Old intern hints

[jpro]

The following was posted about a year ago and then removed. It is by no way endorsed by any official body. Anyway, I thought it was quite helpfull for the first couple weeks of internship even though I would do some things a bit differently. I know many of you are starting soon and would like something like this to hang on to when you have no freakin clue. haha

Intern Hints

*When in doubt, don’t hesitate to ask your senior for help (but first examine the patient, start working up the patient, etc).

* Hypotension: Recheck with a manual cuff, repeat vitals, O2 sats. Baseline BP, urine output; mental status; awake or sleeping. What (antihypertensive) meds is the patient on. Is the patient septic.

-give 250-500mL NS bolus
-if indicated, check cultures
-if indicated, rule out adrenal insufficiency (was the patient recently on steroids)
-if indicated, rule out PE, MI

* Fever: Is there a known source of infection? Is the patient on antibiotics? Blood cultures x 2; U/A with urine culture. Check chest x-ray if pneumonia is a concern. If patient has persistent fevers on abx, see if they have any peripheral IV’s or central lines including PICC lines (line sepsis from femoral lines are common), consider fungal cx also.

-Neutropenic fever: neutropenic precautions, panculture including fungal cultures; IV cefepime +/- IV vancomycin (if the patient has a central line, hypotensive, unstable)

* IV Access: If a patient loses their IV, ask the nurse to try a different site. If the nurse said that he/she tried already, ask if there is a team that is trained to put in tough IVs and let them try. If not, consider an EJ (after the nurse and IV team have attempted IV access).

* Blood Draws: Same as IV access rules. Do a radial art stick to get labs and they can put a line in the am.

* Hyperkalemia: Check if the potassium is hemolyzed. If so, recheck it STAT. If it’s real, get an EKG and check if the patient has symptoms (Diaphoresis, palpitations). Consider calcium gluconate. Give Kayexelate 30grams po, one amp D50 and 10 units of insulin. Recheck potassium in one hour or after BM from Kayexelate. (Mnemonic: C BIG K Drop – calcium gluconate, beta-agonists, insulin+glucose, Kayexelate, diuretics, dialysis)

* Hypertension: Check with a manual cuff. Baseline BP. If BP meds are due, give them early and recheck. If no BP meds, give Clonidine 0.1-0.2 mg PO or Hydralazine 25mg PO. (DO NOT GIVE IV beta-blockers unless the patient is on a monitor)

* Chest pain: Is it new or old? Is the chest pain cardiac? Recheck vitals. EKG. If cardiac, Cardiac enzymes (directed troponin). Check lytes, CBC; consider an ABG with lactate. Give O2. Consider sublingual nitro (as long as it’s not a right sided mi since they are preload-dependent). Morphine; Aspirin, Beta Blocker, Statin, ACE. Consider Heparin drip. CXR. (ddx: MI/ACS, PE, aortic dissection, tension pneumothorax)

* Decreased urine output: See old labs, See if the patient is fluid overloaded (Elevated JVD, Hypoxia, Lung exam, CXR with pulmonary edema). Ckeck orthostatics, and give an IV fluid bolus if dehydrated/orthostatic.

* GI Bleed: Recheck vitals; orthostatics. Make the patient NPO. Rectal exam (guiac/stool for occult blood). Phenergan IV for nausea/vomiting. IV PPI (40mg IV x1 or protonix drip) if actively bleeding. Check lytes, CBC, type and cross for two units. Serial Hb/Hct. Start IV fluids. NG tube with NG lavage to r/o upper GI bleed. Consider EKG and cardiac enzymes. Call your senior, consider GI consult.

* Abdominal pain: Ask about diarrhea,constipation, nausea, vomiting. Examine the patient. Check lytes, amylase, lipase, LFT's, lactic acid if concern for mesenteric ischemia. Acute abdominal series. For constipation, give a Fleets enema, Dulcolax suppository, Lactulose 30cc q2 hours until bowel movements. For diarrhea, check orthostatics and give IV fluids. Check fecal leukocytes, C diff toxin X 3 if pt is on antibiotics. Consider NG tube with suction. Always examine the patient for acute abdomen and bowel sounds. Ask about last BM, abd distension and if patient is passing gas. For a diabetic, check blood sugar. Consider an ABG with Lactate to rule out ischemic bowel.

* Acute Renal Failure: Check urine lytes(Urine Na and creatinine; FeNa), lytes, CBC, Parathyroid Hormone, LFTs. Foley catheter, daily weights, strict Is and Os, Renal US. Orthostatics. Examine patient for fluid overload vs dehydration. Nephro consult possibly.

* Electrolyte repletion: Try to give orally if possible.

Potassium: Oral: Kdurr 40 meq q 2 hours X 2-3 doses; Klorr (liquid). IV: KCL 40meq IVPB X 1-2. (for every 10mEq KCl, K+ increases by 0.1 approximately)

Magnesium: MagOxide 800 po tid X 2 days; Magnesium sulfate 2 grams IVPB X 1

Phosphorus: Oral:Neutraphos one pack po tid, IV: Kphos 15 mmol IVPB X 1

* Nausea and vomiting: Check vitals, IV fluids, Phenergan 12.5-25mg IV q 6hours, check lytes/CBC/Amlyase/Lipase, consider NG tube, NPO, Acute abd series, U/A

* Elevated blood sugar: Follow sliding scale insulin, Give diabetic medications which are due, give subcutaneous Insulin based on blood sugar.

* Hypoglycemia: Is the patient symptomatic? Give 1 Amp D50, recheck sugar and give another amp if needed.

* Shortness of breath: Check vitals and O2 sat, give O2, Examine patient. Get and ABG with lactate, Get a CXR (PA/Lat preferred over portable, but get whatever you can)

I.Asthma exac: Give back to back nebs (albuterol+ipratropium) then q 4hour nebs around the clock. Prednisone.

II. CHF/Fluid overload: Insert foley, give IV Lasix 40-60mg, check urine output.

III. PE: Check ABG, CXR, EKG, O2, PE protocol CT at night if creatinine is normal, V/Q in daytime, r/o DVT (dopplers), Consider starting IV Heparin.

IV. MI: EKG, Cardiac enzymes, EKG, ABG, IV Heparin, Morphine, CXR, Bblocker, ACE, ASA, Statin, IV Fluids, Call Senior and Cards consult STAT

V. Pneumonia: CXR, blood and urine cx, IV antibiotics (Community acquired: ceftriaxone+azithromycin; or IV Levaquin. HCAP: vanc, zosyn, cefepime; add IV clindamycin if post-obstructive)

* Fall: Physical exam to rule out fracture. Check pulses and reflexes and cap refill. Always get a Portable AP view of pelvis for elderly patient that falls. If indicated, noncontrast CT head.

* Altered mental status: Check blood sugar, Vitals with O2 sat, Check med list for narcotics, Give Narcan if patient is on a lot of pain meds. U/A. Consider CT head. EKG, r/o A fib with possible stroke, CXR. Check lytes. Consider blood cultures. IV fluids.

* Dementia: Check reversible causes of dementia labs (Lytes, CBC, RPR, TSH, Vitamin B12, Folate, U/A, blood and urine cx) CT Head without contrast, Consider these meds: Risperdal 0.5mg bid or Haldol 1mg IV or IM if agitated.

* Asthma/COPD exacerbation: Check vitals and O2 sat,. ABG. Back to back nebs then q 4hours around the clock. IV Decadron, peak flows with nebs, Advair, Doxycycline 100mg po qd if patient with COPD has a productive cough. Ask if the patient has ever been intubated before.

* Weakness: Neuro exam with check of motor strength, reflexes and babinskis. Ask patient about bowel/bladder incontinence, Rectal exam to rule out decreased rectal tone. If so, start IV Decadron, get an MRI and call Neurosurgery.

* Alcoholics: Possible restraints, start Alcohol withdrawal protocol with Ativan symptom triggered vs fixed dose. Check lytes and CBC then give Thiamine 100mg IV qd and Folate 1mg IV qd, switch to po when possible

---

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[werd]

some of the details vary by person and institution, but in general this is good advice. ah intern year, i won't miss it.

 

[Apollyon]

Only thing that is black letter wrong is Phenergan IV. Forget about that. Period. Zofran or Reglan. NO Phenergan IV - EVER.

 

[Muscletoe]

This is a great idea--I'll be starting intern year in a few weeks, and really appreciate the advice!

 

[lane]

Only thing that is black letter wrong is NO Phenergan IV - EVER.

fixed

 

[Apollyon]

fixed

I don't get your point. You go with Phenergan IV? You do that, and I'll wave to you when you're at the defendant's table.

 

[OB1🤙]

FWIW, we give phenergan IV quite often. Just make sure you write it (and the nurse delivers it) slow IVPB.

 

[Winged Scapula]

FWIW, we give phenergan IV quite often. Just make sure you write it (and the nurse delivers it) slow IVPB.

Interesting.

When I mistakenly order it IV, the pharmacy calls as they will not dispense it.

 

[Dr. V]

Interesting.

When I mistakenly order it IV, the pharmacy calls as they will not dispense it.

Depends on where you are at I guess as all the hospitals I have rotated at it is frequently given IV.

I personally don't give it (or it is extremely rare for me to) as it is my very last choice.

 

[Apollyon]

When I mistakenly order it IV, the pharmacy calls as they will not dispense it.

What do we know? We're just attendings. Experienced, at that.

 

[lane]

What do we know? We're just attendings. Experienced, at that.

and to say it's black letter wrong is incorrect, as it is still administered (hopefully with caution) in many hospitals. and it still works, even if you do prefer zofran or reglan.

 

[Apollyon]

and to say it's black letter wrong is incorrect, as it is still administered (hopefully with caution) in many hospitals. and it still works, even if you do prefer zofran or reglan.

It's got a black box warning for age 12 and under, and Phenergan necrosis has led to multiple justified med mal cases.

Inapsine is also still administered in many hospitals, still works, and that black box is drawn with an even brighter line. To let a brand new intern (who hasn't made a mistake yet) develop the bad habit of using Phenergan is passing on a mistake that should NOT be passed on, and should be stopped before it can start.

 

[proman]

Promethazine is a highly effective anti-emetic. It is part of the Society for Ambulatory Anesthesia guidelines for prophylaxis and rescue of postoperative nausea or vomiting. When I'm covering our PACUs, I give it practically every day (6.25mg IV diluted in at least 10 cc). Probably over half of our ambulatory patients get it too. It should not be first line option now that we have the 5HT antagonists, but it is still a useful drug.

 

[aphistis]

Phenergan IV, diluted and given slowly, is my standard second-line antiemetic. I'm with proman; I give it regularly, and I think it's a great drug.

 

[Winged Scapula]

I agree that Phenergan is a great drug and many patients find it works better than Zofran or other options.

But as noted above, some hospitals do not allow it to be given IV outside of the OR because of the black box warnings.

 

[proman]

The black box warning only applies to patients <2 years, not 12. This is an example of hospitals restricting the practice of medicine. When used appropriately, promethazine (and droperidol) are both great drugs.

 

[gutonc]

The black box warning only applies to patients <2 years, not 12. This is an example of hospitals restricting the practice of medicine. When used appropriately, promethazine (and droperidol) are both great drugs.

Wait a minute.... Droperidol and promethazine have black box warnings? (N.B. yes, I know they do.) Man...I give that stuff out like candy on the Onc/BMT service. Granted, they're my 5th and 6th line options, but when somebody's already snowed on a 5HT inhibtor, an NK1 inhibitor, ativan and compazine and still somehow managing to puke, I don't hold back.

 

[proman]

Wait a minute.... Droperidol and promethazine have black box warnings? (N.B. yes, I know they do.) Man...I give that stuff out like candy on the Onc/BMT service. Granted, they're my 5th and 6th line options, but when somebody's already snowed on a 5HT inhibtor, an NK1 inhibitor, ativan and compazine and still somehow managing to puke, I don't hold back.

How do the oncologists approach post-chemo N&V? That's more useful to interns than managing post-op N&V.

 

[gutonc]

How do the oncologists approach post-chemo N&V? That's more useful to interns than managing post-op N&V.

In general, compazine or phenergan usually do the trick. A little ativan just to put folks to sleep (it's not technically an antiemetic but sleepy people don't puke as much). If they have prolonged CINV a short steroid taper (8mg dex for 2-3 days, 4mg for 2-3d and 2mg for 2-3d) often helps. Haldol, droperidol and olanzapine (at bedtime) also have a role. Honestly though, except for the BMT patients getting myeloablative chemo, the vast majority of folks only need compazine and a little ativan and they're good to go.

 

[Winged Scapula]

Thanks gutonc - good information.

However, a note to the starting interns:

do NOT put your patients with N/V, especially surgical patients, on steroids as suggested above without checking with your senior resident or attending. This can have some untoward complications you don't want to be blamed for.

 

[Apollyon]

The black box warning only applies to patients <2 years, not 12. This is an example of hospitals restricting the practice of medicine. When used appropriately, promethazine (and droperidol) are both great drugs.

I'll eat that that it is 2 and not 12 - that is my error. However, it is poor, poor advice for a senior resident (in anesthesiology, at that) to advocate for Phenergan (promethazine) and Inapsine (droperidol), saying, "when used appropriately", that these are "great drugs", in a thread for INTERNS, who do not 1. push the meds (like anesthesiologists) and 2. are not astute enough to have the cardiac monitor on, or know to look for fatal QT prolongation, or to know what to do for it (or be aware that it is unrecoverable), or what to do if the Phenergan infiltrated, and to prevent necrosis.

What most of you are missing is that you are nuanced practitioners, and this is for inexperienced, blunt, and harried new practitioners. That is why I advocate for Zofran, Reglan, Compazine, and Benadryl before Phenergan and Inapsine.

Now, if you (in the plural) are advocates of the "you can't be a great doctor until you kill a patient" camp, then you should disclose that up front, as I do not agree with that sentiment.

 

[Winged Scapula]

I'll eat that that it is 2 and not 12 - that is my error. However, it is poor, poor advice for a senior resident (in anesthesiology, at that) to advocate for Phenergan (promethazine) and Inapsine (droperidol), saying, "when used appropriately", that these are "great drugs", in a thread for INTERNS, who do not 1. push the meds (like anesthesiologists) and 2. are not astute enough to have the cardiac monitor on, or know to look for fatal QT prolongation, or to know what to do for it (or be aware that it is unrecoverable), or what to do if the Phenergan infiltrated, and to prevent necrosis.

What most of you are missing is that you are nuanced practitioners, and this is for inexperienced, blunt, and harried new practitioners. That is why I advocate for Zofran, Reglan, Compazine, and Benadryl before Phenergan and Inapsine.

Now, if you (in the plural) are advocates of the "you can't be a great doctor until you kill a patient" camp, then you should disclose that up front, as I do not agree with that sentiment.

Agreed.

 

[Buckeye(OH)]

OH GOD it starts tomorrow!!!!!!!!!!!!!!!!

 

[proman]

I'll eat that that it is 2 and not 12 - that is my error. However, it is poor, poor advice for a senior resident (in anesthesiology, at that) to advocate for Phenergan (promethazine) and Inapsine (droperidol), saying, "when used appropriately", that these are "great drugs", in a thread for INTERNS, who do not 1. push the meds (like anesthesiologists) and 2. are not astute enough to have the cardiac monitor on, or know to look for fatal QT prolongation, or to know what to do for it (or be aware that it is unrecoverable), or what to do if the Phenergan infiltrated, and to prevent necrosis.

What most of you are missing is that you are nuanced practitioners, and this is for inexperienced, blunt, and harried new practitioners. That is why I advocate for Zofran, Reglan, Compazine, and Benadryl before Phenergan and Inapsine.

Now, if you (in the plural) are advocates of the "you can't be a great doctor until you kill a patient" camp, then you should disclose that up front, as I do not agree with that sentiment.

You're changing your song here. You first said:

Only thing that is black letter wrong is Phenergan IV. Forget about that. Period. Zofran or Reglan. NO Phenergan IV - EVER.

Then:

You do that, and I'll wave to you when you're at the defendant's table.

And:

What do we know? We're just attendings. Experienced, at that.

Followed by:

To let a brand new intern (who hasn't made a mistake yet) develop the bad habit of using Phenergan is passing on a mistake that should NOT be passed on, and should be stopped before it can start.

Then 4 people far more knowledgeable about pharmacodynamics of the drugs they order contradict you. Come on, let's give these new physicians some credit. Instead you address the issue in your usual pedantic fashion as if you're the Judge of Proper Intern Advice. It's not malpractice, it's not a NEVER drug, it's not lethal, and can be highly effective. There's not much nuance in saying it's not a first line drug.

No need to be a jerk and talk about killing patients. No intern is walking around with a 1 cc syringe of 25mg promethazine waiting to main line it to the first person who dry heaves. While you're at it, don't recommend completely ineffective treatment either (ie metoclopramide).

 

[Apollyon]

You're changing your song here. You first said:

Only thing that is black letter wrong is Phenergan IV. Forget about that. Period. Zofran or Reglan. NO Phenergan IV - EVER.

Then:

You do that, and I'll wave to you when you're at the defendant's table.

And:

What do we know? We're just attendings. Experienced, at that.

Followed by:

To let a brand new intern (who hasn't made a mistake yet) develop the bad habit of using Phenergan is passing on a mistake that should NOT be passed on, and should be stopped before it can start.

Then 4 people far more knowledgeable about pharmacodynamics of the drugs they order contradict you. Come on, let's give these new physicians some credit. Instead you address the issue in your usual pedantic fashion as if you're the Judge of Proper Intern Advice. It's not malpractice, it's not a NEVER drug, it's not lethal, and can be highly effective. There's not much nuance in saying it's not a first line drug.

No need to be a jerk and talk about killing patients. No intern is walking around with a 1 cc syringe of 25mg promethazine waiting to main line it to the first person who dry heaves. While you're at it, don't recommend completely ineffective treatment either (ie metoclopramide).

What?

First, I'm not changing my tune - no Phenergan, ever. That way, you get in no trouble with necrosis of extremities. That is malpractice. It's "loss of life or limb". Necrotic limbs - lost.

Second, in my "Usual Pedantic Fashion"? You, as a mod, are supposed to be above the fray. Even so, who are the 4 people "far more knowledgeable about pharmacodynamics"? I can't tell.

Finally, "no need to be a jerk and talk about killing patients". Are you serious? Does any intern do this? Yes, they do. Some people walk around with the guilt of having made an error that led directly to a patient death (not me). And you're saying metoclopramide is completely ineffective? Do you have data? I have anecdote, and I have data that it treats headaches.

Why are you complicating things? You cannot, in good faith, recommend black boxed medications to providers who will not even be at the bedside when the ordered medications are given. Why don't you admit this - are you saying that droperidol is risk-free? Do you realized that even anesthesiology interns are actually on the floor, and not in the OR or PACU? Do you realize that most interns are seeing medically sick people (even if they're surgical patients)?

What I do take away from this thread, though, is that many frazzled interns will remember that this thread existed, but not what it said, except that there was some dustup about Phenergan. As such, they won't use it, so I think that the right thing has occurred.

Oh, and, to be equitable, you better call out Winged Scapula for agreeing with me, and tell her that she doesn't know pharmacodynamics either.

 

[proman]

Apollyon have you even read the black box warning on promethazine? It has nothing to do with limb problems. In fact, it has to do with 7 cases of fatal respiratory depression in children <2 years. The ischemic issues with it are related to improper administration, not typically a physician task.

POSTMARKETING CASES OF RESPIRATORY DEPRESSION, INCLUDING FATALITIES,
HAVE BEEN REPORTED WITH USE OF PHENERGAN IN PEDIATRIC PATIENTS LESS
THAN 2 YEARS OF AGE. A WIDE RANGE OF WEIGHT-BASED DOSES OF PHENERGAN
HAVE RESULTED IN RESPIRATORY DEPRESSION IN THESE PATIENTS.
CAUTION SHOULD BE EXERCISED WHEN ADMINISTERING PHENERGAN TO
PEDIATRIC PATIENTS 2 YEARS OF AGE AND OLDER. IT IS RECOMMENDED THAT
THE LOWEST EFFECTIVE DOSE OF PHENERGAN BE USED IN PEDIATRIC PATIENTS
2 YEARS OF AGE AND OLDER AND CONCOMITANT ADMINISTRATIDRUGS WITH RESPIRATORY DEPRESSANT EFFECTS BE AVOIDED.

Metoclopramide is completely ineffective as an antiemetic. Search the literature. I've never said that droperidol is risk free and you know it. My advice to interns: know the drugs that you order, because many people don't.

 

[Mista Suprane]

no Phenergan, ever. That way, you get in no trouble with necrosis of extremities.

the only case where this was reported was with intra-arterial injection. it is not even on the black box warning.

i will admit that you are an attending, and your "n" is much greater than mine. but we are all aware of "recalls" and "warnings" that are due to negative publicity rather than actual danger. it seems as though this complication falls in the former category. the black box is only for children <2, which is not part of this discussion.

perhaps the better advice to give to interns is to openly discuss, in the beginning of the year (when no question is a stupid one), treatment options for nausea with ALL attendings that the intern might be covering. anecdotal experience, while not always grounded in evidence, does play a large role in the medical field, and certain attendings may or may not feel strongly about certain medications, therapies, etc. in the end, it's their license, not yours.

INTERNS: phenergan 25mg IV is a HIGHLY effective anti-emetic, and if zofran doesn't work, as long as your attending is cool with it, have at it - I used it MANY times, and i can say i NEVER had any calls about nausea from a patient once I gave it.

 

[Winged Scapula]

Alright guys...the arguing serves no purpose.

I agree, Phenergan is a great drug. I use it myself for migraine associated nausea/vomiting and I find it works much better than Zofran. However, there are times when it doesn't work; in contrast to Mista above, I HAVE had patients claim it doesn't work. Whatever...there will always be patients for whom seemingly nothing works.

There are some valuable points in this thread:

1) always discuss preference with senior residents and attendings; many have a strict preference for one over another. When I was an intern, Phenergan was banned on the CTS because someone had an arrythmia and died 30 minutes after IV injection. Was it the Phenergan? Who knows? But it became a ritual part of signing out on that service not to use it. Voodoo medicine it may be but those are out there and you'd be well advised as an intern not to try and force some EBM on your crusty old attendings.

2) have multiple options in your armamentarium; patients will be "allergic" to all sorts of things or have odd reactions or preferences you've never heard of. It helps you not at 2 am when your patient tells you they are allergic to Phenergan or Zofran "doesn't work" (I hear that one a lot).

Now let's please get back to providing useful tools to interns. There's a whole new batch today.

 

[Arch Guillotti]

the only case where this was reported was with intra-arterial injection. it is not even on the black box warning.

?

http://www.pbm.va.gov/vamedsafe/IV Promethazine (Phenergan) and Tissue Injury – August 10, 2006.pdf

The formatting sucks but I copied this from the above website. Are you saying that only one case of limb necrosis has ever been reported?

AP PENDIX: CASE RE PORTS
Patient
Characteristics
Drug Dose Route of
Administration
Concomitant
medications
Type of
Procedure
Outcome
Middle-aged
woman
Promethazine 25mg IV – via a left
antecubital vessel
Meperidine HCl,
50mg
Not reported Immediate pain in the distal forearm
and hand, followed by discoloration,
coldness, and numbness. Progressive
gangrene of the fingers and thumb
occurred with amputation through the
distal forearm required seven weeks
later.
64 y/o male Promethazine 25mg IV – via a 19-
gauge regular
needle in the right
antecubital vein
N/A Exploratory
laparotomy;
promethazine was
given for a
generalized skin
reaction after
abdominal
incision.
Within 3 minutes, pt developed
cyanosis of the forearm and fingers.
Prolonged hospitalization with close
monitoring for 4 days. Pt developed
erythema, mild edema, and scattered
patches of pallor on hand and forearm.
Necrotic and gangrenous changes
developed on the back of the hand and
finger tips necessitating skin graft and
eventual amputation of the 3rd, 4th, and
5th fingers at the distal interphalangeal
joints.
43 y/o, 160 lb.
female
Promethazine 25 mg IV – via a catheter
in the patient’s
right hand
N/A Vaginal
hysterectomy
12/17/96 – Pt c/o burning, swelling,
and pain in right hand after receiving
the dose; nurse observed redness,
swelling, and bluish discoloration
around the IV site. Pt was treated with
elevation of the right hand, ganglion
blockade, and corticosteroid therapy.
Pt was monitored for 5 days, where
pain and edema went down while
range of motion improved. No
accidental intra-arterial injection was
diagnosed. Extravasation of
promethazine only. Pt was discharged
in the sixth day. No surgical
intervention was needed.
06/1997 – pt still c/o continued
numbness in the 3rd and 4th digits of
STRICTLY CONFIDENTIAL PRE-DECISIONAL DELIBERATION INFORMATION Promethazine Guidance
February 2007
Updated versions may be found at http://www.pbm.va.gov or http://vaww.pbm.va.gov
10
her right hand. Pt dx’d with carpal
tunnel of both wrists and shoulder sx
secondary to hand injury.
11/1998 – pt c/o mild cold intolerance.
25 y/o, 265 lb.
female
Promethazine 25 mg IV – via a line in
the left dorsum of
the patient’s hand
N/A OB/GYN –
dilation and
evacuation under
intravenous
sedation.
06/02/03 - Pt c/o severe burning in left
wrist and hand, followed by blotchy
cyanosis and discoloration, which
persisted for 12 hours after which pt
was transferred to a tertiary care
hospital for treatment for accidental
intra-arterial injection (including
morphine, temporary sympathectomy
via ganglion and nerve blocks,
anticoagulation therapy, nitropaste,
and limb elevation. Pt was release and
received abx x 2 weeks. 06/15/03 - Pt
persisted with fevers, chills, and the
distal tips of her left index finger, ring
finger, and small finger and thumb
were fully demarcated. 06/23/03 -
Amputation of gangrenous tissue with
skin grafts.
19 y/o female Phenergan Not
Reported
IV N/A Administered in
the ER for relief of
flu-like symptoms
Immediate pain and discoloration
leading to prolonged hospitalization
for 30 days with eventual amputation
of her thumb, index finger, and top of
her middle finger.
Not Reported Promethazine 12.5 mg IV site in the hand N/A Not Reported Burning sensation leading to necrosis
eventually requiring skin grafts and
physical rehabilitation.
Not Reported Phenergan Not
Reported
Not reported Not Reported Not Reported Amputation of 2 fingers.
Female Phenergan Not
Reported
IV Not Reported Administered in
the ER for
treatment of a
migraine
Circulatory problems with progressive
gangrene

 

[fab4fan]

FWIW, we give phenergan IV quite often. Just make sure you write it (and the nurse delivers it) slow IVPB.

Wow. It's absolutely verboten to give phenergan IV in this area (geographically). Try ordering it and just about everyone will think you're cracked.

 

[THP]

We give tons of phenergan at my hospital. 25mg IV is a standing prn order for nausea on almost every service I have been on. I prefer zofran because it lacks some of the euphoric effects.

 

[asmallchild]

incredibly helpful (especially as I am about to undergo my 1st weekend call); many thanks

Intern Hints

*When in doubt, don't hesitate to ask your senior for help (but first examine the patient, start working up the patient, etc).

* Hypotension: Recheck with a manual cuff, repeat vitals, O2 sats. Baseline BP, urine output; mental status; awake or sleeping. What (antihypertensive) meds is the patient on. Is the patient septic.

-give 250-500mL NS bolus
-if indicated, check cultures
-if indicated, rule out adrenal insufficiency (was the patient recently on steroids)
-if indicated, rule out PE, MI

* Fever: Is there a known source of infection? Is the patient on antibiotics? Blood cultures x 2; U/A with urine culture. Check chest x-ray if pneumonia is a concern. If patient has persistent fevers on abx, see if they have any peripheral IV's or central lines including PICC lines (line sepsis from femoral lines are common), consider fungal cx also.

-Neutropenic fever: neutropenic precautions, panculture including fungal cultures; IV cefepime +/- IV vancomycin (if the patient has a central line, hypotensive, unstable)

* IV Access: If a patient loses their IV, ask the nurse to try a different site. If the nurse said that he/she tried already, ask if there is a team that is trained to put in tough IVs and let them try. If not, consider an EJ (after the nurse and IV team have attempted IV access).

* Blood Draws: Same as IV access rules. Do a radial art stick to get labs and they can put a line in the am.

* Hyperkalemia: Check if the potassium is hemolyzed. If so, recheck it STAT. If it's real, get an EKG and check if the patient has symptoms (Diaphoresis, palpitations). Consider calcium gluconate. Give Kayexelate 30grams po, one amp D50 and 10 units of insulin. Recheck potassium in one hour or after BM from Kayexelate. (Mnemonic: C BIG K Drop &#8211; calcium gluconate, beta-agonists, insulin+glucose, Kayexelate, diuretics, dialysis)

* Hypertension: Check with a manual cuff. Baseline BP. If BP meds are due, give them early and recheck. If no BP meds, give Clonidine 0.1-0.2 mg PO or Hydralazine 25mg PO. (DO NOT GIVE IV beta-blockers unless the patient is on a monitor)

* Chest pain: Is it new or old? Is the chest pain cardiac? Recheck vitals. EKG. If cardiac, Cardiac enzymes (directed troponin). Check lytes, CBC; consider an ABG with lactate. Give O2. Consider sublingual nitro (as long as it's not a right sided mi since they are preload-dependent). Morphine; Aspirin, Beta Blocker, Statin, ACE. Consider Heparin drip. CXR. (ddx: MI/ACS, PE, aortic dissection, tension pneumothorax)

* Decreased urine output: See old labs, See if the patient is fluid overloaded (Elevated JVD, Hypoxia, Lung exam, CXR with pulmonary edema). Ckeck orthostatics, and give an IV fluid bolus if dehydrated/orthostatic.

* GI Bleed: Recheck vitals; orthostatics. Make the patient NPO. Rectal exam (guiac/stool for occult blood). Phenergan IV for nausea/vomiting. IV PPI (40mg IV x1 or protonix drip) if actively bleeding. Check lytes, CBC, type and cross for two units. Serial Hb/Hct. Start IV fluids. NG tube with NG lavage to r/o upper GI bleed. Consider EKG and cardiac enzymes. Call your senior, consider GI consult.

* Abdominal pain: Ask about diarrhea,constipation, nausea, vomiting. Examine the patient. Check lytes, amylase, lipase, LFT's, lactic acid if concern for mesenteric ischemia. Acute abdominal series. For constipation, give a Fleets enema, Dulcolax suppository, Lactulose 30cc q2 hours until bowel movements. For diarrhea, check orthostatics and give IV fluids. Check fecal leukocytes, C diff toxin X 3 if pt is on antibiotics. Consider NG tube with suction. Always examine the patient for acute abdomen and bowel sounds. Ask about last BM, abd distension and if patient is passing gas. For a diabetic, check blood sugar. Consider an ABG with Lactate to rule out ischemic bowel.

* Acute Renal Failure: Check urine lytes(Urine Na and creatinine; FeNa), lytes, CBC, Parathyroid Hormone, LFTs. Foley catheter, daily weights, strict Is and Os, Renal US. Orthostatics. Examine patient for fluid overload vs dehydration. Nephro consult possibly.

* Electrolyte repletion: Try to give orally if possible.

Potassium: Oral: Kdurr 40 meq q 2 hours X 2-3 doses; Klorr (liquid). IV: KCL 40meq IVPB X 1-2. (for every 10mEq KCl, K+ increases by 0.1 approximately)

Magnesium: MagOxide 800 po tid X 2 days; Magnesium sulfate 2 grams IVPB X 1

Phosphorus: Oral:Neutraphos one pack po tid, IV: Kphos 15 mmol IVPB X 1

* Nausea and vomiting: Check vitals, IV fluids, Phenergan 12.5-25mg IV q 6hours, check lytes/CBC/Amlyase/Lipase, consider NG tube, NPO, Acute abd series, U/A

* Elevated blood sugar: Follow sliding scale insulin, Give diabetic medications which are due, give subcutaneous Insulin based on blood sugar.

* Hypoglycemia: Is the patient symptomatic? Give 1 Amp D50, recheck sugar and give another amp if needed.

* Shortness of breath: Check vitals and O2 sat, give O2, Examine patient. Get and ABG with lactate, Get a CXR (PA/Lat preferred over portable, but get whatever you can)

I.Asthma exac: Give back to back nebs (albuterol+ipratropium) then q 4hour nebs around the clock. Prednisone.

II. CHF/Fluid overload: Insert foley, give IV Lasix 40-60mg, check urine output.

III. PE: Check ABG, CXR, EKG, O2, PE protocol CT at night if creatinine is normal, V/Q in daytime, r/o DVT (dopplers), Consider starting IV Heparin.

IV. MI: EKG, Cardiac enzymes, EKG, ABG, IV Heparin, Morphine, CXR, Bblocker, ACE, ASA, Statin, IV Fluids, Call Senior and Cards consult STAT

V. Pneumonia: CXR, blood and urine cx, IV antibiotics (Community acquired: ceftriaxone+azithromycin; or IV Levaquin. HCAP: vanc, zosyn, cefepime; add IV clindamycin if post-obstructive)

* Fall: Physical exam to rule out fracture. Check pulses and reflexes and cap refill. Always get a Portable AP view of pelvis for elderly patient that falls. If indicated, noncontrast CT head.

* Altered mental status: Check blood sugar, Vitals with O2 sat, Check med list for narcotics, Give Narcan if patient is on a lot of pain meds. U/A. Consider CT head. EKG, r/o A fib with possible stroke, CXR. Check lytes. Consider blood cultures. IV fluids.

* Dementia: Check reversible causes of dementia labs (Lytes, CBC, RPR, TSH, Vitamin B12, Folate, U/A, blood and urine cx) CT Head without contrast, Consider these meds: Risperdal 0.5mg bid or Haldol 1mg IV or IM if agitated.

* Asthma/COPD exacerbation: Check vitals and O2 sat,. ABG. Back to back nebs then q 4hours around the clock. IV Decadron, peak flows with nebs, Advair, Doxycycline 100mg po qd if patient with COPD has a productive cough. Ask if the patient has ever been intubated before.

* Weakness: Neuro exam with check of motor strength, reflexes and babinskis. Ask patient about bowel/bladder incontinence, Rectal exam to rule out decreased rectal tone. If so, start IV Decadron, get an MRI and call Neurosurgery.

* Alcoholics: Possible restraints, start Alcohol withdrawal protocol with Ativan symptom triggered vs fixed dose. Check lytes and CBC then give Thiamine 100mg IV qd and Folate 1mg IV qd, switch to po when possible

 

[pillowhead]

We give tons of phenergan at my hospital. 25mg IV is a standing prn order for nausea on almost every service I have been on. I prefer zofran because it lacks some of the euphoric effects.

At one of the hospitals I rotate through, IV phenergan is checkbox, standard order on all admission packets.

At another hospital I rotate through, you have to call pharmacy to get approved for IV phenergan and demonstrate that the patient has failed every other anti-emetic under the sun and absolutely will not be able to tolerate po phenergan.

Go figure.

 

[Mista Suprane]

?

The formatting sucks but I copied this from the above website. Are you saying that only one case of limb necrosis has ever been reported?

i stand corrected. still anecdotal, however.

 

[Apollyon]

Metoclopramide is completely ineffective as an antiemetic. Search the literature.

Metoclopramide (Reglan) is ineffective in post-operative nausea and vomiting (my emphasis added). The literature supports this. However, as you state rightly above, post-chemo N/V is more likely to be seen by interns, or N/V that is not medication-related. Metoclopramide is well-supported by the literature for relief of nausea and vomiting in non-medication related cases.

 

[jdh71]

Metoclopramide (Reglan) is ineffective in post-operative nausea and vomiting (my emphasis added). The literature supports this. However, as you state rightly above, post-chemo N/V is more likely to be seen by interns, or N/V that is not medication-related. Metoclopramide is well-supported by the literature for relief of nausea and vomiting in non-medication related cases.

Word

Zofran and Reglan took care of almost all of my chemo-related N/V when I was doing heme/onc

 

[Arch Guillotti]

i stand corrected. still anecdotal, however.

There seem to be some pretty well documented case reports. Seems to be a bit more than "anecdotal".

 

[proman]

Metoclopramide (Reglan) is ineffective in post-operative nausea and vomiting (my emphasis added). The literature supports this. However, as you state rightly above, post-chemo N/V is more likely to be seen by interns, or N/V that is not medication-related. Metoclopramide is well-supported by the literature for relief of nausea and vomiting in non-medication related cases.

I'll let the oncologists recommend treatment for CINV. But, I'm pretty sure that surgical interns take care of post operative patients and their nausea.

 

[Mista Suprane]

There seem to be some pretty well documented case reports. Seems to be a bit more than "anecdotal".

isn't a case report just really anecdotal though? it's just a patient that a physician had the gumption to write up a 100 word note about (funny, in these cases, still secondary to EXTRAVASATION of phenergan, not really intravenous). not enough to cause a recall of the medication OR officially change the stance of the drug company regarding the recommended administration of the medication OR even cause the FDA to put a black box warning on the drug.

do case reports routinely change your clinical practice?

 

[Arch Guillotti]

isn't a case report just really anecdotal though? it's just a patient that a physician had the gumption to write up a 100 word note about (funny, in these cases, still secondary to EXTRAVASATION of phenergan, not really intravenous). not enough to cause a recall of the medication OR officially change the stance of the drug company regarding the recommended administration of the medication OR even cause the FDA to put a black box warning on the drug.

do case reports routinely change your clinical practice?

Friend, I don't mean to argue this ad nauseum. I order phenergan every now and then if i think it is indicated and have no quarrel with anyone else who does the same. But.... according to the ever popular wikipedia anecdote in greek means "unpublished". They are also typically "oral and ephemeral". The document I referenced lists a handful of very real case reports, none of which I consider unpublished, oral or ephemeral. I have also seen warnings posted on fliers around the hospital before warning of its dangers. I don't consider that anecdotal either.

And yes case reports do soemtimes change my clinical practice. If you read the APSF newsletter this month you will see what I am talking about:

http://www.apsf.org/resource_center/newsletter/2009/spring/01_cerebral.htm

It's a discussion on how we should be managing cerebral perfusion pressures in certain individuals under general anesthesia. The author of the article is editor in chief of Mayo Clinic Proceedings. The discussion dates back to 2007 as follows:

In the Summer 2007 issue of the APSF Newsletter, Cullen and Kirby reported on 2 patients in whom a catastrophic, new-onset brain injury was discovered after surgery in the beach chair (barbershop) position.

By your standards this is anecdotal and shouldn't alter your practice patterns. I would argue otherwise.

 

[THP]

we use IV reglan as one of the meds for hyperemesis gravidarum. Its obviously not a single agent but some patients do very well with it as an anti-emetic.

 

[ToldYouSo]

I was curiously navigating the remote regions of the forums and ended up here where all the doctors post, it's rly interesting!

 

[radslooking]

i used to use phenergan more than I do now. I got scared off by recent reports, however true they may be, or how rare IA infiltration may be. In any case, zofran, compazine, ativan, inapsine, etc should do the trick 90+ percent of the time. If there's still doubt, reglan, benedryl, or steroids should do. It should be rare that you need to use a drug that you don't want to.

 

[jdinovit]

I very much like the guide but disagree about the hypotension algorithm.

In my experience, the majority of elderly patients found to be in hypotension are fluid overloaded and giving a 500cc to everyone with hypotension is a big mistake and will KILL PATIENTS!

Physical exam first, then if you hear crackles in the lungs, patient is elderly, recieving 70cc/hr of fluids or greater and has CAD risk factors, do a Stat Portable Chest Xray if time allows to r/o pulmonary edema. Then if they have Pulmonary Edema, give 40 of lasix and stop fluids. If no pulmonary edema then give more IV boluses.

In fact, I would not give greater than one 500cc bolus to any elderly patient recieving IV fluids unless I do a stat portable chest Xray first, because I find that most of them end up being in fluid overload.

It gets more complicated when it is 50/50 if patient is fluid overloaded or not (like pt is elderly, has CAD and on standing IVF 100cc/hr with no obvious edema) and you have to make fast decision to give lasix or to give a bolus. The wrong decision can kill the patient.

Also urine output is useful but can throw you off. Is pt not urinating because you put them into CHF by fluid overloading them or is pt hypovolemic? Or does elderly pt on antibiotics have sepsis now and the kidneys are shot?

 

[Faebinder]

In the medical wards... don't pre-emptive strike a fluid bolus on hypotension... it may be a bad CHF.

In the surgical wards (were patients go NPO for a while)... always bolus fluids for hypotension and then make sure you look to see if you have a CHF in action (i rarely note CHF in the surgical wards).

 

[OTD]

Ok, I'm sorry but unless you want your patient to crash NEVER give lasix to a hypotensive patient unless you KNOW that it is indeed CHF.

Lasix is a vasodilator and can have profound effects on BP, if the patient is hypotensive for another reason the patient can crash before your eyes.

GO SEE THE PATIENT and don't give anything unless you know what you are dealing with. If you need help don't hesitate to CALL YOUR SENIOR.

 

[radslooking]

agreed with the above posters who said pay close attention to volume status, especially in complicated medical patients. Its a holistic type thing...you 1. check for a history of chf, check ins and outs, weights, creatinine current versus baseline (and bun), respiratory status (last cxr, 02 sats versus baseline, etc) And if they've been given blood....they are usually volume up, unless very anemic. Lots of brittle patients given blood get volume overloaded.

Some chf'ers will run chronically low BP's (80's to 100's) and giving them a fluid bolus when they are already hypoxic is asking for trouble. Therefore do a little investigative work before you order a fluid bolus.

Not all hypotension needs to be treated. Ask if its new for the patient and if they are symptomatic. Nurses sometimes will get nervous and pressure you to do something, but there are times I don't treat.

 

[mjl1717]

Overall, helpful info..

 

[jdinovit]

To clarify what I wrote is that many elderly patients I've encountered being hypotensive were actually fluid overloaded and Lasix corrected their hypotention. Yes, Lasix can kill a hypotensive patient unless they indeed do have pulmonary edema where it will save them. So you have to be very careful and only give Lasix when you are certain about it. My point was that you don't automatically give every hypotensive patient liters of IV boluses without doing a portable Chest Xray to rule out pulmonary edema and examining them since overlooking pulmonary edema is a very common mistake.

So if you are 100% certain they have pulmonary edema like if they have diagnosed CHF, have 2+ edema b/l, acute SOB, new crackles diffusely in lungs are on a lot of IV fluids and have no reason to be hypovolemic then giving lasix will resolve their pulmonary edema and save them. Giving a 1L bolus will kill them.

If you are not 100% certain they have Pulmonary Edema but suspect it, then give a 500 cc bolus and order a stat portable Chest Xray to look for pulmonary edema. If it comes back flash pulmonary edema then diurese, if it comes back negative then continue IV bolus.

If you don't suspect pulmonary edema then bolus away but you should F/U with portable CXR on elderly patients you are giving a lot of IV boluses with since many tend to develop pulmonary edema eventually since most have several CAD risk factors and really have subclinical CHF.

 

[Haole]

So I found this thread the other night, literally about an hour after I got home from work where the last thing I did was order 25mg IV phenergan for a vomiting patient. I thought for sure the next morning this dude's arm would be all jacked and he'd have to have it amputated all because of something I did. Well, much to my relief, when I arrived the next morning his arm was fine. This however has motivated me to pull out the old pharmacology book and relearn my drugs. I don't want to learn the hard way!