text: Page 1 Intern Night Float Survival Guide 'Your guide through the dark' SUNY Upstate Medical University List of Topics: Page Number Leaving Against Medical Advice (AMA) 4 Constipation 4 Pain Control 5 Acute Anemia 6 Low Urine Output 7 Hypoglycemia 8 Chest Pain 9 Arrhythmias/ACLS 10 Atrial Fibrillation 11 Hypertension 12 Acute GI bleed 13 Shortness of Breath 14 Oxygen Delivery system 15 Electrolyte Replacement 16 Hyponatremia 17 Hyperkalemia 18 Abdominal pain 19 Hypernatremia 19 Insomnia 19 Hyperglycemia 19 Agitation/Confusion 20 Fever 21 Sepsis 22 Phone Numbers 23 Page 3 INTRODUCTION Welcome to world of 'night float'. Night float is a unique rotation which gives you the autonomy of making many clinical decisions. Remember, 'with great power there must also come - great responsibility! (Ref: Ben Parker, Spiderman), after all, you are 'cross covering' for other physicians' patients. This book has been assembled by senior / chief residents as well as faculty members to help you with important tips and tricks to guide you through your night float rotation. It includes topics which the night float is most commonly contacted about by nursing staff. Each topic includes the information you need to obtain from nursing staff /chart and possible differential diagnosis and management based on etiology. Although this book has several helpful hints and references, please remember to use your clinical judgment in each individual case. Remember: you always have your senior with you! We look forward to working with you and we know it will be a great year! We also look forward to hearing any suggestion / tips from you to make this manual better. Sincerely, SUNY Upstate Medical University. Department of Internal Medicine. RESIDENT AUTHORS FACULTY MENTOR Rushikesh Shah. M.B.,B.S. Viren Kaul. M.B.,B.S. Amit Dhamoon. MD, PhD. CONTRIBUTING AUTHORS Omair Chaudhary. MD. Harvir Singh Gambhir. M.B.,B.S., M.D. Arpan Patel. MD. Subhash Sitaula. M.B.,B.S. Sumendra Joshi. M.B.,B.S. Shalin Kothari. M.B.,B.S. Syed Wajihuddin. M.B.,B.S. Priyanka Pitroda. MD. Aditya Kalakonda. MD. Aakriti Pandita. M.B.,B.S. Pallawi Kopparty. M.B.,B.S. Page 4 PATIENT LEAVING AGAINST MEDICAL ADVICE • Discharge against medical advice (AMA) is a situation in which a patient chooses to leave the hospital before the treating team recommends discharge. • Review patient's chart and ensure that patient does not have a condition that impairs his / her capacity to make decisions. e.g psychiatric problems, mental retardation, encephalopathy, delirium. • Suicidal patient, or patients admitted after attempting to commit suicide are not allowed to leave unless specifically recommended by psychiatry. • Review sign out for instructions from primary team. • Talk to patient. Most common scenarios when patients decide to do this are: • dissatisfaction with their care. • dissatisfaction with staff taking care of them. • feeling uninvolved. Feeling of not being updated on clinical progress. • inadequate pain control • personal problems. • Attempt to answer patient's questions as directly as possible. Attempt to alleviate concerns by providing information. Resolve any medical concerns such as pain control if deemed reasonable. • If patient decides to leave anyway, explain to him / her all possible consequences of leaving prior to completing treatment. Provide them with the appropriate AMA form to sign. • Let the senior NF/ nocturnist know. Complete medical reconciliation to the best of your ability. Provide scripts if needed. NEVER prescribe controlled substance. Advise appropriate follow ups. • Document your conversation with patient. You don't have to do the discharge summary but mention in brief why the patient chose to leave and that you explained the potential risks which he / she understood. Make sure to document that patient had the capacity to understand the decisions regarding his medical care. • Inform the team and concerned attending in the morning. CONSTIPATION • Defined as decrease in frequency ( < 3 BMs / week) or change in consistency to hard / lumpy stool or difficulty in evacuation with feeling of incomplete evacuation. • Prior to prescribing medications, ensure patient is not obstructed. Is the patient passing flatus ? Any vomiting ? Abdominal pain ? If concerned, examine for signs of surgical abdomen. • Review the chart to for medications which can cause constipation: opioids, anticholinergics, 1st degree antihistaminics. • Evaluate patient's bowel medications. (All patients with opioids should be on bowel regimen) • Once dynamic obstruction is ruled out, may order medications as follows: Stool softeners : • Docusate 100 mg BID: Takes 24 - 72 hours for onset of action. Stimulants : • Senna (2 to 4 tablets daily): Works in 6 -12 hours. • Bisacodyl • 10 to 30 mg tablet daily: Works in 6-10 hours. • 10 mg suppository works in 15-60 minutes. Osmotic agents: • Magnesium sulfate 1 - 2 teaspoons in water: Acts in 0.5 – 3 hours (Avoid in renal insufficiency). • Polyethylene glycol 8 to 34 gms daily: Acts in 1-4 days. • Lactulose (10-20 gms): Works in 2 - 4 hours. Enemas: If patient is on reasonably good bowel regimen with no BMs in 3 - 4 days with no signs of obstruction, consider enemas. Can use bisacodyl, tap water, lactulose enema. Avoid phosphate enemas in renal dysfunction and elderly. • Remember, reverse underlying pathologies causing the constipation: pain, urinary retention, recent surgery, opioid use, dehydration. • In intractable cases, may consider manual fecal disimpaction. Page 5 PAIN CONTROL #1. Information from nursing: #2. Information from chart/sign out: • Acuity: New onset vs. exacerbation of known pain? • PQRST ? • Red flags: Fever, focal deficits, LOC, dizziness, chest pain, dyspnea, increased oxygen requirement. • Wounds? Recent surgery? Incisional pain? • Hemodynamic stability especially for chest pain, abdominal pain. • • • • #3. Triage: Does the patient need to be seen? and initial assessment: • Chest pain: Please refer to segment on chest pain. • Headache: New onset, intractable, auras, focal deficits. • Back pain: Neurological deficits, saddle anesthesia, incontinence. • Post operative pain: Incisional healing, signs of infection. • Fall: Evaluate for acute fractures. Does patient need neck stabilization? • Abdominal pain: Surgical signs? No flatus / feces? Guarding / rigidity? • H/O of sickle cell disease: Crisis? acute chest? bone crisis? • ALWAYS ASSESS PAIN IN THE SETTING OF HEMODYNAMIC INSTABILITY. #5. Opioid administration: If patient can take PO and no risk of aspiration: Use lowest dose as one time order. • Tramadol: Synthetic. Use 50 mg doses PRN. • Hydrocodone/tylenol: 5/325 or 5/500 mg (may repeat Q4 - 6 hours) • Oxycodone:5 mg (may repeat Q4 - 6 hours) • Morphine IR: 15 or 30 mg dose. If unable to take PO / aspiration risk: • Fentanyl 25 to 50 mg IV (based on BMI). May repeat Q2 - 4 hours (shorter acting drug) • Morphine 2 or 4 mg IV (based on BMI). May repeat Q 2- 4 hours if needed. Try to find out a cause of the reported pain. Is it known? Existing regimen ? Recommendations from primary team. Review home pain regimen. Review common reasons for contraindication to meds: • NSAIDs: GI bleed, GERD, recent ACS, allergy, AKI. • Tylenol: Acute / fulminant liver failure, toxicity. • Narcotics: Allergy, intolerance, poor respiratory reserve, old age, renal dysfunction. #4. Management: • Work up emergent causes of pain if being considered (as explained in #3) • Non opioid options: • Tylenol: MDD: 4 gm, MDD with liver failure: 2 gm. Maybe used PRN (650 mg Q6H PRN). If not effective, consider standing doses for 24 hours (inform team). Standing tylenol works better than PRN. Can also be administered per rectal. • NSAIDs: Work well for acute pain. • Local agents: Lidocaine patch / gel / ointment, diclofenac gel. • Opiods: Use sparingly. Work well for acute pain, especially post operative pain. Order one time doses only. Inform team in AM. • Already on opioids: If no C/I, give a one time dose after enquiring about the last dose. Try to give same drug as being used. Do not order long acting doses. • Opioid naive: Consider one time doses of lowest dose of opioid (see #4) #5. Important considerations: • Avoid ordering standing doses. Avoid long acting formulations. • Always sign out pain control issues to primary service so they may address it on rounds. • Always assess sign out. Primary service may recommend not using a certain medication for specific reasons. • Handy tool to convert doasage (roughly) from one opioid medication to another: http:// opioidcalculator.practicalpainmanagement.com/ Page 6 ACUTE ANEMIA (CALL FOR DROP IN HEMOGLOBIN / HEMATOCRIT) #1. Information from nursing: • Symptoms ? • Vitals: Hemodynamically stable? : Tachycardia, hypotension. • Orthostatic symptoms and vitals? • Any obvious source of bleeding – GI, urine, sputum, surgical site, wound. #3. Initial assessment: • Whom to assess: Decrease in Hb> 1 unit & Hct > 3 units or active bleeding warrants assessment. • Vitals: Tachycardia, orthostasis, hypotension signifies intravascular depletion especially in setting of anemia / dehydration. Orthostatics are a sensitive exam finding. • If not able to do orthostatic vitals: See HR and BP response to leg raising. • Identify source of bleeding: • GI: hematemesis, melena, hematochezia. Do a per rectal exam if suspicious and send for FOBT. Assess abdomen for surgical signs. • Post surgical/wound : check surgical site or wound. • Hemothorax: Lung exam for decreased sounds. • For concealed bleeding: significant drop w/ hemodynamic compromise: Consider retroperitoneal / abdominal , pelvis or hip bleeding. If recent vascular procedure / cath: Retroperitoneal bleeding high on differential. Consider abrupt in pregnant patients. • If no source of bleeding: • Hemodynamic stability with decrease in all cell lines: Dilution / error. Common in 1st 48 hours of hospitalization. • Nutritional: review/obtain iron panel, Vitamin B12, folate. • Evaluate for hemolysis in appropriate settings: sepsis, autoimmune disease, liver disease, DIC. #5. Reversal of anticoagulation (please see section on reversal of anti coagulation for details): • 2/2 Coumadin / liver disease: Vitamin K (PO preferred, may use IV. Avoid SQ). FFPs. K - centra. • Platelets if thrombocytopenia. • Use desmopressin if patient is uremic. • Hold all anti platelets, especially if hemodynamically unstable. #2. Information from chart review / sign out: • Is there a known source of bleeding under investigation? • Trend the Hb / Hct to assess acuity of drop. Is there a drop in WBC / platelets: Dilution ? • Is patient on anti platelet meds / anticoagulation ? • Did patient have recent surgery or endovascular procedure. #4. Interventions: • Ensure adequate IV access: 2 wide bore IVs. • Investigations / labs: • Repeat CBC if suspecting dilution / error. • Type and cross. • INR / PTT • Send anemia work up as mentioned in #3 if warranted. • CT abdomen / pelvis if concerned for retroperitoneal bleeding / intra abdominal bleeding. • CXR to evaluate for hemothorax. • Hemodynamically unstable: Start fluid resuscitation. Consider PRBC transfusion (see below). Call SNF. Discontinue anticoagulation, consider reversal (please see section on reversal of anticoagulation). • For mild drop in asymptomatic patient w/o hemodynamic compromise: Observe. Send work up as in #3. Follow through night for stability. Inform primary team. • Keep transfusion threshold at Hb < 7 and Hct < 21 or follow primary team's instructions. For patients with active ACS, transfusion threshold is low (around 8 and 24). Can transfuse 1-2 units at a time. • Reversal of anticoagulation: See #4. • For GI bleed: see the section on GI bleed • For surgical site bleeding: D/C anticoagulation if significant bleeding. Consult surgical services. #6. Special considerations: • Jehovah's witness: due to cultural beliefs you can't transfuse these patients. Discuss with the patient and document in chart informing possible risk. You can resuscitate with IVF. • If hemodynamically significant bleed, discuss with SNF, consider MICU consult. • If unable to obtain good IV access, consider CVC. Page 7 LOW URINE OUTPUT #2. Information from chart review / sign out: #1. Information from nursing: • Acuity ? Duration ? • Does patient have Foley catheter ? Is it draining ? • If not: What is the post - void residual urine ? • If < 100 cc: evaluate etiology. • If > 200 cc: straight cath. • If > 400 cc: place a foley catheter and leave it in place. • If patient has ascites, bladder scanning overestimates the bladder volume. • Associated symptoms: fever, signs of infection ? • Oliguria (<500 cc/day or <0.5 cc/kg/hr) / anuria (No urine output). • Fluid status: I/Os, including cumulatives. Does patient have a reason to be hypovolemic ? • Med review: Diuretics, IV fluids, drugs with anti - cholinergic properties (cause retention). • Other factors: Pain / recent surgery / constipation (impair bladder emptying). • Labs: BUN / Cr and Sr. Osm (does it suggest intravascular depletion or overload ?) #4. Treatment: #3. Assessment: • Volume status assessment: Intravascularly depleted or volume overloaded ? • Intravascular depletion: Mucus membranes, skin, BP, HR, UOP, mental status. Remember orthostatic signs are sensitive for detecting depletion especially in cases of bleeding. • Overload: JVD, crackles, edema, S3. • Patient already has Foley ? Ensure it is draining. Ask nursing staff to flush and confirm patency. • Look for underlying causes: • Intravascular depletion: Sepsis, poor PO intake, excessive diuresis etc. • Overload: Fluids, ACS, arrhythmias, CHF. • Overload state: • Consider diuresis. • Treat primary cause or concomitant issues (arrhythmias). • Intravascularly depleted ? • IV fluid boluses: 250 - 500 ml. If improvement noted, place on maintenance fluids (for 1000 ml) and inform primary team. • Treat primary cause: Sepsis, diarrhea, etc. • Remove offending factors: Anti cholinergic meds, pain meds, constipation. NOTES Page 8 HYPOGLYCEMIA #2. Information from chart review / sign out: #1. Information from nursing: • How low is the fingerstick ? • First time or recurrent ? • Is patient symptomatic? Diaphoresis, confusion, tremor, fatigue, loss of consciousness. • When was last insulin dose administered, what type ? Last long acting insulin dose ? Last meal and general PO intake ? #3. Assessment / Treatment: • Is patient diabetic ? • Trend review: IS patient recurrently low on FSGLU (finger stick glucose) at particular times of day ? • Medication review: Patient on insulin ? What is the regimen: home vs inpatient ? Any recent changes ? When was last dose of insulin administered? • Is patient NPO ? Reason ? (pre op vs aspiration precaution etc) • Does patient have AKI which can lead to decreased excretion of insulin ? • Does patient have any signs of sepsis (infection), hepatic failure (impaired glucose metabolism), adrenal insufficiency (Hyper Na, hypokalemia, low BP) ? • Confirm serum glucose by point of care glucometer. • Symptomatic: diaphoresis, confused, seizures, N/V: IV dextrose amp • If patient does not have H/O DM and not on anti-hyperglycemic medication: try oral juice and recheck FS in 15 minutes • For patients who are on glucose lowering agents: • Hold further doses of hypoglycemic agents. • Can take PO: give 15 gms carbohydrate (4 oz juice) • Unable to take PO and has IV access, give ½ amp D50 IV and recheck FS. Repeat as needed • Unable to take PO and no IV access, give 1 mg glucagon IM • Check FS q15 minutes and repeat above till BG>100 mg/ dl. • Re-adjust/hold insulin scale as necessary. #4. Persistant hypoglycemia: • If patient received large dose of insulin or received normal dose insulin in light of acute kidney insufficiency, or received long acting insulin, hypoglycemia can recur. • Place patient on D5NS (@ 75-150 ml / hour) OR D10NS gtt (@ 50 - 100 ml / hour) to maintain FSGLU > 100 mg /dl. Hold all insulin regimens. Be aware of volume status, avoid in patients with heart failure. Preferably use D10 in ESRD / CHF patients. • If refractory to treatment, discuss with SNF. • Inform primary team. NOTES: Page 9 CHEST PAIN #1. Information from nursing: • • • • • Details of pain: Onset, site, nature. Hemodynamic stability. Associated symptoms. Interventions already performed. What is the patient being actively treated for? Is he being worked up for chest pain? #3. Initial assessment: • Details of pain: Determine cardiac vs. atypical vs. non cardiac • Risk factors: Known CAD/CHF?, HTN, HLD, DM, smoking, family and personal history, PVD / AAA ? • Hemodynamic stability. • Focused examination: Reproducibility, BP in both arms, radio-radial and radio-femoral delay, JVDs, heart sounds/murmurs, lung exam, upper abdominal examination. • R/O life threatening/common differentials on H/O or exam: ACS, PE, PT, aortic dissection, esophageal rupture (esp if recent EGD), foreign body. • R/O common differentials: GERD, costochondritis, pneumonia, anxiety, pancreatitis or upper abdominal pathology. #2. Information from chart: • Reason for admission and pending work up. • Cardiac history: Look up previous cardiology notes, echos, stress tests (imaging), D/C summaries. • Rapid risk assessment: Known CAD/CHF?, HTN, HLD, DM, smoking, family and personal history, PVD / AAA. #4. Initial interventions: • ABCs. Call senior on call if hemodynamically unstable and initiate emergent resuscitation. • EKG, set of cardiac enzymes, electrolytes, chest Xray. • If considering other life threatening differentials, please approach as detailed in next section. • Remember to compare EKG to previous. • Anxiety: Consider morphine or ativan (unless contraindicated) • GERD: Protonix IV. • Costochondritis: Tylenol (avoid NSAIDs till ACS ruled out) or morphine. #6. Management of other life threatening conditions: #5. Management of ACS: Always discuss with SNF and consult cardiology prior to initiating specific treatments as outlined under. STEMI: • Call SNF stat. If confirmed STEMI, in collaboration with SNF call cardiology STAT. • Per cardiology recs, consider activating STEMI code. • Rest per under. • REMEMBER ideal time to cath is under 90 minutes. Unstable angina / NSTEMI: • Oxygen to keep saturations > 92% • Morphine (especially if respiratory distress from pulm edema) • Aspirin 325 mg stat + Plavix 600 mg stat (confirm with cardiology fellow prior to administering) • B-blocker therapy if there is no contraindication (hypotension, bradycardia, new onset HF) • Low dose heparin gtt protocol (if no contraindications) • Statin, high dose: atorvastatin 40-80 or rosuvastatin 20-40 mg • Nitrates (SL vs. drip vs. Paste) titrate to relief vs. tolerance (headaches) • Send lipid panel, HbA1c, CIPs, echo (is not already evaluate or no known H/O) • PE: Pre test probability? Well's score?. If very low probability: Ddimer. If moderate to high: CT thorax w/ PE protocol, hydrate patient. (check Cr). Consider empirical high dose heparin gtt protocol / lovenox (caution in renal dysfunction, obesity. • Tension PT: Absent lung sounds, JVD, tamponade physiology? Mediastinal shift on exam or CXR? If unstable, emergent surgery consult for needle decompression. • Aortic dissection: Sudden "tearing" pain radiating to back? unstable? Unequal pulses / BP?, Wide mediastinum on CXR? Resuscitate, stop anti coagulation, stat CTA thorax/abdomen/ pelvis and check INR. Consider stat Vascular Sx consult. NOTES: Page 10 ARRHYTHMIAS / ACLS #1. Information from nursing: • Hemodynamic stability. Vital signs? • Symptoms. Chest pain, LOC, SOB, fever? • Duration of arrhythmia: Constant / intermittent? #2. Information from chart / sign out: Cardiac history: A.fib / flutter, SSS, CAD. Check past EKGs / echos. Current electrolytes. K > 4, Mg > 2? Systemic disease that maybe contributing: Sepsis, dehydration, thyroid disorders, pregnancy. • Risk stratification for common causes: ACS, PE etc. • Medication review: BB, CCB, digoxin, thyroid medications, clonidine etc. • • • • Decision making flowchart: 1. Pulse? : If no pulse, refer to #3. Activate Code. 2. If pulse present: Unstable or stable ? AMS, poor UOP, LOC, desaturations, poor organ perfusion, chest pain, pulmonary edema, shock • Stable / unstable bradycardia: Refer to #4 • Unstable tachycardia: Refer to #5. • Stable tachycardia: Refer to #6. 3. Always treat underlying cause: Address volume status. Reverse Hs/Ts. 4. ASAP: EKG, CBC, BMP, magnesium, CIPs ! 5. Call SNF / MICU to help with situation. #4. BRADYCARDIA w/ pulse: #3. Arrhythmias w/o pulse: CODE BLUE !! FOLLOW ACLS ALGORITHM (See next page) Reverse Hs and Ts: Hypovolemia : Fluid boluses with pressured bag Hypoxia : bag mask ventilation, intubation Hydrogen ion (acidosis) : Bicarb boluses Hypo / Hyperkalemia Hypoglycemia Tension pneumothorax: Needle decompression (SICU bedside) Tamponade (SICU bedside) Toxins / drugs Thrombosis: Pulmonary / Coronary #5. UNSTABLE TACHYCARDIA w/ pulse: Unstable: • Atropine (0.5 mg IV Q 3 - 5 minutes, max dose: 3 mg) • If considerations for beta blocker toxicity: Consider glucagon and insulin IV. • Apply pads. Prepare for transcutaneous pacing. Call SNF/ MICU. Consider cardiology consult. • If hypotensive: Bolus fluids. Treat as shock. • Discontinue all nodal blockers. Stable: Patient asymptomatic: • Sleeping: Physiological. Attempt to wake patient and see response. • Asymptomatic: Obtain EKG. • SInus bradycardia: "Does not need treatment". D/C • blockers • AV block: Check old EKG. D/C blockers. • Consult SNF. If new 2nd or 3rd degree block, • consider cardiology consult. RRT. Call SNF. Obtain EKG. Attach a Zoll monitor. • Regular wide complex i.e VT / SVT with aberrancy: Assume VT. • Sync cardioversion: 100 J, increment if needed. • Post resuscitation, consult cardiology and consider amiodarone / lidocaine gtt. • Torsades: Magnesium IV. Avoid amiodarone (prolongs QTc) • Irregular wide complex: VF (rarely with pulse): DESYNC SHOCK! • Regular narrow complex: Sinus / SVT / flutter: • Sync cardioversion: 50 - 100 J, increment if needed. • Treat underlying cause: Volume depletion vs overload (eg sepsis vs. pulmonary edema), pain, recent sx, Hs / Ts. • Adenosine (6 mg - 12 mg - 12 mg). • See stable tachycardias for other management. • Irregular narrow complex: A. fib, flutter with variable block, MAT: • Sync cardioversion: 120 - 200 J, in increments. • Treat underlying cause as mentioned above. • See stable tachycardias for further management. #6. STABLE TACHYCARDIA: Usually narrow complex • Rx underlying cause. Hs / Ts. Volume status is very important: Give fluids / diurese ! • Pharmacology, narrow complex: • If not hypotensive: • Cardizem bolus (1 mg/kg, max dose: 20 mg) * 2 Q 10 minutes. Start on Cardizem gtt. • Metoprolol 2.5 or 5 mg IV. • If hypotensive: Amiodarone 150 mg loading IV, then gtt. • If known systolic CHF: consider digoxin (usually avoided 2/2 toxicities) • If considering septic shock and have central access: Transfer to ICU, consider esmolol gtt with levophed support (after adequate fluids) Page 11 ATRIAL FIBRILLATION CALL FOR: IRREGULARLY IRREGULAR PULSE / TELE #1. Information from nursing: • Acuity: New or old ? • Is the call because patient's rate is now uncontrolled or because of new A.fib. • Vitals / hemodynamics. • Is there a known cause ? (Please see section on causes). #3. Assessment: • Vitals: Ensure hemodynamic stability. • Examine / ask questions to rule out causes of PE (see the section on causes) #4. Initial interventions: • stat 12 lead EKG: irregular narrow complex tachycardia with no identifiable P waves - atrial fibrillation. Look for signs of ischemia - peaked T waves, ST segment elevation / depression, T wave inversions, Q waves. • Repeat BMP, magnesium levels in not sent within the last 4 hours. • Send a TSH levels if none done recently. • CIPs to rule out ACS especially if concerning symptoms / signs present. • If hypoxic, or symptomatic with risk factors, consider CTA for PE protocol. #2. Information from chart review / sign out: • Acuity: New or old ? • Are there any recommendations from the team regarding rate control ? What's been tried and what worked ? • Review of existing rate controlling meds : BB, CCB, amiodarone, digoxin. Did patient miss any medications ? • Review old EKGs, old cardiology notes. • Check most recent K, Mg, TSH levels. #5. Causes / etiologies: Mnemonic: MARTHA PID • Medications: missed doses of rate controlled agent. Use of theophylline, caffeine. • Acute Coronary Syndrome, acute CHF or existing CAD. • Respiratory (PE, hypoxia, COPD). • Thyrotoxicosis. • Hypokalemia, hypomagnesemia. • Alcohol, illicit drugs (cocaine, amphetamine, bath salts, etc). Always remember withdrawal states! • Pain. Recent sx / injury ? Open areas ? • Infection / sepsis. • Dehydration. Patient not taking PO ? Assess why. #6. Treatment / underlying cause: • Correct underlying cause: • Medications: Assess why patient not taking his PO rate controllers. Consider IV formulations from same family. • Acute Coronary Syndrome: Trend CIPs (refer to section on chest pain) • Acute CHF: Consider diuresis. • PE: stat imaging. Consider empiric anticoagulation if high risk. • COPD exacerbation: Treat with bronchodilators, however exercise caution since beta agonists can exacerbate atrial fibrillation. • Hypokalemia, hypomagnesemia: Replace (see section on electrolyte replacement) • Cocaine use: Consider benzodiazepines. • Alcohol withdrawal: CIWA protocol. • Pain: See section on pain control. • Infection / sepsis: See section on sepsis. • Dehydration: IV hydration. #8. Special considerations: • If A.fib lasts > 48 hours, patient will need anticoagulation depending on CHADS2 / CHADS2 - VaSc score, relay to team regarding considering anticoagulation. #7. Treatment / rate control: If blood pressure acceptable: • Metoprolol 5 or 10 mg IV and repeat as necessary. Once controlled, immediately give PO 12.5 / 25 / 50 mg based on BP. • Cardizem 0.25 mg / kg over 2 mins (Max: 20 mg) IV. Usual dose 10 mg. May repeat after 15 minutes. Once controlled, can start cardizem 30 mg PO q 6 H. If not controlled, start on cardizem drip at 5 / 10 / 15 mg / hr depending on BP. If BP low: CALL SNF. • May use lower doses of IV metoprolol or cardizem. • Amiodarone 150 mg bolus, followed by gtt @ 1 mg / kg for 6 hours, followed by 0.5 mg / kg for 18 hours. Inform team to consult cardiology for further recs. • Esmolol 0.5 mg / kg bolus dose. can use esmolol gtt, but needs MICU consult since may need pressor support. If hemodynamically unstable: acute drop in BP / patient unresponsive – synchronized cardioversion (evaluate risk of causing CVA) : Refer to section on tachycardias for details. Page 12 HYPERTENSION #1. Information from nursing: • Acuity: New or existing issue ? • Machine or manual ? Request a manual reading and in both arms. • Ensure right cuff size: Smaller cuffs falsely elevate BP, larger cuffs falsely underestimate BP • Is patient in pain, anxious, agitated, have urinary retention or constipation ? • Does patient have any red flag symptoms such as chest pain, SOB, headache, N/V, lightheadedness/dizziness ? #2. Information from records / sign out: • Trend the blood pressure to see acute vs. chronic elevation. • Check medication regimen for BP and see MAR if a dose was missed. • Review home medications, check if one of the medications was not prescribed (and why). • Review BMP, recent UOP. #3. Initial assessment: • Confirm BP with appropriately sized cuff (as mentioned in #1). • Signs that BP is reactive: evaluate for pain, anxiety, agitation, urinary retention, constipation. • Signs of end organ damage, especially if patient has red flag symptoms. Eye exam, chest / lung exam, UOP, pulses, CNS exam. #5. Treatment / commonly used oral anti hypertensive medications with doses: • • • • Captopril: 25 mg dose PO / sublingual. Carvedilol: 3.125 to 25 mg daily. Amlodipine: 2.5 -10 mg daily. (MDD is 10 mg / day) Clonidine: 0.1 - 0.3 mg PO #6. Treatment / special considerations: • If HR is low (< 60 / min), avoid BB, CCB. • If patient has AKI (from pre - renal injury) avoid diuretics / ACEi / ARBs. • Patient can have AKI from overload state (CHF): Use diuretics, monitor BUN / Cr and UOP (should improve). • Treat underlying causes: Pain, anxiety, agitation, urinary retention or constipation. NOTES: #4. Treatment: Hypertensive emergency / malignant HTN (signs of organ damage): severely elevated BP (DBP>120) with symptoms such as chest pain, SOB, headache, visual disturbance OR / AND labs such as AKI OR / AND testing such as EKG changes, abnormal imaging: Call SNF for MICU / CCU eval. Aim of Rx: Decrease MAP < 10% in first few minutes and < 15% in first few hours. Possible regimens: • Labetalol 10-20 mg IV q 4 - 6 hours • Hydralazine 10-20 mg q 6 hours • Enalaprilat: 1.25 mg IV q 6 hours • Esmolol: 0.5 mg/kg q 5 mins Hypertensive urgency: SBP > 180 and DBP >120 without symptoms / end-organ damage. Aim of Rx: Lower BP gradually with target of <160/100. May use IV medications one time or PRN basis as described above followed by PO medications or initiate of PO regimens (see section on PO medication). SBP 150 - 180 and DBP < 100 - 120 without symptoms / end organ damage: can add a dose of scheduled medication early or add a one time PO medication dose (see section on PO meds) SBP < 150 / DBP < 100: Give scheduled dose of medications early. If possible request to move patient to quite/alone room and decrease stimuli. Page 13 ACUTE GI BLEED #2. Information from chart / sign out: #1. Information from nursing: • Hemodynamically stable ? : Tachycardia, hypotension. Orthostasis? • Symptoms: Upper vs. lower: melena / hematochezia / hematemesis. Associated symptoms ? • 1st time or recurrent ? #3. Initial assessment: • Symptoms: Site of bleeding, dizziness / orthostatics, abdominal pain. • Examination: Abdominal, oral, rectal. • Assess intravascular depletion: Skin exam, mucosal exam, tachycardia (early), orthostatics / leg raising (15% loss), supine hypotension (40% loss). • Assess severity: Rockall score (see reference tables). • Delineate source, consider etiology (see graphic below) • • • • • Review Hb / Hct trend. Known source of GIB ? Past GI history ? History of liver failure ? Last EGD / colonoscopy ? Known coagulopathy ? Check medications. #4. Initial interventions: • Ensure adequate IV access: 2 wide bore IVs. Consent patient for potential PRBC transfusion. • Investigations / labs: CBC (Hct might not decrease initially), PTT / INR, type and cross, LFTs, BUN / Cr • Hemodynamically unstable: Start fluid resuscitation. Consider PRBC transfusion (see below). Call SNF. Discontinue anticoagulation, consider reversal. • Keep transfusion threshold at Hb < 7 and Hct < 21 or follow primary team's instructions. For patients with active ACS, transfusion threshold is low (around 8 and 24). Can transfuse 1-2 units at a time. • Reversal of anticoagulation: in case of liver disease or Coumadin use when INR>1.6. Use PCC 25 units/kg for INR<4 and 35-50 units/kg when INR>4. If unavailable can use FFPs 10-15 ml/kg. (see section on reversal of anti coagulation for details) #5. Specific interventions: • Suspected upper GI bleed: • Non variceal: pantoprazole 80 mg stat followed by 8 mg/hr gtt. • Variceal: As above plus octreotide 50 mcg IV stat followed by 50 mcg/hr gtt. Notes: • Suspected lower GI bleed: • Source location: • Tagged RBC scan: detect rates of 0.1 - 0.5 ml/hr • CTA abdomen/ pelvis: rates > 0.5 ml / hr • Colonoscopy • If suspecting ischemic colitis: Stat lactate and imaging. Consider surgical consult. • If patient has ascites: Antibiotic ppx with ceftriaxone 1 gm Q 12 hours IV • Consult GI. • Inform SNF especially if hemodynamically significant bleeding. • Please refer to section on acute anemia / drop in H/H for further details. Page 14 SHORTNESS OF BREATH #1. Information from nursing: • • • • • Symptoms: Onset and progression. Associated complaints? Vitals ?: Pulse ox, hemodynamic stability, fever Is patient on tele ? Are fluids running ?: Type and rate. Is it known ? Is patient being treated for a potential cause ? #3. Initial assessment: • Quick ROS: Attempt to differentiate primary pulmonary vs. cardiac etiology. • Hemodynamic assessment with oxygen requirements. • Assess severity: • RS: Tachypnea, accessory muscle use, cyanosis, ronchii / wheezing. Obtundation / twitching (CO2 retention) • CVS: S3, JVD, crackles, edema. New murmurs ? • Pertinent differentials w/ clinical findings: • CHF exacerbation / flash pulm edema: JVD, crackles, S3, edema, fluid overload state, high BP. • ACS: Chest pain, new cardiac findings. • PE: Well's, tachycardia, tachypnea, pleuritic CP, normal lung exam. • Pneumothorax: Absent lung sounds, tamponade physiology. • Aspiration: New ronchii, tachypnea. • COPD exacerbation: wheezing, signs of hypercapnia. Silent chest is indicative of imminent collapse. • PNA: fever, leucocytosis, ronchii. • Atelectasis: recent surgery?, bed bound. • OSA: Asymptomatic, snoring, nocturnal desats on tele. #5. Definitive management of potentially immediately fatal etiologies: • ACS: Please refer to section on chest pain. • PE: Imaging as mentioned in #4. If unable to obtain imaging and clinical suspicion high, ensure absence of contra indications and deliver empiric anticoagulation. If imaging +, start on high dose heparin gatt or Lovenox 1 mg / kg BID (provided no renal dysfunction). • Pneumothorax: If imminent collapse, bedside needle decompression. If stable, consult surgery. #2. Information from chart review / sign out: • Code status: DNR / DNI ? • Baseline / home oxygen requirements ? • Pulmonary / cardiac review: • Relevant PMH: COPD / asthma, CHF, PE, recent surgery, anxiety. • CXR, PFTs, echo, EKG, previous caths. #4. Initial interventions: • Place in head propped up position. Oxygen as required to maintain saturation: NC —> FM —> NRB. (Please see section on oxygen delivery) • Initial investigations / imaging: CXR, continuous pulse ox, EKG, CIPs (if suspecting ACS), ABG. • Use ABGs to assess hypercapnia states. Useful in hypoxia to assess for A - a gradient for shunt pathology. • Normal pH: 7.34 - 7.45 • PaO2: 80 - 100 mmHg • PaCO2: 35 - 45 mmHg • Pertinent differentials being entertained: • CHF exacerbation / flash pulm edema: Clinical + CXR. Consider BNP / pro BNP, EKG, CIPs, echo in AM. • ACS: EKG, CIPs • PE: stat CTA. If AKI or dye allergy, consider V/Q scan. • Pneumothorax: Clinical + CXR. • Aspiration: CXR. Consider swallow eval in AM. • COPD exacerbation: Clinical. ABG to assess for hypercapnia. • PNA: CBC, CXR. #6. Definitive management of other etiologies: • CHF exac: Diuresis (Lasix: creatinine * 20 mg IV eg. For creatinine level of 2.0, Lasix dose will be 40 mg IV), morphine, nitro gtt, hemodialysis. Consider MICU consult for CPAP. • PNA: Appropriate antibiotics (CAP vs HCAP) • COPD exacerbation: Duonebs Q 4 H, albuterol Q2H PRN, consider IV hydrocortisone bolus, BiPAP if ABG shows respiratory acidosis. Consult MICU. • Aspiration: Initiate aspiration precautions. Make patient NPO. Sign out to team to order swallow evaluation. • Anxiety: Consider one time dose of anxiolytic. Important considerations: • Consult SNF if unstable patient or sudden increase in oxygen requirements. Consider MICU consult is patient requiring > 50% FiO2. • If patient requires positive pressure: BiPAP / CPAP or considering intubation, consult SNF and MICU. Call RT and SWAT to assist. NOTES: Page 15 OXYGEN DELIVERY SYSTEMS • By definition, oxygen delivery devices used on floors are low flow systems. • The FiO2 correlates with the flow of oxygen in L / min. Of note, if patient is tachypnic, they will demand more flow than is provided by most of these systems and hence, patients "entrain" oxygen from room. In effect, patients will inhale lower FiO2s than demonstrated here. • If patient's oxygen requirements are increasing, in terms of flow as demonstrated by L / min on wall unit or need for partial / complete non rebreather masks, it is a cause for concern and needs to be evaluated. Please see section on shortness of breath for details. NASAL CANULA Delivers 24 to 44 % oxygen at flows of 1 to 6 L / min. Up to FiO2 of 40%, nasal cannula is the delivery device of choice. May be humidified if not run at < 5 L /min. L / minute on the wall unit 5 1 24 2 28 3 32 4 36 5 40 6 44 SIMPLE MASK Delivers 35 to 55% oxygen at flows of 5 to 12 L / min. Never use at flow rates < 5 L / min to prevent rebreathing of CO2. Some patients are mouth breathers when they sleep, and hence will need masks even though their FiO2 requirements may not be high. PARTIAL REBREATHER MASKS (PRB) Delivers 35 to 60% oxygen at flows of 8 to 15 L / min. Flow rate must be sufficient to keep the reservoir bag inflated 1/3 to 1/2 it's volume at all times. Differentiated from non rebreather masks by lack of valve at the connection of tubing in PRB. NON REBREATHER MASK (NRB) Delivers 60 to 90% O2 at flow rates of 8 to 15 L/min. Flow rate must be sufficient to keep the reservoir bag inflated 1/3 to 1/2 it's volume at all times. VENTURI MASK or AIR ENTRAINMENT MASKS Provide FiO2 from 24 - 50 %. Technically a "high flow oxygen system" because they do not allow entrainment of RA. Size of the entrainment port determines FiO2 and hence increasing the flow of oxygen does not determine FiO2. Different ports are color coded to relate to different levels of FiO2 delivered. Please familiarize yourself with ports used in our setup. INVASIVE / NON - INVASIVE POSITIVE PRESSURE VENTILATION If patient's saturations are not maintained with above mentioned delivery devices, patient may need positive pressure ventilation, for which, please call SNF and consult MICU. Page 16 ELECTROLYTE REPLACEMENT POTASSIUM REPLACEMENT Oral: Potassium chloride (K - Dur in epic as a pill, also available as a liquid) IV: Potassium phosphate IVPB (10 mEq in 100 ml) or double strength (20 mEq in 100 ml) • Check renal function and in patients with ESRD / CKD / AKI, be less aggressive in K replacement since these kidneys won't excrete potassium as a normal kidney would. • If administering intravenous 20 mEq in 100 ml concentration, ensure patient is in ICU on EKG monitoring. • Check Mg (Intracellular Mg prevents outward K flux in ascending loop via ROMK channel and thus prevents its excretion in urine. Low Mg leads to increase urinary K loss) • 10 mEq replacement will raise serum K by 0.1. In absence of gut dysfunction: PO = IV. • ICU protocols for patients with Cr<1.5. • Repeat potassium levels after 2 hours of completion of regimen. Do not exceed 400 meq / 24 hours replacement. PHOSPHORUS REPLACEMENT MAGNESIUM REPLACEMENT Each 1 gm magnesium will raise serum level by 0.1 • If level 1.8 - 2: give 1 gm IV MgSO4 ( = 8 meq) over 1 hour or Mg Oxide PO 400 mg daily for 2 days • If level 1.6 - 1.7: Give 2 gm IV MgSO4 over 2 hours or Mg Oxide 400 mg PO BID for 2 days • If level < 1.5: Give 2 gm MgSO4 over 2 hours x 2 doses. • • • • Consider using K phos orally if levels > 2 If level < 2: 15 mmol sodium phos IV over 4 hours If level <1.5: 30 mmol sodium phos IV over 6 hours If level <1: 45 mmol sodium phos IV over 8 hours CALCIUM REPLACEMENT • Check ionized calcium. Corrects with 1-2 amps of IV calcium gluconate Page 17 HYPONATREMIA: Na < 135 mEq / dl #1. Information from nursing: • • • • Get a sense of fluid status: Overloaded , dehydrated , euvolemic. I/Os. Cumulative since admission ? Any fluids running ? Type and rate ? Symptoms / signs: • Dehydration: Thirst, dry mouth, decreasing UOP. • Overload: Edema, crackles, dyspnea. • Specifically ask for neurological features: Increasing confusion, changes in mental status, seizures. #2. Information from chart review / sign out: Acuity of change: Acute ( < 48 hours) vs chronic ( > 48 hours). Has patient been hyponatremic in past ? Why ? Review fluid balance. Seek etiologies: • Hypovolemic pathologies: DKA, HHS, sepsis, dehydration, alcoholism, advanced dementia, vomiting / diarrhea, excessive diuresis • Hypervolemic pathologies: Cirrhosis, CHF, renal failure, excessive alcohol use. • Medication review: diuretics, medications causing obtundation. • Check blood glucose, lipids and protein levels for pseudohyponatremia. • • • • #3. Initial assessment: • Symptoms: As above. Specifically check for neurological features: AMS, seizures. In light of acute hyponatremia, they represent a MEDICAL EMERGENCY. • Examination: Assess intravascular volume. • Consider etiology / differential diagnosis: Refer to diagram below. #4. Interventions: Acute w/ obtundation / seizures: 3% saline, 100 ml bolus over 15 minutes. Check BMP @ 2 hours. Call SNF and MICU consult. Acute w/o obtundation / seizures: 3% NS at 15-30 ml/hr. Avoid correcting > 12 mEq / 24 hours or > 6 mEq / 12 hours. Chronic: Treatment based on etiology (see underneath). Obtain BMP with serum osmolality; urine Na, Cr, Osm. Avoid correcting > 10 mEq / 24 hours. Chronic hypotonic: Hypovolemic: NS fluid replacement. Hold diuretics / offending meds. - FENa < 1, Ur. Na < 10: GI loss / poor PO intake. - FENa > 1, Ur. Na > 20: Renal losses. - If Euvolemic: SIADH (Urine Osm>100) vs. primary polydypsia (Urine Osm < 100) Euvolemic: Free water restriction. Hypervolemic: Free water restriction. Consider diuresis (especially in CHF state) Chronic hypertonic: Correct underlying pathology Chronic isotonic: Usually pseudohyponatremia needs no Rx. If obtundation / seizures after TURP / lap with acute hyponatremia: 3% saline, 100 ml bolus over 15 minutes. Call SNF and MICU consult. Page 18 HYPERKALEMIA #1. Information from nursing / sign out: #2. Information from chart review: Evaluate chart for potential cause of hyperkalemia as follows: When was the BMP sent ? Symptoms ? Is the patient on telemetry ? If patient is being already treated for hyperkalemia, when was the last doses of administered medications (insulin, calcium gluconate, kayexalate) ? • When was patient's last dialysis session if ESRD patient. • • • • #3. Initial interventions: • Stat EKG, especially if the hyperkalemia is a new finding. Tall Peaked T waves, PR prolongation followed by loss of P waves with QRS prolongation and progression to SINE wave. Except T waves all EKG findings need immediate cardioprotective measures • Repeat BMP if concerns for sampling error such as sample drawn from a line running TPN. • Place patient on telemetry. • BMP Q 4 hours till potassium normalizes. • Inform SNF and discuss treatment options. Excessive Intake: • Iatrogenic (overly aggressive replacement), excessive intake Impaired Excretion: • Kidney disease: Acute or chronic. In CKD is usually only seen in Stage V, Type IV RTA (Aldosterone resistance). Can be seen in any stage of CKD in combination with K sparing diuretics i.e. ACE, aldactones • Adrenal insufficiency i.e,. Adisson's, severe sepsis • DRUGS: ACE, ARB, Bactrim, digoxin toxicity, heparin, NSAIDs Cellular Shift: • Acidosis i.e. sepsis, DKA (CAUTION: DKA can have overall body store depletion of K with serum elevation secondary to Acidosis) • Cell Lysis ie. rhabdomyolysis, tumor lysis • Blood transfusions • Mechanical damage ie. artificial valves False Elevation: • Hemolysis • Lab error • Improper sampling, eg. from site of fluid replacement/electrolyte replacement, or TPN infusion line. #4. Treatment: Cellular shifts / cardioprotection: #5. Treatment: definitive elimination: • If evidence of PR prolongation or QRS widening patient should receive 1 gm IV Calcium Gluconate or Chloride for myocardial membrane stabilization. • Insulin and Dextrose: 50g of dextrose and 10 units IV regular insulin. Onset 30 minutes with duration of action 4-6 hours (can last longer if impaired renal function). • Insulin Drip: In cases of refractory hyperkalemia, patient should be moved to the MICU and can be placed on regular insulin drip running at 5 units/hr with D5 or D10 gtt. Titrate your fluids to maintain blood sugars with consistent drip rate. This is only a stop gap; elimination will be necessary. • Beta2 Agonists: Albuterol 10 - 20mg nebulized (Note: standard dose for bronchospasm is 2.5mg) Onset 15-30 minutes. Duration: 2-4 Hours. Use usually limited by side effects ie. tachycardia. 1/3 of patients will not respond to this. • Sodium Bicarbonate: 1-2 Amps (50 -100meq) IV. Onset: 15-30 minutes Duration: 1-2 hours. Often reserved for patients with CKD and concomitant acidosis but has the least data to show effectiveness. • Kayexalate (Sodium Polystyrene): Ion exchange resin that works in the gut to prevent GI absorption and cause excretion into GI tract. Dose 30-60 grams PO repeated Q 2 hours till patient has BM or 30g as retention enema (Note: K not excreted until patient has BM). Onset slow can take approximately 2 hours. Contraindicated In allergic patients, can precipitate anaphylaxis and in post op GI patients can cause bowel necrosis and perforation. GI bleeding is not an absolute contraindication. • Loop Diuretics: Cause excretion of K in the loop. At UH we most commonly use Lasix. One of the rare times it would be acceptable to give patient IVF and diuretics. Dose 20 -160mg IV depending on renal function and hemodynamics. Least effective in ESRD patients and contraindicated in patients with underlying kidney injury as etiology of hyper K. Onset: 30-60 minutes. • Dialysis: Requires Nephrology consult as well as dialysis catheter placement (if not established ESRD patient). If your patient is not responding to conventional methods beginning planning early. #6. Important considerations: NOTES: • Discuss with SNF. Consider MICU consult if very high levels, or rapidly rising levels not responding to treatment, or patient hemodynamically unstable. • Stop offending medications. • Do not forget: Cellular shift does not equal elimination. • Give patient's low potassium diet. Page 19 ABDOMINAL PAIN Very broad topic and beyond the scope of this manual. Here are some of things one should be extremely careful not to miss as cross cover / night float. If you suspect the following, obtain a surgical consult along with ongoing work up and consult SNF + / -‐ MICU as well: • Peritonitis / perforated viscous: Severe pain, rigid abdomen with rebound and guarding. Absent bowel sounds. Unstable vital signs. Upright X-ray shows air under diaphragm. Rx: NPO + IV fluid boluses + broad spectrum antibiotics + surgery. • Ischemic bowel: Pain out of proportion to physical exam findings. Bloody stool. Lactic acidosis. Rx: NPO + broad spectrum antibiotics + surgery. • Obstruction: Nausea / vomiting, bloating, distention, hyperactive / absent bowel sounds. X-ray shows air fluid levels. Rx: NPO + NG suction (decompression) + surgery. • Cholangitis: Fever, RUQ pain, jaundice. LFTs show obstructive pattern. GI emergency. Rx: NPO + broad spectrum antibiotics + IV fluid boluses. Needs urgent ERCP if septic. Other commonly encountered differential diagnosis: HYPERNATREMIA • More common in ICU setting, in sedated, sick patients. Also seen in patients who are NPO. • Usually does not happen in patients who have access to free water (who can drink), or are on TPN. • Usually not an emergency and it's safe to pass on to the team. • If sodium levels increasing very rapidly, consider treatment • Calculate free water deficit: 0.6 x weight (kg) x (current Na / 140 -1) • Administer the calculated total volume of D5 free water at 75 - 100 ml / hr to correct Na 8-10 mEq over 24 hours. Avoid correct at rapid rates. • Inform the primary service in AM. INSOMNIA • Ask about reason for insomnia. E.g. pain, delirium, withdrawal of any home medication. Correct these before prescribing medication. • Do not give any sleep medicines towards early morning as patient might be sleepy during primary team's rounds which will impair their evaluation. • If you have to choose, consider one of the following: • Trazodone 25 - 50 – 100 mg. Start low. • Ambien (5 mg) – extreme caution in elderly • Benadryl (25-50 mg) – in young healthy patients. • Never use benzodiazepines for insomnia as it might increases the risk of delirium. • Diffuse abdominal pain: • Gastroenteri+s (nauseas & vomi+ng , diarrhea) • Metabolic (acidosis, DKA) (check BMP, glucose, BHB) • Func+onal ? • Localized: • Epigastric: PUD, gastri+s (NSAID use) , pancrea++s (lipase, amylase) , MI (EKG, CIPs) • RUQ: cholecys++s / biliary colic (USG, LFTs) , hepa++s (LFTs, US), pneumonia (CXR) • LUQ: Pancrea++s, gastri+s. • RLQ: Appendici+s (Mac burney point tenderness, CT) , Renal colic (CT) • LLQ: Diver+culi+s (CT), renal colic, IBD , IBS • Hypogastric: UTI (UA) , ureteric stone , bladder disten+on (Foley, clogged cath?) HYPERGLYCEMIA • Evaluate for DKA / HHS: Glucose levels > 400 mg / dl or patient symptomatic with abdominal pain, nausea / vomiting. Check last BMP for anion gap / betahydroxybutarate if AG positive. MICU consult if DKA is diagnosed. • Trend fingerstick glucose levels in last 24 hours. In hospitalized patients levels between 140 -180 mg / dl are acceptable. Avoid hypoglycemia. • Review patient's insulin therapy (short acting vs. both short and long acting). Check if patient is getting them regularly (was there a missed dose ? ). Is the hospital regimen different from home regimen (if so, why? ). • Is patient receiving any fluids with D5 and if so change it. Make sure patient is on carb control diet. • In asymptomatic patients with elevated sugar, you can cover with dose of short acting insulin based on sliding scale( e.g. for glucose of 300 if patient should receive 10 units regular insulin, cover patient with the same dose). If this occurs > 1 occasion, let team know in AM to re-adjust insulin regimen. DO NOT change insulin regimen. Only give one time orders. Page 20 CONFUSION / AGITATION: Delirium - Maybe hyperactive or hypoactive: Fluctuating disturbance in attention, awareness and cognition that develops over a short period of time, representing a change from baseline, not explained by preexisting or evolving neurocognitive conditions. #1. Information from nursing: • • • • • • • Acuity: New development vs ongoing Altered level of consciousness and / or disorganized thinking ? Physically violent: Harm self or others ? Vitals: EWS score ? Pain : Recent Sx / open wounds / trauma ? Urinary / bowel retention ? Recently administered medications ? #2. Information from chart review / sign out: • Med review: Anticholinergics, steroids, anticonvulsants, dopamine agonists, antibiotics. • Neuro: Stroke, seizures (status) • Toxidrome / withdrawal state • Systemic / general medical: CO2 retention, hypoxia, dehydration, sepsis / infection • Change in environment (ICU delirium) vs above causes • Dyselectrolytemia #3. Night float assessment and testing • • • • • • • • • Vitals and pain assessment Respirations: rate, effort, evaluate for pathology: ?PNA / aspiration CVS assessment Abd: Distention / surgical abdomen Skin: Dehydration, cellulitis, edema CNS: GCS, threat response, orientability, focal deficits CBC, BMP, electrolytes Sepsis work up if appropriate Drug levels: Digoxin, lithium, quinidine #5. Interventions per cause: • D/C offending medications. Reverse opioid overdose with naloxone if causing respiratory depression with CO2 retention. • Stat CT head w/o cont if worried for CVA. Consider stroke code after consulting with senior. ? Neuro • Ativan IV if seizing. Consult senior stat. ?Neuro • Ativan for EtOH withdrawal / cocaine use. • Goal directed Rx for sepsis (see related section). • Treat pain: if surgical - standing tylenol, PRN oxycodone. Avoid IV pain medications • Rx constipation: Consider enema if tolerated. • Acute urinary retention: Straight cath, monitor post void residual urine. Important considerations: • All antipsychotics carry increased risk of cardiovascular mortality especially in dementia. • Restraints (discuss with family if possible). #4. Non pharmacological interventions: • • • • • Reorient and decrease stimuli if agitated. Involve family and other known faces if available. Address comfort: pain / constipation / incontinence Provide fluids if asking if no aspiration risk. Take off wires / tubes unless absolutely required. #6. Pharmacological restraint in agitation: Tolerating PO: (increasing sedative effects, lowest dose first) - Seroquel 12.5 mg / 25 mg Haloperidol 0.5 mg / 1 mg Risperidone 0.5 mg / 1 mg Olanzapine 2.5 mg / 5 mg If Qt. > 500: Aripiprazole 2-5 mg Q2hours PRN. Check EKG after 2nd dose. Unable to take PO: - 1st line: Haloperidol 0.5 - 1 mg Q2hours PRN IV/IM - 2nd line: Olanzapine 2.5 - 5 mg Q2hours PRN IM - If QTc > 500: Valproic acid 125 - 250 mg Q8hours PRN AVOID unless absolutely necessary: • Benzodiazepines and anticholinergics. • Restraints (discuss with family if possible). Page 21 FEVER #2. Information from chart / sign out: #1. Information from nursing: • • • • First reading or persistent ? Tmax ? Route: axillary / oral / rectal / foley ? Vital signs: Determine hemodynamic stability. #3. Initial assessment: • Assess stability. • Examine to locate common sources: PNA / UTI / Abdominal path / C.diff / cholecystitis / cellulitis / sinusitis / sacral ulcers. • Examine existing lines / PICCs / ports / recent surgical sites / foley / supra pubic catheters. • Think about hardware patient may already have: Orthopedic / pacemakers / AICDs / wires / staples / stents. • Consider non infectious differentials: DVT / PE / malignancy / drug fever / blood product reaction / post op 2/2 anesthesia or atelectasis. #5. Important considerations: • Consider non infectious causes, some can be life threatening like PE ! • Low threshold for considering sepsis and activating pathway. • Hemodynamic stability comes first, always fix ABCs first. • Check the sign out / notes: Team may already have worked up the fever / started treating / have a plan. • Neutropenic fever is a medical emergency ! • Be permissive with treating fever (it is a defense mechanism). Review primary team's notes for possible existent causes. Is patient already on antibiotics ? Source identified ? Chronic lines / foley ? Has any work up been sent ? Follow that up. Any differentials being entertained ? See section on non infectious causes. • Is patient neutropenic ? • • • • • • #4. Interventions: • Treat fever: Tylenol PO, rectal. Avoid IV unless patient can't take PO / rectal. • If hemodynamically unstable / sepsis : See sepsis protocol and call senior on call. • If no previous work up: Basic panculture: B.Cx * 2, sputum cx, CXR, UA / UC and repeat CBC. • Expanded work up: LFTs, USG abdomen, C.diff, stool work up, USG renal (pyelo), CT abdomen/pelvis (if abdominal signs), paracentesis (SBP) • Other infectious work up (usually team can do this): Osteomyelitis (MRI extremity / spine), LP (nosocomial meningitis is rare unless patient presented with relevant symptoms: neck pain/ rigidity, photophobia etc.), echo (endocarditis) • If not on antibiotics: Choose appropriate regimen (see below) • If already on antibiotics: Consider expanding coverage. • If neutropenic: Expand coverage to include anti - pseudomonas activity. Common empiric antibiotic regimens: (Please confirm disease specific doses unless otherwise specified here) • CAP: azithromycin + ceftriaxone / doxy in COPD patients / levofloxacin if patient has cardiac H/O (Azithromycin and levofloxacin prolong QTc). • HCAP: vancomycin + Zosyn. • First or uncomplicated UTI: cefazolin / ceftriaxone / bactrim. • Recurrent / complicated UTI / indwelling foley: Zosyn. • Meningitis: vanco + ceftriaxone (2 gm Q 12 hours). Add ampicillin for age > 50 years. • Cellulitis: MRSA coverage (clinda / doxy / bactrim / vanco). No suspicion of MRSA: cephalosporins. C.diff: PO vancomycin / Flagyl. Severe: IV Flagyl. Abdominal infections: cipro + Flagyl / Zosyn. SBP: ceftriaxone. PCN allergy: cipro. Suspected line infection: Ensure vanco as part of coverage. • Endocarditis: vanco + zosyn. • Osteomyelitis (especially with open wound): vanco + zosyn. • Neutropenic fever: Expand coverage to include anti pseudomonas antibiotics and continue old antibiotics. • • • • Page 22 SEPSIS #1. Initial interventions / work up for sepsis: SIRS: 2 or more of following present: • • • • Place on telemetry, vitals Q2H. Ensure access: 2 large bore IVs. Send lactate levels. IV fluids (NS). 30 ml/kg. Usually 4 - 5 liters unless contra indicated (very low EF) • Initiate empiric antibiotics (within 1 hour) with wide coverage after sending blood cultures. • CBC, CMP, PT / PTT / INR, lactic acid. • Repeat lactate in 6 hours to check clearance. Temperature > 38.3 C or < 36 C Heart rate > 90 beats / min Respiratory rate > 20 / min or PaCO2 < 32 mmHg WBC > 12,000 or < 4,000/mm3 or bands > 10% Sepsis: Systemic Inflammatory Response Syndrome + Source of Infection Severe Sepsis: Sepsis + organ hypo perfusion = MEDICAL EMERGENCY 2014 mortality rate: 32.5 % Lactate > 4 mmol / L Hypotension UOP < 0.5 ml/kg/hr for > 2 hours despite fluids Acute lung injury. PaO2 / FiO2 < 300 w/o pulmonary pathology Creatinine > 2 mg / dl Bilirubin > 4 mg / dl Platelets < 100,000 / microliters INR > 1.5 #2. Interventions / work up for severe sepsis: ( 3 hour bundle ) Interventions as in #1. iSTAT lactate in < 60 minutes. Ensure blood cx before abx. Discuss with SNF, consider MICU consult. Consider other sources of infection: Echo, LP, CT abdomen/pelvis, C.diff PCR (after appropriate examination), stool examination, cellulitis. • What organisms are being targeted and what organs? • Discontinue drugs that may contribute to hypotension. • Evaluate patient's steroid needs (will he need stress dose steroids ?) • • • • #3. Interventions for septic shock: Septic shock: MEDICAL EMERGENCY 2014 mortality rate: 40% Persistent hypotension despite adequate fluid resuscitation requiring pressor support. • As above and consult MICU. • Check access: Does patient have PICC ? IF not, will he need CVC placement (preferably with CVP monitoring) • Initiate pressors: Levophed is usually first line but administer only via central access. May start phenylephrine via IV to bridge via central access being obtained. Goals in 1st 6 hours: CVP 8 - 12 mmHg MAP > or equal to 65 mmHg UOP > or equal to 0.5 ml / kg / hr Central venous saturation > or equal to 65% Special considerations: • Use multiple clinical factors to assess fluid status such as: SBP, MAP, skin turgor, mucosal hydration, orthostatics, leg raising, HR, bedside IVC evaluation, arterial waveform evaluation. • Tachycardia may not be seen in patients on beta blockers, calcium channel blockers and those with low Mg , K. • Consult SNF whenever concerned for severe sepsis / septic shock. Special considerations: • SWAT nurses respond to and can be requested to help with all acute situations in the hospital. The are experts in gaining quick access and they can obtain iSTAT lactate as well. • Shock is shock: In acute situations fluid resuscitation comes first. • Consider adjunctive treatments: Stress dose of steroids, blood for acute anemia. Page 23 For any floor: vocera 4-1400 and say floor name (e.g. 6A) to call floor 6A Bed Board – vocera – Bed control OR Pager 467-2265 Radiology Reading room – 4-8349 Nursing supervisor – 467-7280 Transfer Center – 4-5449 5A – 4-6536 Poison Control – 4-5369 5B – 4-6533 Firm-A – 4-5240 6A – 4-6556 Admitting – 4-5047 6B – 4-9272 Cardiac Pacer – 467-2828 6K – 4-5374 Endoscopy – 4-5728 6H – 4-2750 Hematology – 4-6820 6I – 4-4863 Micro – 4-4459 7A Blood Bank – 4-6701 7U – 4-9700 Lab – 4-6821 8G – 4-6553 MRI – 4-6924 8E – 4-5215 CT Scan – 4-6925 8F - 45460 9G – 4-6566 10G – 4-2770 10E – 4-6500 10H – 4-9100 ODS – 4-3942


text:
ROMA (Sputnik) — Russia has never considered the European Union as an opponent and views the bloc as the country's most important partner, Russian Ambassador to Italy Sergei Razov said Thursday.
"Now we do not consider the European Union as an opponent. It is our natural and most important partner. It is another matter that the potential cooperation is significantly higher than the current state of affairs in our relations," Razov said in an interview with Italian newspaper Quotidiano Nazionale.
He said that despite the complexity of the political situation, Russia was ready for re-establishment of cooperation with the block.
"Now we have the situation, when the European Union has frozen a political dialogue with Russia, introduced economic sanctions that are illegal under international law, and cut back the cooperation in the sphere of energy at the expense of its own interests. We are ready for re-establishment of our relations, but, obviously, on the basis of equality and mutual respect," Razov said.
He added that Russia values a lot Italian Prime Minister Matteo Renzi's aspirations to facilitate bilateral cooperation in different spheres, referring to the prime minister's four meetings with Russian President Vladimir Putin during the last year and a half.
Since 2014, the United States, the European Union and their allies have imposed several rounds of sanctions against Russia accusing it of meddling in the internal crisis in Ukraine. Kremlin denied the accusations.

subset: commoncrawl


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Cool Chile Co Tomatillo Salsa 270g
Tomatillo Salsa by the Cool Chile Co packs a fresh, tangy punch. The combination of sour green tomatillos and chillies will spice up your traditional salsa routine, leaving you (and your tortilla chips) wanting more.
It's the perfect addition to any of your favourite Mexican dishes. Try as a dip for corn tortilla chips, with sour cream and guacamole to make nachos or simply blend with mashed avocado.
Dodie Miller, founder of Cool Chile Co, believes that there are certain warm, earthy flavours and smells that instantly transport you to Mexico. Whether it's salsas and sauces made with toasted dried chillies, tortillas fresh from the comal, Mexican oregano rubbed over pozole, or black beans bubbling in a pot with epazote, these are the tastes and spice sensations that they want to bring into your home.
Once opened, refrigerate and use within 1 week.
Ingredients: tomatillos (73.7%), onion, coriander, sunflower oil, sea salt, hot green chilli. Made in a factory that handles gluten, crustaceans, eggs, fish, peanuts, celery, soybeans, milk, nuts, mustard, sesame. Allergens are listed in bold.
Size: 270g
Minimum shelf life: 3 months
Categories: American Sauces & Condiments Cool Chile Co Ingredients Mexican Food & Ingredients Sauces & Condiments
|Delivery Option
|Hermes Economy ?
|DHL Express ?
|£6.99 - or Free for orders over £75
|Parcelforce Age-Verified ?
|Suspended due to COVID-19
These summary details have been prepared for information purposes only, and are designed to enhance your shopping experience on the Sous Chef website. While we have taken care in preparing this summary and believe it is accurate, it is not a substitute for your reading the product packaging and label prior to use. You should note that products and their ingredients are subject to change.


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Watertown, NY 13601
Emergency Department Nurse needed at a hospital in NY. In 2012, several services were added to the hospital, it has since seen significant growth and the new service lines reflect that, they have been continually growing and expanding.
The hospital prides itself on high quality outpatient, inpatient and specialty services to meet individual and community needs through partnerships with their patients and communities they serve. They deliver high quality inpatient care, emergency services and outpatient services for routine and diagnostic testing.
Located in northern New York, this opportunity is in a fantastic area for anyone who enjoys outdoor sports. Right near the St. Lawrence river you have easy access to great fishing. There is easy access to snow sports such as skiing in Canada, NY and Northern VT. Snowshoeing or cross country skiing are available in your backyard!
For more information, please email me at email@example.com.
Please click APPLY ONLINE or email us a copy of your resume directly (my email is next to my profile). Be sure to check out all of our jobs at http://jobs.ka-recruiting.com. We look forward to working with you!
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Copyright K.A. Recruiting, Inc.. All Rights Reserved.


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Thanks for your interest in GoToMeeting Schedule Meeting!
I'm currently working on a detailed video to get you the latest information on this…
But in the meantime…
Checkout the best ClickFunnels offers, benefits, and features below.
In this day as well as age, the way your business runs online could make or damage you.
Just how do most companies presently have a visibility online?
The reality of the matter is, nonetheless, that internet sites have actually significantly advanced over the previous years – and also the techniques of old are not sensible for contemporary service.
In the past, it would certainly suffice to have an easy internet site with a web page, solutions, prices, regarding us, and also get in touch with pages.
A prospective consumer would go to your website, scroll around, see the various web pages and also eat material as they please.
Nevertheless, if you are a company spending any type of money on advertising and marketing, you intend to regulate exactly what clients are learning about on your website, present offers at the correct time, as well as optimize the profits you make from each individual.
How does one attain this?
Using sales funnels.
Get in ClickFunnels
ClickFunnels is the simplest means to make high transforming sales and advertising funnels.
It is a special tool created particularly to transform potential clients right into purchasers.
It actually is an all-in-one option to produce sales funnels as well as includes touchdown web pages, e-mail combination, invoicing, webinars, membership sites, therefore much more. No wonder it has quickly come to be a preferred tool for marketing experts.
Below is my thorough ClickFunnels Review, consisting of favored attributes, rates, pros/cons, and comparisons versus competitors.
GoToMeeting Schedule Meeting: But First, Exactly What Is a Sales Funnel?
Sales funnels (likewise called advertising funnels) are multi-step projects that are created to relocate potential prospects through your sales process, and also turn them into buyers.
Image a real-life channel. At the top, you pour liquid in, which narrows down towards one taken care of location.
In sales, a similar occasion takes place. On top, visitors reach your internet site, however not all that go into make it out of the other end as purchasers.
Lots of things have to happen from the time a visitor enters your channel, to the time they act and efficiently finish a purchase.
By damaging down the client's journey into smaller sized steps, you can be a lot more exact about how and when you offer an offer to your audience.
The detailed action in a channel might look something such as this:
- Unqualified lead gets to touchdown web page
- Web page interacts the first offer (something totally free to gather an e-mail).
- As soon as email is accumulated, main offer is pitched.
- Lead ends up being a paying client.
- Even more e-mail interaction providing consumer value.
- Further relationship building
- Persisting sales.
ClickFunnels also has a graphic that clarifies this in a basic way:.
Exactly what is ClickFunnels?
As pointed out previously, ClickFunnels is the very best sales channel software application around today.
The business makes the bold case of offering you every little thing you should market, sell, and provide your items online – and they definitely provide.
A conventional funnel will make use of an opt-in web page (to accumulate email addresses), an email automobile responder (to send out e-mails to your customers), plus an added sales web page with some content as well as an order form, potentially adhered to by additional content, a membership site, and so on
. Formerly, you would certainly have to use various platforms and also devices to complete all these jobs such as:
- Develop a site
- Locate Hosting
- Discover an autoresponder service
- Locate subscription site software application
- Discover split-testing software application … and so on
Yet ClickFunnels deals with everything with their platform. You not only save a lots of money by not having to acquire various products/services, but you also avoid the technological mess of needing to set everything up, as well as can focus on just what's truly important – growing your business.
ClickFunnels supplies a Complimentary 14-Day Test, so you get to discover the tool as well as really see if it's appropriate for your company.
Favored Functions
* Rapidly Create Pages Utilizing Templates as well as Components *.
Before obtaining also much, it is necessary to comprehend that a channel is a collection of web pages put together in a tactical order, with the objective of transforming as lots of leads into clients. And also a page is just a collection of numerous aspects created to obtain somebody to take a particular activity.
ClickFunnels offers more than 50 different components to help you construct the excellent web page. The editor is very very easy to make use of and all you have to do is drag and also go down different elements on to the web page, and update the text and also appearance to fit your needs – no coding skills needed!
ClickFunnels likewise makes your life easier by supplying you with a lots of totally free templates.
Actually, ClickFunnels provides over 37 kinds of web pages for you to mix and also match with. These are damaged down right into the adhering to 10 groups:
- Presell Pages: Study Web Page, Post Page, Presell Page, Clickpop Web Page
- Optin Pages: Squeeze Page, Reverse Squeeze Web Page, Lead Magnet, Coupon
- Thanks Pages: Thank You Web Page, Offer Wall, Bridge Page, Share Web Page
- Sales Pages: Video Sales Page, Sales Letter Web Page, Product Release Page
- OTO Pages: Upsell Web Page, Downsell Page
- Order Forms: Two Step Order Page, Standard Order Web Page, Video Clip Sales Letter Order Page, Sales Letter Order Page, Product Introduce Order Web Page
- Webinar Pages: Webinar Registration Page, Webinar Confirmation Web Page, Webinar Program Room, Webinar Replay Space
- Membership Pages: Gain Access To Web page, Participant's Area
- Affiliate Pages: Accessibility Web Page, Associate Area
- Various Other Pages: Application Page, Ask Page, Store Front, Web Page, Hero Web Page, Hangout Web Page, Live Trial Web Page
The pre-built layouts are totally customizable, and are what most users use.
You have the ability to pick a theme, edit or replace the components with your personal, and also your new page prepares to go.
You can likewise connect any funnel you create with your very own e-mail advertising service (if you don't utilize the one consisted of in ClickFunnels), and utilize the ClickFunnels constructed in payment system.
This is also a fun time to discuss that ClickFunnels supplies really helpful and understandable training videos when you initially register. I highly recommend going through those due to the fact that they rapidly allow you to make use of the tool at its complete capacity, as well as you'll have more enjoyable playing around. GoToMeeting Schedule Meeting
* Create One-Click Membership Websites *.
Among the best attributes with ClickFunnels is the capacity to conveniently produce membership websites as well as deliver web content to your audience in one area.
Your subscription site will come total with enrollment pages, membership accessibility web pages, and also content web pages which you can quickly secure or drip feed to your clients inning accordance with purchases they made in your funnel.
ClickFunnels membership websites enable you to send out emails, easily manage your e-mails, as well as build a community all while removing the stress and anxiety that's connected with other options such as Kajabi, or WordPress systems.
It's actually convenient to not have to buy a separate software application or plugin to produce membership sites.
* Email Assimilation & Actionetics *.
With every channel comes email list building possibilities.
ClickFunnels sustains email integration with all the significant e-mail automation systems such as:
- Active Campaign
- Aweber
- Constant Contact
- ConvertKit
- Drip
- Get Response
- Hubspot
- InfusionSoft
- Mad Mimi
- MailChimp
- Market Hero
- Ontraport
- Salesforce
- Sendlane
- And others
Nonetheless, ClickFunnels also has their very own effective automation tool called Actionetics.
Although you can create, timetable, and deliver e-mails just like other e-mail marketing system, Actionetics is a lot extra.
I love Actionetics since it not just replaces your e-mail advertising and marketing however carrier marketing and also SMS advertising software applications as well. This takes automation to a whole brand-new level and assists you interact the ideal message to your consumers, precisely when they need it. A video review of Actionetics will be offered additionally listed below.
* Invoicing and also Repayment Combination *.
An outstanding feature within ClickFunnels is the capability to accumulate every one of the billing details from your customers exactly on your sales page. Marketing is made a lot less complicated when clients don't have to leave your website.
ClickFunnels integrates with major repayment entrances such as PayPal, Red Stripe, and InfusionSoft, among others.
ClickFunnels Pricing.
While you could begin with the Free 14-Day Test, there are 3 various rates alternatives with ClickFunnels:
- $ 97/month.
- $ 297/month.
- $ 997 bulk discount strategy (advised).
I'll explain for each and every of these strategies listed below.
1. ClickFunnels Criterion Strategy – $97/month.
The common strategy consists of every one of the attributes you would require within ClickFunnels, but with constraints on the variety of funnels (20) as well as web pages (100) you could have in your account, in addition to how many site visitors (20K) can see your web pages per month.
You likewise do not receive innovative functionality such as ClickFunnels own e-mail marketing as well as affiliate tracking devices.
2. ClickFunnels Etison Collection – $297/month.
This strategy includes all the bells and whistles of the conventional plan, with no limitations. It additionally comes with 2 additional items created by ClickFunnels called Actionetics (e-mail marketing) and Backpack (associate management platform).
In Actionetics – you could manage every one of your get in touches with that subscribe to your checklist, send out email broadcasts, and produce a host of other automations. GoToMeeting Schedule Meeting
The difference between both plans really is the restrictions, and also Actionetics/Backpack. If you are a standard individual as well as don't expect to utilize more than 20 funnels in your account – the Requirement Plan ought to suffice.
However, if you prepare to have an associate program or want to maintain your e-mail marketing within ClickFunnels and not make use of a 3rd party software program, the Etison Suite is for you.
You could always start on the lower plan and also upgrade if needed.
3. Funnel Hacks System – $997
For any person that's serious concerning their service, the ClickFunnels Funnel Hacks System is the offer of the century.
The $997 Funnel Hacks System has robust training programs packed with 6-month accessibility to the ClickFunnels Etison Suite.
This is an unbelievable deal since outside of this program, 6-months of Etison Suite alone would certainly cost you $1782.
Not just are you conserving $785 but you're getting a lots of trainings as well as guides to help you get the most from ClickFunnels!
ClickFunnels Pros and Cons
- Producing funnels is very simple, easy, and quick
- All-in-one system with everything your business needs to win
- Split screening and also conversion tracking consisted of
- Email integration with all of the significant e-mail autoresponder platforms
- Repayment handling capacities within ClickFunnels
- ClickFunnels is constantly adjusting and also updating to the times
- There is constantly support readily available (whether live or otherwise).
- Extremely energetic Facebook Group Area.
- Free 14-Day Trial – enables you to try it take the chance of totally free.
- As awesome as ClickFunnels is, it absolutely is not an economical remedy and also needs a continuous registration to utilize
- Assistance isn't really always the fastest and might draw from 1 min to 24 hours depending on the concern.
ClickFunnels versus Everyone Else.
Many people ask exactly how ClickFunnels compares to various other landing web page builders such as Leadpages, Unbounce, and Infusionsoft.
For the most part it's not truly a reasonable comparison because each of these devices stands out is one location or the various other.
The graph over offers a thorough analysis – yet I'll highlight several of the significant contrasts below.
ClickFunnels vs Leadpages
Prior to ClickFunnels, Leadpages was the big dog.
Leadpages is merely a lead capture software application – nothing more. You could create landing web pages, lead boxes, accumulate leads … that's virtually it. In addition, the Leadpages design templates are also limited on modification.
ClickFunnels is much more functional – it's much easier to use and also does so much more compared to create lead capture web pages.
Simply put, Leadpages is actually simply a landing page home builder, while ClickFunnels is focused around building extremely incorporated funnels.
ClickFunnels vs Infusionsoft
Infusionsoft is not a landing page or sales page builder. It has some of that capability constructed it, however that's not exactly what it's recognized for.
At it's core, Infusionsoft is a CRM platform – one that permits you to manage your entire customer data source. ClickFunnels has this capacity with Actionetics, yet it's not almost as advanced as Infusionsoft.
Infusionsoft is also very costly and also pressures every brand-new client to pay $2000 for an obligatory kickstart training package simply to discover ways to use the intricate system (which is infamously challenging to make use of).
ClickFunnels Affiliate Program
There are two major courses people decrease as ClickFunnels customers.
Those that prefer to utilize the tool for their business – in hopes of one day accomplish the Two Comma Club (over $1M in revenue).
And those that are interested in making passive income as a ClickFunnels Affiliate and winning the Desire Car Competition (where they pay $500/$1000 towards your dream automobile if you get to 100/200 active month-to-month signups, specifically).
With a monstrous 40% monthly reoccuring commission, ClickFunnels conveniently has one of the best affiliate programs of any platform available.
That's right – you earn money a continuous 40% compensation on every associate signup you make with the ClickFunnels Affiliate Program. But, just what does that really correspond to?
The fundamental strategy is a $97/month investment as well as the Etison Suite plan is a $297/month financial investment. as a result you make $38.80 each standard strategy and $118.80 each Etison Collection plan … each and every month!
Generally, every 100 signups will certainly bring in $4000/month in affiliate payments (more or less relying on how many Etison Strategy users are in there).
Go here to find out more concerning becoming a ClickFunnels Affiliate.
All-time Low Line
ClickFunnels is pass on the greatest system if you are aiming to conveniently construct high converting sales funnels.
Since it was developed from scratch to be the very best sales channel contractor, it vanquishes all of the competitors in that respect.
On the surface, it may not be the least expensive product out there – but if you use it to its complete capability, your company will come to be more rewarding and also you will conserve money from not having to utilize other devices. GoToMeeting Schedule Meeting
If you've read this far into my ClickFunnels Evaluation, I recommend you see for yourself with a Free 14-Day Trial right here.


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Knutsford Badminton club have faced some difficulties recently with their home venue leisure centre. It has transpired that Sundays have been now designated as early closing - no doubt a cost cutting measure. Subsequently Knutsford faced losing their Sunday evening slot having arranged all of their fixtures for the season. Fortunately they have been able to arrange alternative accommodation as follows:
Egerton Boys club in Knutsford (home venue of Canute BC)
Mereheath lane
Sunday 7.30pm till 9.30 pm effective from 1st September 2019
If your club is scheduled to play at Knutsford please be aware of this change. This should incur no extra travel time for you.
Crewe and District Badminton League
All comments should be sent to the


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So I Creep…Allegedly
The rumors surrounding boxing champ Gervonta Davis are that he, and Trina are creeping around. Contrary to what his baby mom Dretta Star told everyone on Instagram yesterday night! Allegedly Masika Kalysha had to be whisked away with the help of Davis baby mom before Ariana Fletcher flew into town.
Dretta Star, spilled the tea on her baby frather (whom she says she is in a good place with ), and couldn't care less. She says Ari isn't "slow", and knows exactly what's going on. Well if she didn't she knows now.
It's a little confusing because according to Dretta Gervonta was a "dead beat" about a month ago!
It Wasn't Me
We guess bye gones, are gones, and the two are co parenting just fine. Masika Kalysha took to Twitter to dispel any rumors that she was indeed there for the feather weight division undefeated champ Davis. Presumably Sika went on to insult Dretta's facial features amongst other insults.
Riding For Mines
Dretta's cousin Juicy Juice Box ( idk her actual name) came out the gate swinging. She went on to check Masika for speaking ill about her family! She told as Juicy Juice calls Masika "Hoesika" to chill, and with her wigs up!
Many fans that were in the Baltimore area are saying Trina was actually the Love & Hip Hop Star he has been tip toeing with! Fans are saying Masika was actually there to see Dreezy's man Jaquees! People are saying Trina was the one in Baltimore creeping with Gervonta!
Ole Thang Back
Trina and Gervonta Davis dated back in 2017,and the romance was short lived. Davis denied he was seeing the Diamond Princess , but pictures of the two still linger. The two look quite happy as they cuddled up for the camera. The Florida native's mother has just passed away, and we doubt Trina is here for the mess as she mourns her lost.
Mean while Ari can be heard in the shower while Gervonta went live, so whatever the situation the two seem to be fine. Ari has yet to go on social media to address the rumors.
Follow Us On Instagram For Updates @rappedout_
Categories: Uncategorized


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A study and transcription of a group of selected Christmas villancicos from the period 1740 to 1780 from the cathedrals of Guatemala City and Mexico City
Garcia-Landois, Oscar Rene
MetadataShow full item record
The cathedrals of Mexico City and Guatemala City possess an impressive inventory of sacred music from masters of Spain, from other European countries as well as chapel masters from the New World and composers related to those and other cathedrals. The sacred villancico occupies an exceptional place in the music history of Spain and the New World due to its vitality that can be explained through its origin as secular genre, its unique opportunity to reflect popular elements in music and text as well as its ability to implement new developments in Western art music. The Christmas villancico also brings to this genre the old tradition of religious theater, in particular, that of the Officium Pastorum.. In the field of study of the villancico, a considerable effort from musicologists and researchers from other fields is required in order to provide more and more accurate scores, texts, analyses, inventories and biographical data. This muchneeded effort may be able to bring the genre of the villancico to a level of understanding similar to that of other musical genres in Western art music. The present dissertation is only a little step into that direction and consists of a modern critical edition of a selected group of Christmas villancicos from the cathedrals of Mexico City and Guatemala City from the period 1740 to 1780. It also provides translation of texts, includes a chapter which traces the villancico as poetical genre and discusses important aspects of the history of the villancico as musicalpoetic genre. The dissertation also includes poetical considerations of the villancicos presented and a detailed study of their musical aspects as well as their music-historical context.
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Podcast: Play in new window | Download
03-17-2013 message by Pastor Jeff Gilboy
I need to be honest with you…I have a phobia. And it's not public speaking. My phobia is trypanophobia or Needle Phobia. I've had this irrational fear my whole life and it hasn't gotten any better. Heidi really knew the depth of my love for her when I was willing to have my blood drawn in order to get a life insurance policy early in our marriage. I think that might be the last time I was poked with a needle.
Even thinking about needles or seeing other people get poked gives me the heebie-jeebies. One of my daughters had to go in for a CT scan a couple of years ago, so I took her up to the hospital. I didn't know they were going to be injecting an IV contrast dye. Neither did she. So I'm standing next to her, trying to be supportive, while the technician is setting up the torture devices. And I start getting all the symptoms–sweating, nausea, drop in blood pressure, fainting. So I say, "I'm just going to get a quick drink of water, honey," take off my coat, look away, take some deep breaths, try to stop shaking.
I'm not a total freak: an estimated 10% of Americans have needle phobia. Researcher Dr. James G. Hamilton suggests that needle phobia may be genetic – our genetic ancestors who avoided getting poked with sharp things had a greater chance of surviving and passing on their DNA.
What about you? What's your phobia? What are some other common phobias people face? public speaking, pain, death, spiders, heights, clowns, the future, being alone, intimacy, rejection, snakes, people, failure, driving, ghosts, enclosed spaces, water, cockroaches
Maybe you don't have a crazy phobia like I do, but we all face times of fear and anxiety. responses—fight or flight…or freeze fear = certain or immediate external threat; anxiety = unavoidable, uncontrollable perceived threats
TENSION: What do we do about the fears/anxieties we face? Maybe we can avoid some fears by living in denial or avoiding hospitals/circuses/roof tops. But what about the unavoidable fears: pain, the future, relational intimacy, possible rejection, potential failure in our lives or the lives of our children/grandchildren?
Even the 12 guys who hung out with Jesus every day for three years faced fear & anxiety!
READ Mark 4:35-41
|Mark 4 (NLT)35 As evening came, Jesus said to his disciples, "Let's cross to the other side of the lake." 36 So they took Jesus in the boat and started out, leaving the crowds behind (although other boats followed). 37 But soon a fierce storm came up. High waves were breaking into the boat, and it began to fill with water. 38 Jesus was sleeping at the back of the boat with his head on a cushion. The disciples woke him up, shouting, "Teacher, don't you care that we're going to drown?" 39 When Jesus woke up, he rebuked the wind and said to the waves, "Silence! Be still!" Suddenly the wind stopped, and there was a great calm. 40 Then he asked them, "Why are you afraid? Do you still have no faith?" 41 The disciples were absolutely terrified. "Who is this man?" they asked each other. "Even the wind and waves obey him!"
|Psalm 107:23-32 (NLT)23 Some went off to sea in ships,
plying the trade routes of the world.
24 They, too, observed the Lord's power in action,
his impressive works on the deepest seas.
25 He spoke, and the winds rose,
stirring up the waves.
26 Their ships were tossed to the heavens
and plunged again to the depths;
the sailors cringed in terror.
27 They reeled and staggered like drunkards
and were at their wits' end.
28 "Lord, help!" they cried in their trouble,
and he saved them from their distress.
29 He calmed the storm to a whisper
and stilled the waves.
30 What a blessing was that stillness
as he brought them safely into harbor!
The CRAZY TALK question: "Why are you afraid?" Well, because we're about to capsize & drown, Jesus!
Context to this story: earlier in ch. 4 Jesus is teaching a large crowd on the shore from a boat on the West side of the Sea of Galilee (in Jewish territory) & then having some private conversations with his disciples. Then they head across the lake/sea to the East side into non-Jewish territory where you have pig farmers in Mark 5. (Jews don't eat pork or raise pigs.) And this storm crops up on their way across the lake.
Backstory: God controlling the weather in Psalm 107 (calming the storm, stilling the waves). When the disciples ask, "Who is this man?" the answer is in Ps. 107 – only God can calm storms. Psalm 107 is a poetic celebration of God leading the Jewish people out of captivity in Babylon and the stormy seas in Psalm 107 represent the enemy nations who are stilled as God brings His people out of the storm and into a safe harbor. Mark is setting up Jesus as the true God who leads all of His people out of an exile in sin, sickness, oppression, fear and into the safe harbor of healing, forgiveness, freedom and faith.
|End of Mark 4
|Beginning of Mark 5
|Jesus has authority over the wind/waves4:41 disciples are afraid after wind/waves obey
4:41 disciples wonder who Jesus is: "Who is this? Even the wind and sea obey Him!?"
|Jesus has authority over demons5:15 the crowd is afraid after the demons obey
5:7 the demon-possessed guy knows exactly who Jesus is: "Jesus, Son of the Most High God."
Humorous contrast between 4:40-41. Jesus' understatement (1st) question: "Why are you all timid/cowardly?" and the exaggerated reality of what the disciples were actually experiencing, literally something like, "And they feared with a great fear," or as the NLT puts it: "The disciples were absolutely terrified."
The whole key to this story is in the second question Jesus asks the guys in the boat: "Do you still not have faith?" There's a truth that Jesus knows that the disciples have still not picked up on…FAITH ERASES FEAR.
ILLUS: Use "FAITH" to erase "FEAR" from white board
In a few minutes, you're going to leave the relative safety of this harbor and get back out onto the sea of your life. You might be in the middle of a terrifying storm right now, or you might be enjoying some smooth sailing. But I'm going to encourage you to do three things in the next seven days to help you navigate whatever waters you are facing.
1. Anticipate storms. Some storms are unavoidable. People will let you down. You will fail others. You will go through difficulties. These storms will cause you to experience fear/anxiety. This week, make a list of the storms and potential storms you are facing.
2. Remember: you're not alone in the boat. You're not the only one who is feeling fear and anxiety. Look around the room: we're in the boat with you. Be vulnerable. Ask for help. Encourage and support someone else who is on the same journey. Gal. 6:2 "Share each other's burdens." This week, make a list of some key people in the boat with you. Pick one name from your list and reach out to them this week to either offer or request help and encouragement.
3. Cling to faith when you face fear. Not only are you in the boat with each of us, there's someone else in the boat with you who can actually do something about the storms. FAITH erases FEAR. Your natural fear response may be fight, flight, or freeze. But you can change your instincts and begin a process of conditioning yourself to intuitively cling to faith in Jesus when you are navigating stormy waters. In order to do that, you'll need to get to know Him better so that you can trust Him more. We're spending 6 weeks in the book of Mark, looking at some of the crazy things Jesus said. There are 16 chapters in Mark. This week, read through the 16 chapters of Mark. You can do it in one sitting in a little over an hour, or 10-15 minutes each day this week. You'll discover something new about Him that will help you instinctively cling to faith the next time you experience fear.
Imagine what it would look like if:
- we all started being more honest about our fears/anxieties with one another
- we were a harbor from life's storms where people could come to allow faith In Jesus to erase their fears
- we spread out through this community, bringing the hope that comes with faith in Jesus to our coworkers, classmates, neighbors, families


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