CCS WorkshopCCS Workshop

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Webinar – Muting/ UnmutingWebinar – Muting/ UnmutingWELCOME! We will begin as soon as all the attendees WELCOME! We will begin as soon as all the attendees

arrive! Thank you!arrive! Thank you!

Some times there is an echo/ noise that gets transmitted in Some times there is an echo/ noise that gets transmitted in to webinar from the attendee’s surroundings. If you are to webinar from the attendee’s surroundings. If you are using a computer microphone, there should be a mute using a computer microphone, there should be a mute option for you. If there is an echo from your side, you can option for you. If there is an echo from your side, you can mute yourself and un-mute when you wish to talk.mute yourself and un-mute when you wish to talk.

If there still is a noise, we will keep you muted. In that If there still is a noise, we will keep you muted. In that case, if you have Questions, please raise your hand so case, if you have Questions, please raise your hand so that you will be un-muted as soon as possible and your that you will be un-muted as soon as possible and your questions will be answeredquestions will be answered

CCS TipsCCS TipsNote the setting (location) of the patient encounter. The setting Note the setting (location) of the patient encounter. The setting helps you decide on the aggressiveness of your treatment orders helps you decide on the aggressiveness of your treatment orders and whether to send the patient home. It also gives a clue to the and whether to send the patient home. It also gives a clue to the medical diagnosis. medical diagnosis.

In the setting of ER, do not waste time if vitals are unstable. If you In the setting of ER, do not waste time if vitals are unstable. If you are not sure of the medical diagnosis, admit the patient and work are not sure of the medical diagnosis, admit the patient and work him up. You can always discharge him from the hospital, the next him up. You can always discharge him from the hospital, the next day. day.

Write down the age, sex, chief complaint, and allergies of the patient Write down the age, sex, chief complaint, and allergies of the patient on the writing sheet provided at the exam. This will help you save on the writing sheet provided at the exam. This will help you save time when considering medical differential diagnosis. time when considering medical differential diagnosis.

If you did not write it down the important points in History, do not If you did not write it down the important points in History, do not panic. You can always access it from the Order sheet button. Click panic. You can always access it from the Order sheet button. Click on “Write order” button and then select “Progress notes”. Your on “Write order” button and then select “Progress notes”. Your patient’s initial H & P as well as updates are stored under this patient’s initial H & P as well as updates are stored under this section. section.

CCS TipsCCS Tips

Two “Times” on the softwareTwo “Times” on the software““Real” time – the time on the bottom of the screen Real” time – the time on the bottom of the screen on the right side.on the right side.

““Simulated” time – the time on the bottom of the Simulated” time – the time on the bottom of the screen on the left side screen on the left side

““Real” TimeReal” Time““Real” time – the time on the bottom of the screen on the right side. Real” time – the time on the bottom of the screen on the right side.

You have “25” minutes to complete the case. “20” minutes for active case You have “25” minutes to complete the case. “20” minutes for active case management + “5” minute screen. management + “5” minute screen. Real time is not scored. However, if you run out of the real time of “20” Real time is not scored. However, if you run out of the real time of “20” minutes - your “5” minute screen will pop up. Since you cannot do certain minutes - your “5” minute screen will pop up. Since you cannot do certain important steps on 5-minute screen, make sure you set your goals on your important steps on 5-minute screen, make sure you set your goals on your case and reach them before the 20 minutes are complete. Eg: Think about case and reach them before the 20 minutes are complete. Eg: Think about some long cases like DKA or Hypokalemia/ adrenal mass. Your goal in DKA some long cases like DKA or Hypokalemia/ adrenal mass. Your goal in DKA is to close the “anion gap” and to monitor if your treatment is working, you is to close the “anion gap” and to monitor if your treatment is working, you need to advance the clock quickly to receive the follow up BMP results. need to advance the clock quickly to receive the follow up BMP results. Otherwise, you will run out of your “20” minutes active time. Otherwise, you will run out of your “20” minutes active time. You cannot do certain steps on 5-Minute screen You cannot do certain steps on 5-Minute screen

you cannot change patient locationyou cannot change patient locationyou cannot advance the clockyou cannot advance the clockyou cannot discharge the patientyou cannot discharge the patientyou cannot obtain results you cannot obtain results you cannot assess the patient lateryou cannot assess the patient later

You can do certain important steps on 5 Minute screenYou can do certain important steps on 5 Minute screenAdd any needed ordersAdd any needed ordersDiscontinue any unnecessary orders ( Please check the “simulated” time Discontinue any unnecessary orders ( Please check the “simulated” time before you discontinue any crucial orders. You do not want to discontinue before you discontinue any crucial orders. You do not want to discontinue any stabilizing orders on day 1 or if your patient has just arrived)any stabilizing orders on day 1 or if your patient has just arrived)You can order all “Counseling” orders “at once”. Choose the timing as You can order all “Counseling” orders “at once”. Choose the timing as “Now” – “non invasive” steps like “counseling” do not bring your score “Now” – “non invasive” steps like “counseling” do not bring your score down. If anything, you might get credited for some counseling orders. down. If anything, you might get credited for some counseling orders. Use the “Later” option to your maximum advantageUse the “Later” option to your maximum advantageSchedule “Screening” tests for a “Later” date Schedule “Screening” tests for a “Later” date

““Simulated” TimeSimulated” TimeThe time that is scoredThe time that is scoredIt is the time since the patient arrived in the “ER” or the time since It is the time since the patient arrived in the “ER” or the time since you first saw your patient in the “office” on a CCS caseyou first saw your patient in the “office” on a CCS caseIn the ER cases, keep the simulated time low i.e; try to complete the In the ER cases, keep the simulated time low i.e; try to complete the “Life saving” steps or important diagnostic tests in the least “Life saving” steps or important diagnostic tests in the least simulated time possible. This is highly scored. simulated time possible. This is highly scored. Simulated time will change only when :Simulated time will change only when :

You advance the clockYou advance the clockDo a physicalDo a physicalDo a “Interval” historyDo a “Interval” history

If you order the tests and wait, nothing will show up. Simulated time If you order the tests and wait, nothing will show up. Simulated time will not change but your real time will run.will not change but your real time will run.Advance the clock to make things happen. However, check the Advance the clock to make things happen. However, check the “report” time of your orders on the order sheet, know what you are “report” time of your orders on the order sheet, know what you are waiting for and then advance the clock to that “particular” report waiting for and then advance the clock to that “particular” report time.time.

Sometimes, you can advance the clock in a way that can make you look Sometimes, you can advance the clock in a way that can make you look very efficient. Move the “Simulated time” to the “Report” time that you are very efficient. Move the “Simulated time” to the “Report” time that you are waiting for by “completing a previously unfinished physical” or by “Interval/ waiting for by “completing a previously unfinished physical” or by “Interval/ follow up” history. Interval history will advance the clock by 2 minutes. follow up” history. Interval history will advance the clock by 2 minutes.

ER SettingER SettingVitals first Vitals first

This is the screen where you make up your mind regarding the This is the screen where you make up your mind regarding the “UNSTABLE” scenario. Define Shock or Respiratory failure. “UNSTABLE” scenario. Define Shock or Respiratory failure. Tachycardia per se, is not usually an unstable vital unless it is Tachycardia per se, is not usually an unstable vital unless it is associated with irregular rhythm ( you will know on physical) or associated with irregular rhythm ( you will know on physical) or Shock.Shock.A high temperature should remind you of the possibility of “Sepsis”, A high temperature should remind you of the possibility of “Sepsis”, “Infection” or “Heat Stroke”. Remember that some non-infectious “Infection” or “Heat Stroke”. Remember that some non-infectious conditions like “Drug fever”, “Malignancy” or “Pulmonary embolism” conditions like “Drug fever”, “Malignancy” or “Pulmonary embolism” can also have fever. A high temperature may not always be can also have fever. A high temperature may not always be “INFECTION” ( know the definition of “SIRS” and “Sepsis”). A high “INFECTION” ( know the definition of “SIRS” and “Sepsis”). A high temperature is not usually an “UNSTABLE” vital unless there is a temperature is not usually an “UNSTABLE” vital unless there is a suspicion of “Heat stroke”suspicion of “Heat stroke”

PertinentPertinent physical exam physical examDo not waste time doing complete physicalDo not waste time doing complete physicalFast treatment – first stabilize. After stabilizing, you can Fast treatment – first stabilize. After stabilizing, you can proceed with proceed with complete complete physical ( do not forget it!)physical ( do not forget it!)

ShockShockShock – defined as SBP < 90 or MAP < 65Shock – defined as SBP < 90 or MAP < 65Different types of Shock Different types of Shock

Hypovolemic shockHypovolemic shockDistributive shockDistributive shock

Septic ShockSeptic ShockAnaphylactic ShockAnaphylactic ShockOpiod OverdoseOpiod Overdose

Cardiogenic ShockCardiogenic ShockRight Ventricular MIRight Ventricular MILeft Ventricular MILeft Ventricular MICardiac tamponadeCardiac tamponadeVSD/ Papilalry muscle rupture – post MIVSD/ Papilalry muscle rupture – post MI

Obstructive ShockObstructive ShockTension PneumothoraxTension PneumothoraxPulmonary EmbolismPulmonary EmbolismAir EmbolismAir EmbolismCardiac TamponadeCardiac Tamponade

Initial Step in ShockInitial Step in ShockSuspected cause Suspected cause of Shockof Shock

History cluesHistory clues Physical cluesPhysical clues Initial therapyInitial therapy

HypovolemiaHypovolemia -MVA with bleedingMVA with bleeding-DehydrationDehydration-DiarrheaDiarrhea-VomitingVomiting-Vaginal bleedingVaginal bleeding

Remember, Strong clues from history & vitals reveal “Shock” Remember, Strong clues from history & vitals reveal “Shock” Proceed to order sheetProceed to order sheet

No clues from history No clues from history do 2 minute physical, to evaluate the do 2 minute physical, to evaluate the cause of shock ( add abdomen to focused physical if history cause of shock ( add abdomen to focused physical if history suggestive) – doing 2 minute physical will determine your next suggestive) – doing 2 minute physical will determine your next life saving step herelife saving step here

-Orthostatic hypotension Orthostatic hypotension -( you have to order this ( you have to order this

on the screen)on the screen)-Dry oral mucosaDry oral mucosa-TachycardiaTachycardia-Stool guaic positiveStool guaic positive-Gross bleedingGross bleeding-Abdominal signs suggestingAbdominal signs suggesting

bleeding or perforation or bleeding or perforation or peritonitisperitonitis-Heavy Vaginal bleedingHeavy Vaginal bleeding

IV Fluid – NS bolusesIV Fluid – NS boluses

If suspecting hemorrhagic If suspecting hemorrhagic shock – order Type and cross shock – order Type and cross match and blood transfusion match and blood transfusion right away ( Don’t wait for CBC)right away ( Don’t wait for CBC)

Distributive Distributive

shockshock

- Clues to anaphylaxis- Clues to anaphylaxis-Clues to infection ( fever on “vitals” screen)Clues to infection ( fever on “vitals” screen)-Clues to drug useClues to drug use

-Fever may point to septic shockFever may point to septic shock-Wheals - anaphylaxisWheals - anaphylaxis

-Always, IV Normal saline Stat ( Always, IV Normal saline Stat ( fill up the SVR)fill up the SVR)- Epinephrine if anaphylaxisEpinephrine if anaphylaxis-Antibiotics if SespsisAntibiotics if Sespsis

Obstructive Obstructive

ShockShock

- Chest pain/ sob – can indicate tension pneumothorax, cardiac - Chest pain/ sob – can indicate tension pneumothorax, cardiac tamponade or PE – history clues are not very suggestive tamponade or PE – history clues are not very suggestive proceed to 2 minute physicalproceed to 2 minute physical

2 minute physical ( RS, CVS)2 minute physical ( RS, CVS)-Reveals absent breath sounds Reveals absent breath sounds

Tension pneumothoraxTension pneumothorax-Reveals pulsus paradoxus, JVDReveals pulsus paradoxus, JVD

– – Cardiac tamponadeCardiac tamponade-Reveals normal physical + Reveals normal physical + -historical clues historical clues suspect PE suspect PE

After 2 minute After 2 minute

Physical, order life saving stepPhysical, order life saving step

Pneumo – chest tubePneumo – chest tube

Tamponade pericardiocentesis Tamponade pericardiocentesis & then window& then window

PE – Spiral ct and then tpa, PE – Spiral ct and then tpa, hold heparinhold heparin

Air – trendelenberg positionAir – trendelenberg position

Cardiogenic Cardiogenic shockshock

Chestpain, sobChestpain, sob 2 minute physical – make sure 2 minute physical – make sure chest is clear. If rales chest is clear. If rales Left Left ventricular MI. Then get EKGventricular MI. Then get EKG

If chest clear If chest clear IV Fluids. If IV Fluids. If rales rales hold IV fluids, GET hold IV fluids, GET EKG, then IABC and cardiac EKG, then IABC and cardiac cath. Order other MI cath. Order other MI managementmanagement

Respiratory FailureRespiratory FailureRespiratory Rate > 30 – unstable, tachypneaRespiratory Rate > 30 – unstable, tachypneaAddress it STATAddress it STATIf you have a clue, go straight to order sheet ( hx of Asthma, COPD, If you have a clue, go straight to order sheet ( hx of Asthma, COPD, PE clues)PE clues)If no clues from history or associated with chest pain If no clues from history or associated with chest pain do 2 minute do 2 minute physical ( R.S, CVS) eg : D/D includes Tension pneumothorax, physical ( R.S, CVS) eg : D/D includes Tension pneumothorax, pulmonary edema, MI with pulmonary edema, PE. By doing a 2 pulmonary edema, MI with pulmonary edema, PE. By doing a 2 minute exam, you can order the “stabilizing and life saving step” minute exam, you can order the “stabilizing and life saving step” within 2 minutes of “Simulated” time . At 2 minutes of simulated within 2 minutes of “Simulated” time . At 2 minutes of simulated time:time:

Chest tube if pneumothorax ( don not wait for CXR)Chest tube if pneumothorax ( don not wait for CXR)Pericardiocentesis if cardiac tamponadePericardiocentesis if cardiac tamponadeCT chest and tpA if highly suspected PECT chest and tpA if highly suspected PEMorphine and furosemide if Acute Pulmonary EdemaMorphine and furosemide if Acute Pulmonary EdemaNebulizations ( Albuterol + Ipratropium) and corticosteroids if Nebulizations ( Albuterol + Ipratropium) and corticosteroids if asthma/ COPD exacerbation ( wide spread wheezes, accessory asthma/ COPD exacerbation ( wide spread wheezes, accessory muscle use)muscle use)

Get ABGs in all cases of respiratory failure ( other place Get ABGs in all cases of respiratory failure ( other place where ABGs are needed is when you see low metabolic where ABGs are needed is when you see low metabolic abnormalities on BMP – you need to know Ph here)abnormalities on BMP – you need to know Ph here)

SepsisSepsisKnow the definition of “SIRS” – “Systemic Inflammatory Response Know the definition of “SIRS” – “Systemic Inflammatory Response Syndrome”. “SIRS” is indicated by at least two of the following: Syndrome”. “SIRS” is indicated by at least two of the following:

Fever or hypothermia—temperature 38°C or higher or 36°C or lower Fever or hypothermia—temperature 38°C or higher or 36°C or lower Tachypnea > 20 breaths/min or more ( > 30 is “Unstable”)Tachypnea > 20 breaths/min or more ( > 30 is “Unstable”)Tachycardia > 100 beats/ minTachycardia > 100 beats/ minWhite blood cell count – leucocytosis (12,000 cells/mm3 or more) or White blood cell count – leucocytosis (12,000 cells/mm3 or more) or leucopenia ( 4,000 cells/mm3 or less, or greater than 10% bands on leucopenia ( 4,000 cells/mm3 or less, or greater than 10% bands on differential count)differential count)

““SIRS” is not always due to infection. “SIRS” can be due to :SIRS” is not always due to infection. “SIRS” can be due to :InfectionInfectionBurnsBurnsPancreatitisPancreatitisTraumaTraumaPulmonary embolismPulmonary embolismVasculitisVasculitis

Sepsis : To diagnose “Sepsis”, there should be a “presumed” or Sepsis : To diagnose “Sepsis”, there should be a “presumed” or “known” “known” site of infectionsite of infection + evidence of a systemic inflammatory + evidence of a systemic inflammatory response ( SIRS)response ( SIRS)

SepsisSepsisSepsisSepsis : To diagnose “Sepsis”, there should be a “presumed” or “known” : To diagnose “Sepsis”, there should be a “presumed” or “known” site of infectionsite of infection + evidence + evidence of a systemic inflammatory response ( SIRS)of a systemic inflammatory response ( SIRS)

A presumed or known site of infection is indicated by one of the following: A presumed or known site of infection is indicated by one of the following: Purulent sputum or endotracheal secretions ( finding from history)Purulent sputum or endotracheal secretions ( finding from history)Physical exam with neck stiffness, altered mental status or no other source of sepsis Physical exam with neck stiffness, altered mental status or no other source of sepsis – suspect “meningitis”– suspect “meningitis”chest x-ray with new infiltrates that can not be explained by a noninfectious process chest x-ray with new infiltrates that can not be explained by a noninfectious process Radiographic or physical examination evidence of an infected collection ( CT showing Radiographic or physical examination evidence of an infected collection ( CT showing “abscess” or “physical” revealing reduced breath sounds or an “abdominal” mass or “abscess” or “physical” revealing reduced breath sounds or an “abdominal” mass or “abscess” or “joint” swelling)“abscess” or “joint” swelling)Presence of leucocytes in a normally sterile body fluid ( Ascites with > 250 Presence of leucocytes in a normally sterile body fluid ( Ascites with > 250 neutrophils is SBP)neutrophils is SBP)Positive blood culturesPositive blood culturesSuspicion of Clostridium difficle from previous use of antibiotics in the past 3 months Suspicion of Clostridium difficle from previous use of antibiotics in the past 3 months pr recent hospitalization or previous history of C.difficlepr recent hospitalization or previous history of C.difficleUrinalysis showing positive leuco-esterase or nitrite and WBCs especially, when Urinalysis showing positive leuco-esterase or nitrite and WBCs especially, when associated with urinary symptomsassociated with urinary symptoms

When you have “SIRS” and you “Presume” that there might be infection When you have “SIRS” and you “Presume” that there might be infection please DO NOT WAIT! please DO NOT WAIT! Start presumptive therapy with antibiotics ( but you should have a rationale regarding the “presumed” Start presumptive therapy with antibiotics ( but you should have a rationale regarding the “presumed” source. Example: Patient has “SIRS” and urine leucoesterase is positive, no other source identified source. Example: Patient has “SIRS” and urine leucoesterase is positive, no other source identified immediately immediately it is absolutely fine to presume that Sepsis is possible and the “presumed” source is it is absolutely fine to presume that Sepsis is possible and the “presumed” source is “UTI” – so, please get cultures ( blood and urine) and start antibiotics right away pending cultures. ( do “UTI” – so, please get cultures ( blood and urine) and start antibiotics right away pending cultures. ( do not wait for cultures to come back to start antibiotics)not wait for cultures to come back to start antibiotics)

Septic ShockSeptic Shock

Suspicion or evidence of sepsis + ShockSuspicion or evidence of sepsis + Shock

Follow quick sepsis guidelinesFollow quick sepsis guidelinesABCABC

OxygenOxygen

Continuos B.P monitoringContinuos B.P monitoring

Pan culturesPan cultures

IV FLUIDS – NS – MOST IMPORTANT IV FLUIDS – NS – MOST IMPORTANT

If BP does not improve, add a pressor. If your patient is If BP does not improve, add a pressor. If your patient is tachycardic, choose Nor-epinephrine. If your patient has a tachycardic, choose Nor-epinephrine. If your patient has a low output state, use Dopamine. low output state, use Dopamine.

Early antibiotics to address the “presumed” sourceEarly antibiotics to address the “presumed” source

““Presumed” or “Known” site of Presumed” or “Known” site of infectioninfection

Possible “Bugs”Possible “Bugs” Emperical therapyEmperical therapy

Community acquired pneumoniaCommunity acquired pneumonia S.pneumoniae, Legionella, mycoplasma, S.pneumoniae, Legionella, mycoplasma, H.influenzaeH.influenzae

Third generation cephalosporin + Third generation cephalosporin + macrolide or Newer Quinolonemacrolide or Newer Quinolone

Early Hospital Acquired Pneumonia ( < 5 Early Hospital Acquired Pneumonia ( < 5 days)days)

Gram negative rods – non resistant Gram negative rods – non resistant ( e.coli, proteus, klebsiella), ( e.coli, proteus, klebsiella), S.pneumonia, H.influenzae, legionella S.pneumonia, H.influenzae, legionella

PIP/TAZO, Unasyn, Cefepime or newer PIP/TAZO, Unasyn, Cefepime or newer quinolone quinolone

Late Hospital Acquired Pneumonia ( > Late Hospital Acquired Pneumonia ( > 5days)5days)

Resistant gram –ves (ESBL), Resistant gram –ves (ESBL), Pseudomonas, MRSAPseudomonas, MRSA

Use anti-pseudomonal drugs – Use anti-pseudomonal drugs – PIP/TAZO + quinolone, Cefepime, PIP/TAZO + quinolone, Cefepime, Imipenem, Vancomycin (if MRSA Imipenem, Vancomycin (if MRSA suspected)suspected)

Intra abdominal infections ( diverticulitis)Intra abdominal infections ( diverticulitis) Enteric gram –ve rods ( E.coli), Enteric gram –ve rods ( E.coli), Anerobes (B.fragilis)Anerobes (B.fragilis)

Use good anerobic coverage : Use good anerobic coverage : Cipro+flagyl, Pip/tazo, Ertapenem, Cipro+flagyl, Pip/tazo, Ertapenem, Imipenem. Do not use cephalosporin Imipenem. Do not use cephalosporin alone ( add metronidazole if using it)alone ( add metronidazole if using it)

Urinary tract infectionsUrinary tract infections E.coli, proteusE.coli, proteus

EnterococciEnterococci

Quinolone, ceftriaxone, extended Quinolone, ceftriaxone, extended

spectrum beta lactums,spectrum beta lactums, if enterococci is if enterococci is

present present use ampicillin or vancomycin use ampicillin or vancomycin

MeningitisMeningitis S.pneumonia, H.influenzae, S.pneumonia, H.influenzae, N.meningitidis, E.coli. In ages < 1month N.meningitidis, E.coli. In ages < 1month or > 50 years -Listeriaor > 50 years -Listeria

Vanco+Ceftriaxone. If listeria suspected, Vanco+Ceftriaxone. If listeria suspected, add Ampicillin. Give Dexametasone prior add Ampicillin. Give Dexametasone prior to antibioticsto antibiotics

Pseudomembranous colitis/ C.Difficle Pseudomembranous colitis/ C.Difficle DiarrheaDiarrhea

c.difficlec.difficle Metronidazole p.o. If resistant, use vanco Metronidazole p.o. If resistant, use vanco p.o ( do not use I.V vanco – not p.o ( do not use I.V vanco – not effective)effective)

Simple Guidelines for antibiotic management of Sepsis/ Infections on a CCS caseSimple Guidelines for antibiotic management of Sepsis/ Infections on a CCS case

ER Setting – A simple approachER Setting – A simple approachPresenting IssuePresenting Issue Next Step on CCSNext Step on CCS

Vitals” are very unstable + you, absolutely, have no clue Vitals” are very unstable + you, absolutely, have no clue about the diagnosis from the historyabout the diagnosis from the history

Go to “physical screen “ – do a very focused physical ( 2 Go to “physical screen “ – do a very focused physical ( 2 minutes – Chest and Cardiovascular. Consider minutes – Chest and Cardiovascular. Consider “abdomen” only if history revealed abdominal pain or “abdomen” only if history revealed abdominal pain or trauma) trauma) Proceed to order sheet (Remember that when Proceed to order sheet (Remember that when you have no clue from the history, a “Life” saving step for you have no clue from the history, a “Life” saving step for a severely unstable vital may not be identified until you a severely unstable vital may not be identified until you do the “2-Minute” ( Chest, Cardiovascular) physical). do the “2-Minute” ( Chest, Cardiovascular) physical). Remember that if this step is done early ( less “Simulated” Remember that if this step is done early ( less “Simulated” time), you will get maximum score time), you will get maximum score

““Vitals” are “UNSTABLE” ( Shock or respiratory failure) + Vitals” are “UNSTABLE” ( Shock or respiratory failure) + you have a clue about the diagnosis from the historyyou have a clue about the diagnosis from the history

Proceed to “Order sheet” and try to stabilize. Write Proceed to “Order sheet” and try to stabilize. Write “Stabilizing” orders, “Basic” orders, “Symptom” relieving “Stabilizing” orders, “Basic” orders, “Symptom” relieving orders. Write “Specific” diagnostic tests and “Specific” orders. Write “Specific” diagnostic tests and “Specific” treatment since you already have a clue about the treatment since you already have a clue about the diagnosis from the history ( Some examples: Anaphylactic diagnosis from the history ( Some examples: Anaphylactic shock, Hypovolemic shock from MVA , strong clues of shock, Hypovolemic shock from MVA , strong clues of “PE” in the history )“PE” in the history )

““Vitals” are “Stable” no “ Pain”Vitals” are “Stable” no “ Pain” Full physical and then go to “order” sheetFull physical and then go to “order” sheet

“ ““ “Vitals” stable but History reveals severe “pain” Vitals” stable but History reveals severe “pain” Address pain first and then come back to physical screen Address pain first and then come back to physical screen ( except in abdominal pain – do abdomen exam first and ( except in abdominal pain – do abdomen exam first and then address pain)then address pain)

ER settingER setting

In most ER cases, you can proceed to the order In most ER cases, you can proceed to the order sheet to stabilize your patient or to treat the sheet to stabilize your patient or to treat the severe symptoms. But sometimes you do not severe symptoms. But sometimes you do not have a clue about the diagnosis and your patient have a clue about the diagnosis and your patient may be crashing may be crashing in such cases, do a 2 minute in such cases, do a 2 minute physical exam to formulate your differential physical exam to formulate your differential diagnosis for shock or respiratory failure ( A diagnosis for shock or respiratory failure ( A focused exam of CVS and RS may give you a focused exam of CVS and RS may give you a great clue regarding the diagnosis and at 2 great clue regarding the diagnosis and at 2 minutes, you will be able to offere a definitive minutes, you will be able to offere a definitive treatment for your patient!)treatment for your patient!)

PainPain

Addressing severe pain is extremely important. Addressing severe pain is extremely important.

If your patient is in severe pain and vitals are If your patient is in severe pain and vitals are stable, go to order sheet, give a pain medication stable, go to order sheet, give a pain medication first and then come back to physical ( except in first and then come back to physical ( except in abdominal pain where pain medication may abdominal pain where pain medication may mask abdominal exam signs). mask abdominal exam signs).

Most ER pains, can use Morphine if severeMost ER pains, can use Morphine if severe

Pain in office Pain in office follow “analgesic ladder” follow “analgesic ladder”

ER SettingER Setting

Admission if required – move patient to Admission if required – move patient to ward or ICUward or ICU

Criteria for admission to the ICU – shock, Criteria for admission to the ICU – shock, resp failure, DKA, Acute MI, Refractory resp failure, DKA, Acute MI, Refractory electrolyte issues, Acute deliriumelectrolyte issues, Acute delirium

General ApproachGeneral Approach

Stabilization ordersStabilization ordersBasic TestsBasic TestsSymptomatic treatment ( address signs Symptomatic treatment ( address signs also)also)Specific diagnostic tests ( if you have a Specific diagnostic tests ( if you have a clue from the history. If not please do clue from the history. If not please do focused physical before ordering disease-focused physical before ordering disease-specific tests)specific tests)Specific Treatment ( if you are pretty sure)Specific Treatment ( if you are pretty sure)

Basic set of ER ordersBasic set of ER orders

VitalsVitalsOxy ( pulse ox, oxygen)Oxy ( pulse ox, oxygen)IVA ( IV Access)IVA ( IV Access)EKGEKGCardiac monitorCardiac monitorUrinalysisUrinalysisBMP ( CMP takes 2 hours, BMP 30 mins. If you need BMP ( CMP takes 2 hours, BMP 30 mins. If you need LFTs order them seperately)LFTs order them seperately)CBCCBCChecking interval hx oftenChecking interval hx oftenDon’t enter blood cx and antibiotics together. Blood cx Don’t enter blood cx and antibiotics together. Blood cx first, advance clock by 1 min and then antibioticsfirst, advance clock by 1 min and then antibiotics

Indications for ICU admissionIndications for ICU admission

ShockShock

Respiratory failureRespiratory failure

Post –op 24 hoursPost –op 24 hours

Post MIPost MI

DKA/ Refractory electrolyte abnormalitiesDKA/ Refractory electrolyte abnormalities

Acute delirium/ altered mental statusAcute delirium/ altered mental status

General ICU OrdersGeneral ICU Orders

Elevate head end of the bed ( to prevent Elevate head end of the bed ( to prevent aspiration pneumonia in ICU setting)aspiration pneumonia in ICU setting)DVT Prophylaxis ( order compression stockings DVT Prophylaxis ( order compression stockings or TED stockings)or TED stockings)Stress ulcer prophylaxis ( orders PPI such as Stress ulcer prophylaxis ( orders PPI such as pantoprazole)pantoprazole)Activity ( Bed rest, ambulate in room)Activity ( Bed rest, ambulate in room)Output monitoring ( Foley if obstruction or if Output monitoring ( Foley if obstruction or if unresponsive/ delirium)unresponsive/ delirium)Diet ( NPO, Diet or NG Tube if disoriented)Diet ( NPO, Diet or NG Tube if disoriented)

Time required and Invasiveness – Time required and Invasiveness – tests in ERtests in ER

You need have an idea about how long it takes for You need have an idea about how long it takes for certain tests and invasiveness of certain diagnostic testscertain tests and invasiveness of certain diagnostic testsChecking report time by putting in certain orders gives Checking report time by putting in certain orders gives you an idea how long it takes for the test results to come you an idea how long it takes for the test results to come backbackV/Q scan vs. CT angiogram in Unstable PEV/Q scan vs. CT angiogram in Unstable PEBMP vs. CMP in DKABMP vs. CMP in DKACT chest vs. TEE in aortic dissection ( both take same CT chest vs. TEE in aortic dissection ( both take same time. Though TEE is more specific, CT scan is least time. Though TEE is more specific, CT scan is least invasive)invasive)ABI with arterial doppler vs. Angiogram for PADABI with arterial doppler vs. Angiogram for PAD

Unresponsiveness in ERUnresponsiveness in ER

Get basic stuff quick :Get basic stuff quick :

- CHECK VITALS FIRSTCHECK VITALS FIRST- ABCs – suction airwayABCs – suction airway

- Do not intubate right away with out knowing the possible cause of coma Do not intubate right away with out knowing the possible cause of coma ( for example, if finger stick shows low glucose – patient might respond ( for example, if finger stick shows low glucose – patient might respond right away by giving dextrose)right away by giving dextrose)

- fingerstick glucose stat, - fingerstick glucose stat, - naloxone given if opiates are suspected (Pupils)- naloxone given if opiates are suspected (Pupils)- thiamine added to IV fluids if alcoholic. thiamine added to IV fluids if alcoholic. Not all comatose patients need this cocktail. Check the Not all comatose patients need this cocktail. Check the

history – you may find clues ( heat stroke, fever with history – you may find clues ( heat stroke, fever with delirium, motor weakness with delirium)delirium, motor weakness with delirium)

Obtaining ConsultsObtaining Consults

Whether in ER setting or office setting there are some Whether in ER setting or office setting there are some issues where you must get consults issues where you must get consults

certain procedures – surgeries, tube thoracostomy, thoracotomy, certain procedures – surgeries, tube thoracostomy, thoracotomy, depression, suicide attempt, drug overdose, cardiac catheterization, depression, suicide attempt, drug overdose, cardiac catheterization, ptca, ST elevation MI, Orthopaedic procedures, eye procedures, ENT ptca, ST elevation MI, Orthopaedic procedures, eye procedures, ENT stuff, EGD, Colonoscopy – get appropriate consultsstuff, EGD, Colonoscopy – get appropriate consults for expert opinionfor expert opinion

You will be credited for asking necessary consultsYou will be credited for asking necessary consultsYou can type “Obtain consent for procedure” to get You can type “Obtain consent for procedure” to get consent.consent.If you are obtaining a surgical consult, get the consult first . If you are obtaining a surgical consult, get the consult first . Then, advance the clock to the “report” time of consult. If Then, advance the clock to the “report” time of consult. If the patient is accepted for procedure now order :the patient is accepted for procedure now order :

NPONPOType and crossmatchType and crossmatchName of the procedure itself ( Name of the procedure itself ( eg: hysterectomy, adrenalectomy e.t.c)eg: hysterectomy, adrenalectomy e.t.c)

Using keywordsUsing keywords

OxyOxyCouCouStopStopAvoidAvoidDietDietFluidsFluidsAdviseAdviseVacci etcVacci etc

Advancing clockAdvancing clock

Advance only after putting appropriate Advance only after putting appropriate ordersorders

If you don’t advance you will use up your If you don’t advance you will use up your real time without nothing happening with real time without nothing happening with the patientthe patient

If you don’t advance means you have not If you don’t advance means you have not done the orders you wrotedone the orders you wrote

Advance clock to get results when neededAdvance clock to get results when needed

Before advancing clock!Before advancing clock!

Think twice is there anything else that needs to Think twice is there anything else that needs to be done, Esply true for ER Casesbe done, Esply true for ER CasesIf you did not do complete physical earlier, this is If you did not do complete physical earlier, this is the time to do it – while awaiting the lab results, the time to do it – while awaiting the lab results, imaging studies etc – do not advance the clock imaging studies etc – do not advance the clock just to get results unless you have nothing else just to get results unless you have nothing else left to do. left to do. Eg: you order a CBC – Let us say order time is Eg: you order a CBC – Let us say order time is 8:40 and report time is 9:20 – do an interval hx 8:40 and report time is 9:20 – do an interval hx or a previously unfinished physical in the mean or a previously unfinished physical in the mean time that will automatically advance the clock time that will automatically advance the clock further. further.

Using control buttonUsing control button

You can select multiple orders by using You can select multiple orders by using control button so that u don’t waste much control button so that u don’t waste much timetime

Diet ordersDiet orders

Order appropriate diet for admissionsOrder appropriate diet for admissions

Type “diet” to select what u need in your Type “diet” to select what u need in your casecase

Follow up & Interval HxFollow up & Interval Hx

It does not hurt to ask a pt “how are you?” It does not hurt to ask a pt “how are you?” intermittently. Do not advance the clock if u need intermittently. Do not advance the clock if u need to put some other orders at the same time. to put some other orders at the same time. Obtain interval hx/follow up in pts with distress. Obtain interval hx/follow up in pts with distress. They might give you some valuable feedback They might give you some valuable feedback that may change your treatment strategythat may change your treatment strategyDrug side effects – Order panels during follow Drug side effects – Order panels during follow up visits – liver panel, lipid panel etc to follow up up visits – liver panel, lipid panel etc to follow up your drug side effects as well as the efficacy.your drug side effects as well as the efficacy.Ordering follow up tests at a later date works Ordering follow up tests at a later date works only on the 5 min screenonly on the 5 min screen

Follow up appointmentsFollow up appointments

Schedule follow up appointments for office Schedule follow up appointments for office visits where required and then advance visits where required and then advance clock to get them back in ur office.clock to get them back in ur office.

Take f/u hx each time u visit an inpatient Take f/u hx each time u visit an inpatient or during OP follow upor during OP follow up

CounselingCounseling

Needed in all office visitsNeeded in all office visitsUsually done on 5-minute screenUsually done on 5-minute screenCounsel on appropriate stuff Counsel on appropriate stuff

- Weight loss, exercise, diet, smoking & alcohol cessation- Weight loss, exercise, diet, smoking & alcohol cessation - Driving with seatbelt- Driving with seatbelt - Safe sexual practices- Safe sexual practices- Asthma careAsthma careAvoid stat counseling unless extremely needed. Like in Avoid stat counseling unless extremely needed. Like in

panic attack / nervous ptpanic attack / nervous ptType “counsel” press control and then select what u need Type “counsel” press control and then select what u need

at the end of the caseat the end of the case

Appropriate screening for office Appropriate screening for office visitsvisits

Age specific screeningAge specific screening

You will be credited for thisYou will be credited for this

If the patient came with an acute problem, If the patient came with an acute problem, address the acute problem and diagnostic address the acute problem and diagnostic work-up on the active screen. You can work-up on the active screen. You can always do Screening on the 5-minute always do Screening on the 5-minute screen.screen.

Invasiveness of investigationsInvasiveness of investigations

You will not get penalized for ordering an You will not get penalized for ordering an unnecessary non invasive investigation. unnecessary non invasive investigation. However, sometimes what seemed initially However, sometimes what seemed initially unnecessary might give you useful information unnecessary might give you useful information ( LFTs, Chem7)( LFTs, Chem7)Do not order EGDs, Intubation, Colonoscopies, Do not order EGDs, Intubation, Colonoscopies, ERCPs, Chest tubes, CT with contrast if they are ERCPs, Chest tubes, CT with contrast if they are not very much needed – they are invasive and not very much needed – they are invasive and could be harmful.could be harmful.For most invasive investigations you need For most invasive investigations you need consults ( cardiac cath, colonoscopy, EGD, consults ( cardiac cath, colonoscopy, EGD, ERCP)ERCP)

Indications for admission in an Indications for admission in an office visitoffice visit

Look at vitals in office visit. A severe symptomatology may require stat Look at vitals in office visit. A severe symptomatology may require stat orders – cbc, chem., cardiac enz, ekg, iv access – if something unstable orders – cbc, chem., cardiac enz, ekg, iv access – if something unstable or serious or if indications of admission are present as per labs/ vitals or or serious or if indications of admission are present as per labs/ vitals or inability to take PO meds – send pt to ER and then admit. After entering inability to take PO meds – send pt to ER and then admit. After entering ER, address initial problem and then only transfer to floor/ICUER, address initial problem and then only transfer to floor/ICUIndications for admission in office – pneumonia case ( CURB 65 – Indications for admission in office – pneumonia case ( CURB 65 – CONFUSION, UREMIA, RR>30, SBP<90, AGE>65)CONFUSION, UREMIA, RR>30, SBP<90, AGE>65)Indications for admission in office – Pyelonephritis/ PID caseIndications for admission in office – Pyelonephritis/ PID caseObtaining consults for office visits i.e; colonoscopy( anemia, weightloss, Obtaining consults for office visits i.e; colonoscopy( anemia, weightloss, constipation), EGD(weightloss, heartburn, anemia, Dysphagia, constipation), EGD(weightloss, heartburn, anemia, Dysphagia, persistent vomiting, age) , bronchoscopy (lung mass), cystoscopy persistent vomiting, age) , bronchoscopy (lung mass), cystoscopy (hematuria) etc – order consult as routine, see the report time of consult (hematuria) etc – order consult as routine, see the report time of consult procedure and then schedule follow up visit after the consult report is procedure and then schedule follow up visit after the consult report is obtained.obtained.

Sending Patient home from OfficeSending Patient home from Office

Do not keep patient waiting in the office. Do not keep patient waiting in the office. Address their current symptoms, hit move pt Address their current symptoms, hit move pt button, schedule a follow up visit, usually in a button, schedule a follow up visit, usually in a week (pay attention to result report time while week (pay attention to result report time while scheduling follow ups)scheduling follow ups) You do not want pt to You do not want pt to come to your clinic for follow up even before you come to your clinic for follow up even before you got the test result. – you can always call her got the test result. – you can always call her back if something dangerous comes out on labs back if something dangerous comes out on labs even prior to the next follow up visit. – hit the even prior to the next follow up visit. – hit the move patient icon.move patient icon.

Moving the PatientMoving the Patient

Can not use “ transfer to icu” order on the Can not use “ transfer to icu” order on the 5 min screen5 min screen

Moving the pt home while awaiting orders Moving the pt home while awaiting orders on Clinic case – after addressing only the on Clinic case – after addressing only the current symptomscurrent symptoms

Schedule follow up office visitSchedule follow up office visit

Order follow up labs for pts on certain Order follow up labs for pts on certain drugs eg: lipid Panel, lfts etcdrugs eg: lipid Panel, lfts etc

5-minute screen5-minute screenYou cant change location or obtain resultsYou cant change location or obtain resultsIf you dint have time to put your essential Rx orders and the If you dint have time to put your essential Rx orders and the case ended , put them nowcase ended , put them nowD/c unnecessary orders at this timeD/c unnecessary orders at this timeAdd d/c home medicationsAdd d/c home medicationsIf pt is ready to go home, switch IV meds to oralIf pt is ready to go home, switch IV meds to oralDo counselingDo counselingIs your patient eating?- if not already put , enter diet orders.Is your patient eating?- if not already put , enter diet orders.VERY IMP ( you can do this only on 5 min screen) VERY IMP ( you can do this only on 5 min screen) enter enter follow-up tests at afollow-up tests at a later later date i.e; following drug toxic effects date i.e; following drug toxic effects (LFTs, cbc etc), following the drug efficacy (lipid panel, INR (LFTs, cbc etc), following the drug efficacy (lipid panel, INR monitoring etc), following disease activity ( follow up TSH monitoring etc), following disease activity ( follow up TSH etc)etc)

Enter elective screening tests for a Enter elective screening tests for a LATERLATER date in date in an inpatient i.e; colonoscopy, pap smear, mammograman inpatient i.e; colonoscopy, pap smear, mammogramEnter age appropriate and disease appropriate vaccines if Enter age appropriate and disease appropriate vaccines if not entered beforenot entered before

Use control button – save timeUse control button – save time

Arthrocentesis ordersArthrocentesis orders

Fluid analysis ordersFluid analysis orders

Counseling orders on the 5 min screenCounseling orders on the 5 min screen

Cases ending before timeCases ending before time

Why do many cases end quickly? – how Why do many cases end quickly? – how will I know if I did well if case ended will I know if I did well if case ended quickly ? quickly ?

that’s the reason why you check interval that’s the reason why you check interval hx and vitals oftenhx and vitals often

ChecklistChecklist

Imaging & EKG Imaging & EKG   EKG, EEG, Echo, Ultrasound, Carotid DopplerEKG, EEG, Echo, Ultrasound, Carotid DopplerCXR, X ray Joints, acute abdominal seriesCXR, X ray Joints, acute abdominal seriesCT, MRI, Exercise treadmill, Cardiolyte / Thallium scan for angina.  CT, MRI, Exercise treadmill, Cardiolyte / Thallium scan for angina.  

Nursing orders Nursing orders NPO, Diet, IV Fluids, Vitals, Input/output, Physical NPO, Diet, IV Fluids, Vitals, Input/output, Physical

therapytherapy Tubes- NG, FoleyTubes- NG, Foley Pulse oximetry & Oxygen, cardiac monitor Pulse oximetry & Oxygen, cardiac monitor 

Medication orders Medication orders Counseling Counseling

Weight loss, exercise, diet, smoking & alcohol Weight loss, exercise, diet, smoking & alcohol cessation. cessation. 

ChecklistChecklist

Labs: Labs: CBC, CMP, Urine routine, TSH, Lipid Profile, CBC, CMP, Urine routine, TSH, Lipid Profile, Cardiac enzymes, ABG, Glucometer check, Cardiac enzymes, ABG, Glucometer check, Drug levels, Toxicology screen-Urine and Drug levels, Toxicology screen-Urine and serum, ANA, ESR.serum, ANA, ESR.

– Bleeding & pre-op pts– Type Blood and cross Bleeding & pre-op pts– Type Blood and cross match, PT/INR, PTT.match, PT/INR, PTT.

– Infections – cultures of Blood, Urine, Sputum or Infections – cultures of Blood, Urine, Sputum or CSF, as appropriate.CSF, as appropriate.

– Acute abdomen – order amylase, lipase, b HCG & Acute abdomen – order amylase, lipase, b HCG & acute abdominal X ray series. acute abdominal X ray series. 

DyspepsiaDyspepsia

- If warning signs or age > 50, - If warning signs or age > 50, please do EGDplease do EGD

-If doing EGD, add biopsy, gastric If doing EGD, add biopsy, gastric mucosa – H.pylori stain. mucosa – H.pylori stain.

DiarrheaDiarrhea

Make an attempt to calssify Make an attempt to calssify Infalmmatory vs. Non inflammtaory. Infalmmatory vs. Non inflammtaory.

If inflammatory, is it bacterial or non –bacterial?If inflammatory, is it bacterial or non –bacterial?Get stool wbc, occult blood and bacterial cultures as Get stool wbc, occult blood and bacterial cultures as

main work up in acute diarrhea work upmain work up in acute diarrhea work up

Acute MIAcute MIEKG will decide further MxEKG will decide further Mx

EKG will take 15 minsEKG will take 15 minsThrombolytics vs. cardiac CathThrombolytics vs. cardiac Cath

What if similar to dissection? Think of your What if similar to dissection? Think of your “Triad” “Triad”

Pericarditis – the EKG differences. Look Pericarditis – the EKG differences. Look “reciprocal depressions” are not seen in “reciprocal depressions” are not seen in

pericarditispericarditis

StrokeStroke

TIA – Thrombotic vs.EmbolicTIA – Thrombotic vs.EmbolicCT head CT head with outwith out contrast contrast

ASA vs. AggrenoxASA vs. AggrenoxEKG, 2D Echo to r/o cardiac originEKG, 2D Echo to r/o cardiac origin

Carotid doppler to r/o carotid stenosisCarotid doppler to r/o carotid stenosisIf carotid stenosis and meets criteria ? If carotid stenosis and meets criteria ? CEA CEA

ShockShock

Respiratory FailureRespiratory Failure

Polymyalgia RheumaticaPolymyalgia Rheumatica

Exclude other differential diagnosisExclude other differential diagnosisGet an ESR. ESR > 100 very suggestive of polymyalgia in Get an ESR. ESR > 100 very suggestive of polymyalgia in

presence of typical clinical features presence of typical clinical features Temporal aretery biopsy if suggesting associated temporal arteritis. Temporal aretery biopsy if suggesting associated temporal arteritis.

Get baseline DEXA if starting steroidsGet baseline DEXA if starting steroidsPrevent osteoprorosis if starting steroids Prevent osteoprorosis if starting steroids

HUSHUS

Diarrhea preceding PresentationDiarrhea preceding PresentationR/o other causes of microangiopathic hemolysisR/o other causes of microangiopathic hemolysisDemonstrate schistocytes on peripheral smearDemonstrate schistocytes on peripheral smear

Supportive theray as initial choiceSupportive theray as initial choiceMonitor CBC and BMPMonitor CBC and BMP

If Clinical picture worsens, get plasmapheresis If Clinical picture worsens, get plasmapheresis If BMP worsens, get HD If BMP worsens, get HD

Delirium in ElderlyDelirium in Elderly

Sun downingSun downingDementiaDementia

Sepsis : UTI, Pneumonia and Sepsis : UTI, Pneumonia and C.difficleC.difficle

Secondary HypertensionSecondary HypertensionHyperaldosteronism Hyperaldosteronism

Hypokalemia with leg crampsHypokalemia with leg crampsGet hormonal tests ( PAC/ PRA) prior to CT imagingGet hormonal tests ( PAC/ PRA) prior to CT imaging

Spironolactone as medical therapySpironolactone as medical therapyCT may show adrenal adenomaCT may show adrenal adenoma

Call surgical consultCall surgical consultIf accepted, order adrenalectomy If accepted, order adrenalectomy