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On Call Principles and Protocols. ISBN 1437723713, 978-1437723717

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On Call Principles and Protocols. ISBN 1437723713, 978-1437723717

ISBN-10: 1437723713. ISBN-13: 978-1437723717. On Call Principles and Protocols Full PDF DOCX Download

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On Call Principles and Protocols

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Principles
& Protocols
SHANE A. MARSHALL, md, frcpc
Consultant Cardiologist
King Edward VIIth Memorial Hospital
Paget, Bermuda

Director
The Cardiac Echo Lab
Paget, Bermuda

JOHN RUEDY, mdcm, frcpc, lld (hon), DMED (HON)


Professor (Emeritus) of Pharmacology
Faculty of Medicine
Dalhousie University
Halifax, Nova Scotia
Canada

5 th
edition
1600 John F. Kennedy Blvd.
Suite 1800
Philadelphia, PA 19103-2899

PRINCIPLES AND PROTOCOLS 978-1-4377-2371-7

Copyright © 2011, 2004, 2000, 1993, 1989 by Saunders, an imprint of Elsevier Inc.

No part of this publication may be reproduced or transmitted in any form or by any


means, electronic or mechanical, including photocopying, recording, or any information
storage and retrieval system, without permission in writing from the publisher. Details on
how to seek permission, further information about the Publisher's permissions policies
and our arrangements with organizations such as the Copyright Clearance Center and the
Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright
by the Publisher (other than as may be noted herein).

Notices

Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional
practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or
experiments described herein. In using such information or methods they should be
mindful of their own safety and the safety of others, including parties for whom they
have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised
to check the most current information provided (i) on procedures featured or (ii) by
the manufacturer of each product to be administered, to verify the recommended dose
or formula, the method and duration of administration, and contraindications. It is
the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors,
or editors, assume any liability for any injury and/or damage to persons or property as
a matter of products liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data or Control Number


Marshall, Shane A.
On call : principles & protocols / Shane A. Marshall, John Ruedy. – 5th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4377-2371-7 (pbk. : alk. paper) 1. Medical emergencies–Handbooks,
manuals, etc. 2. Medical consultation–Handbooks, manuals, etc. I. Ruedy, John. II. Title.
[DNLM: 1. Emergencies–Handbooks. 2. Emergency Medicine–Handbooks. WB 39]
RC86.7.G55 2011
616.02'5–dc22 2010038586

Acquisitions Editor: James Merritt Senior Project Manager: Sarah Wunderly


Developmental Editor: Barbara Cicalese Project Manager: Joanna Dhanabalan
Publishing Services Manager: Patricia Tannian Design Direction: Steve Stave
Team Manager: Radhika Pallamparthy

Printed in United States of America

Last digit is the print number:â•… 9â•… 8â•… 7â•… 6â•… 5â•… 4â•… 3â•… 2â•… 1
To our families in
Bermuda and Canada
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Preface

Taking calls at night is one of the traditional duties of medical


students and residents in teaching hospitals. On Call Principles
and Protocols is designed to facilitate the transition of medical
students and residents from the classroom to the hospital set-
ting. We believe that the initiation of the medical student to
hospital practice need not be one of trial and error and need
not be recalled as a time of stress and uncertainty.
The fifth edition of On Call Principles and Protocols pro-
vides referenced updates for the assessment and management
of common problems for which medical students and resi-
dents are called at night. A separate chapter on the diagnosis
and management of stroke has been added in this edition.
The popular On Call Formulary, a quick reference of com-
monly prescribed medications, has also been expanded and
updated.
We have been careful to maintain an approach that pro-
vides both instruction and reference while emphasizing the
rational thought processes required for optimal patient care in
specific clinical situations. In this edition of On Call Principles
and Protocols, medications are in green type and, where appro-
priate, the thought processes behind management decisions
and instructions are indented.
It is our belief that this structured approach deserves
greater emphasis in the undergraduate years, and we are
hopeful that it will help students in their introduction to clin-
ical medicine.

vii
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Acknowledgments

We are grateful to the physicians and allied healthcare


workers who provided helpful and detailed comments
on individual chapters, particularly Dr. Keith Chiappa,
Mrs. Janice DeSilva, Dr. Ron Goldschmidt, Dr. Richard
Jones, and Mrs. Debbie Jones. We would also like to thank
Dr. Jean Gillies for her major contribution to the first edi-
tion of On Call Principles and Protocols, and to Mr. James
Merritt for his patience and encouragement during the
preparation of the fifth edition of this book.

Shane A. Marshall
John Ruedy

ix
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Structure of the Book

The book is divided into three main sections.

The first section covers introductory material in four


separate chapters:
• Chapter 1, Approach to the Diagnosis and Management
of On-Call Problems
• Chapter 2, Documentation of On-Call Problems
• Chapter 3, Assessment and Management of Volume Status
• Chapter 4, AIDS, HBV, HCV, Influenza, and the House
Officer
Volume status is discussed in the introductory section because
assessment of volume status is essential for the proper man-
agement of many problems in hospitalized patients. A state-
ment on AIDS is included because of the small risk that caring
for HIV-infected patients poses to healthcare workers.

The second section contains the common calls associated


with patient-related problems. Each problem is approached
from its inception, beginning with the relevant questions that
should be asked over the phone, the temporary orders that
should be given, and the major life-threatening problems to
be considered as one approaches the bedside. The names and
doses of medication are in green for easy location and ref-
erence. The rationales behind questions that are asked are
indented, and the thoughts behind management decisions
that are recommended are set off with a vertical green line.

Each chapter in the second edition is divided as follows:

PHONE CALL
Questions
Pertinent questions that should be asked to assess the urgency
of the situation.
xi
xii Structure of the Book

Orders
Urgent orders to be carried out before you arrive at the
bedside.
Inform RN
The time you anticipate arriving at the bedside.

ELEVATOR THOUGHTS
The differential diagnosis that should be considered while
you are on the way to assess the patient (i.e., while in the
elevator).

MAJOR THREAT TO LIFE


Identification of the major threat to life is essential in providing
a focus for the effective management of the patient.

BEDSIDE
Quick-Look Test
A rapid visual assessment to place the patient in one of three
categories: well, sick, or critical. This helps determine the
necessity for immediate intervention.
Airway and Vital Signs
Selective History
Selective Physical Examination
Management
The third section contains the common calls associated with
laboratory-related problems.
The appendixes consist of reference items that are useful
in managing calls.
The On Call Formulary is a compendium of commonly
used medications that are likely to be prescribed by the stu-
dent or resident on call. The alphabetically arranged formu-
lary serves as a quick reference for drug dosages, routes of
administration, side effects, contraindications, and modes of
action.
Commonly Used
Abbreviations

ABD Abdomen
ABG Arterial blood gas
AC Ante cibum (before meals)
ACE Angiotensin-converting enzyme
ACLS Advanced cardiac life support
ACS Acute coronary syndrome
ACTH Adrenocorticotropic hormone
ADH Antidiuretic hormone
AED Automated external defibrillation
AFB Acid-fast bacillus
AICD Automatic implantable cardioverter defibrillator
AIDS Acquired immunodeficiency syndrome
AMI Acute myocardial infarction
AMP Adenosine monophosphate
ANA Antinuclear antibody
AP Anteroposterior
aPTT Activated partial thromboplastin time
ARDS Adult respiratory distress syndrome
ASD Atrial septal defect
AV Atrioventricular
BBB Bundle branch block
BID Twice a day
xiii
xiv Commonly Used Abbreviations

BLS Basic life support


BP Blood pressure
BPH Benign prostatic hypertrophy
C+S Culture and sensitivity
Ca Calcium
CABG Coronary artery bypass graft
CBC Complete blood (cell) count
CCU Cardiac care unit
CGL Chronic granulocytic leukemia
CHF Congestive heart failure
CLL Chronic lymphocytic leukemia
CMV Cytomegalovirus
CNS Central nervous system
CO Cardiac output
CO2 Carbon dioxide
COPD Chronic obstructive pulmonary disease
CPK Creatine phosphokinase
CPR Cardiopulmonary resuscitation
CrCl Creatinine clearance
CSF Cerebrospinal fluid
CT Computed tomography
CVS Cardiovascular system
CXR Chest x-ray
D5NS 5% dextrose in normal saline
D5W 5% dextrose in water
D10W 10% dextrose in water
D20W 20% dextrose in water
D50W 50% dextrose in water
DC Direct current
DIC Disseminated intravascular coagulation
DKA Diabetic ketoacidosis
Commonly Used Abbreviations xv

DVT Deep venous (vein) thrombosis


ECF Extracellular fluid
ECG Electrocardiogram
ED Emergency department
EDTA Edetate disodium
EF Ejection fraction
ELISA Enzyme-linked immunosorbent assay
EMT Emergency medical technician
ENDO Endocrine
ENT Ears, nose, and throat
ESR Erythrocyte sedimentation rate
ET Endotracheal
Ext Extremities
FDA Food and Drug Administration
FDP Fibrin degradation product
FEV1 Forced expiratory volume in 1 second
FFP Fresh frozen plasma
Fio2 Fraction of inspired oxygen
FPBG Finger-prick blood glucose
FTA-ABS Fluorescent treponemal antibody absorption
FUO Fever of unknown origin
G-6-PD Glucose-6-phosphate dehydrogenase
GERD Gastroesophageal reflux disease
GI Gastrointestinal
GTT Glucose tolerance test
GU Genitourinary
HAART Highly active antiretroviral therapy
Hb Hemoglobin
HBV Hepatitis B virus
HCV Hepatitis C virus
HEENT Head, eyes, ears, nose, throat
xvi Commonly Used Abbreviations

HIV Human immunodeficiency virus


HJR Hepatojugular reflux
HPI History of present illness
HR Heart rate
HS Hora somni (at bedtime)
IBW Ideal body weight
ICF Intracellular fluid
ICU Intensive care unit
ICU/CCU Intensive care unit/cardiac care unit
Ig Immunoglobulin
IM Intramuscular
IO Interosseous
INR International normalized ratio
IP Intraperitoneally
ISI International Sensitivity Index
ITP Idiopathic thrombocytopenic purpura
IV Intravenous
IVP Intravenous pyelogram
J Joule
JVP Jugular venous pressure
K Potassium
L Liter
LDH Lactate dehydrogenase
LLL Left lower lobe
LLQ Left lower quadrant
LMWH Low-molecular-weight heparin
LOC Level of consciousness
LP Lumbar puncture
LUQ Left upper quadrant
LV Left ventricle (ventricular)
LVH Left ventricular hypertrophy
MAO Monoamine oxidase
Commonly Used Abbreviations xvii

MAOI Monoamine oxidase inhibitor


MCV Mean corpuscular volume
MD Doctor of medicine
MHA-TP Microhemagglutinin assay—Treponema pallidum
MI Myocardial infarction
Misc Miscellaneous
MRI Magnetic resonance imaging
MSS Musculoskeletal system
MVP Mitral valve prolapse
NA Sodium
Neuro Neurologic system
NG Nasogastric
NMR Nuclear magnetic resonance (scan)
NNRTI Non-nucleoside reverse transcriptase inhibitor
NPH Neutral protamine Hagedorn (insulin)
NPO Nil per os (nothing by mouth)
NRTI Nucleoside/nucleotide reverse transcriptase inhibitor
NS Normal saline (0.9% saline in water)
NSTEMI Non–ST-elevation myocardial infarction
NSAID Nonsteroidal anti-inflammatory drug
NYD Not yet diagnosed
OD Overdose
P2 Pulmonic second sound
PA Posteroanterior
PAo2 Calculated partial pressure of oxygen
Pao2 Measured partial pressure of oxygen
PAC Premature atrial contraction
PAT Paroxysmal atrial tachycardia
PB Barometric pressure
PC Post cibum (after meals)
PCI Percutaneous coronary intervention
Pco2 Partial pressure of carbon dioxide
xviii Commonly Used Abbreviations

PEA Pulseless electrical activity


PEEP Positive end-expiratory pressure
PEFR Peak expiratory flow rate
PH2O Partial pressure of water vapor in the lung
PI Protease inhibitor
PMN Polymorphonuclear cell
PND Paroxysmal nocturnal dyspnea
PO Per os (by mouth)
Po2 Partial pressure of oxygen
PR Per rectum
PRN Pro re nata (as needed)
PSVT Paroxysmal supraventricular tachycardia
Psych Psychiatric
PT Prothrombin time+
PTH Parathyroid hormone
PUD Peptic ulcer disease
PVC Premature ventricular contraction
QD Every day
QHS Quaque hora somnia (every hour of sleep)
QID Four times a day
R Respiratory quotient
RA Rheumatoid arthritis
RAD Right axis deviation
RBBB Right bundle branch block
RBC Red blood cell (count)
Resp Respiratory system
RLL Right lower lobe
RLQ Right lower quadrant
RN Registered nurse
ROM Range of motion
RR Respiratory rate
Commonly Used Abbreviations xix

RTA Renal tubular acidosis


RUQ Right upper quadrant
RV Right ventricle (ventricular)
S3 Third heart sound
SA Sternal angle
SAH Subarachnoid hemorrhage
SBE Subacute bacterial endocarditis
SC Subcutaneous
SI International System of Units
SIADH Syndrome of inappropriate antidiuretic hormone (secretion)
SL Sublingual
SLE Systemic lupus erythematosus
SOB Shortness of breath
SSR Selective serotonin reuptake inhibitor
SSS Sick sinus syndrome
stat Statim (immediately)
STEMI ST-elevation myocardial infarction
STS Serological test for syphilis
SV Stroke volume
SVT Supraventricular tachycardia
T3 Triiodothyronine
T4 Thyroxine
TB Tuberculosis
TBW Total body water
Temp Temperature
TIA Transient ischemic attack
TID Three times a day
TKVO To keep the vein open
tPA Tissue plasminogen activator
TPN Total parenteral nutrition
TPR Total peripheral resistance
xx Commonly Used Abbreviations

TSH Thyroid-stimulating hormone


TTP Thrombotic thrombocytopenic purpura
UFH Unfractionated heparin
URTI Upper respiratory tract infection
UTI Urinary tract infection
. .
V/Q Ventilation-perfusion
VF Ventricular fibrillation
VIPoma Vasoactive intestinal polypeptide-secreting tumor
VP Ventriculoperitoneal
VSD Ventricular septal defect
VT Ventricular tachycardia
WBC White blood cell (count)
WPW Wolff-Parkinson-White
ZN Ziehl-Neelsen
Contents

Introduction
1 Approach to the Diagnosis and Management
of On-Call Problems . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2 Documentation of On-Call Problems . . . . . . . . . . . 6

3 Assessment and Management of


Volume Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

4 HIV, HBV, HCV, Influenza, and the


House Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Patient-Related Problems: The Common Calls


5 Abdominal Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . 33

6 Chest Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

7 Combativeness: The Out-of-Control Patient . . . . 64

8 Confusion/Decreased Level of Consciousness . . . . 69

9 Decreased Urine Output . . . . . . . . . . . . . . . . . . . . 82

10 Diarrhea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

11 Fall Out of Bed . . . . . . . . . . . . . . . . . . . . . . . . . . 101

12 Fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

13 Gastrointestinal Bleeding . . . . . . . . . . . . . . . . . . 124

14 Headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136

xxi
xxii Contents

15 Heart Rate and Rhythm Disorders . . . . . . . . . . . 149

16 High Blood Pressure . . . . . . . . . . . . . . . . . . . . . . 176

17 Hypnotics, Laxatives, Analgesics,


and Antipyretics . . . . . . . . . . . . . . . . . . . . . . . . . 186

18 Hypotension and Shock . . . . . . . . . . . . . . . . . . . 197

19 Leg Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208

20 Lines, Tubes, and Drains . . . . . . . . . . . . . . . . . . . 226

21 Polyuria, Frequency, and Incontinence . . . . . . . 270

22 Pronouncing Death . . . . . . . . . . . . . . . . . . . . . . . 279

23 Seizures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284

24 Shortness of Breath. . . . . . . . . . . . . . . . . . . . . . . 297

25 Skin Rashes and Urticaria . . . . . . . . . . . . . . . . . . 324

26 Stroke. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333

27 Syncope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345

28 Transfusion Reactions . . . . . . . . . . . . . . . . . . . . . 355

Laboratory-Related Problems:
The Common Calls
29 Acid-Base Disorders. . . . . . . . . . . . . . . . . . . . . . . 365

30 Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374

31 Calcium Disorders . . . . . . . . . . . . . . . . . . . . . . . . 380

32 Coagulation Disorders . . . . . . . . . . . . . . . . . . . . 389

33 Glucose Disorders . . . . . . . . . . . . . . . . . . . . . . . . 401

34 Potassium Disorders . . . . . . . . . . . . . . . . . . . . . . 413

35 Sodium Disorders . . . . . . . . . . . . . . . . . . . . . . . . 421


Contents xxiii

Appendixes
A Advanced Cardiovascular Life Support
Core Drugs and Therapy . . . . . . . . . . . . . . . . . . . 430

B Blood Products . . . . . . . . . . . . . . . . . . . . . . . . . . . 469

C Reading Electrocardiograms . . . . . . . . . . . . . . . . 474

D Miscellaneous . . . . . . . . . . . . . . . . . . . . . . . . . . . 479

E SI Units Conversion Table . . . . . . . . . . . . . . . . . . 488

F The On-Call Formulary . . . . . . . . . . . . . . . . . . . . 496

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