You are expected toAct professionally and collegially. Be enthusiastic.Report to work at 8Am and leave on time.Write your notes within hours and sign your orders within 24 hours. After you finish the rotation, you have to logon the Signature healthcare portal remotely, sign and complete any delinquent charts.You are expected to read critical care during the rotation. There will be a test at the end of the rotation.Read a critical care article. Prepare a 5-slide power point presentation and a 15 minute discussion. Give us a copy of the article and prepare a multiple choice question for presentation at the Critical Care Journal Club on the last day of IM resident rotation.Pre-round and examine patient and have all the labs, vitals and notes etc ready for rounds.Attend the daily huddle at 9:15Am and be prepared to talk about nosocomial issues and administrative/quality issues of the CCU in the last 24 hours
Coming soon...
FOUR Postmortem
FOUR for Dye Induced Nephropathy
FOUR for Cardiac Arrest
FOUR for Every Foley insertion
Nasogastric Tube
Resident & App Education
Cheat Sheets
BRAVE
YouTube Channel
Channel
FOUR
Page 2 of 2
Consults
Cardiac Arrest
BIS Monitor
Infection Control
Dorms and core Measures
Interns
Antibiotic Stewardship
Legibility and Verbal Orders
RRT
Resources
ICU Resident Orientation
Welcome to Brockton Hospital. This rotation is unique in a lot of aspects. Please try to get the best of it. It’s helpful to set aside your ultimate goals of subspecialisation aside and concentrate on learning from this rotation enthusiastically as if you are destined to spend the rest of your life in critical care.Please set Goals and work on achieving them in this rotationYou should finish this rotation able to run a small community ICU or be at the level of a junior fellow.You should be certified in all the procedures we do in this rotation or at least do more than one of each.You should be able to finish a central line in 10 minutes (in to out of the room)
Also have reasonable expectationThis rotation is physically demanding. I advise not to schedule big personal events during this rotation. Be prepared physically and mentally.There is a chance that you won’t be able to sleep for 28 hours. Please rest before your call day. Take advantage of opportunities to rest if there is a down time (day or night)You cannot spend more than 28 hours continuously. So you will definitely leave at 12noon the next day when you are on long call.The pre-call resident starts at 8am and leaves at 7pm (no exceptions)
FOUR for Cardiac Arrest
1. 3% saline 500bolus and 100ml/hr Chem10. q3 hours til NA 160
2. Keppra 1500 bid X1 day
3. Tylenol ATC
4. Cooling 35.5-36.5
Others
Consider steroids
Keep PO2 less than 100
Keep PCO2 around 40
Baseline CT
FOUR for Dye Induced Nephropathy
1. Mucomyst 1200 bid X4doses
2. Vit C 3G daily for 2 days
3. Bicarb 100mls/Hr X1 litre
4. Remote ischemic preconditioning
Four Postmortem
BRIEF Event note describing death exam and ACLS (if any)D/C summary (no meds)Death certificateCall PCP service, leave a message
OthersNurses will call NEOB immediatelyResident to call family and intensivist
Any procedure that is normally done in the ICU by the intensivist, cardiologist or neurologist should by the resident supervised by such physician.
Certain procedures are considered an life and death emergency and you need to do it whether you have done it before or notExample; insertion of decompression needle for tension pneumothorax using 14 gauge angiocaths or 12 gauge inserted perpendicular to the chest wall in the second intercostals space at the midclavicular line. Note; that only applies to tension pneumothorax.
Example; changing a non-cuffed, more than 14-day-old tracheostomy tube to a cuffed one. Note; the anesthesiologist should be standby for possible need for laryngoscopic intubation. Note; if the tracheostomy is less than 14 days old, surgery resident should be consulted immediately.
Example; pericardiocentesis during a code.
Our goal for intensive insulin therapy is 120-150
All patients in the unit should be on insulin sliding scale to maintain blood sugar below 150.
Five categories of patients need insulin drip if blood sugar is above 160 for 2 consecutive values;Mechanically ventilated patientThe septic shock patientSurgical patients with contaminated surgery
Once on the insulin protocol, you have to chose a source of glucose, e.g. tube feeds, TPN or D5NS etc
Head of the bed elevation
Cuff pressure more than 20 cmH2O
Peridex/ nystatin mouth wash
Reglan unless contraindicated
Daily sedation holiday
Protonix
Lovenox. Heparin SC
Albuterol inhalation
No patient should be transferred to a tertiary care center because he/she is too sick for Brockton. Patients should be transferred for a specific reason/ service that is not available at Brockton or if the family requests so.
All transfers should be discussed with the intensivist before initiation of family discussion.
There is a daily ICU lecture on the weekdays at 8Am. Please make every effort to attend and put it at the top priority.
Lecture topics are attached. The schedule will vary depending on your topic requests and experience.
Journal club: each resident will choose or be assigned an article to present in 15 minutes. If you have an interesting case, the discussion could start with the case and then the article.
Nurses are essential to daily rounds
Nutritionists like to be consulted on every patient that is not eating by mouth. That doesn’t mean that you can’t initiate feeds with what you feel appropriate until nutrition see the patient.
Respiratory therapists are an integral part of the learning experience. Unless there is a specific order written, residents should be by the bedside with the respiratory therapists trying different modes of ventilation for the decompensated patient. Residents are also encouraged to be there during patient extubation if possible.
Rounds start at 7:10Am. The attending and the postcall resident will start. At 8Am, lecture is given. At 9:00-9:15 Am preparation for sitting rounds. sitting rounds followed by walk rounds to conclude at 12:00 Noon or before 1330 as a maximum. After walk rounds, procedures are done.
Presentation starts with a brief history then 24-hour events (or merely overnight events) then numbers and meds then system by system plan. There will be no interruption of the presenting resident.
The short call resident is responsible for all non-rounds related activities. You may be required to answer questions that you just met for the first time. Check with your colleagues for questions and sign-out.
All CMO patients need social work consult after CMO order is signed. The nurse also informs the ethics committee.
Ideally all CMO patients should be transferred to the floor or TCU.
Brockton DNR should not be confusing. It means NO defibrillation, NO pacing, NO chest compression, NO ACLS medications, NO endotracheal intubation OOOONLY in the case of cardiac arrest. All of the above could be done if the patient has a pulse.
CMO means no treatments i.e. no meds, no antibiotics, no nutrition, no oxygen, no labs, no tests. You can only give analgesics, sedatives, anticonvulsants, antiemetics, antisialogogues---etc for comfort only. That is different than hospice care. Hospice care should be at least DNR, DNI and no hospital admission.
Our hospital doesn’t recognize decisions made by the next of kin. If the patient is incompetent and has a healthcare proxy, a proxy invocation form will be filled and then consents will be obtained from the healthcare proxy. If the patient is incompetent and doesn’t have healthcare proxy, the next of kin will be informed and administrative consents will be obtained. Emergency care doesn’t need consent. If the patient is competent, consents will be obtained from the patient and a social work consult will be obtained to encourage the patient to assign a healthcare proxy for future occurrences.
Every day you’ll be asked on rounds if you spoke to the family or not. Social work and nursing could in certain patients be a sufficient substitute for the residents talking to families. If social work identifies a potentially complicated family, a family meeting will be scheduled ASAP.
Septic shock patient maximum ER to ICU time 60 minutes.
EGDT including an upper body line and only for 6 hours. Also applies to floor or post surgical patients
Broad-spectrum antibiotics within 4 hours with preceding cultures.
Early Levophed, vassopresin, no dopamine.
Intensive insulin
Steroids
This rotation is all about triage skills and prioritization. Take advantage of that. For example ER patients who are mechanically ventilated and/or on pressors do not absolutely have to be evaluated in the ER.
CAP, MI and CHF.
For CAP please follow the attached CMS guidelines. The bottom line you have to have a very strong reason to start a CAP patient on anything other than ceftriaxone IV and azithromycin IV (both IV). If the first dose was PO, give it again IV. If a different antibiotic was given, still give ceftriaxone and azithro IV. These required interventions/orders are in bald print on the admission order sheet.
Documentation in the progress note is imperative. You can’t write just pneumonia. You have to specify CAP, HAP, HCAP or aspiration pneumonia. Note; core measures only include CAP. Note you need to write no pneumonia if you are stopping the antibiotics that were started to treat CAP.
SCIP ( surgical measures): remove Foleys within 2 days of surgery or document the reason to keep Foley, beta blocker when appropriate, postop prophylactic antibiotics for less than 24 hours. Please leave the perioperative antibiotic form valid and don’t reorder the prophylactic antibiotics.
Orders have to be clear, complete and cannot ever be confusing.
Sign telephone orders from any one of the team within 24 hours, print, date and time it at the time of your signature. Keep telephone and verbal orders to a minimum.
Cooling to 36 degrees celcius.
3% saline
Keppra prophylaxis
Tylenol standing
Possible steroids
Keep PO2 less than 100
Keep PCO2 around 40
Try to involve the interns in CCU patient care as much as you can.
Try to teach them and supervise them as much as you can
We own 5 BIS Monitors. Try to use them at all times. Try to prioritize. Paralyzed patients obviously have a priority.
Enjoy the resources that we have here. Cathy Schwartz and Barbie Malacaria are available for any logistic/ staffing/ how to do questions.
Roger Browm, our clinical pharmacist, is on call 24/7 for any questions.
Before touching any ICU patient, we are required to clean hand with Calstat.
Strict adherence to universal precautions in patients with resistant organisms.
If you suspect C-diff send the toxin assay and put the patient on precautions until the results of the test and wash hands with soap and water
- Documentation tool is available on all floors on the crash cart.
- Half the tool is filled by the patient’s nurse and the other half is a short note written by the CCU resident.
- The primary team is the CCU resident, CCU nurse supervisor or manager, and the respiratory therapist,
- Secondary responders who will respond if specifically called: surgery resident, lab, blood bank, pharmacy, phlebotomy.
- Surgery patients: the surgery resident will replace the CCU resident.
- Pediatric patients: the RRT will stabilize but the care will be directed by the pediatrician in house.
- Any questions regarding RRT should be directed to the intensivist on call.
- The resident is supposed to give a call to the primary care physician or the hospitalist in charge of the patient and document as such.
All consults can be placed as a service consult except nephrology, you have to specify the group.
Restricted antibiotics are (Zosin, carbapenems,Tigecyclin, Antifungals, Linezolid). You have to call Dr. Greenberg for approval till 5pm and then the ID person on call after hours to approve the second dose onwards. The first dose doesn’t require approvals.
If there is no response from ID within the 60 minutes, call pharmacy. They will give you the antibiotic.
Preferred antibiotic regimen for HCAP/HAP/VAP is (vanco, ceftaz, cipro).
The CCU team consists of the intensivists, residents, advanced practice providers, and a transitional year intern. All patients are admitted to the intensivist service except Bariatric surgery and when an explicit request from the surgeon to keep on surgical service is put forth.When called for an evaluation and after making the assessment and the plan, call the intensivist and run the case by him/Her. Following that, you need to convey your plan for disposition to the attending physician/ hospitalist. If there is any disagreement about the disposition, the hospitalist/ attending physician may call the intensivist to discuss the case. In case of ER evaluations, if the CCU resident and the intensivist agree to decline the unit admission of a patient, the unit resident will call the hospitalist that will be accepting the patient on the floor and discuss the case with him/her. Decision about ER patient disposition should be made within 30 minutes as much as possible.
All lines should be supervised by the intensivist. If the line is needed urgently and the intensivist is involved with another patient, the ER physician will help. The CCU residents are encouraged in certain situations to place IntraOsseous lines or call the ER nurse to do it.
Procedure note should be filled and it also includes site verification and procedural sedation if any. Also fill the name of the supervising attending.
If the line was done using ultrasound guidance, please indicate that in the procedure note.
Logs for procedures need to be filled through rotation and periodically during the rotation.
The preferred site is subclavian followed by internal jugular followed by external jugular. Femoral lines are not acceptable. If in a code situation or came from the ER with a femoral line, line will be removed within 24 hours.
The resident alone can conduct discussions with the family about CMO but preferably the intensivist, hospitalist, primary care attending, nurse and/or social worker should be present. Before initiation of CMO discussions, the intensivist needs to be informed.
Our hospital doesn’t recognize decisions made by the next of kin. If the patient is incompetent and has a healthcare proxy, a proxy invocation form will be filled and then consents will be obtained from the healthcare proxy. If the patient is incompetent and doesn’t have healthcare proxy, the next of kin will be informed and administrative consents will be obtained. Emergency care doesn’t need consent.
On admission, the CCU resident will dictate a history and physical if the patient is coming from the ER, C3, TCU or direct admission from an outside facility. The resident will write an admission note in case of floor transfers. The MICU resident will also write all the admission orders, inform the CCU charge nurse and update the sign out.
No orders on the CCU service patients will be accepted except from the ICU team. Consultants, hospitalists, surgeons or primary care physicians are encouraged to see the patients and write the recommendation in their consults and/or communicate verbally with the MICU resident.
On transfer to the floor, the CCU resident will write the transfer order, transfer order set and a brief transfer note. If the floor that the patient is going to is known, the CCU resident will contact the hospitalist assigned to that floor for verbal sign-out (phone list available) and document the name of the hospitalist receiving the sign-out.
In case of delay in communication, the CCU resident will inform the CCU director or nurse manager. If by 4pm the patient is not assigned a bed still, The CCU resident will call the admitting hospitalist to give a verbal sign-out for the patients leaving the unit. P.S. all telemetry patients go to B2 (B2 hospitalists are to be contacted as soon as the decision to transfer is made)
On transfer to an outside facility or discharge of patients to home with visiting nurse or hospice services, the CCU resident will fill the transfer documents (page 1, dictation of discharge summary).
On discharge without services, the CCU resident will dictate the discharge summary, write the needed prescriptions and write a list of the discharge medication in the orders section of the chart.
In case of patient’s death, in addition to discharge summary, the ICU resident will inform the intensivist and the primary care physician’s service anytime day or night. The nurse will inform NEOB.
A copy of all dictations should be sent to the primary care physician.
Closed ICU and interaction with other services
Line Placement
Presentations
Page 1 of 2
Swing Resident
Emergencies
DNR, CMO, Consent, Healthcare proxy
Ventilator associated Pneumonia / Ventilator Bundle
The Septic Shock Bundle
Blood Sugar
Didactics
Transfers
Triage Skills
Procedures
Nurses, Nutritionists, Respiratory Therapists
CCU Order Sets
Table of Contents
Overview
BIDMC Resident Orientation
All calls for questions about the patients should be directed to the intensivists FIRST (no exceptions) who may in turn ask for emergent/urgent subspecialty consultations or to contact the original service. The resident is obligated to inform the intensivist of any change in the patients’ conditions.
If you are having trouble getting a response from any service, please call the intensivist.
Time requirements to inform the intensivist: A] maximum of 2 hours after admitting a patient (remember, this is the max. That means you can call multiple times before, during and after the admission process, but if you have no questions and it’s a straightforward admission, you still need to make a contact with the intensivist within 2 hours. B] Immediately when you decide not to accept a patient before you talk to the other services. This is designed to guide you through a different community hospital setting that you are not used to. C] Before you initiate CMO discussions (unless planned). D] Not more than 8 hours after patient’s death. E] Before you perform an invasive procedure. F] Immediately if there’s a major change in patient status.
If the patient is competent, consents will be obtained from the patient and a social work consult will be obtained to encourage the patient to assign a healthcare proxy for future occurrences.
Every day you’ll be asked on rounds if you spoke to the family or not. Social work and nursing could in certain patients be a sufficient substitute for the residents talking to families. If social work identifies a potentially complicated family, a family meeting will be scheduled ASAP.
Calling the intensivist: Any intensivist who covers has to provide at least 2 methods of contact. Call the second number immediately if no response for the first number. We observe Leap-Frog guidelines. The contact between the resident and the intensivist has to happen in less than 10 minutes. If you can’t reach the intensivist for any reason, call Dr. Sorour cell phone number, if no response, hang up and call again IMMEDIATELY (don’t wait), if still no response, IMMEDIATELY call home, if not call Beeper, wait 2 minutes, if no response, call wife’s phone, if no response, IMMEDIATELY call son’s phone, if no response, wait 30 minutes, call the cell phone one more time if no response, call the Anesthesiologist on call who in turn will call the Chief of Anesthesia who in turn will arrange for coverage.
Texting is acceptable but you have to get a response to ensure that the contact has happened.
Use universal precautions with a full body drape technique. The supervising attending should be fully gowned and gloved. All personnel in the room should wear a mask. A lines and other procedure require full sterility, hat and a mask but not necessarily a gown. Use antibiotic impregnated catheters and biopatches to decrease line infection.
Changing lines over wire should be avoided when possible.
Line kits have everything that you need for the procedure. Do not open the line kits to take an item and then put them back.
Line tip cultures should only be performed only when the patient has signs of systemic or local infection.
FOUR for Every Foley Insertion
1. UA
2. Urine Culture (not reflex)
3. Cranberry 120ml pot id
4. Bacitracin to the meatus 1 Pack BID
Dobhoff Insertion Technique
Awake Fiberoptic Intubation
Alcohol Withdrawal Algorithm
Acidosis Algorithm
Routine Bilevel
1) Insert 25cm and place end in cup of water
2) Look for bubbles. If yes, in airway. If no, in esophagus
3) Advance to 50cm
4) Inject 100 cc of water
5) Roll patient on right side
1.The fluid and right decubitus help to advance into small intestine
6) Advance to 75cm
7) Take Abd X-ray to confirm position
20 min
1. Reglan 10
2. Robinul 0.4
3. ETT in warm water
10 min
1. 4% lido neb
2. Cetacaine spray
3. Atomizer lido
4. Viscous lidocaine
5. Lido ointment
( Afrin nasal spray and neo lido soaked Q tips)
1min
Haldol and. Benadryl
Open App
Feedback
The information in this application is meant to foster communication between members of the peri-operative team. It can be modified at any time and without prior notice. It does not constitute medical advice and in no way supersedes the judgement of the practitioners.
Difficult Mask Ventilation
CVCI
(Can’t Ventilate Can’t Intubate)
Difficult Intubation Score
Brockton Predicted Difficult Airway Pathway
Please Rotate Your Phone
(Press to Zoom)
Use a syringe of Urojet 2 sprays of Afrin in the nostrilStart with the right side if the 2 nostrils are equal (or the larger nostril)The insertion direction of the NGT should be pointing towards the occiput not towards the top of the head.Positioning in the sitting position with flexed head foreword (chin touching the chest)Hold head in Flexion position in non-cooperative patients.Chose the largest size for NGT that will fit comfortably ( less chance of kinking).Measure the NGT on the patient’s body from the outside to determine the desired depth. Instruct patient to sip water using a straw after the NGT passes the nasopharynx.If repeated entry into the lungs or if the respiratory rate is more than 25 bpm, put the outer end under water (when 30cm mark is reached) to look for bubbles. In case of the presence of bubbles, withdraw and advance the NGT only to 15cm and then time further advance with exhalation or coughing.
Use a syringe of Urojet 2 sprays of Afrin in the nostrilStart with the right side if the 2 nostrils are equal (or the larger nostril)The insertion direction of the NGT should be pointing towards the occiput not towards the top of the head.Positioning in the sitting position with flexed head foreword (chin touching the chest)Hold head in Flexion position in non-cooperative patients.Chose the largest size for NGT that will fit comfortably ( less chance of kinking).Measure the NGT on the patient’s body from the outside to determine the desired depth. Instruct patient to sip water using a straw after the NGT passes the nasopharynx.If repeated entry into the lungs or if the respiratory rate is more than 25 bpm, put the outer end under water (when 30cm mark is reached) to look for bubbles. In case of the presence of bubbles, withdraw and advance the NGT only to 15cm and then time further advance with exhalation or coughing.
The advance should be quick.NGT tape Appropriate chemical and mechanical restraints Consider the bridleinsert the NGT in Cold water if repeated coiling Intermittent not continuous suction Confirm positioning with auscultation (and CXR if tube feeds are to be started)If the patient is intubated, insertion using a laryngoscope can be performed (if coiling is the problem)If the issue is further than 30cm, then call GI for endoscopic placement.
Acetylcysteine/APAP OverdoseAminocaproic Acid Bolus/Maint –Amniodarone – 110 timesCapsofungin Bolus/MaintCCU – Admission Order SetCCU – Alcohol WithdrawalCCU – AM Labs/TestsCCU – Diuresis ProtocolCCU – Epidural AnalgesiaCCU – Foley BundleCCU – Lumbar PunctureCCU – Paracentesis Order SetCCU – Paralytics – 14 timesCCU – Regular Insulin SetCCU – Sepsis of Unknown Origin CCU – Septic ShockCCU – Thoracentesis Order SetCCU – Tube FeedsCCU – Urine LytesCCU – Vap Protocol
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cefTAZidime Bolus/MaintCisatracurium Bolus/Maint Dexmedetomidine Bolus/MaintDigoxin Bolus/Maint AbnormalDigoxin Bolus/Maint NormalElectrolyte ReplacementEptifibatide Renal Bolus/MaintEptifibatide Standard Bolus/MaintEsmolol Bolus/MaintExtubation SetFluconazole Abnormal Bolus/MaintFluconazole Normal Bolus/MaintFurosemide Bolus/MaintIMIpenem/Cilastatin Bolus/MaintLevETIRAcetam Bolus/MaintMethylene Blue ProtocolPhenytoin Bolus/MaintTromethamine Bolus/Maint (Tham)Tube FeedingsZosyn Bolus/Maint