On-Call Pearls: Quick Reference Guide

A rapid-access clinical resource for overnight hospital calls and acute clinical scenarios. This guide emphasizes rapid assessment, red flag identification, and evidence-based interventions for the busy resident.

Pain Management

Every pain complaint requires structured evaluation before jumping to narcotics.

Initial Assessment Framework

Before prescribing, always determine:

Nature of pain: Is this new acute pain or exacerbation of chronic pain?
Characterization: Use PQRST (Provocation, Quality, Radiation, Severity, Timing)
Red flags requiring urgent intervention:
Fever with new pain (infection/sepsis)
Focal neurological deficits (CVA, cord compression)
Loss of consciousness
Hemodynamic instability

Red Flag Presentation

New acute pain with fever, focal deficits, or hemodynamic changes requires urgent evaluation. Do not mask symptoms with pain medications until serious causes are excluded.

Non-Opioid Analgesics (First-Line)

Always attempt non-pharmacologic and non-opioid approaches before opioids.

Medication	Dosing	Indications	Cautions
Lidocaine patches	Apply topically q12h	Localized neuropathic, musculoskeletal pain	Max 3 patches simultaneously
Acetaminophen	650mg PO/PR q6h	Mild-moderate pain, fever	Max 4g/day; avoid active liver disease
Ibuprofen	200–800mg PO q6h	Mild-moderate pain, inflammation	Avoid GI bleed, GERD, ACS, CHF, AKI
Naproxen	500mg PO q12h	Mild-moderate pain	Avoid GI bleed, GERD, ACS, CHF, AKI
Ketorolac	30mg IV/PO q6h (max 5 days)	Moderate acute pain	Avoid GI bleed, GERD, ACS, CHF, AKI; short duration only

Opioid Analgesics (When Necessary)

When opioids are indicated, use the lowest effective dose for the shortest duration. Prefer oral formulations when possible.

Medication	Dosing	Duration	Notes
Tramadol	50mg PO q4–6h	4–6 hours	Use cautiously; lower seizure threshold
Hydrocodone/APAP	5–10mg/325mg PO q4–6h	4–6 hours	Watch total acetaminophen dose
Oxycodone	5mg PO q4–6h	4–6 hours	Short-acting, useful for acute pain
Morphine (IR)	15–30mg PO q4h or 2–4mg IV q4h	4 hours	Use lower IV doses in renal disease
Hydromorphone (Dilaudid)	1mg IV q4–6h (0.5mg if elderly/frail)	3–4 hours	Potent; appropriate for severe pain
Fentanyl	0.1mg IV (onset 1–2 min)	1–2 hours	Reserved for acute severe pain

Opioid Prescribing Strategy

Write one-time orders rather than standing schedules when possible. Reassess need at every interaction. Always offer non-opioid alternatives first.

Respiratory Depression Risk

Monitor for respiratory depression and altered mental status, especially in elderly patients and those with underlying pulmonary disease. Keep Narcan at bedside.

Opioid Reversal

Naloxone (Narcan): 0.4mg IV; repeat q2–3min if needed. Watch for opioid withdrawal.

Opioid Conversion Reference

When switching between opioid formulations, convert to morphine equivalent first (MEQ), then calculate the new agent dose.

Drug (Route)	IV Morphine Equivalent	PO Equivalent	Duration
Morphine (IV)	10mg = 1 MEQ	30mg PO	4 hours
Hydrocodone (PO)	—	30mg PO	4 hours
Oxycodone (PO)	—	20mg PO	4 hours
Oxycodone (IV)	10mg = 1 MEQ	—	4 hours
Tramadol (IV/PO)	100mg IV = 1 MEQ	120mg PO	4 hours
Hydromorphone (IV)	1.5mg IV = 1 MEQ	7.5mg PO	4 hours
Fentanyl (IV)	0.1mg = 1 MEQ	—	1–2 hours

Nausea and Vomiting

Nausea is a symptom, not a diagnosis. Always consider the underlying etiology before treating.

Differential Diagnosis Framework

Critical Assessment

Before administering antiemetics, obtain:

Vital signs (fever, tachycardia, hypotension suggest serious pathology)
Focused abdominal and neurological exam
Consider stat imaging (CT abdomen/pelvis, CT head) if red flags present
Check recent labs and medication list

Antiemetic Medications

Drug	Dosing	Mechanism	Cautions
Ondansetron	4–8mg PO/IV q8h	5-HT3 antagonist	Check QTc; avoid if prolonged
Promethazine	25mg IV or 50mg PO q4–6h	Anticholinergic + antihistamine	Sedating; caution in elderly; risk of necrosis if IV push extravasates
Metoclopramide	10mg IV/PO q6h	Dopamine antagonist	Check QTc; avoid in bowel obstruction
Prochlorperazine	5–10mg IV q4–6h	Dopamine antagonist	Monitor for dystonia, QTc prolongation

Assessment Required

Do not reflexively prescribe antiemetics without evaluation. Masking symptoms may delay diagnosis of serious pathology (obstruction, GI perforation, CNS lesion).

Insomnia

Insomnia in hospitalized patients often reflects underlying disease or medication effects, not merely poor sleep hygiene.

Root Cause Identification

Before reaching for sedatives, investigate:

Pain (undertreated analgesia is a major cause)
Delirium (confusion/disorientation with insomnia suggests encephalopathy, not primary insomnia)
Medication withdrawal (benzodiazepines, alcohol)
Environmental factors (frequent vital signs, monitors, roommate)
Circadian disruption (overhead lighting, frequent daytime sleeping)

Non-Pharmacologic Interventions

Consolidate vital signs and lab work to minimize nighttime interruptions
Dim lights after dusk; encourage daytime activity
Address pain adequately
Avoid sedating medications early in the morning (impairs neuro exam)

Sleep Medication Options

Drug	Dosing	Notes
Melatonin	3–9mg PO qhs	Natural, low risk; variable efficacy
Trazodone	25–100mg PO qhs (start low)	Can cause orthostatic hypotension and priapism
Zolpidem	5mg PO qhs	Extreme caution in elderly (fall risk, delirium)
Diphenhydramine	25–50mg PO qhs	Use only in young, healthy patients; anticholinergic risks in elderly

Benzodiazepines Contraindicated

Never use benzodiazepines for insomnia in hospitalized patients. Markedly increases delirium risk, falls, and respiratory depression. Reserve benzos only for seizure, severe anxiety, or withdrawal.

Anxiety

Anxiety can be a symptom of serious underlying illness. Always differentiate primary anxiety from secondary causes.

Red Flags: Anxiety Masking Critical Illness

Anxiety + tachypnea: Suspect PE, pneumonia, sepsis, MI
Anxiety + disorientation: Suspect hypoglycemia, delirium, hypoxia
Anxiety + fever: Suspect sepsis, meningitis
Anxiety + chest pain: Suspect ACS, PE, pneumothorax

Medication History

Carefully review home medications: - Is the patient on chronic benzodiazepines? If yes, holding them may cause withdrawal (tachycardia, tremor, agitation) - If withdrawal suspected, institute benzodiazepine replacement before acute anxiety treatment

Anxiolytic Options

Drug	Dosing	Duration	Notes
Lorazepam	1–2mg PO/IV q4–6h	4–6 hours	Short-acting; monitor for over-sedation
Alprazolam	0.25–0.5mg PO q8h	6–8 hours	Longer-acting; avoid in renal failure
Hydroxyzine	50–100mg PO/IV q4–6h	6 hours	Non-controlled; good alternative to benzos

Benzodiazepine Caution

Use short-acting benzodiazepines cautiously. Monitor for delirium, respiratory depression, and falls. Always rule out serious causes before treating anxiety pharmacologically.

Hypertension

Hypertension in hospitalized patients is usually reactive. Aggressive treatment can cause harm.

Initial Evaluation

Differentiate acute hypertensive urgency from hypertensive emergency:

Hypertensive urgency: SBP/DBP >180/120 WITHOUT end-organ damage (asymptomatic)
Hypertensive emergency: SBP/DBP >180/120 WITH end-organ symptoms

Red Flag Symptoms (Hypertensive Emergency)

Chest pain or dyspnea
Severe headache
Vision changes or fundoscopic papilledema
Focal neurological deficits
Decreased urine output
Signs of left ventricular failure (orthopnea, pulmonary edema)

Workup for Severe HTN

Study	Purpose
EKG	Assess for ischemia, LVH
Troponin	Rule out ACS
CXR	Evaluate for pulmonary edema
Metabolic panel	Assess renal function, K
CBC with differential smear	Rule out hemolysis, thrombotic microangiopathy
Urinalysis	Check for proteinuria, RBC casts
Head CT	If altered mental status or neuro findings

Antihypertensive Agents

Oral Agents (for hypertensive urgency, asymptomatic)

Drug	Dosing	Mechanism	Cautions
Clonidine	0.1–0.3mg PO	Central alpha-2 agonist	Reflex tachycardia; rebound HTN if stopped abruptly
Captopril	25mg PO	ACE inhibitor	Caution in AKI; hyperkalemia risk
Carvedilol	3.125–25mg PO	Combined alpha/beta-blocker	Avoid if HR <55; may worsen CHF acutely
Amlodipine	2.5–10mg PO	Calcium channel blocker	Slower onset; good for chronic control

Intravenous Agents (for more rapid control or hemodynamic instability)

Drug	Dosing	Onset	Cautions
Labetalol	10–20mg IV q4–6h	5–10 min	Avoid in acute CHF, bradycardia
Hydralazine	10–20mg IV q6h	10–20 min	Reflex tachycardia; lupus-like syndrome with chronic use
Nicardipine	5–15mcg/kg/min drip	5–10 min	Titrable; good for rapid control
NTG drip	5–400mcg/min	1–3 min	Use for ACS + HTN; causes tachyphylaxis

Treatment Goals

Hypertensive urgency (asymptomatic, >180/120): Gradual reduction; target <160/100 over hours
Hypertensive emergency (symptomatic): Controlled reduction; target 75% of admission BP initially
Maximum safe reduction: Do not drop MAP >30% or SBP >40mmHg in first hour (risk of stroke, AKI)

Conservative Approach

Avoid aggressive BP lowering in asymptomatic patients. Most hypertension resolves with treatment of underlying cause (pain, anxiety, retained urine, constipation) without antihypertensive medications.

Hypotension

Hypotension is a sign, not a diagnosis. Always assess volume status, cardiac function, and perfusion.

Immediate Actions

Recheck BP (verify it's not a cuff artifact)
Review medications (timing, doses—did a vasodilator just get given?)
Assess symptoms: Dizziness, chest pain, dyspnea, confusion
Check telemetry: Arrhythmia? Bradycardia?
Baseline BP: Is this patient's normal BP?

Clinical Assessment

Exam: Skin perfusion, mental status, urine output, JVD, lung sounds, lower extremity edema
Bedside ultrasound: IVC diameter and collapsibility (assess volume status); look for free fluid (bleeding) or pericardial effusion (tamponade)

Shock Classification

Stabilization

If hemodynamically unstable (altered mental status, signs of poor perfusion):

Lay patient flat
Activate rapid response/call attending
Establish IV access (two large-bore lines)
Begin fluid resuscitation (bolus 500mL–1L over 15–30min if hypovolemic)
Supplemental oxygen to maintain SpO2 >94%
Prepare for transfer to ICU

Diagnostic Labs and Imaging

Test	Rationale
CBC	Evaluate for anemia, infection
Metabolic panel	Assess renal function, electrolytes, glucose
PT/INR	Coagulopathy assessment
Lactate	Marker of tissue hypoperfusion
Blood cultures	If sepsis suspected
Type & screen	For potential transfusion
EKG	Assess for ischemia, arrhythmia
CXR	Pulmonary edema, cardiomegaly, pneumonia
Transthoracic echo	Cardiac function, pericardial effusion, tamponade
CT PE protocol	If PE suspected (high risk, D-dimer positive)
Abdominal imaging	If occult bleeding suspected (CT with contrast)

Ongoing Management

Reassess BP and perfusion q15–30min until stable
Avoid unnecessary diuretics (worsens hypovolemia)
Target urine output ≥0.5mL/kg/h
Persistent hypotension despite fluids: ICU transfer, central line placement, vasopressor consideration

Red Flag: Persistent Shock

If SBP remains <90 despite fluids, or if patient shows signs of end-organ dysfunction (creatinine rising, altered mental status), transfer to ICU immediately.

Confusion and Agitation

Confusion and agitation are NEVER nuisance calls. They represent acute changes in mental status that demand rapid evaluation for life-threatening causes.

Differential Diagnosis

Common etiologies in hospitalized patients:

Medications: Anticholinergics, corticosteroids, dopamine agonists, antibiotics (fluoroquinolones, macrolides)
Neurological: Stroke, intracranial hemorrhage, seizures
Hypoxia/Hypercarbia: Low SpO2, high CO2 from respiratory failure
Metabolic: Hypoglycemia, hyponatremia, hypercalcemia, uremia
Infectious: Sepsis, UTI, meningitis, encephalitis
Circulatory: Poor cerebral perfusion, arrhythmia
Toxidromes: Anticholinergic, cholinergic, withdrawal (alcohol, benzodiazepines)
Environmental: Dehydration, constipation, retained catheter/foley

Initial Assessment

Vital signs: Fever (infection), tachycardia (sepsis, hypoxia), hypotension (shock)
Recent medication administration: Timing and agents
Physical violence risk: Assess for danger to self/others before approaching
Catheter/lines: Retained foley, feeding tube (common delirium triggers)

Diagnostic Workup (Order Immediately)

Test	Rationale
Accucheck	Hypoglycemia is reversible; check first
Pulse oximetry/ABG	Hypoxia, hypercarbia
CBC with differential	Infection, anemia
Metabolic panel	Na, glucose, Cr, urea
Urinalysis	UTI (often subtle in elderly)
Urine and blood cultures	Infection workup
EKG	Arrhythmia, ischemia
CXR	Pneumonia, pulmonary edema
Head CT	If focal deficits, trauma, or sudden onset
Urine drug screen	Assess for intoxication, withdrawal

Specific Interventions by Cause

Cause	Immediate Action
Hypoglycemia	Dextrose 50% 1 amp IV or IM glucagon
Opioid overdose	Naloxone 0.4mg IV
Benzodiazepine overdose	Flumazenil 0.2mg IV (caution: seizure risk)
Stroke concern	STAT head CT; call neurology
Seizure	Lorazepam 2–4mg IV; EEG if persistent seizure
Withdrawal (CIWA score)	Benzodiazepine dosing per CIWA protocol
Sepsis	Blood cultures, broad-spectrum antibiotics, fluids
Hypercarbia	Assess ventilation; consider intubation if severe

Pharmacologic Management

Only after reversible causes are addressed.

Oral Medications (for agitation with some cooperation)

Drug	Dosing	Notes
Quetiapine	12.5–25mg PO	Start low; minimal orthostasis at low doses
Haloperidol	2–5mg PO (1mg if elderly)	Typical antipsychotic; monitor QTc
Risperidone	0.5–1mg PO	Atypical; less dystonia risk
Olanzapine	2.5–5mg PO	Atypical; lower dystonia risk
Aripiprazole	2–5mg PO	Atypical; use if QTc >500ms

IM/IV Medications (for severe agitation, no cooperation)

Drug	Dosing	Duration	Notes
Haloperidol	2–5mg IV/IM	4–6 hours	Monitor QTc; max 20mg/day
Olanzapine	2.5–5mg IM	4–6 hours	Good IM option
Ziprasidone	10mg IM	2–4 hours	Lower dystonia; good short-term use

Nonpharmacologic Strategies

Reorientation: Frequent interaction, clock/calendar visible, family presence
Environmental: Minimize stimuli (dim unnecessary lights, reduce alarm volume)
Comfort: Address pain, ensure adequate bathroom access
Lines/tubes: Remove unnecessary catheters, central lines, feeding tubes
Monitoring: 1:1 sitter for safety; bed alarm for fall risk
Avoid restraints unless absolutely last resort (increase agitation, thromboembolism risk)

QTc Monitoring

Obtain EKG before and periodically during antipsychotic therapy. Discontinue if QTc >500ms.

Avoid Benzodiazepines and Anticholinergics

These worsen delirium. Reserve benzodiazepines only for seizure, severe withdrawal, or acute anxiety in specific contexts. Never use anticholinergics (diphenhydramine, scopolamine).

Fall Evaluation and Prevention

Falls cause significant morbidity. Systematic evaluation is essential.

Circumstances of Fall

Witnessed vs. unwitnessed: Affects diagnostic approach
Syncope: Loss of consciousness suggests arrhythmia, severe hypotension
Weakness: Stroke, spinal cord compression, severe infection
Incoordination: Cerebellar process, intoxication, medication toxicity
Confusion: Delirium, hypoglycemia
Environmental: Unsafe mobility aids, bed height, obstacles

Medication Review

Excessive sedation from recent doses (opioids, sedatives, anticholinergics)
Antihypertensives causing orthostasis
Over-aggressive diuresis
Recent initiation of drugs affecting balance

Physical Examination

General: Height of fall, landing surface, immediate complaints
Head/neck: Trauma, lacerations, palpable step-offs
Neuro exam: Mental status, focal deficits, cranial nerves, strength
Orthostatics: BP and HR lying/sitting/standing
ROM: Painful areas, restricted movement suggesting occult fracture
Skin: Lacerations, contusions, integrity

Diagnostic Imaging

Indication for CT Head/Spine	Indication for X-rays
Fall from height on anticoagulants	Complaints of pain in specific area
Loss of consciousness	Mechanism suggests fracture
Focal neurological deficit	Immobility/inability to bear weight
High-risk mechanism	Fall in elderly on anticoagulation

Fall Prevention Orders

Bed alarm: Alert staff if patient attempts to exit bed
Fall precautions sign: Visual alert for all staff
1:1 sitter: If high fall risk (delirium, intoxication, recent fall)
PT/OT evaluation: Mobility assessment, safe walking aids
Medication review: Consider holding sedating agents if possible
Environmental: Bedside commode, clear pathways, adequate lighting

Constipation

Constipation is uncomfortable and can precipitate delirium. Assess for obstruction before treating.

Red Flags for Obstruction

Before prescribing laxatives, exclude bowel obstruction:

Severe abdominal pain or distension
Absence of flatus or stool for >48h
Persistent nausea/vomiting
Abdominal tenderness or guarding
Consider abdominal X-ray (AXR) if obstruction suspected

Laxatives in Obstruction

Administering laxatives in the setting of mechanical obstruction can cause perforation. Always assess for obstruction first.

Medication Review

Discontinue or reduce if possible:

Opioids (primary culprit; nearly all patients on opioids require bowel regimen)
Anticholinergics (diphenhydramine, atropine, scopolamine patches)
Antihistamines (first-generation H1 blockers)

Bowel Regimen Strategy

Start all patients on opioids with a scheduled bowel regimen from day one. Progress through medications as needed.

Agent	Dosing	Onset	Mechanism	Notes
Docusate	100mg PO BID	24–72h	Stool softener	Ineffective as monotherapy
Miralax	17g PO daily–BID	1–4 days	Osmotic (polyethylene glycol)	Safe, well-tolerated
Magnesium hydroxide	30–60mL PO	6–12h	Osmotic	Avoid in renal failure; rapid onset
Magnesium citrate	150mL PO	Rapid (1–2h)	Osmotic	Very rapid; use when urgent
Lactulose	10–30cc PO q4–6h	1–2h	Osmotic (galactose)	Causes bloating; less tolerated
Senna	2–4 tablets PO daily–BID	6–12h	Stimulant	Natural alternative
Bisacodyl	10–30mg PO or PR	6–10h	Stimulant	Rectal suppository faster
GoLytely	4L PO or NG tube	1–2h	Osmotic (polyethylene glycol solution)	Very aggressive; reserved for severe impaction

Refractory Opioid-Induced Constipation

Methylnaltrexone (Relistor): 8mg or 12mg SC every other day; peripheral mu-opioid antagonist (doesn't cross BBB, so preserves analgesia)
Rectal interventions: Glycerin suppositories, bisacodyl suppositories, enemas (avoid Fleet in renal failure—risk of hyperphosphatemia)
Manual disimpaction: Last resort; may require sedation and GI consultation

Proactive Bowel Management

Do not wait for constipation to develop. Initiate bowel regimens proactively when starting opioids, anticholinergics, or high-dose iron.

Diarrhea

Diarrhea can rapidly lead to dehydration and electrolyte derangement.

Etiologic Assessment

Infectious: C. difficile (recent antibiotics, hospitalization), viral, bacterial (Salmonella, Shigella)
Medication-induced: Antibiotics, magnesium-based laxatives, proton pump inhibitors, metformin
Dietary: High sorbitol, lactose intolerance
Inflammatory: IBD
Functional: Irritable bowel syndrome

Clinical Evaluation

Frequency, volume, consistency: Small frequent stools vs. large volume?
Blood/mucus: Suggests infectious or inflammatory process
Abdominal pain, fever: Infection vs. medication effect
Recent antibiotic use: C. difficile concern
Hydration status: Orthostasis, urine output, mucous membranes

Symptomatic Treatment

Drug	Dosing	Notes
Loperamide	4mg initial dose, then 2mg after each loose stool	Maximum 16mg/day; avoid in bloody diarrhea or toxic megacolon
Bismuth subsalicylate	30mL PO q6h	Anti-inflammatory; acceptable for most infectious diarrhea

Avoid Antidiarrheals in

Bloody diarrhea (risk of toxic megacolon)
Suspected C. difficile (can worsen toxin-mediated injury)
High fever or severe abdominal pain

Fluid Replacement

IV fluids if unable to tolerate PO or severe losses
Electrolyte replacement (especially potassium if on diuretics)
Consider stool studies/C. difficile testing if persistent or blood-stained

Seizure and Status Epilepticus

Seizures represent acute brain dysfunction. Rapid recognition and treatment are essential.

Definitions

Seizure: Single event of abnormal electrical discharge
Status epilepticus: Continuous seizure activity lasting >5 minutes OR recurrent seizures without recovery of consciousness between events

Immediate Actions (ABCS)

Airway: Position on side, avoid forced objects in mouth
Breathing: Ensure adequate ventilation; consider oxygen
Circulation: Establish IV access, continuous monitoring
Seizure termination: See medication algorithm below

Identify Reversible Causes

Treat underlying etiology:

Hypoglycemia: Dextrose 50% 1 amp IV (or 25g glucose PO if conscious)
Hyponatremia: Sodium replacement
Hypocalcemia: Calcium gluconate
Hypomagnesemia: Magnesium replacement
Opioid toxicity: Naloxone 0.4–0.8mg IV
Alcohol/sedative withdrawal: Benzodiazepines
Infection/sepsis: Antibiotics after cultures
Intracranial pathology: Head CT after seizure control

Diagnostic Labs and Imaging

Test	Rationale
Glucose	Hypoglycemia common cause
Electrolytes (Na, Ca, Mg)	Imbalance can trigger seizures
ABG	Assess oxygenation, acidosis
Anticonvulsant levels	If known epileptic on medications
Toxicology screen	Withdrawal, intoxication
CBC	Infection, anemia
Blood cultures	If infection suspected
Head CT	Rule out hemorrhage, structural lesion
EEG	Continuous monitoring if altered mental status or recurrent seizures

Medication Protocol for Seizure Termination

First-Line (Benzodiazepines)

Choose one:

Lorazepam: 0.1mg/kg IV push (typical dose 4mg IV over 2 min); can repeat x2 at 5-min intervals
Midazolam: 0.15mg/kg IV or IM (typical dose 10mg); repeat x2 if needed (onset slightly faster than lorazepam IM)

Second-Line (if first-line fails after 3–5 minutes)

Choose one:

Levetiracetam: 60mg/kg IV (max 4500mg); infuse over 15 min
Fosphenytoin: 20mg phenytoin equivalents (PE)/kg IV (safer than phenytoin); infuse at ≤150mg PE/min
Valproic acid: 30mg/kg IV; infuse at ≤6mg/kg/min
Phenytoin: 20mg/kg IV slow push; monitor cardiac rhythm (risk of arrhythmia, hypotension)

Refractory Status Epilepticus

If seizure persists despite 2 rounds of first-line and second-line agents:

Intubate (protect airway, enable sedation)
Continuous infusions (maintain seizure suppression for 24h after last clinical seizure):
Midazolam: 0.1–2mg/kg/h IV
Propofol: 1–3mg/kg/h IV (risk of propofol infusion syndrome with prolonged use)
Phenobarbital: 15–40mg/kg loading, then 0.5–2mg/kg/h maintenance
Transfer to ICU with neuromonitoring and EEG capability

Post-Seizure Management

Continue second-line antiepileptic for 24h after last seizure before tapering
Head imaging (CT or MRI) to exclude structural lesion
EEG if status lasted >30min or multiple recurrences
Neurology consultation
Assess for aspiration risk; consider NPO pending evaluation

Timing is Critical

Status epilepticus causes permanent neurological injury and death. Aim to terminate seizures within 3–5 minutes of onset.

Shortness of Breath

Dyspnea is a common emergency. Rapid assessment of etiology guides management.

Differential Diagnosis

Initial Rapid Assessment

Immediately determine:

Severity: Can complete sentences? Sitting upright? Cyanotic? Altered mental status?
Vital signs: RR, HR, BP, SpO2, temperature
Timeline: Acute (minutes), subacute (hours), chronic (days)
Last known O2 requirement: Baseline oxygenation status?
Code status: Resuscitation preferences?

Physical Examination

Finding	Differential
Tachypnea (RR >30)	Pulmonary edema, pneumonia, PE, metabolic acidosis
Accessory muscle use	Obstructive airway disease, severe hypoxia
Cyanosis	Severe hypoxemia
Wheezing	Asthma, COPD, CHF (cardiac asthma)
Crackles	Pneumonia, pulmonary edema, atelectasis
Decreased breath sounds	Pneumothorax, pleural effusion, severe airflow obstruction
JVD	Right-sided heart failure, tamponade, tension pneumothorax
Lower extremity edema	Right heart failure, DVT/PE
Reproducible chest wall pain	Musculoskeletal; less likely to be serious

Diagnostic Workup

Test	Rationale
ABG	Assess oxygenation, CO2, acid–base status
CXR	Pneumonia, pneumothorax, pulmonary edema, cardiomegaly
EKG	Ischemia, arrhythmia, signs of PE
Troponin	ACS assessment
D-dimer/CT PE protocol	PE evaluation (especially if risk factors present)
Echocardiogram	Ventricular function, pericardial effusion, RV strain
CBC	Anemia, infection
Procalcitonin	Infection likelihood (if not already on antibiotics)

Oxygen Therapy Escalation

Apply oxygen to maintain SpO2 >94% (>90% in COPD with hypercarbia risk).

Modality	FiO2 Delivered	Use
Nasal cannula	24–40%	Mild hypoxemia, comfort
Face mask	40–60%	Moderate hypoxemia
Venturi mask	24–50% (precise)	COPD with hypercarbia concern
Non-rebreather mask (NRB)	60–95%	Severe hypoxemia; use as bridge
High-flow nasal cannula (HFNC)	Up to 100%	Severe hypoxemia, post-extubation support
BiPAP	Variable (titrate FiO2)	Hypercapnic respiratory failure, pulmonary edema

BiPAP Settings for Respiratory Support

Setting	Starting Value	Titration
IPAP (inspiratory)	10 cmH2O	Increase if poor oxygenation/ventilation
EPAP (expiratory)	5 cmH2O	Increase if refractory hypoxemia
FiO2	100% (titrate down)	Reduce as oxygenation improves

Criteria for ICU/Intubation

Consider transfer to ICU or intubation if:

SpO2 <90% despite 50–100% NRB oxygen
Respiratory rate >35 or <8
Severe accessory muscle use, diaphoresis, altered mental status
Inability to protect airway or handle secretions
PaO2 <60mmHg or PaCO2 >50mmHg on ABG
pH <7.3 (respiratory acidosis)
No improvement on BiPAP after 1–2h

Respiratory Failure

Respiratory failure is defined as pO2 <60 or pCO2 >50 with pH <7.3. Do not delay intubation if hemodynamically unstable or rapidly deteriorating.

Hypoglycemia

Symptomatic hypoglycemia (glucose <70 mg/dL) requires immediate treatment.

Risk Assessment Before Treatment

How low is the glucose? (affects urgency)
Diabetic vs. non-diabetic patient? (influences treatment)
First episode or recurrent? (recurrent suggests medication issue)
Insulin regimen or sulfonylureas? (higher hypoglycemia risk)
NPO status? (affects feeding strategy)
Renal/hepatic failure? (affects glucose metabolism)
Adrenal insufficiency? (contributes to recurrent hypoglycemia)

Symptomatic vs. Asymptomatic

Symptomatic: Tremor, diaphoresis, anxiety, palpitations, altered mental status → treat immediately
Asymptomatic: Incidental low glucose check → cautious treatment to avoid over-correction

Acute Treatment

If symptomatic:

Route	Dose	Onset	Notes
IV dextrose 50%	1 amp (50mL = 25g glucose)	Immediate	Preferred if unable to take PO
IM/SC glucagon	1mg	10–15 min	Effective even if altered mental status; teaches family self-injection
PO dextrose	15g carbs (4oz juice, 4 glucose tablets)	10–15 min	Only if awake and cooperating

Follow-up Glucose Checks and Treatment Adjustments

Glucose Range	Action
<70 mg/dL and symptomatic	Treat with IV dextrose or glucagon; repeat check in 15 min
70–100 mg/dL	Give PO carbs (10–15g) plus protein; recheck in 1h
>100 mg/dL after treatment	Resume normal diet; sign out to day team

Ongoing Management Based on Diabetes Status

Patients WITHOUT diabetes

PO option: Juice, glucose tablets, crackers with peanut butter; recheck in 15 min
No insulin: Do not initiate unless diabetes diagnosed

Patients WITH diabetes

Hold glucose-lowering agents (insulin, sulfonylureas, metformin)
PO option: 15g fast-acting carbs (juice); recheck in 15 min
No PO option: D50 IV or glucagon 1mg IM; repeat checks until glucose >100
Persistent/recurrent hypoglycemia: Continuous IV dextrose infusion

Continuous Dextrose Infusions

Use for persistent hypoglycemia refractory to bolus dosing.

Infusion	Indication
D5W or D5½NS at 75–150mL/h	Standard approach; adequate for most patients
D10 at 50–100mL/h	Use in ESRD/CKD or CHF (fluid-restricted patients)
D20 or D25	Requires central line (risk of phlebitis); rarely used

Medication Adjustments

Sulfonylureas/meglitinides: Hold until glucose normalized; reassess dosing
Insulin: Reduce dose or hold until glucose trend improves
Other agents (metformin, GLP-1 agonists): Hold during hypoglycemia phase; restart once stable

Avoid Over-Treatment

Overcorrection to glucose >200 is common and worsens outcomes. Use 15g carbs, wait 15 min, and recheck. Do not give repeat doses of IV dextrose without rechecking glucose.

Hyperglycemia

Hyperglycemia in hospitalized patients is common. Determine if acute management or sign-out is appropriate.

Assessment

Glucose trend over 24h: Single elevated check vs. persistent elevation?
Symptoms: Polyuria, polydipsia, DKA/HHS warning signs (Kussmaul respirations, fruity breath, altered mental status)?
Recent medications: D5/D10 fluids, corticosteroids, vasopressors?
Baseline glucose control: Diabetic already, or new hyperglycemia?

Inpatient Target Glucose

General ward: 140–180 mg/dL acceptable (tighter control increases hypoglycemia risk)
ICU: 140–180 mg/dL (avoid <110, risk of neuroglycopenia)
Perioperative: 180 mg/dL upper limit

Asymptomatic Mild-to-Moderate Hyperglycemia (140–300 mg/dL)

Sliding scale insulin: Short-acting insulin based on glucose level
Sign out to day team: Allow their endocrinology/diabetes management
Monitor glucose: q6h initially, then q4h if trending up

Symptomatic or Severe Hyperglycemia (>300 mg/dL)

Suspect DKA or HHS if:

Glucose >300–400
Symptomatic: Polyuria, polydipsia, altered mental status, Kussmaul respirations
Metabolic derangement: Check BMP for anion gap metabolic acidosis
Ketones: Urine ketones or serum beta-hydroxybutyrate positive

If DKA/HHS suspected: - Call Endocrinology stat - Transfer to ICU (high-dose insulin infusion, aggressive fluid resuscitation) - Labs: BMP (anion gap, K, Cr), venous/arterial pH, serum beta-hydroxybutyrate, lactate - IV fluids: Normal saline at high rate (typically 500–1000mL/h initially) - Insulin infusion: 0.1 units/kg/h (typically 5–10 units/h)

Medication Review

Remove D5/D10 fluids: Switch to D5W with insulin or non-dextrose-containing IV fluids
Hold corticosteroids if possible or reduce dose
Reduce vasopressor support if glucose normalizing
Adjust renal replacement if on CRRT (dextrose-free dialysate if available)

Stacking Risk in Renal Failure

Avoid giving extra short-acting insulin doses in patients with rising creatinine or ESRD (risk of stacking and prolonged hyperinsulinemia). Use longer-acting agents or insulin infusion instead.

Day Team Sign-Out

Most modest hyperglycemia (140–250) can be safely signed out with a note to recheck glucose and adjust insulin regimen. Reserve ICU transfer for DKA/HHS or glucose >500 with symptoms.

Fever (Temperature ≥100.4°F/38°C)

Fever is a sign of infection or other serious illness. Systematic evaluation is essential.

Initial Assessment

First fever or persistent? (first suggests new infection; persistent suggests inadequate treatment or resistant organism)
Existing source of infection? (known pneumonia, UTI, surgical site—is it worsening?)
Recent antibiotics started? (adequate coverage for anticipated organisms?)
Chronic indwelling lines? (central line, foley—risk of device-associated infection)
Immunosuppression? (steroids, malignancy, HIV—atypical presentations expected)

Common Fever Sources in Hospitalized Patients

Source	Risk Factors	Red Flags
Pneumonia (PNA)	Intubation, aspiration, immobility	Cough, sputum, hypoxia, infiltrate on CXR
Urinary tract infection (UTI)	Foley catheter, female	Dysuria, frequency, pyuria on UA
Osteomyelitis	Recent surgery, prosthetic joints	Localized bone/joint pain, swelling
Intra-abdominal pathology	Recent surgery, perforated viscus	Abdominal pain, guarding, sepsis
Cellulitis	IV lines, skin breakdown	Erythema, warmth, edema at site
Clostridioides difficile (C. diff)	Recent antibiotics	Diarrhea (often bloodless), abdominal pain
Sacral pressure ulcers	Immobility, poor nutrition	Stage III/IV ulcers, purulent drainage
Surgical site infection	Post-op day 3–7	Erythema, drainage, dehiscence

Non-Infectious Causes of Fever

Thromboembolism: DVT, PE (fever often low-grade, may lag symptoms)
Atelectasis: Post-op or immobile patients
Aspiration: Food, gastric contents → aspiration pneumonia
Drug-induced: Antibiotics (beta-lactams), anticonvulsants
Transfusion reaction: Within hours of product infusion
Uremia: Elevated urea in end-stage renal disease
Malignancy: Tumor burden itself
Neuroleptic malignant syndrome: Recent antipsychotic; accompanied by rigidity, high CK
Malignant hyperthermia: Perioperative; life-threatening
Thyroid storm: Thyrotoxicosis; tachycardia, altered mental status
Alcohol/benzodiazepine withdrawal: Autonomic hyperactivity

Diagnostic Workup

Test	Rationale
Blood cultures x2	Before antibiotics; aerobic and anaerobic bottles
Urinalysis and urine culture	UTI assessment
CBC with differential	WBC elevation, bands suggest bacterial infection
Comprehensive metabolic panel	Assess renal function, glucose, electrolytes
PT/INR, PTT	Assess for DIC (severe sepsis)
Lactate	Marker of tissue hypoperfusion; prognostic
CXR	Pneumonia, atelectasis, pulmonary edema
Procalcitonin (if not already on antibiotics)	Higher sensitivity/specificity for bacterial infection
CT abdomen/pelvis	If abdominal pain, post-op, perforation concern
Lower extremity ultrasound	DVT assessment if immobile
Stool studies	C. difficile toxin if diarrhea present
Lumbar puncture	Meningitis concern (fever + headache + neck stiffness + altered mental status)

Empiric Antibiotic Coverage

If sepsis suspected (fever + hemodynamic instability, lactate elevated, altered mental status):

Start broad-spectrum antibiotics immediately after blood cultures
Common empiric regimen: Ceftriaxone or cefepime + vancomycin (add gentamicin if Pseudomonas risk)
Consider local antibiogram and patient risk factors for resistant organisms

If source identified:

PNA: Ceftriaxone ± azithromycin (community-acquired); Cefepime/Pip-tazo (hospital-acquired)
UTI: Ceftriaxone or fluoroquinolone (if uncomplicated); cefepime if pyelonephritis/sepsis
Cellulitis: Cefazolin or cephalexin; vancomycin if MRSA concern
C. difficile: Vancomycin 125mg PO q6h (IV ineffective—poor colonic penetration)

Symptom Management

For fever ≥103°F:

Acetaminophen: 650mg PO/PR; do not exceed 4g/day
Ibuprofen: 400mg PO q6h (if no contraindications)
Cooling measures: Cooling blankets, tepid sponging if very high fever (>104°F)

Fever as Defense Mechanism

Fever is the body's immune response (HEAT trial showed no benefit to aggressive fever reduction). Treat discomfort, but do not aggressively lower fever unless approaching critical temperature (>104°F) or in specific populations (cardiac disease, elderly).

Inadequate Initial Coverage

Do not delay antibiotics while awaiting culture results. Start empiric coverage immediately if sepsis suspected. De-escalate once sensitivities available.

Atrial Fibrillation with Rapid Ventricular Response (RVR)

Atrial fibrillation is common in hospitalized patients. Distinguish rate-controlled AF from RVR requiring acute intervention.

Initial Assessment

New vs. known AF? (new AF requires urgent workup)
Rate: Is HR >120 or >100 at rest? (defines RVR)
Hemodynamically stable? (SBP >90, no chest pain, no acute pulmonary edema)
Symptoms: Palpitations, chest pain, dyspnea, syncope?
Last known rhythm: EKG and prior records?

Precipitants (Often Reversible)

Trigger	Mechanism
Missed home beta-blocker/CCB	Loss of rate control
Excessive caffeine	Stimulant effect
Acute coronary syndrome	Ischemia triggers arrhythmia
Acute heart failure	Elevated atrial pressure
Pulmonary embolism	Acute RV strain
Hypoxia	Low SpO2 from any cause
COPD/asthma exacerbation	Airway inflammation
Thyrotoxicosis	Excess thyroid hormone
Hypokalemia	Low serum K
Hypomagnesemia	Low serum Mg
Alcohol/withdrawal	Autonomic destabilization
Sepsis	Systemic inflammation
Pain, anxiety, fever	Sympathetic stimulation

Diagnostic Workup for New AF

Test	Purpose
12-lead EKG	Confirm AF, assess rate, look for ischemia
CBC	Infection, anemia
Metabolic panel	K, Mg, Cr, glucose
Troponin	ACS assessment
TSH	Thyroid dysfunction
CXR	Cardiomegaly, pulmonary pathology
Echocardiogram	Ventricular function, structural heart disease (if new AF)
D-dimer/CT PE	PE assessment if risk factors

Rate Control Strategy

Hemodynamically STABLE AF-RVR

Goal: HR <110 at rest (lenient rate control per RATE-AF trial shows safety)

First-line agents:

Drug	Dosing	Mechanism	Cautions
Metoprolol	5–10mg IV q4–6h	Beta-blocker	Avoid if hypotensive or bradycardic; caution in asthma/COPD
Diltiazem	10mg IV bolus; repeat at 15mg if needed; may start drip at 5–10mg/h	Calcium channel blocker	Avoid if hypotensive, bradycardic, or in acute CHF
Verapamil	2.5–5mg IV slow push	Calcium channel blocker	Caution: negative inotrope

If inadequate response:

Amiodarone: 150mg IV bolus over 10 min, then 360mg infusion over 6h, then 540mg over 18h (rate control + rhythm control)
Esmolol: Ultra-short-acting beta-blocker; 50–300mcg/kg/min IV drip (useful if need rapid titration/reversal)
Digoxin: 0.5–1mg loading (slower onset; useful in CHF; narrow therapeutic window)

Hemodynamically UNSTABLE AF-RVR

If SBP <90, pulmonary edema, chest pain, or altered mental status:

Lower-dose rate control: Reduced doses of metoprolol (2.5–5mg) or diltiazem (5mg), assess response
Avoid aggressive dosing (risk of cardiogenic shock)
Consider alternatives:
Amiodarone: Maintains better hemodynamic stability
Esmolol: Rapid titration and reversal
Digoxin: In CHF (improves contractility while slowing AV node)

Severely Unstable AF-RVR

If the patient looks like they're dying (SBP <80, altered mental status, severe pulmonary edema, ongoing chest pain):

Synchronized electrical cardioversion: 100–200J biphasic (sedate first if conscious)
Prepare: ICU, intubation capability, defibrillator at bedside

Rhythm Control vs. Rate Control

Lenient rate control (target HR <110): Safe for most patients with AF-RVR
Rhythm control (convert to sinus rhythm): Consider if new AF, hemodynamic instability, or symptoms persist despite rate control
Antiarrhythmic agents (flecainide, sotalol): Requires cardiology consultation; more risks in structural heart disease

Most AF in Hospital

Most AF-RVR in hospitalized patients is secondary to a reversible cause (pain, anxiety, fever, medication non-compliance). Address the precipitant; rate control often resolves as the underlying issue improves.

Stroke Risk in New AF

New-onset AF carries stroke risk. Discuss anticoagulation (apixaban, rivaroxaban, dabigatran, edoxaban) with attending or cardiology. Do not delay anticoagulation in absence of contraindication.

Chest Pain

Chest pain is a medical emergency until proven otherwise. Rapid evaluation is essential.

Immediate Triage

If any of these present → Call EMS, establish IV, continuous telemetry, oxygen, EKG immediately:

Severe pressure/tightness
Diaphoresis, pallor
Hemodynamic instability
Respiratory distress

Characterization

Obtain rapid history:

Onset: Sudden vs. gradual? What were you doing?
Quality: Pressure, sharp, pleuritic, burning, tearing?
Radiation: Neck, arm, jaw, back?
Associated symptoms: Dyspnea, nausea, diaphoresis, palpitations?
Cardiac risk factors: Age, smoking, diabetes, hypertension, family history, prior MI/stent?
Medication history: Cocaine, stimulants?

Physical Examination

Finding	Significance
Reproducibility with palpation	Suggests musculoskeletal (but doesn't rule out ACS)
Asymmetric blood pressures (>20mmHg diff)	Aortic dissection concern
Unequal breath sounds or hyperresonance	Pneumothorax
New murmur	Acute valve disease (endocarditis, dissection)
Absent pulses in extremity	Dissection, thromboembolism
Unilateral leg swelling/warmth	DVT → PE risk
Rub on auscultation	Pericarditis
Hypotension, JVD, muffled heart sounds	Tamponade (Beck's triad)

Life-Threatening Diagnoses to Rule Out

Condition	EKG Finding	Imaging	Action
Acute MI (STEMI)	ST elevation	Troponin positive	Cardiology stat; cath <90 min
Acute MI (NSTEMI/UA)	ST depression, T-wave changes	Troponin positive	Antiplatelet, anticoagulation, cardiology consult
Aortic dissection	Usually normal	CTA chest (gold standard)	Cardiothoracic surgery stat; BP control
Pulmonary embolism	Sinus tachycardia (nonspecific)	CT angiography	Anticoagulation (if low bleeding risk)
Pneumothorax	Sinus tachycardia	CXR, CT if unclear	Chest tube if large/tension
Esophageal rupture	Nonspecific	CT with oral contrast	Surgery stat (high mortality)
Acute pericarditis	Diffuse ST elevation, PR depression	Echocardiogram	NSAIDs, colchicine; serial ECGs
Tension pneumothorax	Extreme tachycardia (dying)	Clinical diagnosis	Needle decompression followed by chest tube

Rapid Diagnostic Workup

Test	Timing
EKG	Within 10 min of arrival
Troponin (high-sensitivity)	Stat; repeat at 3h if initial negative and concern remains
CXR	Within 15 min
CBC, CMP	Baseline labs
D-dimer or CT angiography	If PE suspected
Echocardiogram	If pericarditis, tamponade, or valvular disease suspected
CT chest with contrast	If aortic dissection concern

ACS Management (STEMI/NSTEMI/Unstable Angina)

STEMI: - Call cardiology stat: Percutaneous coronary intervention (PCI) target door-to-balloon <90 minutes - ASA: 325mg (unless allergy) - Anticoagulation: Unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) - Nitroglycerin: 0.3–0.6mg SL; repeat q5min if SBP >90; hold if RV infarction (right-sided EKG leads) or hypotensive

NSTEMI/Unstable Angina: - Cardiology consultation (may not need emergent cath; can risk-stratify) - Dual antiplatelet therapy: ASA 325mg + loading dose of P2Y12 inhibitor (clopidogrel 600mg, prasugrel 60mg, or ticagrelor 180mg) - Anticoagulation: UFH or LMWH - Beta-blocker: Metoprolol or carvedilol (if stable BP and HR) - Statin: High-intensity statin (atorvastatin 80mg or rosuvastatin 40mg) - NTG: As above for symptom relief - Morphine: 2–4mg IV for pain not relieved by NTG; repeat q5–15min

Aortic Dissection

Suspect with tearing chest/back pain, especially if hypertensive or Marfan syndrome. Blood pressure control is critical (target SBP 100–120 and HR 60); use beta-blocker first, then vasodilator. Do NOT delay CTA imaging.

EKG Leads Matter

Always obtain right-sided leads (V3R, V4R) if inferior MI suspected (RV involvement). RV infarction is preload-dependent; avoid aggressive nitroglycerin/diuretics (can cause cardiogenic shock).

Acute Anemia

Acute anemia (falling hemoglobin/hematocrit) requires rapid evaluation and stabilization.

Risk Stratification

Determine urgency:

Hemoglobin level: >10 usually tolerates without transfusion; <7 often requires transfusion
Hemodynamic stability: Hypotension or tachycardia indicates hemodynamic compensation
Bleeding source: Known vs. occult bleeding
Cardiac history: ACS, CHF—lower tolerance for anemia

Etiologic Assessment

Source	Risk Factors	Red Flags
GI bleeding	PUD, varices, anticoagulants	Hematemesis, melena, hematochezia
Surgical site bleeding	Recent surgery, anticoagulation	Drainage, expanding hematoma, fluctuant swelling
Concealed bleeding	Trauma, coagulopathy, anticoagulation	Abdominal pain, flank ecchymosis, retroperitoneal hemorrhage
Hemolysis	G6PD, autoimmune, prosthetic valve	Elevated bilirubin, LDH, jaundice, dark urine
Nutritional deficiency	Chronic bleeding, poor diet	Macrocytic (B12/folate), microcytic (iron) anemia
Bone marrow failure	Chemotherapy, myelodysplasia, sepsis	Pancytopenia (low WBC, Plt)

Clinical Evaluation

Finding	Differential
Hemodynamic instability	Active major bleeding; transfuse immediately
Orthostatic vital signs	Volume depletion; IV fluids and transfusion
Melena or bright red blood per rectum	GI source
Abdominal pain, guarding	Retroperitoneal bleed, perforation
Jaundice, dark urine, palpable spleen	Hemolysis
Petechiae, bleeding gums	Thrombocytopenia, coagulopathy

Diagnostic Labs

Test	Purpose
CBC with differential	Confirm anemia; assess WBC, platelets (pancytopenia suggests bone marrow issue)
Reticulocyte count	Bone marrow response to bleeding (elevated in hemolysis/acute bleeding)
Coagulation studies (PT/INR, PTT)	Assess for coagulopathy
Fibrinogen, D-dimer	DIC assessment
Type & screen or crossmatch	Blood product availability
Peripheral blood smear	Hemolysis (schistocytes), infections, malignancy
Comprehensive metabolic panel	Renal function, K, glucose
Bilirubin, LDH, haptoglobin	Hemolysis workup
Reticulocyte hemoglobin	Assesses iron stores (low in iron deficiency)
Rectal exam with FOBT	GI source assessment

Transfusion Strategy

Hemoglobin	Clinical Context	Action
<7 g/dL	Any patient	Transfuse 1 unit pRBC; recheck Hgb; goal Hgb 7–9
7–10 g/dL	Stable, no bleeding	Consider transfusion if symptoms (dyspnea, chest pain) or ongoing bleeding
7–8 g/dL	ACS/cardiac history	Transfuse to Hgb 8–9 (lower tolerance for anemia)
>10 g/dL	No active bleeding	Treat underlying cause; transfuse only if continued bleeding

Management of Ongoing Bleeding

If bleeding continues despite transfusion:

Maintain two large-bore IVs (consider central line if difficult access)
Type & cross additional units (prepare for massive transfusion protocol)
Activate massive transfusion protocol if anticipated need for >4 units PRBC in 24h
Obtain imaging (CT angiography if pulmonary source; abdominal CT if intra-abdominal source)
Consult GI, surgery, interventional radiology as indicated
Hold anticoagulation (unless life-threatening indication like PE/ACS)
Correct coagulopathy (FFP, platelets, cryoprecipitate as needed)

Avoid Over-Transfusion

Transfusion carries risks (fluid overload, TRALI, infection). Use restrictive strategy (transfuse at Hgb <7) except in specific populations (ACS, symptomatic anemia).

Patient Requesting to Leave AMA (Against Medical Advice)

Patients have the right to refuse treatment. However, certain patients cannot legally leave AMA.

Determination of Capacity

Before accepting an AMA request, the patient must have decision-making capacity:

Understands their medical condition
Understands the proposed treatment
Understands the consequences of refusal
Can communicate their choice consistently

Patients WITHOUT capacity cannot leave AMA: - Advanced dementia with no surrogate decision-maker - Acute delirium with inability to reason - Intoxicated or actively withdrawing from substances - Involuntary psychiatric hold (1013 hold)

Attempt to Retain Patient

Understand the reason: Why do they want to leave? (Pain, cost, misconception, family emergency?)
Address concerns: Can you solve the underlying problem?
Involve case management and social work for resource barriers (financial, transportation, housing)
Involve family (if appropriate) in discussion
Clearly explain risks: What could happen if they leave without complete treatment?

AMA Documentation

If patient insists on leaving after discussion:

Contact the attending physician immediately (do not allow departure without attending knowledge)
Have patient sign AMA form (document understanding of risks)
Document in chart:
Statement of patient's reason for leaving
Medical risks explained (be specific)
Capacity assessment and findings
Plan for follow-up (outpatient appointment, primary care referral)
Patient's understanding of treatment alternatives
Witness signature (RN, MD, or both)
Provide discharge instructions (medications, follow-up appointments, warning signs)

Involuntary Psychiatric Hold (1013)

Patients on psychiatric hold cannot legally leave the hospital. Requires psychiatry clearance before release. Do not discharge against 1013 hold without attending psychiatry approval.

Pronouncing a Death

Pronouncing death is a somber but essential skill. Always perform a thorough examination.

Confirmation of Death

Examine for signs of death:

Finding	Timeline
Absent pulse (check brachial/carotid for 60 sec)	Immediate
No heart sounds on auscultation	Immediate
Absent breathing (listen for breath sounds; no fog on mirror)	Immediate
Fixed, dilated pupils (nonreactive to light)	Within minutes
Pallor mortis (paleness of skin)	Within 15 min
Rigor mortis (body stiffening)	2–6 hours
Livor mortis (dependent purple discoloration)	20–30 min
Algor mortis (cooling of body)	Hours

Pronounced Exam

In the presence of family (if appropriate):

Auscultate heart (listen >60 seconds)
Auscultate lungs
Palpate pulse (carotid and brachial)
Assess pupil reactivity to light
Note absence of breath sounds/movement
Check for any response to painful stimuli

Time of death = time you complete the examination (not time of last vital signs or last observed movement)

Death Certificate and Documentation

Death note in medical record:
Time of examination
Vital signs findings (all absent)
Physical exam findings
Time death pronounced
Circumstances (expected vs. sudden)
Attending physician name
Death certificate (legal requirement):
Must be completed by attending physician
Primary cause of death + contributing conditions
Submit to vital records within specified timeframe
Family responsible for funeral home arrangements
Notify family (if not present):
Compassionate but direct communication
Offer support services (chaplaincy, social work, grief counseling)
Explain what happens next (organ donation discussion, funeral home contact)
Release of body:
To funeral home of family's choice
Requires signed release form
No autopsy unless requested/indicated

Family Presence

When possible, allow family to be present during examination and at time of death pronouncement. Provides closure and validates the loss. Offer continued support and grief resources.

Summary: Key Pearls for Night Call

Assess before treating: Every symptom has a differential. Rule out serious causes before giving comfort medications.
Recheck vitals: Many "urgent" issues resolve after rechecking BP, SpO2, or blood glucose.
Call early: Don't wait to escalate; transfer to ICU sooner rather than later for unstable patients.
Know your limits: When unsure, involve the senior resident or attending early.
Document thoroughly: Your note may be the only record of overnight events.
Communicate handoffs: Clearly sign out to the day team; don't leave surprises.
Sleep when you can: Fatigue impairs judgment; prioritize your safety and your patients' safety.

Last Updated: 2026 Version: 1.0

Last update: April 12, 2026