/CCRT need to Management
be called? 1. Identify the most likely underlying cause and address
it; may need to get rapid response, CCU or ICU involved
Management --- better to have them come early then when you are
- if it is not new, it may be secondary to poor cardiac running the code
function at baseline (grade 4 LV), end stage liver 2. iv fluids in most cases will not hurt as long as there is
disease, consequence of medical therapy no evidence of pulmonary edema
- hold any antihypertensive medications (don’t forget to 3. initial pressor that may be given peripherally is
remove the nitro patch), hold nonessential meds that dopamine (start at 5ug/kg/min) as patient getting
cause hypotension (opiods, etc.) lined/transferred
- if volume status is low, consider iv fluid bolus and 4. to buy you some time consider giving some
reassess; check to see what urine output is if recorded phenylephrine (100 mcg iv at a time to support BP) ---
and the trend in urea/creatinine if available though your senior should be there by this stage
- Is this an early presentation of shock? If so, assess 5. order appropriate investigations during/following
more fully and initiate appropriate management (see acute resuscitation.
right side)
SPECIFIC MANAGEMENT FOR CAUSES OF SHOCK:
Brief overview only.
SEPSIS:
ABCs. Consider additional support/monitoring. Fluids ++ (often 6-8L crystalloid), caution if significant
renal failure, poor LVEF. Cultures, broad spectrum abx, source control. Involve CCRT/ICU for central
lines, art line, pressors/inotropes, transfer
CARDIOGENIC:
ABCs. Consider additional support/monitoring If hypotension more significant than pulmonary edema
can give fluids (small bolus and R/A). Call CCU/cardiology and/or ICU for consideration of cath,
inotropes, BiPAP, Intubation, IABP
ANAPHYLAXIS:
ABCs. Consider additional support/monitoring. Assess +/- secure airway (call code blue). Stop
offending agent (antibiotic, blood, etc.). Epi 0.3 mg IM (or consider IV, bolus 0.1 mg +/- infusion (2-10
mcg/min), Fluids, Ventolin, Diphenhydramine 50 mg IV (for utricaria/pruritis), Ranitidine 50 mg IV,
Methylprednisolone 125 mg IV
PE:
ABCs. Consider additional support/monitoring . Fluids (500 cc- 1L +/- repeat) – caution as too much
may worsen RV function. Consider need for vasopressors (norepi). Consider empiric anticoagulation
before investigation (risk vs benefit). Consider thrombolysis if persistent hypotension.
TAMPONADE:
ABCs. Consider additional support/monitoring. Call CCU. Fluids (500 cc- 1L). Intubation may worsen
filling – avoid if possible. If hypotension attributable to tamponade - need pericardiocentesis.
HYPOVOLEMIA/HEMORRHAGE:
ABCs. Consider additional support/monitoring. Establish large bore peripheral IVs. Give fluids +++
and/or blood if haemorrhaging. Reverse coagulopathy. Identify source of fluid/blood loss and treat
(consider need or embolization, OR, etc.)
Approach to Chest pain on call
Ddx: Common- ACS, angina, PE, pneumonia, reflux, PUD. Rare in hospital but possible:
pericarditis. Rare but fatal: Aortic dissection, pneumothorax (esp. If tension)
Focused history: Onset, duration, activity when onset occurred, character (e.g. pleuritic
or not), dyspnea, associated symptoms, etc.
Focused physical: Vitals (inc. BP in both arms). If new discrepancy >10-20mmHg,
suspect dissection. If tachycardic or hypoxic, this is likely a very sick patient. Examine
for heart failure (lung fields, JVP, edema), check pulses bilaterally, do screening
precordial exam.
Investigations: ECG (STAT), ?consider 15 lead: Compare to previous.
o New ST elevation >1mm in 2 contiguous leads or new LBBB: If present and new
or unknown duration, stat cardiology consult for possible code STEMI
o New ST depression or T-inversion: Indicate ongoing ischemia.
o +/- CXR for pulm edema or wide mediastinum
o CBC (for precipitants)
o Troponin, CK q8h x 3- remember that this will not usually help you at the bedside
(initial usually not positive in MI)
o INR, PTT, lytes, Cr (to help guide treatment)
Treatment:
o If ST elevation or new LBBB with ongoing chest pain: code STEMI
o If not, treat as NSTACS (NSTEMI or unstable angina) consider cardiology consult,
CCRT/ICU as appropriate:
o ASA 160mg PO chewed
o B-blocker: not if HR already <60-70 or CHF. Careful with conduction
abnormalities on ECG. If on monitor, metoprolol 5mg IV. Otherwise, metoprolol
12.5-25mg PO.
o Heparin: if no contraindication and ongoing pain with ECG changes
unfractionated heparin or LMWH is indicated. UFH infusion if >75, obese,
consider about need to possibly rapidly reverse or significant renal failure- fill
nomogram. LMWH otherwise.
o Plavix load: is an option in NSTACS, but if considered would usually talk to
cardiology first.
o NTG 0.3mg SLq5 min x 3. May consider NTG patch, but if ongoing pain without
patch, will probably need more definitive treatment. If drops BP with NTG, give
fluid and think about RV infarct (do 15-lead). NB- NTG is symptomatic relief only.
o Morphine: Symptomatic relief; 1-2mg iv/sc x 1.
Ddx: Airway – asthma, COPD, mucous plug; Parenchymal – pneumonia, ILD; Mecahnical –
pleural effusion, pneumothorax, neuromuscular; Vascular – PE, pHTN
Cardiac, Metabolic, anxiety, other
o If saturation relatively normal but significant tachypnea consider the possibility of
compensation for a metabolic acidosis.
Focused history: Onset, duration, sudden, chest pain, aspiration, orthopnea, associated
symptoms, etc.
Focused physical: Vitals (inc. BP in both arms). If tachycardic or hypoxic, this is likely a
very sick patient. Examine for heart failure (lung fields, JVP, edema), cardiorespiratory
exam, signs of respiratory distress.
Investigations: CXR – portable (STAT): Compare to previous.
o CBC (for precipitants), lytes, Cr, INR, PTT, Troponin, CK q8h x 3- remember that
this will not usually help you at the bedside (initial usually not positive in MI).
ABG. ?CT to rule out PE
Treatment:
o Directed at the underlying cause
o Consider need for non-invasive or invasive ventilation
o If requiring >40% by face mask, signs of respiratory distress or fatigue, consider need for
closer monitoring
o If unsure what to do next, call senior, consider RT (generally very helpful), CCRT/ICU
involvement
-
SEIZURE
Most seizures last 1-2 minutes (i.e. they are over before you have returned your page). If patient still
seizing when you return the page, urgent intervention required, consider having the nurse call a code blue
as you go to manage patient.
Management
ABCs. Roll on side, apply oxygen. Apply monitors.
Consider accucheck or empiric administration of D50 IV. Can use glucagon if no IV.
Lorazepam 2-4 mg IV push over 1-2 min. May give up to 8-10 mg (beyond this need code blue/ICU
backup). If no IV consider Versed 5 mg IM.
1. If seizure persists/you want to try to prevent recurrent seizure, consider dilantin 20mg/kg IV (1-
1.5g over 20 minutes). Patient will need cardiac monitoring during load. Can load dilantin PO
with no cardiac monitoring, give 20 mg/kg total, but divide it into 3 doses spaced 4 hours apart.
Beyond this (or during dilantin infusion if ongoing seizure) need ICU, intubation, consideration of
propofol, phenobarb, etc.
Investigate cause
Examine patient, collateral history, review chart
CBC, lytes, renal, Ca profile, liver enzymes, +/-anticonvulsant levels, +/-tox screen, consider CT head
Causes:
Structural: trauma, mass, bleed, stroke
Metabolic: Hypoglycemia, hypoNA, other lytes/metabolic abnormailities
Drugs: Intoxication or withdraw
Infection: encephalitis, meningitis
Hypoglycemia, Hyperglycemia and Diabetes
Practical Tips
NEVER leave patients with Type 1 DM without insulin (can use low dose long acting with
IV glucose or insulin infusion if NPO)
If using sliding scale, reassess dose frequently so you have approximate daily insulin
requirements for discharge (plan ahead).
Goal is not perfect control for inpatients, it is to prevent acute complications (a sugar of 12
won’t kill anyone acutely, but a sugar of 1 can); usually aim for 7-11
Hypoglycemia is generally more of an oncall concern than hyperglycemia
HYPOGLYCEMIA:
If patient is awake, alert, able to eat can often deal with over the phone
Fix the sugar
o if awake, give sugar water or feed patient (e.g., PB and J sandwich, Orange Juice)
o if decreased LOC or BG <2.5 give IV sugar (D10W infusion, D50W push)
o if no IV, give Glucagon 1mg SC/IM
o octreotide can be used for treatment of sulfonylurea-induced hypoglycaemia
o consider need for further dextrose infusion
o Check glucose q15 mins until >5, then frequently to ensure it does not decrease again
(depends on etiology of hypoglycaemia)
o NEVER leave patients with Type 1 DM without insulin
HYPERGLYCEMIA:
Tight glycemic control is not necessary in medical inpatients, especially over a short
period. The major goal should be to prevent hypoglycaemia with a secondary goal of achieving
fasting sugars of 4-7 and post prandial of 5-10. I generally am not worried by sugars in the teens
(but would consider small doses of insulin)
o Find when the patient last ate/when they will eat next
o Find out when they last got insulin or other DM meds
o Ensure that the insulin on board has almost worn of, or sugar is still very high after
the last dose has peaked before adding more insulin
o If they are on standing insulin, determine how insulin sensitive they are (see below
for sensitivity factor) and prescribe insulin to bring the sugar closer to normal
o Inform the team of the high sugar, so they can take long term action to prevent it from
happening next time you are on call
I. Background and Review
Oral Agents
Biguanides (e.g., metformin), thiazolidinediones (e.g., rosiglitazone) are peripheral
insulin sensitizers (liver and muscle) and generally do not cause hypoglycemia
Sulfonylureas (e.g., glyburide), meglitinides (e.g., repaglinide) increase pancreatic insulin
secretion and can cause clinically significant hypoglycemia
Alpha-glucosidase inhibitors (e.g., acarbose) slow intestinal absorption of starch and
sucrose; not frequently used
Insulin Formulations:
Can be Novolin® or Humulin® brand (different types of injectors, different names)
Formulation Onset Peak Duration
Rapid (Lispro/Humalog,Aspart/Novorapid) 5-15 min 30-60 m 2-4 h
Regular (R, Toronto) ~30 min 2-4 h 5-8 h
Long-Acting (NPH, N, Lente) ~2 h 6-10 h ~24h
Very Long-Acting (glargine/Lantus, ~2 h None ~24h
detemir)
*note: times are approximate, depend on the patient and vary according to reference.
Basics
Reactive, not proactive
See MSH website for sample sliding scales
NEVER leave patients with Type 1 DM without insulin (need some standing insulin)
Useful during hospital admission because of flexibility (frequently NPO, variable diet and
insulin requirements due to illness)
Aim in Type 2 DM is not optimal control, but prevention of acute complications
Everyone has their own style based on experience (e.g., “tightness” of control)
Need to be reassessed frequently to optimize control, may need to add standing doses if
requirements high
Can be TID ac meals or QID (with hs dose)
o If QID, remember that patient is not eating with last dose as is the case during the
day, so will require less insulin or risk overnight hypoglycaemia (or consider evening
snack)
Can be tailored to each patient’s own requirements
o Can estimate “insulin sensitivity” based on total daily insulin requirements
o 100/(total daily insulin) = sensitivity factor (SF)
o 1 unit of insulin (rapid or regular) will cause decrease in BG of SF mmol/L
Patients have a hard time sleeping in the hospital for various reasons. Maybe they are anxious,
maybe they are in a loud room or uncomfortable. You will be called about patients who can’t
sleep all the time. Usually this is an easy, though perhaps annoying (as you may have been
asleep yourself) call to deal with. My approach is as follows:
Quickly think about why a patient can’t sleep and make sure that:
They aren’t getting stimulants like PREDNISONE or RITALIN late in the day, if
possible
They aren’t withdrawing from benzos or ETOH.
They aren’t urinating excessively because of poorly timed diuretics
They aren’t suffering with poorly controlled pain.
Then think quickly about whether or not there is a reason why that patient should not receive a
sleeping/sedative medication.
Are they at severe risk of falls?
Is their LOC already significantly impaired?
Do they have sleep apnea/other reasons for resp. depression? (avoid in these pts)
Are they delirious or prone to delerium? Will your medication make them worse?
PEARL: Benzodiazepines in the frail elderly are like giving them a pitcher of beer to
drink. Some people will be happy drunks, some people will go to sleep, and others will
turn into brawlers. You don’t know who is who until you give the drug, then you can’t
take it back
Do they need to be alert and awake in <6 hours?
Then prescribe a mild sedative for a short period (not to exceed 1-2 weeks). If on call and this is
not your patient, order the dose x 1, then sign over in the morning to see if the team wants to
continue
zopiclone 7.5 mg po QHS PRN (3.75 mg in smaller elderly)
lorazepam 1 mg po QHS PRN (0.5 mg in smaller elderly)
"Acute" Management of Constipation
Isaac Bogoch, 2008
Ensure that the patient is only constipated, not impacted, obstructed or perforated.
Not having 1BM per day is *not* constipation. Unfortunately many don't appreciate this.
Think about causes and fix those that you can:
Drugs: narcotics, antidepressants, calcium/iron supplements, calcium channel blockers,
others
Metabolic: hypercalcemia, hypothyroidism, hypoK/Mg
Structural: Recent abdominal surgery, abdominal masses
Other: Poor intake (nothing in = nothing out), diet, fluid intake, age, immobility,
neurogenic
Significant discomfort, bloating, nausea associated with constipation lasting several days
consider plain films of the abdomen to exclude ileus, obstruction and to "grade the
constipation"
If full of stool on the X-ray will probably need what I call the "two-pronged" or
"pincer" approach
Therapies:
o Start from above if not impacted or no suspicion of obstruction
o Start at initiation of narcotics to avoid this side effect
Stimulants: Senna 2 tabs po QHS or po BID PRN. Expect effect in AM.
Avoid long term use. Helpful with narcotic induced constipation. Alternative:
Bisacodyl (Dulcolax) 15mg PO OD PRN.
Osmotic: lactulose 15-30cc po QHS or PO BID PRN. If on narcotics may
need daily dose
Is this an emergency?
Is the patient arresting ACT NOW, Call Code Blue
Is the patient unstable ACT NOW
Is the potassium >=7 ACT NOW, confirm it is real
Are there ECG changes (see page 2) ACT NOW
If you are ACTING you must remember to THINK later
ACT 1: Stop the exogenous potassium and hold potassium increasing medications
(such as NSAIDs, TMP/SMX, ACEi/ARB, K+ sparing diuretics)
ACT 2: Stabilize the myocardium
If arresting Calcium Chloride 1 AMP IV push
If ECG changes, unstable, and/or K~>=6.5** you should give Calcium
Gluconate 1 AMP IV slow push over 5 minutes. Repeat in ~10-15 minutes
if ECG changes persist.
NB: Caution in patient on DIGOXIN (can precipitate arrhythmia)
ACT 3: Shift the potassium into cells (if K+>=5.8 or ECG changes)
IV Humulin R 15-20 units IV PUSH after 1-2AMPS of D50 IV push.
Accucheck Q20mins x 3 to watch for hypoglycemia
Ventolin 4-8 puffs STAT. NB: Caution for tachycardia
Sodium Bicarbonate 1 AMP IV slow push over 5 minutes.
May need to repeat shifting in 2-4 hours. Recheck the potassium and re-
shift as necessary.
ACT 4: Eliminate Potassium from the Body.
URINE (if the patient makes urine):
If volume overloaded FUROSEMIDE 40mg IV for normal kidneys,
may need more for abnormal kidneys
If euvolemic or mildly hypovolemic then you should give ~500cc-
1L NS over 1-2h with FUROSEMIDE as above
If hypovolemic then give normal saline alone.
STOOL (if patient can swallow)
Calcium Resonium 15-30g in 60cc PO SORBITOL. Caution in
patients post-op from bowel surgery, if ileus is present or if on
opiods as cases of gut necrosis with sorbitol are reported
DIALYSIS
Always an option. Especially in patients already dialysis dependent.
Usually shifting will get you enough time to get dialysis ready.
THINK
Why was the patient hyperkalemic?
Was it a problem with too much exogenous potassium?
i.e. on IV NS with 40K+ for days and days.
Dietary -- Does this patient need a low-potassium diet
Prepare yourself:
Ask the RN to provide you with a brief history:
Was the death expected? Was the patient “DNR”?
Is the family at the bedside? Have they been informed?
You may wish to ask the RN to accompany you to the patient’s room to introduce you to
family members present and to provide additional support
Quickly look at the chart/signout:
Timing and reason for admission
Discussions pertaining to philosophy of care
Events immediately preceding the death
Likely cause of death, when staff should be notified, organ donation etc.
Clinical Examination:
1. Check ID band
2. Check response to tactile stimuli
3. Check for heart sounds and pulse
4. Check for spontaneous respiration
5. Check pupil position and response to light
6. Record the time of death
Follow-Up:
Approach the family to answer any questions that they may have
Families are often uncertain of what to do next
Ask if they have made funeral arrangements and let them know that they should
contact the funeral home who will then make all subsequent arrangements with
respect to their loved one
Ask if the would like an autopsy to be performed and if yes, then complete an
autopsy consent form, contact the pathology department and ensure that security
is aware
Ask if they would be interested in organ donation (Contacting Trillium Gift of
Life for every death is now a mandatory step in death pronouncement, even if
family members decline).
Ask if they would like you to call a chaplain (many hospitals have a chaplain on
call 24 hours/day) or whether there are special rites or practices which should be
observed
Expressing condolences is appropriate
Inform the attending physician of the patient death. If the death was expected this can
happen in the morning. If it was unexpected, ensure they know before they arrive in the
morning.
Ideally call the family physician (and referring institution if applicable) during business
hours to inform them of the death
Documentation:
In the chart:
1. Record the date and time
2. Brief statement of the cause of death
3. Note absence of pulse, spontaneous respirations, pupil response
4. Note whether family present or informed
5. Note discussion pertaining to autopsy and organ donation
6. Note whether attending and/or family physicians were informed
7. Note whether chaplaincy, SW or other services were involved
8. Note any involvement of the coroner
Fill out hospital specific form if required (necessary at UHN, not MSH)
Indicates:
Whether autopsy requested by family or required by coroner
Documentation of contact with Trillium Gift of Life Network
Second page of this document is a useful resource which outline indications for
mandatory notification of the coroner
If you are uncertain as to whether a death meets criteria to become a “coroners case”, you
can page the coroner on call through locating and discuss
Phone numbers:
Trillium Gift of Life: 416-363-4438
Coroner’s Office: 416-314-4100
Blood culture results on call
When called about positive blood culture results, this often needs to be acted on immediately because
unless a contaminant, means that the patient is bacteremic, and therefore if not yet very sick, they will be
without appropriate treatment.
Your jobs:
1) Decide whether the patient requires treatment
2) Look at current therapy and decide whether needs changing
3) See the patient and see whether they need to be in a higher intensity area (i.e. are they septic?)
Is it a contaminant?
This is hard to decide based on gram stain, since S. aureus (which needs treatment) and S.
epidermidis (which is usually a contaminant) look the same (gram +ve cocci in clusters)
CNST (coagulase negative Staph sp.), Gram positive bacilli (corynebacterium and bacillus sp.) are
frequent contaminants.
For Gram positive infections – Vancomycin 1-1.5g IV q12h is a good empiric choice
For Gram positive infections in a very sick patient (ICU bound) – consider adding Ancef 1g IV q8h
SPICE are part of the group of bacteria termed “ESBL (extended-spectrum beta lactamase). There are
also other types of ESBL. SPICE organisms have inducible beta lactamases. The induction of the beta
lactamase is caused by "inducing agent" antibiotics. This means that initial c+s may show sensitivity, but
exposure to these antibiotics will lead to the development of resistance.
If you see these bugs, do not use beta lactam (e.g. ceftriaxone, amp, pip-tazo). Need quinolone or
carbapenem. Empiric treatment for a bacteremia caused by these organism should be a carbepenem. For
any bacteremia caused by a SPICE organism or another ESBL, an ID consult is a very good idea. Also
consider calling the microbiology lab to discuss the isolate/resistance pattern.
Some tips/pearls:
1) When in doubt, start antibiotics
2) Start with IV antibiotics
3) Re-culture liberally (prior to Abx if possible)
4) Be very careful with S. aureus, enterococcus. Other “bad actors”: S. anginosus / milleri, Staph.
Lugdunesis (behaves like Staph Aureus), gram negatives like enterobacter, citrobacter
5) If you ever see S. aureus in the urine, it likely came from the blood.
6) If you see a SPICE organism, don’t start a beta lactam.
7) Look for and remove the source- e.g. line, I+D, OR etc.
8) Consider calling for an Infectious disease consult/phone advice