Acute Onset Non-Spe Begin standard resusitation measures (IV fluids, NGT, Cath, ete.) ¥ Start Antibiotics per Antibiotic Guideline Lab (CBC, UA, BMP, ICON, +LFTs, Amylase) Chest/Abd xrays, EKG-as indicated ¥ Emergent EGS Consult for Admission Urgent EGS consult for admission EGS and POP notified ic Abdominal Pain Disclaimer: These guidelines have been developed to assist in the decision-making processes for patlant admission to VUH. In no way are they intended to substitute for the independent clinical judgment of the treating physicians and staff. They have been prepared with the expectation that departure from the guidelines is appropriate at the discretion of the physician, based on each individual patient's candition and the attandant circumstances Comments or suggested changes should be made to: Dr, Jose Diaz, Dr. Willie Melvin, Dr. lan Jones or Dr, Seth Wright iVorkup suggests surgical problem Continue ED ? ‘Workup Recommend GT| ABD & Pelvis with Contrast IviPO Findings require inpatient eae 2 Yes _Refered to surgical clinic 7 ‘Appropriate clinic land POP notified, as appropriate 711103ACUTE BACTERIAL MENINGITIS Suspect Acute Bacterial Meningitis (Adults only) @ ANTIBIOTIC TREATMENT PROTOCOL Stat lv: Disclaimer: ‘These guidelines have been developed to assist in the Idecision-making processes for patient admission to VUH. STAT Blood In no way are they intended to substitute for the Sere Dexamethasone 10mg independent clinical judgment of the treating physicians ecw Dit ah st pi and staff. They have been prepared with the expect BMP Usk Loe Cetrnxone 2 that departure from the guidelines is appropriate at the discretion of the physician, based on each individual patient's condition and the attendant circumstances. Culture: For severe CS allergy (wheezing, anaphylaxis) substitute Meropenem tom |Commien: rected Dr, Robin Hemphill ‘questions or suggestions should be Abnormal mental status OR risk of mass lesion * STAT LP (with CSF fam stain, WBC w! (Papilledema, focal neuro diff, Protein & defects, recent head trauma, malignant Glucose), neoplasm or hie CNS mass lesion) Ces ‘OR immunosuppressed HIV, see HIV Protaco) 2 ¥ Begin Treatment protocol oa ‘CSF cloudy) ‘or high suspicion of bacterial meningitis ves ‘Abnormal CSF ¥ (WEC >5/mm3, glucose #45 mg/dl or Protain > 50mgidl) ? STAT Head CT ‘wi Contrast (on CSF stain or SF PMNL >100!mm3, o NO CSFibload glucose <.5, or seen anylime except July, Aug, Sept, of age <35? ? No ves 4 Mass effect NS Consult 2 Continue ED Workup. Consider Viral Meningitis Intiate treatment protocol * Consider risk! amit benefit of LP with suspected or Continue ED. known platelet Workup count <20,000 DATE T1103Begin standard resusitation measures (IV fluids, NGT, Gath. etc.) Start Antibiotics per protocol Emergent EGS Consult for Admission Admit to Medcine * Ransons criteria; Non-gallston pancreatitis Age > 55 yo WEC>1 6,000/mm3 Gluc>200mg!100ml -LOH>3501U/L -AST>25U/100m! Gallstone pancreatitis: ‘Age >70 yo WBC>18,000/mma -Gluc®220mq/ 100m! LDH>4001U/L AST>250U!00mi ves, Minimal stranding ACUTE PANCREATITIS Peritonitis with shock Labs (CBC, BMP, UA, Amylase LFTs, Ca, loon), Chesvabd xrays, EKG as indicated U/S Abd RUQ OTS Positive Tor Suggests mild pancreatitis (minimal pain, <3 Ransons criteria 1*, Amylase <1000 ? >3 Ranson's oriteria®, Amylase > 1000) ves Recommend CT abdipetvis +CIVIPO Moderate to severe tarenchymal edema, +1 necrosis. ? Disclaimer: ‘These quidelines have been developed to assist in the decision-making processes for patient admission t@ VUH. Inno way are they intended to substitute for the independent clinical judgment of the treating physicians and staff. They have been prepared with the expectation that departure from the guidelines is. appropriate at the discretion of the physician, based ‘on each individual patient's condition and the attendant circumstances. Comments or suggested changes should be made to! Dr. Jose Diaz, Dr. Willie Melvin, Dr. lan Jones or Dr. Seth Wright Urgent EGS consult Urgent EGS: Consult TH03Disclaimer: ‘These guidelines have been developed to assist in the Acute Stroke decision-making pracesses for patient admission to VUH. In ne-way are they intended to substitute for the independent clinical judament of the treating physicians and Acute Focal Neurological Deficit: limb paresis or plegia, visual field deficit, numbness, dysarthria, dysphasia, ataxia staff. They have been prepared with the expectation that depariure {rom the guidelines is appropriate at the discretion of the physician, based on each individual patient's condition and the attendant circumstances. ‘Comments or suggested changes should be made to: Alert CT scanner of stroke patient en route Or. Adrian Jarquin-Vaidivia Dr. Jason Thurtrian Dr. Bill Lummnus Or. Anne O'Duffy H & P to include time of onset of symptoms, Dr. Howard Kirshner V.S., body weight, contraindications to thrombolysis. ‘ontraindications to IV thrambalysi 1) Evidence of intracranial bleed 2) Suspicion of SAH F 3) Recent intracranial surgery, trauma or stroke O, by nasal cannula if pulse ox < 92%. If GCS within 3 months <8, intubatate, Avoid hypotension. 4) History of ICH 5) Uncontrolled hypertension at time of treatment (eg, 2185/10 torr), use labetalol, enalaprilat, nicardipine or nitroprusside IV IV NS based on hydration status, 2nd IV hep 6) Seizure at onset lock 7) Active itnernal bleeding 8) Intracranial neoplasm, AVM.or aneurysm, 9) Bleeding diathesis, including: current use of Lab to include CBC IP, bedside glucose, PT, PTT, anticoagulants with PT> 15 seconds, use a . lipid profile, tox screen, plus cardiac enzymes, ae ent last 48 hours, platelet count pregnancy test as indicated and stool guaiac, EKG & 10) Glycemia >400 or <50 mg/dL. CXR 11) Recent artetial puncture at non-compresible site,

22 or <4 14) Rapidly improving symptoms 415) Major surgery within 14 days Positive for acute blood? ‘Consult Neurology! See Page 2 See ‘Symptomsisigns < 3 hrs, NIHSS<22 & bayond Isolated sensory or ataxia sx and no contraindications to IV tPA" Goal: Door to Delivery of tPA<45 min. If sx <6 his, also call stroke attending IV tPA protocol for acute ischemic stroke: Jo. 9mavkg tPA; max 90 mg total dase, [Give 10% as IV bolus & 90% over next 60 min. Discard unused tPA immediately No anticoagulants or antiplatelet agents In next 24 hrs. JAvoid Foley cath for 6-12 hrs. Type & screen [Admit to ICU [Symptoms/signs sill present: ‘Admit, discuss ICU vs. flaor. Discuss IA thrombolysis. ‘Symptoms sill present or ‘other risk factors: admit, discuss IGU vs. tim vs. floor 74103,ACUTE LOWER GI BLEEDING (Hematochezia) Disclaimer: These guidelines have been developed to assist in the decision-making processes for patient admission to VUH. Inno way are they intended to substitute for the independent clinical judgment of the treating physicians and staff. They have been prepared with the expectation that departure from the quidelines is appropriate at the discretion of the physician, based on each individual patient's condition and the attendant circumstances. H & P (include orthostatics) 1 Institute standards resuscitative measures if in shock j ‘Comments or suggested changes should be made to: Dr. David Raiford Dr. Glenn Eisen Dr. Keith Wrenn Negative aspirate or aspirate not done —_—__ fp Consult GI service. Admit to ICU of floor. Lab to include CBC/pit, BMP, PT, and type and cross 4u PRBC Massive Bleeding? Consider NG tube (especially for brisk bleeding) ‘ositive aspirate or risk factors for UGI bleed? Consult G! service. Admit to ICU (usually) oF floor. Emergent EGS consult 744103,Disclaimer: These guidelines have been developed to assist in the decision-making processes for Patient admission to WUH. In no way are they intended to substitute for the independent clinical judgment of the treating physicians and staff, They have been prepared with the expectation that departure from the ‘guidelines is appropriate at the discretion of | based on each individual condition and the attendant clreumstances. Comments, questions, or suggestions should be directed to’ Dr. David Raiford br. Gienn Eisen Dr. Keith Wresin ACUTE UPPER GI BLEED (Hematmesis, coffee ground emesis, melena) H&P es Institute standard resuscitive measures if in shock rs Labs to include BMP, Liver Profile, CBC/pit, PT, and Type and Cross - 4u PREC rs Intitial resuscitation and stabilization: | All patients receive Protonix 80 mg IV bolus, then 18 mg/hour IV |- If cirrhosis/portal htn. give octreotide 100meg IV bolus, then 50 meg/hour IV — | Establish pre-endoscopy risk of rebleed assessment Predictors of Rebleeding ‘Age>60 Cirrhosis/Portal hypertension Renal disease Anticoagulant use Coagulopathy Shock at presentation Cardiac disease High risk of rebleeding or hemodynamically unstable? Yes ICU admission with urgentfemergent endoscopy Consult Gi Service Low risk of rebleeding and hemodynamically stable Hold in ER if young, otherwise healthy & EGD feasible in Gl lab within 34 hrs (weekdays 8 AM -4 PM) OR Admit to Gl service 7/14/03.Begin standard FT LOWER QUADRANT ABDOMINAL PAIN Acute LLQ Abd pain - suspect diverticulitis H&P resusitation measures (IV fluids< NGT, Cath, etc.) no ¥ * Start Antibiotics Lab (CBC, UA, per protocol BMP, Icon), Chest! abd Xray, EKG as indicated ¥ Emergent EGS Consul for Admissions ves ves No» * Recommend CT abd & Pelvis, +CIVIPO Urgent EGS yes Need Consult Inpt care 2 No EGS & PCP Referred to notified surg clinic 2 Disclaimer: 1es have been developed to as: the decision-making processes for patient admission to YUH. In naway are they intended to substitute for the independant clinical judgment of ‘he treating physicians and staff. They have been prepared with the expectation that departure from the guidelines is appropriate at the discretion of the physician, based on each individual patient’s condition and the attendant circumstances. tin Comments or suggested changes should be made to: Dr. Jose Diaz, Dr. Willie Metvin, Dr. lan Jones or Dr. Seth Wright Consider pelvic US for OB/GYN pathology Consider ‘OBiGyn Consult Appropriate clinic & PCP notified F408RLQ ACUTE ABDOMINAL PAIN SUSPECT ACUTE APPENDICITIS Disclaimer: These guidelines have been developed to assist in the Jdecision-making processes for patient admission to YUH. In no way are they intended to substitute for the independent clinical judgment of the treating physicians Begin standard and staff. Thay have been prepared with the expectation resusitation Clinical that departure from the quidelines is appropriate at the measures (W }#—YES. peritonitis. discretion of the physician, based on each individual fNuids, NGT, Cath, th shock patient's condition and the attendant circumstances, etc) t [Labs (CBC, BMP, UIA, ICON LFTs, Comments or cuggesied changes should be |Amylasa), Chasv/Abd Xrays, EKG as made to: Start Antibiotics. indicated Dr. Jose Diaz, Dr. Willie Melvin, Dr. tan Jones per protocol or Dr. Seth Wright Emergent EGS Consult for insske symptoms and signs 0 Urgent EGS Admission dironon, rer iereened WO Consult Workup Continue ED: ves So casi NO—*) Wioreup or refer ? Suspect Consider OBIGYN YES) “pelvic No vs pathology ? ¥ Recommend CT Workup Suggests surg YES. Apes win problem 2 \ViPO NO Pelvic UIS Urgent £68 Consider Urgent Pevic US get Es EGS Consult Coast Continue ED No workup or refer to YES appropriate = EGS and | eS -Feteredio PCP Refer to O87 notified urgical clinic? GYN service. xe rama ‘Appropriate clinic. and PCP notified, as appropriateRUQ ACUTE ABDOMINAL PAIN SUSPECT BILIARY PATHOLOGY Disclaimer: These guidelines have been developed to assist in the decision-making processes for patlent admission to YUH. In no way are they intended to substitute for the independent clinical judgment of the treating physicians and staff, They have been prepared with the expectation that departure from the guidelines is appropriate at the discretion of the physician, based on ‘each individual patient's condition and the attendant ‘circumstances. Begin standard resusitation measures (Iv fluids, NGT, Cath, ete.) + Start Antibiotics. ar protocol Lab (CBC, BMP, UIA. LFTs, Amylase, ICON) & ChestAbd Xrays, Emergent EGS b Consult for EKG as indicated, ‘Admission UIS AbdiRUQ ‘Comments or suggestions should be made to: Dr. Jose Diaz, Dr. Willie Melvin, Dr. lan Jones or Dr. ‘Seth Wright Workup suggests surgical problem: 2 ves ves Recommend CT Abd/Pelvis with, contrast WIPO no ¥ i Lined Urgent EGS EGS & PCP wate consutt notified 2 no Continue ED ‘workup or refer to appropriate servios 7403,BOWEL OBSTRUCTION SUSPECTED BOWEL OBSTRUCTION Begin standard resusitation YES Clinical measures (IV Peritonitis & fluids, NGT, Cath, ‘Shock etc.) > eaters Labs (CBC, BMP, UA), Chest & v abd xrays, Emergent EGS. EKG as indicated Consult for Admission ‘Continue ED workup. Use RUG, RLQ, LLG o¢ non specific abd pain guid as necessary Previous ab surgery 3 Urgent EGS ‘Consult Recommend CT abd & pelvis, 40 IV PO I Urgent EGS ‘Consult Disclaimer: These guidelines have been developed to assist in the decision-making processes for patient admission to VUH. In noway are they intended to substitute for the Independent clinical judgment of the treating physicians and staff. They have been prepared with the expectation that departure from the guidelines is appropriate at the discretion of the physician, based on each individual patient's condition and the attendant circumstances Comments or suggested changes should be made to: Dr, Jose Diaz, Or. Willie Melvin, Dr. lan Jones or Dr. Seth Wright NO 74703.Disclaimer: ‘These guidelines have been developed to assist in the decision-making processes far patient admission to YUH. Inno way are they intended to substitute for the independent clinical judgment of the treating physicians and staff. They have been prepared with the expectation that departure from the guidelines is appropriate at the discretion of the physician, based on each individual patient's condition and the attendant circumstances. femodynarrically Unstable? (BP < 90, RR 02 Sat < 90%, syncope, need for vaso- Suspected Pulmonary Embolus pressors)* Physical Exam CXR, EKG ‘YES Rx accordingly jen PE tkaty? Questions for Suggestions should be directed to: Dr. Keith Wrenn Dr. Art Wheeler Dr, Rick Belcher Dr. Jake Block Rx accordingly Admit to appropriate ICU * 4) If patient too unstable and P.E. Is in differential, empiric treatment and ICU admission may be best action initially, 2) In this setting, bedside Echocardiogram may be indicated, Physical Exam, CXR, YES ¥ EKG Choose imaging test: US of legs, OR VO (either is available 7A-10P. If indicated but unavailable, admit for test in spiral CT of, chest Positive tor PE? (PA and ICU Admit ADDITIONAL INFORMATION: 1, D-dimer alone should not be done Low probability Hx, 1 of 3 imaging test and D- Dimer negative? Home or look for alternate diagnosis 2. TUS done first and another test needed, then VQ or CT is second choice (or vice versa) 3. Hao dissection is in differential after Hx, P.E. and CXR, then spiral CT of chest should be test of first choice 4, CT alone should not be done (US and d-dimer are adjuncts) 5. ICT of US positive for VTE, admit 74i03 High probability Hx and negative tests or discordance between Imaging and D-Dimer Get another imaging test If available or admit te patient's private jattending (or Pulmonary) Rogers service if unattached) test positive for PE? Treat for PE with LMW heparin (unfractionated heparin for renal failure or morbid obesity)