Cross Cover Survival Guide

Electrolyte Replacement

Normal Values Replacements

Potassium 3.5-5.3 mmol/L Oral: K-dur (tab) or K-lyte (liquid) 20-40 mEq
IV: KCl 20-40 mEq or Kphos 15-30 mmol IVPB

Teaching points on KCl: Tabs are big and sometimes hard to swallow; liquid tastes terrible;
burns in a peripheral IV so sometimes takes a long time to run in. Central line preferred for IV
administration. Always know the patients current BUN/Cr before prescribing supplemental
potassium (avoid in renal failure).

For every 0.1 mmol/L deficit below 3.5, replace with 10mEq of Potassium.

Normal Values Replacements

Magnesium 1.6-3.0 mg/dL Oral: MgOxide 400mg PO BID
IV: MgSulfate 2g IVPB

Teaching points on Mg: MgOxide can cause diarrhea. If both K and Mg are low, replace Mg
first.

Normal Values Replacements

Phosphorus 2.3-5.0 m/dL Oral: NeutraPhos 1-2 packets TID with meals
IV: NaPhos or KPhos 15-30 mmol IVPB

**Calcium 8-10.6 mg/dL Oral: OsCal 1 Tab PO TID

IV: Do not replace by IV on the floor unless in
overt tetany or EKG changes. Call your resident.

Teaching points on Ca: Always calculate the corrected calcium (with the help of albumin) before
supplementing.
Hyperglycemia and Hypoglycemia
Regular insulin sliding scale:

Glucose Regular insulin

0-200 no insulin
201-250 2U
251-300 4U
301-350 6U
351-400 8U
<60 - >400 call house officer

<60mg/dL and if patient AAO X 3, feed the patient (OJ, crackers) and recheck
accucheck in 20 minutes
<60 mg/dL and if patient not AAO X 3, then give 1 ampule of D50 IVP. If no IV
access, give Glucagon 1mg SC/IM STAT (If not on the floor, call Pharmacy)
>400 inquire about clinical scenario prior to deciding insulin dose( eg, patient may be in
DKA so check the anion gap, etc).

Hyperkalemia
For K > 5.4, ask for current heart rate and ask for a STAT 12-lead EKG. Review the
EKG. If bradycardic and/or EKG changes are present, give:
1 amp Calcium Gluconate or Calcium Chloride
1-ampule of D50 + 10 units of regular insulin subcutaneously
30 grams of Kayexalate orally

If no EKG changes or no bradycardia, do not give IV Calcium

Stop all Potassium supplements (oral, IVPB, in IV fluids)
May add Inhaled Albuterol via nebulizer (2.5mg ampule X 2) to regimen.
Bicarbonate should be used only in Code Blue situations

Chest Pain
Over the phone, ask for vitals, ask for STAT 12-lead EKG, ASA to chew, one SL-NTG,
oxygen and then see the patient immediately
Distinguish between cardiac and noncardiac chest pain by history and physical exam
o If EKG changes (ST elevation) call the Cardiology fellow on-call
If needed, get 12-lead EKG and compare to old one
If cardiac pain or EKG changes present, sublingual NTG (0.4mg) q5minutes X
o If pain persists, also add morphine 2-4mg IVP, draw blood for CPK + troponins
o Call for additional help if needed
Positive Blood Cultures
Any blood cultures with Gram Negative and Fungi needs immediate appropriate
antibiotics. Fungi typically need change in any central lines (seeding).
For Gram Positive cultures, decide use of appropriate antibiotics based on the clinical
situation (fever, bp, WBC count, diagnosis, mental status).
If unclear, evaluate the patient and the chart.

Death Pronouncement
Ensure death by doing ALL the following……..
Ensure no response to vocal and pain stimuli
Ensure that pupils are fixed and dilated
Ensure that conjunctival and corneal reflexes are absent
Ensure there are no spontaneous movements
Ensure there are no breathing movements/no heart and breath sounds
Ensure there are no pulses palpable
Note the time and write a brief “Death Note” in the patient’s chart documenting above

DOCUMENT ALL OF THE ABOVE in the chart

Inform the attending and document that you informed the attending
Call the family and ask them to come to the hospital ASAP. Please don’t tell them of the
death over the telephone. Say something to the effect of, “your family member’s
condition has taken a turn. Please come to the hospital as soon as possible.” Document
that you called the family.
Once the family arrives, tactfully inform them of the death. Ask them if they would like
a Pastor present or if they would be interested in an autopsy. There is also on-call Social
Work to assist the family with grievance/funeral arrangements.

Blood Transfusion Reactions

Stop the transfusion
Increase IV fluids (caution in ESRD or CHF patient) and ensure 200cc/hr urine output
Send labs for hemolysis profile (LDH, Haptoglobin, total and direct bilirubin, Hb)
For symptoms, give Benadryl 50mg IVP X 1 and Tylenol 650 mg PO
If ineffective, give Hydrocortisone 100 mg IVP X 1
Sign transfusion reaction incident form and notify the Blood Bank
Document the reaction in the chart and cc your resident and the patient’s attending

Fever Associated with Blood Product Transfusions

For fever >100.5 deg F, first give Tylenol (assuming liver function normal)
Have the temp checked again 30 minutes. If fever subsides, then begin transfusion and
have vitals checked qProtocol.
If fever does not subside, then evaluate the patient.

Pain Management
 For those patients with known Liver Disease, NO ACETAMINOPHEN (Tylenol, Tylenol
#3, Tylenol #4, Vicodin, Vicodin ES, Percocet)
For those patents with known PUD, severe anemia, low platelets NO NSAIDS (ASA,
Ibupofen, Naproxen, Cox-II inhibitors)
For those patents with seizures or ESRD, NO MEPERIDINE (Demerol)
For ESRD, NO HYDROMORPHONE OR MEPERIDINE because of impaired excretion

Sleep Aid
Choices: Benadryl 25-50 mg IVP or PO, Ambien 5-10mg PO, Restoril 15-30 mg PO X 1
Use small doses and avoid Benadryl in the elderly

Hypoxia
Call your resident and evaluate the patient immediately
Oxygen
o Nasal cannula up to 4 L
o 40-60% Venti Mask
o 100% nonrebreather mask
Keep SpO2 >90%
Albuterol/Atrovent breathing treatment if wheezes present
STAT Portable Chest Xray
Consider getting an Arterial Blood Gas; evaluate for V/Q mismatch

Ethanol Withdrawal/Delerium Tremens

Ativan 2-4 mg IVP q4 hours; monitor oxygen status and level of consciousness!
Seizure and Fall Precautions
Thiamine 100 mg PO qDay (IV if patient is delirious and unable to take PO)
Folate 1 mg PO qDay (IV if patient delirious)
Multivitamin 1 Tab PO q Day
IV fluids (Use D5-0.45NS if not Diabetic). Give Thiamine first!
Look for hallucinations, tachycardia, seizure, hyperthermia, and hypertension – consider
transfer to MICU if airway unstable.

Status Epilepticus
Ativan 2mg IVP
Seizure and Fall Precautions
Dilantin 1000mg IV bolus
Call your resident and Neurology on-call
See treatment algorithm below
Status Asthmaticus
Oxygen
Stat Albuterol (2.5 mg in 3cc 0.9 NS) breathing treatment
Solumedrol 125 mg IVP X 1 then 60mg IVP q 6hours
Call your resident/MICU if airway seems compromised

Hypertensive Urgency
Consider trying to control BP with extra dose of current medication
Use Clonidine only if patient is already on Clonidine
Can use Labetalol 10-20mg IVP or Hydralazine 10 mg IVP
o If these are ineffective consider need for a drip