Case Reviews with Dr. Weeman and Dr. McMurray

Meningitis

• Strep Pneumo most common pathogen, consider when recent sinusitis or OM
• N meningitis: group living, recent exposure, rash 
• S aureus: IVDU
• HIV/immunocompromised: also consider Listeria, cryptococcus, TB
• Perform CT prior to LP if any focal deficit, seizure, AMS,  hx tumor, age > 60, papilledema 
• Give steroids (10 mg IV dexamethasone) 20 min prior to Abx as part of your empiric coverage because it decreases mortality in S pneumo 

TTP 

TTP is decreased ADAMTS-13 which cleaves vWF, without it vWF forms multimers that lead to microthrombi 

Present with fever anemia thrombocytopenia, renal failure, AMS, only 20-30% of pts have the classic pentad 

Microthrombi result in end organ damage 

Dx with plt <20K, MAHA, schistocytes, elevated retic count, LDH, unconjugated bilirubin

Normal coags and normal fibrinogen

Tx: steroids, FFP, HD can temporize 

Gold standard is PLEX which removes autoantibodies and replaces ADAMTS-13

Avoid platelet transfusion-> provokes thrombosis

Caplacizumab is a monoclonal antibody against vWF to impede interaction with platelets, very expensive.. not prescribed if plts >30K. Prescribed for prevention but may also be used in inpatient management 

Tox Review with Dr. Eisenstat

-Contraindications to activated charcoal include aspiration risk (think of toxins with high risk of seizures, somnolence, vomiting, etc)

-GHB acts on GABA receptors. Short acting. Classic case is obtunded requiring intubation then later self extubates

-Organophosphate toxicity: Tx with atropine and pralidoxime 

-Serotonin syndrome: clonus, give cyproheptadine 

-NMS give bromocriptine, malignant hyperthermia give dantrolene

-Cyanide toxicity: house fire with lactic acidosis, hypotension, bradycardia. Gives hydroxycobalamin 

-Amatoxin containing mushroom-> NAC

-Digoxin toxicity-> Don’t give calcium. 

-Indications for hyperbaric for carbon monoxide: Carboxyhemoglobin level >25% or >15 if pregnant, also anyone with LOC or severe lactic acidosis 

ID Review with Dr. Shoff

-Flexor tensynovitis-> Kanavel’s signs: pain with passive extension, percussion tenderness, uniform swelling, flexion posture

-Most common septic arthritic: Staph aureus 

-Missisppi Valley-> histoplasmosis

-Southest US-> blastomycoisis 

-California-> coccidiomycosis 

Varicella: lesions in various stages

Smallpox: lesions in same stage 

Pertussis: treat close contacts

Rabies: PEP for any bat exposure. Vaccine day 0,3,7,14. Administer immune globulin around wound, any leftover goes IM

Lightning Lecture – Advance Directives
– Living Wills – May contain DNR but typically do not
– Health Care Proxy – legal document that establishes who makes decision on behalf of the patients
– DNR orders can vary by state
– There are different types of DNRs
– POLST/MOLST – Physician/Medical Orders for Life-Sustaining Treatments – Kentucky’s newest forms
– Be open, honest, and compassionate when it comes to discussing end-of-life care
– At ULH, we have 24/7 palliative care services which are available in the ED

Lightning Lecture – Steven-Johnson Syndrome
– Extreme immune reaction causing keratinocyte necrosis diffusely
– Causes – medications, infections (Mycoplasma pneumonia), malignancy, immunosupression (HIV)
– Onset 1-3 weeks
– Prodromal viral symptoms – headache, fevers, msk pain
– Macular rash with bull -> skin sloughing (+/- Nikosky sign)
– Genital lesions, GI necrosis, pneumonia, interstitial pneumonitis
– Workup – basic labs, inflammatory markers, CXR
– ScorTEN – scoring algorithm to assess overall mortality
– SJS <10% TBSA involvement
– SJS/TEN Between 10-30% TBSA involvement
– TEN > 30% TBSA involvement
– Treat it like a burn – stop suspected offending agent, give a significant amount of IVF, local wound care, pain management

Interesting/Important EKG Findings
– P waves best seen in V1 and lead II
– In lead II, SA node P waves should be upright
– In lead VI, SA node P waves should be biphasic
– P pulmonale – right atrial enlargement
– P mitrale – left atrial enlargement
– Q waves usually occurs in the setting of post-MI
– Not all Q waves are indicative of MI
– One small box wide and one small box deep inside the Q wave is more indicative of pathologic Q waves
– T Waves – predominately upright
– Usually when inverted they represent ischemia vs strain
– U waves are rare upright waves following T waves typically only seen in significant dysfunction and illness
– Normal QRS: 60-100msec
– Incomplete BBB: 100-120msec
– Complete BBB: >120msec
– Short QT (500) Syndromes exist
– R wave progression – R waves should slowly appear through the precordial leads
– Should at lest be present by lead V2
– R should be isoelectric around V2-V3
– R wave should peak by V4-V5
– Early RWP can be lead placement, RVH, PHTN, or RBBB
– Late RWP can be old infarct, lead placement, LBBB
– Bundle Branch Blocks
– Is the terminal QRS deflection (last deflection) positive in V1? then in is a RBBB
– Is the terminal QRS deflection (last deflection) negative in V6? then in is a RBBB
– Is the terminal QRS deflection (last deflection) negative in V1? then in is a LBBB
– Is the terminal QRS deflection (last deflection) positive in V6? then in is a LBBB
– Most of the time, a true new LBBB does not pass the “eye test” – i.e. they look terrible in person
– If higher STEMI in Lead II vs Lead III -> likely LCx lesion instead of RCA lesion
– aVR – care about it because it can represent a left main lesion
– Reciprocal changes help identify a posterior MI
– Sgarbossa Criteria
– Concordant ST elevation > 1mm in leads with a positive QRS complex (positive terminal deflection of QRS complex with elevation in the T wave)
– Concordant ST depression > 1mm in V1-V3 (negative terminal deflection of QRS complex with depression in the T wave)
– When to obtain a posterior EKG:
– If posterior heart is infracting, should have reciprocal changes in the anterior waves (V1-V3)
– Lead II, Lead III, Lead aVF all negative deflections – this makes it a LAFB – NOT a LBBB equivalent
– A flutter – rate around 300bpm, vent rate usually 2:1
– AVNRT is the most common form of SVT
– Brugada Algorithm exists
– 200j is a good idea for most everything
– Run a 12 lead rhythm strip if possible while defibrillating unstable arrhythmia
– Causes of cardiogenic syncope
– ARVC, QT Syndromes, Conduction Delays, Etc
– Short PR interval in the right setting is a sign of WPW
– Brugada has types?
– Brugada pattern is when EKG changes present without symptoms
– Brugada Syndrome – EKG changes with syncope, chest pain, heart failure symptoms
– Metoprolol has more significant breakthrough events with long QT syndrome so Propranolol and/or Nadolol are preferred
– T wave inversions present in V1-V3 with syncope is concerning ARVD – look for epsilon waves – notching immediately after QRS
– Arrhythmogenic Right Ventricular Dysplasia
– Fatty infiltrative disease of the right ventricular free wall

Brief Review of Statistics
– Normal Distribution – 68%, 95%, 99.7%
– P value is the probability that the observed effect within the study would have occurred by chance if, in reality, there was no true effect
– Confidence interval provides a range of values within a given confidence including the accurate value of the statistical constraint within a targeted population
– Type I Error – the result of the study is said to be statistically significant but in-reality it was not
– Type II Error – the result o the study is said to not be statistically significant but in-reality is was
– Closely associated with the power of the study
– Power – ability to correctly reject a null hypothesis that is indeed false
– Higher powered studies are better when evaluating high risk and/or life-threatening stuff?
– SPin and SNout
– PPV and NPV
– Higher prevalence, higher PPV and Lower NPV
– memorize the chart
– Prevalence – total existing cases/total population
– Incidence – new (over a certain time period) cases / total population
– Precision vs Accuracy
– Probability – event of interest / total events measured
– Odds – event of interest / not event of interest
– Risk Ratio – probability of one group / probability of another group
– Odds Ratio – odds/odds
Confidence intervals -> crosses 1 -> no difference
– Meta-analyses and Systemic Reviews are the best type of evidence based medicine
– High bias = low validity

IVC POCUS Lecture
– POCUS is just one data point
– How to perform an IVC View
– Start with the traditional subxiphoid view and rotate the probe 90 degrees (indicate to the head if abdominal probe, indicator to the toes if cardiac probe)
– How to measure the IVC
– Don’t use M Mode – the least right way to perform this study
– Use B Mode
– Measure 2cm from IVC/RA junction or 1cm from IVC/hepatic vein junction
– Freeze the image, use cine mode to find the maximum and minimum of the images
– Caval Index – (max – min)/max x 100
– Note, if the patient is vented, the change collapse is reduced
– If IVC appears small/collapsible or plethoric, that is when this US is very useful
– Different commonly used terms for these findings:
– Volume Status – poorly defined term
– Volume Responsiveness – better defined term
– Volume Tolerance – “Can the RV handle it? Can the LV use it?
– Note – CVP does not equal volume responsiveness

“What in the Baby is Going on Here”
– Thrush – can present on most surfaces in the oropharynx – treat with oral nystatin and need to sterilize all bottles/nipples
– Periodic Breathing – differentiate from apnea – concerning characteristics – pauses 20+ seconds, cyanosis, increased web – normal, resolves around 6 months of age
– Jaundice – breast fed vs formula fed? stool transitioned? birth weight? term vs preterm? any siblings needing phototherapy? ABO compatibility and/or other risk factors?
– Unconjugated Hyperbili – increased bilirubin production (hemolysis) vs decreased bilirubin clearance vs increased bilirubin circulation (breast mild jaundice) vs breast feeding jaundice (inadequate intake)
– Labs: total and diet bilirubin, CBC with Diff, reticent count, CMP, Coombs/DAT
– Start phototherapy and/or double up phototherapy
– Normal Saline bolus ( +encourage feeding if otherwise stable)
– Trend total bilirubin as an inpatient
– Neurotoxicity risk factors: GA < 38, albumin <3, isoimmune hemolytic disease, sepsis, concerning symptoms within 24 hours
– Omphalitis – different from umbilical granuloma
– Management: CBCd, Blood Culture
– Treatment: Admit for IV antibiotics: Vanc and Pip/Tazo
– Febrile Neonate
– CBC, CMP, CRP, Procal, Blood Culture, POC Glucose, UA with UCx, HSV Swabs, Lumbar Puncture for CSF Studies
– Treatment: IV Antibiotics and possibly antivirals (Ceftaz, Amp, Acyclovir)
– Hypothermic Neonate
– No clear consensus on management/workup at this time
– 96.5F is the partial consensus, WHO definition is <36.5C (97.7F)
– Bundling/skin-to-skin contact
– If well-appearing, try re-warming, if failed, then start a septic workup
– If ill-appearing, full septic workup and IV antibiotics
– Lethargy
– Ingestion, too, hypoglycemia, seizure, meningitis, sepsis, NAT/Head Trauma, intussusception, inborn error of metabolism, congenital adrenal hyperplasia, cardiac etiology

Opioid Use and ALTO Therapy
– Every week of opioids prescribed corresponds with an additional 20% increased risk of overdose and/or misuse
– Kentucky SOS (Statewide Opioid Stewardship)
– Reduce opioid prescribing by reducing opioid use
– ALTO – Alternatives To Opioid
– 600mg Ibuprofen and 1000mg Acetaminophen does the world good
– Toradol 15mg IV/IM has similar analgesia without additional side effects seen with higher doses
– IV Lidocaine 1.5mg/kg over 15 minutes (max 200mg) – use extremely cautiously due to side effects
– Do not use if pregnant, seizure history, severe cardiac disease, history of arrhythmia
– Ketamine 0.15mg/kg (max 20mg) over at least 5 minutes
– Magnesium 15mg/kg (approximately 1-2grams) over 15 minutes
– New Renal Colic PowerPlan has been created – ED Renal Colic PowerPlan
– Naproxen 500mg BID as a discharge med is probably the best NSAID for patients with complex cardiac histories

Campus Health Counseling 101
– Services are free, confidential, and do NOT impact your student/resident records
– Clinical services, couples counseling, psychiatric services, crisis services, case management and referrals
– Can call 502-852-6446 Campus Health to schedule an appointment – M-F 8-1630
– Currently there are two licensed counsellors but they are hoping to expand to four licensed counsellors shortly

Lightning Lecture – Necrotizing Fasciitis
– Fournier’s Gangrene – polymicrobial, associated with T2DM, if on SGLT2 inhibitor they are at higher risk
– If have any suspicion at all, consult surgery immediately
– Use broad spectrum ABx – vancomycin + Meropenum or Zosyn + Clindamycin
– Additional Therapies: IVF, Tdap booster, pRBCs if needed
– Hyperbarics and/or IVIG is controversial
– Factors that increase mortality – WBC>30000, Creatinine >2, Age >60, TSSS, Clostridial infection, Delay in surgery >24 hours

Lightning Lecture – Skin Cancers
– Basal Cell Carcinoma is the most common type and it is the least aggressive form
– Rarely metastasizes
– White skinned people are the most affected
– More common in older individuals and men
– Biggest risk factor is exposure to UV light, possibly more important in childhood years
– Nodular BCC is the most common type
– If noted in the ED, referred to dermatology
– Cutaneous Squamous Cell Carcinoma
– More malignant
– Affects white individuals more
– Same risk factors
– Cutaneous SCC in situ (Bowen’s Disease) is erythematous, well-demarcated scaly plaque
– Diagnosis based on skin exam and biopsy
– IF seen in the ED, refer to Dermatology
– Melanoma
– 5th most common cancer in men and women in the US
– Survival depends on when it is diagnosed
– ABCDE criteria
– Management – refer to dermatology
– LDH levels can be elevated if metastatic
– Most common site of mets = LN, skin, lung, liver, brain
– Karposi Sarcoma
– AIDS-defining illness
– Vascular tumor associated with HHV8
– Typically develops in those with CD4 counts less than 200
– Corticosteroid use increases the risk for development of KS undergoing organ transplant or those with lymph-proliferative disorders
– If noted in the ED, bigger concern is significant immunocompromised state

Discussion of Burn/Wound Care Dressings
– Adaptic – vaseline impregnated gauze – applied after a topical ointment
– Cuticerin is the same as adaptic but it is typically larger – impregnanted with aqua-phor
– Vaseline Gauze – larger sizes, impregnanted with more vaseline than adaptic
– Mepilex can be used for up to 7 days technically – silicone based dressing – great simple dressing for a smaller burn wound
– SSD is a sulfa drug and is oculo-toxic so it is not recommended for for face and/or hands, bacitracin is typically a safe option

Caustics Lecture
– Caustic = any xenobiotic that causes functional and histologic tissue damage
– Kids are more likely to be damaged with ingestions due to smaller areas of mucosa, so burns are relatively larger to body area
– Ophthalmic Exposure
– Irrigate, irrigate, irrigate
– Morgan lens vs taping a cut IV near the eyelids
– No intervention really reduces injury from a caustic ingestion
– Some evidence that steroids may help reduce GI strictures down the line but evidence is flimsy but may also harm
– Do not neutralize acids with a base due to exothermic reaction
– Prophylatic ABx is not warranted
– When to scope for ingestion – early but not too early
– <12 hours may be too quick for tissue injury to fully demarcate
– >72 hours may be too late because tissue is weakest at this time and iatrogenic injury is more likely
– The presence of oral injury does not correlate/indicate the degree of mucosal involvement further along in the GI tract
– If evidence of perforation – don’t call GI, call cardiothoracic surgery and/or general surgery
– Persistence of symptoms, intentional ingestions should normally be scoped
– If a kid with unintentional ingestion looks good, is tolerating po intake, and is observed for a few hours, can go home
– Hydrofluoric Acid is bad
– Systemically – drops concentration of calcium significantly – time of onset is inversely related to concentration
– Higher concentration is quicker
– Greater than 50% concentration will likely cause immediate injury
– Give calcium and magnesium as quickly as possible
– Place a central line for calcium chloride rather than gluconate
– Keep giving calcium until vtach and/or vfib resolves
– Start calcium and mag immediately
– Can reduce dermal absorption with calcium gluconate gel – if no gel, then can grind up tums in aquaphor and/or bacitracin
– If a hand, fill a glove with this calcium gel

PALS vs ACLS Lecture
– When to pick which one? if over 50 kilos, typically use adult dosing
– PALS – Bradycardia Pathway
– Causes – hypothermia, hypoxia, and/or medications
– Treatment – oxygenation, epinephrine, atropine
– Start CPR is HR is less than 60bpm in neonates/infants
– Young kids are heart rate dependent, cannot compensate as well
– Atropine max dose is reduced in PALS vs ACLS
– Weight Based dosing with adenosine (up to 6mg, 12mg, and/or possibly 18mg)
– Procainimide and/or amiodarone are also options for SVT as well
– PALS – pulseless arrhythmia – epi + shock
– 5mg/kg of Amiodarone for pediatric patients but no clear max per PALS algorithm
– Endotracheal epinephrine (max 2.5mg) due to lower rate of absorption – followed by 3-5 puffs of positive pressure ventilation
– Asystole/PEA pathway is the same
– Give Epi after a pulse check if it is due around time of pulse check for maximum effect
– Rapid Sequence Intubation
– Pre-mediation
– Atropine – children under the age of 1 year of age to prevent bradycardia
– Max dose of 0.5mg in child, 1mg in adolescent
– Dose is 0.02mg/kg
– Lidocaine – controversial and falling out of favor
– Dose is 1mg/kg
– Max dose is 100mg
– Adverse effects are bradycardia and hypotension so may be more harm than good
– Pain/Sedation Medications
– Midazolam – Gaba agonist
– Dose 0.1mg/kg
– Fentanyl – Mu opioid receptor
– Dose 1mcg/kg
– Max dose is 100mcg
– High Dose therapy is 5mcg/kg
– Should be given slowly over 2-5 minutes to prevent chest wall rigidity
– Ketamine
– Dose 0.5-3mg/kg – usually 2mg/kg for intubation
– Possible increase in ICP but more likely increases CCP rather than ICP
– Causes a lot of secretions when given to younger individuals
– No data in those less than 3 months of age
– Etomidate
– stimulates GABA receptors to block neuroexcitation
– Dose 0.2 – 0.6mg/kg – max dose 20mg
– Does cause some adrenal suppresion, so not perfect in those with sepsis
– Propofol
– GABA agonism and decreased glutamatergic activity via NMDA receptor blockade
– Rocuconium
– non-depolarizing blocker
– Dose 1mg/kg
– Half-life of 30-45 minutes
– Succinylcholine
– depolarizing neuromuscular blocker
– Dose 1-2 mg/kg (max 200mg)
– Increased ICP

Cocaine Lecture
– Amphetamines push out more neurotransmitters whereas cocaine blocks re-uptake
– Functions as a norepinephrine re-uptake blocker
– The only local anesthetic agent that is also a vasoconstrictor
– Cocaine can cause a brief transient bradycardia secondary to stimulation of the vagal nuclei followed by a quick tachycardia
– Microwave cocaine + baking powder = crack cocaine which can now be smoked
– Cocaine effects – persistent rhinitis, intra-nasal erosions, epistaxis, crack eye (ulceration from crack smoke)
– Increases body temperature – hyperthermia not a fever – worsened by psychomotor agitation and vasoconstriction at the skin
– Elevated core body temperature is directly linked to mortality
– Can develop seizures from cocaine – sympathomimetic effect and sodium blocking effect (same at TCAs)
– Cocaine increased risk of strokes, myocardial infarction (risk >24x in the hour after ingestion)
– Cocaine affects gestational birth weight, fetal growth, and the likelihood of a term delivery
– Also increases the risks of abruption, spontaneous abortions, and IUGR
– No real decon strategies for people with traditional use
– Decon strategy for a packer/stuffer – whole bowel irrigation to help move the packets along
– Do not use if any evidence of gut wall ischemia is present as this could lead to perforation
– If a packer has evidence of ruptured packet, needs to go to the OR stat
– No role for dantrolene if a patient is hyperthermic from cocaine overdose
– Start cooling around 105, stop around 101