RESIDENCY PREP

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The Cross-Cover Guide is a practical, educational resource designed to support physicians during routine and urgent cross-cover issues that arise in hospitalized non-pregnant adults on medicine services. This guide is intended for educational purposes only and does not replace clinical judgment.


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Acute Clinical Emergencies

APPROACH TO RAPID RESPONSES (RRT)

A two-column infographic outlining best practices for managing Rapid Response Team (RRT) events, split into “During RRT” (left) and “After RRT” (right):

Left Column – DURING RRT:
1. Calling an RRT:

You may be notified by the bedside nurse, but anyone can activate RRT for any acute concern (arrhythmia, hypotension, chest pain, respiratory failure, neurologic changes, etc.).

Use your judgment—better to overcall than undercall.

2. Introduce yourself:

Stand at the foot of the bed.

Ask what triggered the RRT.

If you're not the primary team, request to be notified.

3. Immediate Actions:

Get a full set of vitals.

Perform a focused history and physical.

Review the chart if unfamiliar with the patient.

4. During the RRT:

State your differential diagnosis (DDx) out loud.

Begin empiric work-up and treatment based on DDx.

Ask for suggestions from the RN or other team members.

Ask for help—don't hesitate to escalate to ICU, code, etc.

Summarize frequently and close the communication loop.

Determine disposition (telemetry, ICU, same unit, etc.).

Right Column – AFTER RRT:
1. Notify Others as Appropriate:

Supervising or primary attending.

Consultants.

Family.

2. Document a Note:
A template labeled “RAPID RESPONSE / EVENT NOTE” includes:

Time of notification and reason.

Clinical Assessment (subjective symptoms).

Objective findings (vitals, labs, imaging).

Differential Diagnosis (list format).

Treatment Plan (medications, fluids, escalation).

Checkboxes for:

Whether the attending was notified.

Other service notified.

Family notified.

3. Reflect and Ask for Feedback:

Debrief with the team.

Read next-day notes to see outcomes.

Write down one learning point.

Benefits of Good RRT Documentation and Communication:

✅ Improved communication (between residents, attendings, and teams).

✅ Improved clinical reasoning.

✅ Medicolegal advantage.

Reviewed and edited by Dr. Jacob Mack, MD

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Agitation

Reference: modified from www.ttreducators.com/compendium

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Atrial Fibrillation with RVR

CHADSVASC Calculator

Reviewed and edited by Dr. Marty Tam, MD, MHPE

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Altered Mental Status (Acute)

A diagnostic algorithm for AMS evaluation:

Immediate actions:

Airway protection, POC glucose, thiamine IV if Wernicke risk, ABG, naloxone, full physical/neuro exam.

Red triangle warns of herniation signs (e.g., blown pupil + posturing): elevate head, give hypertonic saline or mannitol, call neurosurgery, head CT.

Branching Based on Exam:

Focal deficit on exam: Urgent CT and neuro consult for stroke/hemorrhage.

No focal deficit: Evaluate for toxic (meds, overdose), metabolic, endocrine, infectious, delirium, or neuro causes.

Further Testing:

CBC, CMP, tox screen, TSH, B12, cultures.

Imaging: head CT, brain MRI if needed.

EEG if seizure suspected.

LP for meningitis/encephalitis if no alternative found.

Naloxone Use: Low threshold if respiratory depression or pinpoint pupils. Dose escalation protocol shown.

Reviewed and edited by Dr. Kurt Sieloff, MD

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Bradycardia with a Pulse

Authors: Dr. Lauren Heidemann MD, MHPE & Dr. Matt Rustici MD

Reference: 2025 American Heart Association Algorithms

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Chest Pain

HEART Score EDACS Score TIMI Score GRACE Score

Reviewed and edited by Dr. Marty Tam, MD, MHPE.

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Fever

SOFA Score SIRS Criteria

Reviewed and edited by Dr. Owen Albin, MD.

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GI Bleed (Acute)

Created by Dr. Amit Gupta, MD, MHPE

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Hypertension (Severe)

Flowchart for inpatient management of severe hypertension (SBP ≥180 or DBP ≥120):

Do Not Panic reminder that many cases are asymptomatic and don’t need rapid treatment.

Immediate Actions: Repeat BP with proper cuff size, assess for end organ damage (e.g., stroke, AKI, ACS), and test appropriately (CBC, EKG, troponin, etc.).

Branch 1: Asymptomatic Markedly Elevated BP:

Treat with PO medications (not IV).

If patient has no known HTN: coordinate outpatient follow-up.

If patient has chronic HTN: restart or escalate home meds (e.g., labetalol, amlodipine).

Rare cases (e.g., pre-op) may require quicker PO treatment (e.g., captopril, clonidine).

Branch 2: HTN Emergency (w/ End Organ Damage):

Admit to ICU.

Use IV medications (e.g., nitroglycerin, labetalol, nicardipine) based on specific scenarios (e.g., flash pulmonary edema, dissection, stroke).

Goal: lower BP by ~25% in first hour, then to 160/100 over 2–6 hrs.

Reviewed and edited by Dr. Monee Amin, MD

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Hypotension

Created by Dr. Jacob Mack, MD

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Seizure

Reviewed and edited by Dr. Kurt Sieloff, MD

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Shortness of Breath

Reviewed and edited by Dr. Kayla Kolbe, MD and Dr. Mark Kolbe, MD

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Stroke (Acute)

NIH Stroke Scale TPA Contraindications

Reviewed and edited by Dr. Kurt Sieloff, MD

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Tachycardia with a Pulse

Authors: Dr. Lauren Heidemann MD, MHPE and Dr. Matt Rustici MD

Reference: 2025 American Heart Association Algorithm

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Common Overnight Cross-Cover Scenarios

GI CONCERNS (Constipation, Diarrhea, Nausea/Vomiting)

Reviewed and edited by Dr. Jacob, Mack, MD

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Insomnia, Cough, Itching, Headache

Reviewed and edited by Dr. Kristen E. Fletcher, MD

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PAIN MANAGEMENT: Non-Opioid Medications

Alt text – Pain management medications by class Table organized into three columns: Medication class, Medication with typical dosing, and Considerations. Topicals Options include heating pads or ice packs based on patient preference; lidocaine gel, cream, ointment, or patch applied up to 12 hours per day; diclofenac gel or patch as a topical NSAID with minimal systemic absorption and safe use in renal impairment; and capsaicin cream, which may help but commonly causes burning. Acetaminophen (Tylenol) Typical dosing is 325–1000 mg every 6 hours as needed, oral or IV. Maximum dose is 4 grams per day in most patients and 2 grams per day in cirrhosis. Generally very safe but requires caution in acute liver injury or failure. A reminder notes to account for hidden acetaminophen in combination products such as opioid-containing medications. NSAIDs Includes: Ibuprofen 200–400 mg every 4 hours as needed, with lower maximum dosing in hospitalized patients Ketorolac (Toradol) 15–30 mg IV or 30–60 mg IM every 6 hours, limited to 5 days due to high risk of gastrointestinal side effects Cautions include chronic kidney disease, acute kidney injury, coronary artery disease, heart failure, prior stroke, gastrointestinal ulcer or bleeding, thrombocytopenia, planned iodinated contrast exposure, and avoidance in cirrhosis. Muscle relaxants Medications listed include: Cyclobenzaprine (Flexeril) 5 mg three times daily as needed, up to 10 mg Methocarbamol (Robaxin) 1.5 grams orally up to four times daily or short-course IV dosing Tizanidine (Zanaflex) 2–4 mg every 6 hours These medications carry risks of sedation, dizziness, anticholinergic effects, falls, and hypotension. The table recommends avoiding muscle relaxants in older adults, using short courses only, and notes that baclofen is intended for spasticity rather than acute pain. Neuropathic pain A note states these medications may take days to weeks to reach maximal effect. Options include: Nortriptyline starting at 12.5 mg nightly and titrated slowly; avoid in older adults due to anticholinergic effects, arrhythmias, confusion, and QTc prolongation Duloxetine (Cymbalta) 60 mg daily; avoid if creatinine clearance

Reviewed and edited by Dr. Kristen E. Fletcher, MD

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Pain Management: Opioids

Opioid medication comparison chart showing recommended starting doses for opioid-naive patients, with notes on renal/hepatic adjustments, equivalency conversions, opioid use disorder considerations, and side effect risks. Includes medications like Tramadol, Oxycodone, Hydrocodone, Morphine, Hydromorphone, and Fentanyl.

MME Calculator Opioid Converter

Reviewed and edited by Dr. Kristen E. Fletcher, MD

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Electrolyte Disorders

SODIUM

Reviewed and edited by Dr. Junior Uduman, MD, MS, FASN

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POTASSIUM AND MAGNESIUM

Reviewed and edited by Dr. Monee Amin, MD

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CALCIUM AND PHOSPHORUS

Reviewed and edited by Dr. Junior Uduman, MD, MS, FASN

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ABOUT

This guide was created by Dr. Lauren Heidemann, MD, MHPE, a hospitalist at University of Michigan. This project would not have been possible without the expertise, insight, and generous time of many colleagues who reviewed and contributed to the content. Sincere thanks to everyone who helped shape this resource, listed below. This guide is updated annually. Last update January 2026.

Owen Albin, MD – Infectious Disease specialist at University of Michigan
Monee Amin, MD- Hospitalist at Emory
Kristen E. Fletcher, MD – Medicine Pediatrics Hospitalist at University of Kentucky
Amit Gupta, MD, MHPE – Gastroenterologist at University of North Carolina
Anna Harleen, MD –Internal Medicine resident at University of California San Francisco
Kayla Kolbe, MD – Pulmonologist at University of Michigan
Mark Kolbe, MD – Hospitalist at University of Michigan
Jacob Mack, MD – Hospitalist at St. Louis VA
Kurt Sieloff, MD – Neurologist at University of Michigan
Marty Tam, MD, MHPE – Cardiologist at University of Michigan
Junior Uduman, MD – Nephrologist at Henry Ford Health
Julia Witowska, MD – Medicine Pediatrics 4th year Resident at time of review, University of Michigan