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Archer CCS Strategies discussion - iara2
#71
2 - min screen priorities
It is important to prioritize the actions on 2-min screen because we have very less time. Orders for screening tests and some routine orders such as diet are not even scored. Priority should be placed on:
a. Entering any necessary treatment orders that you were unable to enter on the active screen.
b. Adding consult requests that are crucial. Eg: Surgical consult for emergency surgery that you were unable to request on active screen. Enter name of that surgical procedure.
c. Follow up tests and labs for later date and for stat use. Enter those Stat labs that are important but you did not have time to order by the time you reached 2-min screen.
- Entering the stat labs on 2-min screen allows the software to know that you have thought about it and ordered it.
Remember that on active screen you can order labs and advance clock to get results. But on 2-min screen you can order but can not advance the clock to see results. Though you can not get the results, just by entering them on 2-min screen you can get at-least a partial score.
- Enter any follow-up labs for later date using the calendar. These include follow up labs and procedure to monitor efficacy or toxicity of an intervention or a drug that you started on active screen.
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#72
iara, I need clarification on which pressor to use when in the ICU?
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#73
mansa...shock cases in archer videos illustrate that very well.
For sepsti shock that doe snot improve after large amount of fluid boluses, make sure to keep MAP > 65 using a pressor
Insert arterial line
If HR rate too high, start Norepinephrine.
If HR not an issue, start Dopamine. Add dobutaime if cardiac output low or mixed venous saturation gradient > 30.
Additional pressors are added on top of above if MAP not maintained despite one pressor.
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#74
Do you always discontinue orders on 2min screen?

1. This is an extremely important point. Archer says some cases of CCS failure are due to premature discontinuation of inpatient orders anticipating discharge. Discontinuation of orders in anticipation of discharge should only be done when “simulated time” is appropriate for discharge and discharge criteria are met.

Sometimes, case ends very soon. For example, Pneumothorax case on Primum USMLE Software ends in 2 hours of simulated time. So when you reach 2 min screen, you are at around 2 hours of simulated time after you placed chest tube and subsequently would have obtained a follow-up chest x-ray. So if you discontinue the chest tube at this point, the software would read it as you have discontinued chest tube 2 hours after placing it while the patient is still in the hospital within 24 hours after admission. The criteria for discontinuing chest tube is not reaching the 2 minute screen but making sure that the air leak had stopped. Once the air leak stops, chest tube can come out. For this to happen, you need to wait at least a day and advance clock 24 hours later but the software typically is not looking for all these and will end this case at 2 hours of simulated time. So anyone who attempts to discontinue the chest tube at this point will be heavily penalized and some people have lost the cases because of these actions. Unfortunately, Uworld CCS which most of us use does not explain all this properly. So please do realize that reaching the 2 minute screen is not an automatic indication to discontinue the orders. Discontinuation of the orders should be dependent on the simulated time criteria as well as may discharge/discontinuation criteria.

Another example: A patient with pneumonia and fever, age greater than 70 is admitted to hospital and he was started on IV antibiotics. He is not swallowing properly, has nausea and vomiting. On day 1, as you advance the clock, 2 min screen may appear. Now. do not discontinue IV antibiotics and switch over to oral antibiotics yet because you are still on DAY 1 simulated time. The software has not alerted you that the patient started to take things orally again. So it is important to pay attention to all of these. I think your question is very important, several examples like these shown in Archer CCS and cleared up my confusion with this.
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#75
the last one was really good iara
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#76
I postponed my exam due to personal issues. Looking for quick review of CCS once again. Have you finished your exam, valencia?
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#77
not yet, plan to take in July
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#78
Please clarify when do you order neurochecks and how often?
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#79
A 67 year old man in the hospital for COPD exacerbation and on third day developed redness and tenderness at the IV site , fever at 100F, .....how do you manage a case like this?
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#80
mansa; that is a case of superficial thrombophlebitis in a patient with IV line in place. Like any case where you have redness and warmth in extremity, we will need to do venous doppler to r/o DVT.

Superficial thrombophlebitis does not need any anticoagulation unless there is deep vein extension. Anticoagulation is indicated in those with righ risk for deep vein extension ( eg: cancer patients, bed ridden, prior hx of DVT, estrogen therapy).

Management is with:
Analgesics, antiinflammatory drugs like naprosyn, cold compresses.
Extremity elevation
compression stockings

If there is high fever/ chills or drainage from the area; start antibiotics for superimposed infection ( suppurative thrombophlebitis)
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