Mycobacterium lightning lecture

• TB
  • 1/3 of world infected with TB
  • 2^nd leading cause of death
  • Symptoms
    • Cough
    • Hemoptysis
    • Night sweats
  • Management
    • Respiratory isolation
    • Contact health department
    • Isoniazid/rifampin/pyrazinamide/ethambutol
• Tuberculous Lymphadentis (scrofula)
  • Enlarging painless neck mass in child
  • Treated similarly as TB
• M. Leprae
  • Dry hypopigmented macules
  • Hair loss
• MAC
  • CD4 < 75
  • Fever/dyspnea/night sweats/cough
  • Azithromycin/erythromycin/ethambutol
• M. Marinum
  • Ascending lymphangitis in aquarium workers
  • Azithromycin or clarithromycin with ethambultol.
  • Treat for 25 weeks.

Rabies lightning lecture

• Acute progressive encephalitis
• Bats are #1 vector in the US.
• Management
  • Treatment is palliative in symptomatic patients
  • Postexposure prophylaxis is recommended if bite cannot be ruled out
    • Watch animal for 10 days if available
    • High risk animals – raccoons, skunks, foxes, bats
    • One dose of HRIG and 4 doses of rabies vaccine over a 14 day period. 5 of 28 days if immunocompromised
• Tetanus
  • Neuro illness from toxin created by clostridium tetani
  • Generalized – diffuse muscle spasms and rigidity
  • Cephalic – cranial nerve palseys
  • Neonatal- passed from unvaccinated mothers

Public Health Updates

• Restaurant inspections, STD tracking, vaccination tracking, septic systems
• Important to find niche outside of EM in your career, Public health could be a good option
• Covid
  • Significantly decreased level of acuity since onset.
  • Downtrending cases and deaths
• Yearly patterns
  • Upticks in November/December and right at start of school year
• Myocarditis
  • Can get from vaccine, but also from covid at an even higher rate

Lightning Lectures

• HIV
  • 1.2 million infected in US, 30-40,000 new cases per year
  • At risk populations
    • MSM 67%
    • Heterosexual contact 24%
    • IV drug use 6%
  • AIDS
    • CD4 count less than 200 or with AIDS defining illness
  • Considerations
    • Privacy when discussing matter with patient
    • Consider AIDS defining illnesses and contraction of rare illnesses
    • Low threshold to start antibiotics if ill appearing
  • History 
    • Does patient know CD4 count or viral load
    • Are they compliant with medications.
  • West Nile
    • Most common in US
  • Dengue
    • Most common worldwide
    • Can cause hem fever
  • Yellow Fever
    • Can cause hem fever
  • Chikungunya
    • Can cause hem fever

Sepsis Clinical Pathways

• Widespread inflammation and organ distress initiated by any type of microorganism
• Leading cause of hospital death 15-20% mortality overall, 50% if associated septic shock
• Defined:
  • Sepsis – suspected infection with SIRS+ or lab abnormalities
  • Septic shock – suspected or proven infection, signs of inflammation, signs of organ failure, + requiring pressors after fluid resuscitation. 
• qSOFA
  • AMS, RR>22, SBP<100
• SIRS
  • Temp < 96.4 or > 100.4
  • HR > 90
  • RR > 20
  • WBC > 12,000 or < 4,000
  • Meeting 2+ criteria is positive SIRS response
• Within 3 hours of patient presentation
  • Lactate measurement
  • Cultures > abx administration
  • 30ml/kg crystalloid fluid
  • repeat lactate before 6 hours
• Resuscitation
  • 20-30ml/kg LR if appropriate for patient
  • broad spectrum abx
  • If BP not responsive, vasopressors (norepinephrine) with target MAP 65 
• Abx
  • Vanc/zosyn or vanc/cefepime
    • Cefepime does not cover anaerobes

Multi-Drug Resistant Organisms: management overview

• MDRO – organism resistant to one or more classes of antibicrobial agents – CDC
  • Organisms of significant concern are resistant to MANY
    • VRE, ESBL, Carbapenemase producing organisms
  • Antibiogram available at pharmacy desk!!!
    • Use this when choosing your antibiotics please
  • VRE treatment
    • Daptomycin or linezolid
      • Both are equivalent 
  • ESBL treatment
    • Cystitis
      • Macrobid, Bactrim, fosfomycin
  • CRO treatment (consult ID)
    • Serine carbapenemase susceptibility
      • Ceftazidime/avibactam
      • Meropenem/vaborbactam
    • I mipenem/relebactam
    • Metallo-betalactamase susceptibility
      • Aztreonam+ceftazidime/avibactam

Documentation Changes

• Will Begin in January 2023
• MDM based
  • Number and complexity of problems addressed
  • Amount or complexity of data reviewed
  • Risk of complications
• Make sure you document all diagnoses considered in your workup.

Pericardiocentesis

• Perform if tamponade present
• Usually from penetrating trauma
• 2 techniques: parasternal and subxiphyoid
• 18guage spinal needle with angiocatheter
  • insert needle, aspirate during insertion until blood return, advance angiocath, draw off fluid until improvement, place stopcock.

Tick Born Disease

• prevention
  • insect repellant
  • Tick removal ASAP
    • Grab as close as possible to skin and pull straight off without twisting
• Lyme
  • B. burgdorefi
  • Ixodes tik
  • Erythema migrans (20% may not have rash)
  • Disseminated disease if untreated
    • Bells palsy – bilateral
    • Migratory arthritis
    • Heart block
• STARI – sourthern tick associated rash illness
  • Rash after being bit by tick
  • Lonestar tick – white dot on back
  • Does not cause severe disseminated disease
• RMSF
  • Macular/popular rash > Petechial Rash on extremities
  • Rickettsia rickettsi
  • Carried by Dog tick
  • Clinical diagnosis
• Erlichiosis
  • Carried by lonestar tick
• Anaplamosis
  • Ixodes tick
• Tick borne relapsing fever
  • Borrelia species
  • Soft shell tick
• Treat with docyycline for all

• Babesiosis (martha’s malaria)
  • Babesia microti
  • Peripheral smear with parasites (maltese cross)
  • Atovoqone and arythromycin
• Tularemia
  • Francisella tularensis
  • Lonestar tick and dog tick
  • Also in flies/contaminated meat
  • Conjuncitivis/ulcerative lesions, tonsillar exudate, typhoidal form
  • Treat if any antibody is +
    • Streptomycin 1g IM BID
• Tick Bite prophylaxis
  • Confirmed ixodes tick
  • Engorged or present graeter than 36 hours
  • Has it been 72 hours since removal
  • Can they take doxycycline
  • Is it a lyme endemic area? Ky is not.
  • IF all answers are yes – 1 dose of 200mg doxycycline