Smart Phrases And Workups – Neuro/Psych

ALCOHOL USE DISORDER
Alcohol Use Disorder
Last drink:
- continue CIWA protocol with ativan
- thiamine, folate, vitamin, D5NS
- if hemodynamic compromise or history DT/seizure/ICU admission, STOP ativan and start phenobarbitol
- SW consult for cessation resources
AMS	
Altered Mental Status
CBC, BMP, LFTs, lactate, POC glucose, B12/folate, TSH, RPR, VBG
If focal neuro deficits, ABG and non-con head CT
- delirium precautions with frequent reorientation, mobilize with PT/OT, OOB to chair, glasses/hearing aids, minimize lines/catheters, volume repletion, avoid retraints if possible, lights on during the day, melatonin at night
- limit opioids, benzodiazepines, steroids, anticholinergics, antihypertensives, antiepileptics, penicillins/cephalosporins
BUPRENORPHINE INITIATION
Buprenorphine Initiation
Begin buprenorphine induction per protocol once all operative procedures are completed and pain control is stabilized: 
- Order clinical opiate withdrawal scale (COWS)
- Give buprenorphine 8 mg, 8 hours after last dose of opioids or when COWS >12  (plan for induction at 08:00), give a second dose of buprenorphine 4 mg at 12:00, give a third dose of buprenorphine 4 mg at 16:00 for total dose of 16 mg daily, then start 16 mg once daily the following day
- Substance use navigator consult to assist with discharge planning
- Please notify us in advance of planned discharge
- Please call us prior to any anticipated procedures where buprenorphine may need to be held or adjusted

If precipitated withdrawal occurs, please provide the following, at the discretion of primary team:
- Hydroxyzine 50-100 mg PO q6h prn for anxiety or restlessness
- Trazodone 50-150 mg PO qhs prn for insomnia
- Loperamide 2-4 mg PO q4h prn for diarrhea
- Ondansetron 4-8 mg PO prn for nausea or vomiting
- Methocarbamol 500-750 mg PO q8h prn for muscle cramping
- Acetaminophen or NSAIDs (if safe to do so) for myalgias or headache

Buprenorphine side effects: nausea, vomiting, constipation, muscle aches, cravings, insomnia, irritability, fever
ETOH	
Acute Alcohol Withdrawal
Last drink:
Hx ICU admissions, hallucinations, seizures
Symptoms: anxiety, tremulousness, headache, tachycardia, chills, insomnia, N/V, body aches
Admission CIWA score:
- telemetry, continuous pulse ox, fall/seizure/aspiration precautions
- continue CIWA with ativan
- vitals q4h if CIWA <10, otherwise q1h
- daily Mg, Phos, K; replete prn
- thiamine, folate, glucose, multivitamin supplementation
- Social work referral for alcohol cessation resources
- on discharge consider medication assisted therapy with acamprosate 666 mg TID, naltrexone 50mg QD (decrease dose in cirrhosis), baclofen 5-10mg TID, gabapentin 600mg TID (JAMA 2014;174:70)
INTRACRANIAL HEMORRHAGE
Intracranial Hemorrhage
- f/u STAT non con CT head, PT/INR
- f/u non con CT head in 6h
- NSGY consulted, appreciate recs
- goal SBP <140, IV labetalol prn or nicardipine gtt
- INR >1.5, plt >50
- keppra for seizure ppx
SEXUAL ASSAULT	
Sexual Assault
- f/u pregnancy test, gonorrhea/chlamydia NAAT, HIV, hep B, syphilis
- psychiatry consulted, appreciate recs
- gonorrhea and chlamydia ppx with CTX 500 mg IM x1 and azithromycin 1g PO x1, trichomonas ppx with metronidazole 2g PO x1
- HIV PREP with tenofovir/emtricitabine + dolutegravir (substitute raltegravir in WOCBP)
- consider ulipristal emergency contraception
- social work consult for supportive counseling
- hepatitis B vaccine if unvaccinated
STROKE	
Stroke
Last known well:
- telemetry, NPO, HOB >30 degrees
- f/u CBC, BMP, LFTs, PT/INR, TnT, UA, UCx, UDS, antiepileptic drug levels
- f/u EKG, non con head CT, CTA head and neck
- goal BP <180/105 after tPA or <220/120 if not tPA candidate
- ASA 325 mg x1 then ASA + clopidogrel x3-4 weeks then ASA daily