Lightning Lecture – Syphilis by Landon Pehle

• Treponema pallidum
• “The Great Imitator”
• Stages
  • Primary – painless chancre
  • Secondary – rash, lymphadenophty, condyloma lata
  • Tertiary – meningitis, aortitis, aneurysms, argyll robertson pupil
  • Congenital syphilis 
• Testing
  • PRP/VDRL (1st line screening)
  • FTA-ABS (specific testing)
  • Darkfield microscopy
• USPSTF recommends screening in high risk groups
• LP in neurologic, ocular, latent syphilis, HIV coinfection
• Treatment
  • Penicillin G
    • Jarisch-Herxheiner reaction
    • Desensitization

Lightning Lecture – Botulism by Madison Wilson

• Clostridium botulinum
  • Spores
  • Found in soil, water
  • Anareobic
• DDX for MG, GBS, tick paralysis, hypothyroid
  • Botulism with no CNS effects
• Workup
  • Neutralization assay is gold standard
  • CT head
  • Basic lab work
  • LP
• CDC algorithm for initiating treatment
  • Equine derived antitoxin
• Admit to ICU
  • Airway watch, NG tube, foley catheter
  • Recovery is slow
• Infantile botulism
  • pH is higher in GI tract, easier for spores to colonize and release in large intestine
  • Flaccid paralysis, loss of head control, respiratory failure, loss of reflexes
  • Human based botulism IG
• Wound botulism
  • In vivo toxin 
  • Treat with debridement, penicillin, and antitoxin
• Inhalation botulism
  • Aerosol for bioterrorism

Infectious Recommendations from Pharmacy – Dr. Hannah Moore

• Sepsis
  • 30CC/kilo fluids
  • Empiric antibiotic therapy
    • Assess risk factors
    • Previous + micro
      • Previous resistance?
    • MRSA – Vanc (IV), Doxy (PO)
    • Pseudomonas – Zosyn (IV), Cefepime (IV), Cipro/Levaquin (PO)
  • Bacterial meningitis
    • S pneumo, N meningitides, listeria, GBS, H influenza, HSV, VZV
    • CSF findings – bacterial vs viral vs fungal
    • Empiric therapy
      • Ceftriaxone, vanc, ampicillin, acyclovir
    • Steroids
      • Early treatment with decadron improvs outcomes wacute bacterial meningitis 
      • 10mg Q6
  • Bacterial PNA
    • S pneumo, N meningitides, listeria, GBS, H influenza, mycoplasma, chlamydia
    • Outpatient therapy
      • No comorbidities – amoxicillin or doxy, or macrolide
      • Comorbities – augmentin or cephalosporin and macrolide or doxy or respiratory fluoroquinolone
    • Inpatient therapy
      • Non severe vs severe
        • See IDSA guidelines, multiple therapy options given patients history, severity
  • Intraabdominal infections
    • Classifications – uncomplicated vs complicated
    • E coli, proteus, bacteroids, kleibsiella, bacteroides
    • Empiric therapy
      • Based on severity (mild to high risk)
        • See IDSA guidelines, usually recommending combination therapy with flagyl
  • UTI
    • Classifications – uncomplicated vs complicated
    • Asymptomatic bacteriuria
      • Treat pregnant women, patient undergoing urologic procedures, patient with kidney transplant w/n 3 months
    • E coli, klebsiella, proteus, pseudomonas, enterococcus, staph, enterobacter
    • Empiric therapy
      • See IDSA guidelines
  • Skin/soft tissue infections
    • Staph, strep, clostridial, aeromonas
    • See IDSA guidelines
  • Hypersensitivty reactions
    • Type 1 – IgE, anaphylaxis
    • Type 4 – T cell mediated, SJS/TEN
    • Penicillin desensitization in the ED

Sepsis – Dr Hugh Shoff

• Hospital scoring
• Patient safety measures and trends

Infective endocarditis – Dr Jarred Thomas

• Most common site of infection – tricuspid valve
• Most common bacteria – S aureus
• Highest risk factor – previous IE
• Average age of infection is now increasing
  • Current high risk: MRSA, prosthetic valves, ESRD, IV drug use
• Acute vs subacute
• Systemic issues from IE based on left vs right side infection
• Blood cultures
  • Ideally three sets as well as fungal culture
  • Do not obtain from port site
• Treatment
  • Abx
  • Surgery
• Valvular conditions that needs PPX as established by AHA 2021 Guidelines

Beef with the Chiefs

Systemic infections – Dr Robin Lund

• Rocky mountain spotted fever
  • Highest mortality in children, males, most common in Midwest
  • Treatment – doxycycline
• Kawasaki Disease
  • CRASH symptoms
  • Kawasaki Disease Shock Syndrome
  • Treatment – IVIG, ASA
  • KD vs MISC
    • MISC more GI symptoms, usually older kids, higher inflammatory markers
• Meningits
  • Most likely in neonates – GBS
  • Most likely in other peds – Strep pneumo
  • Classic signs/symptoms
    • HA, fever, AMS, paradoxical irritability
  • Cannot exclude meningitis based on labs, CSF
  • Treatment – Abx, steroids
• Osteoarticular infections
  • Septic arthritis
    • More common in males, < 20 yo
    • Typically hematogenous spread
    • Erythema, edema, tenderness
  • Acute hematogenous osteomyelitis
    • More commonly in metaphysis
  • Typical pathogens – Staph, GABHS, S pneumo
  • Workup – Joint tap, blood cultures
  • Treatment – Abx

Acetaminophen Toxicity – Justin Arnold

• Acetaminophen in multiple combination drugs
• Adult dosing
  • Immediate release 325mg
  • Extra strength 500mg
  • Arthritis 650mg
  • Max 4g/day, 2.5g/day in liver failure patients
• MOA: don’t really know
  • Inhibition of COX, PGs
  • Reduction in pain signaling
• Single toxic dose – in a 24 hour period
  • Adults: 7.5g
  • Pediatrics: 150mg/kg
• 4 stages of toxicity
  • Stage 1 – Asx/mild symptoms (day 1)
  • Stage 2 – Liver toxicity (day 2,3)
  • Stage 3 – Liver failure (day 3,4)
  • Stage 4 – Recovery (day 4-10)
• Treatment – NAC
  • Goal to administer within 8 hours of ingestion
  • Possible anaphylactoid reactions
    • Most likely during 1 hour load
    • Treat as you would with anaphylaxis
    • Start again at half the rate
• Diagnosis
  • Need a tylenol level on every ingestion patient
  • Rumack-Matthew Nomogram
  • King’s College Criteria for prognosis/transplant need

Wellness Day 

• Wellness rotation and fellowship – Reach out to Dr Huecker and Dr Dennison if any questions

Lightning Lecture – Tuberculosis by Hannah Hudson-Knapp

• ⅓ world population infected
  • Special populations – pediatric, AIDS patients, 
• Infection types – Primary, latent, reactivation, miliary
• Evaluate with: Tuberculin skin test (PPD) -> PCR Sputum Assay (gold standard), IGRA, Acid-Fast stain
• Management
  • RIPE therapy
  • Modifications with pregnancy (RIE therapy)
  • Vit B6 prescribed with isoniazid (to decrease seizure risk)
• New vaccines currently in clinical trial
• Disposition
  • Admit
  • Louisvilleky.gov for health department information on patient cases

Lightning Lecture – Tetanus by Jonathan Mattingly

• Mortality rate 45%
• Clinical features
  • Type: Neonatal, local, generalized, cephalic
  • Grade I-IV presentations
  • Timeline: Incubation, acute, and convalescent phases
  • + Spatula test
  • Wound cultures often negative
• Management
  • TIG  directly into wound and IM, metronidazole or clindamycin

Teaching Strategies – Feedback Models by Matt Lyons

• One minute preceptor
  • Get a commitment
  • Probe for supporting evidence
  • Teach a brief principle
  • Reinforce what was done right
  • Correct errors
• Pendleton model
  • Ask, tell, ask, tell

Question Review – Metabolic, Nutrition, Endocrine by Nicole Harris

R2 Pathway – Sepsis by Makayla Campbell and Olivia Stanforth

• Sepsis definition – Life threatening organ dysfunction caused by dysregulated host response to infection
• Surviving sepsis Guidelines (2024)
  • Hour 1 Bundle: Lactic, blood cultures, broad spectrum abx, fluids, vasopressors (if needed)
    • Studies show benefit with LR vs NS
      • Special considerations – managing fluids in heart failure, cirrhotic patients
    • “Broad spectrum” antibiotics initiation = improvement in mortality
      • Special consideration – kidney injury (renally dosing abx)
    • Vasopressors
      • Norepinephrine first line, vasopressin second line/add on if needed
  • Special populations: Neutropenic fever, transplant recipients
• Refer to updated Sepsis Pathway on Room Niner

Image Review – by Dr Kahra Nix, Dr Jeff Baker, Dr Alex Bequer

• POCUS during cardiac arrest
  • CAN increase length of pulse checks, CAN decrease in hospital mortality
  • Use POCUS in PEA/asystole, also use after ROSC
    • Record clip 
    • 3 questions: Is there tamponade, RV strain, or cardiac activity? 
    • Do not delay for shocks
  • Can assess peripheral veins for DVT if concerned for PE

McGowan – Teaching series

Scaffolding – 

• Establish a baseline (Know your audience)
• Cues
• Leading qs vs reflective
• Breakdown tasks

Ex ) 

• SOAP notes
• ACGME milestones
• Certifying exam checklist
• Procedural skill learning
• Sim
• OSCE
• SLOE

• Consider graphic organizers for ddx
  • Gridded Charts
  • Flow charts 
  • Worksheets 

Final thoughts

• Assess learners baseline
  • Adjust level of intervention based on thiss

• Have clear objectives
• Short and sweet
• break down to smaller tasks
• Foster safe environment
• Failing is ok if you learn from it

Coffman – Question

Kelesis – RM9 Follow Up

27 F  w ho asthma, prior suicide attempt presents after unknown but large ingestion ibuprofen

• 5 large bottles 200mg ibuprofen empty

VBG 7.3/33.5/82/-9.5

CHEM8 139/3.6/108/143/1.14

Lactic 5.0

Intubated for aspiration risk w prop fent

CXR ok

CT head ok

C/f for lactic acidosis (AGMA), bleed, kidney injury

Rpt gas w ph 7.1, lactic to 8.3, Gap 19

HD placed, admitted to MICU underwent HD, still admitted to 3N

Reversible binding COX1/2 -> depletion of thromboxane = bleed

Peak plasma concentration 1-2hrs

Activated charcoal within 2 hrs of ingestion can be considered

Davenport – Shock US

I – indications

A – acquisition

I – interpretation

M – MDM

Pump – heart squeeze, beating, effusion

Pipe – IVC – plump, collapsable

Problem

Cardiogenic shock

• LV dysfunction w PLAX, PSAX
• IVC – plethoric
• EPSS on PLAX
  • Line on mitral valve
  • Measure peak of valve to septum
  • >7 = poor LVEF
• Lungs
  • Needs to be 15cm to be considered B line
  • Consider turning off tissue harmonics for brighter B line
  • 3 B lines per view for dx

Obstructive

• Tamponade
  • Speed of accumulation important 
  • Mitral valve inflow integral
    • Doppler at mitral valve outflow on A4C
    • Measure tallest expiration wave to lowest expiration wave
    • >25% = pulsus paradoxus
  • Plethoric IVC
• PE
  • D sign on PSAX, bc higher pressure in R heart
  • Mcconnel sign on A4C, bc RV free wall hypokinetic
  • Tricuspid annular plane systolic excursion
    • M node on  A4C on tricuspid
      • Measure peak to valley <16-17 = acute heart strain
• Tension ptx
  • Plethoric ivc
  • Heart could be hyperdynamic, flattening of R heart
  • Lung slide
    • Can mmode for barcode sign
    • US more sensitive than CXR
  • Lung point

Hypovolemic

• Hyperdynamic echo
• FAST
• Aorta – measure outer to outer, anterior to anterior

Distributive 

• Hyperdynamic echo
• Flat IVC
• RUQ
  • Pericholecystic fluid
  • Anterior wall thickening in short access
    • <3mm normal
  • Sonographic murpheys
  • CBD
    • Measure inner to inner

VEXUS (on icu pts s/p open heart sx)

• Measurement on venous congestion
• Organ perfusion pressure
• Determine modality of tx
• Prevent AKI, HF, pulm edema, poor wound healing

IVC widest diameter in subcostal view, >2cm moveone, less thant 2 = noncongestion

Hepatic vein w indicator towards pt head, find vein entering IVC

• Doppler

Portal vein w indicator towards back

• Doppler

Renal vein

Compare waveforms and grade

• High grade = diuretics

Obrien – Pituitary

Sheehan – pituitary grows in pregnancy but not blood supply, vulnerable to hypotension

• Tx w hydrocortisone

Pituitary apoplexy 

• Tx w hydrocortisone to address ACTH deficiency

Acromegaly – excess GH from pituitary adenoma

• Dx w serum insulin like growth factor level

SIADH – 

• Tx hypona sz with hypertonic, consider amps of bicarb
  • Aim to correct 4-6 meq/L
  • Beware of cerebral edema
  • Avoid isotonic fluids – makes them worse cause they hold onto free water

Congenital hypopituitary

• Hypoglycemia, sex organ weirdness, jaundice, midline deficits
• Tx glucose and hydrocortisone

Optic chiasma – pituitary masses compress this 

• Bitemporal hemianopsia
• Little = endocrine issues
• Big = mass effect

Prolactinoma – most common pituitary tumor

• Tx cabergoline to inhibit prolactin release

Zach; Vitamins

B1 Thiamine

• Deficiency
  • Early Beriberi (wet – cardiac) (dry- muscle wasting)
  • Late Wernicke- Korsakoff 
• Malnutrition, AIDS, Alcoholics
• Tx, replete 

B2 Riboflavin

• Erythematous lesions, ulceration, mucositis
• Breast fed children, skim milk, pregnant women
• Tx, replete

B3 Niacin

• Pellagra
  • 4ds
    • Diarrhea, dermatitis, dementia, death
• Alcoholics, aids, IBD, malnutrition

B5 Pantothenic Acid

• Fatigue, headache, muscle weakness, nausea
• Usually deficient with another b vitamin

B6 Pyridoxine

• Dermatologic, dental changes
• Consequence of medicines
  • INH,  valproic acid, phenytoin, hydralazine, carbamazepine
• Also decreased renal function, autoimmune disease, inborn metabolic errors

B7 Biotin

• Dermatologic and neurologic manifestation
• In pregnant women, IBD, isotretinoin, long term antiepileptics 

B9 Folate

• Megaloblastic anemia, glossitis
• Don’t confuse w B12
  • Normal MMA, elevated homocysteine
  • Elevated in both for B12
• Deficiency, pregnancy, burns, alcoholics

B12 Cobalamin

• Megaloblastic anemia, SCD, neuropathic symptoms
• Old people, vegans, IBD

C

• Scurvy
• Corkscrew hair, gingival hemorrhage, petechiae
• Malnutrition, alcoholics, pirates

Caroline; Hypoglycemia

• <70
• Symptoms generally develop <50-55
• More common in T1DM vs T2DM
• Whipple’s triad
  • Do you have low glucose
  • Do you have symptoms from low glucose
  • Do you get better with glucose
• Mechanisms against hypoglycemia
  • Glycogenolysis, gluconeogenesis
• S/Sx
  • Adrenergic; anxiety, diaphoresis, hangry, tremor
  • Neuroglycopenic; lethargy, confusion, seizures, agitation
• Most commonly in diabetics, usually overcorrection
• Nondiabetics; malnourishment, drugs/alcohol, insulinoma, critical illness, adrenal insufficiency, hypopituitary
• Workup
  • POC glucose
• Tx
  • Sugar
  • Glucagon
• D50 vs D10
  • Risk of overshooting w D50
  • D50 and be caustic
• Refractory?
  • D10 drip
  • Consider octreotide
• Has insulin pump?
  • Don’t dc pump
  • Supportive treatment 
  • Contact manufacturer to troubleshoot
• Pediatric hypoglycemia
  • Often asymptomatic until seizure
  • New onset T1DM
  • Maternal dm in neonates
  • Medicine ingestion; bb, ethanol, sulfonylurea
  • Glucose bolus 2ml/kg D10

Lyvers; pediatric endocrine

Hypoglycemia

• Causes
  • Fatty oxidation disorder
  • Insulin mediated
  • Ketotic hypoglycemia
  • Disorder of gluconeogenesis
• Other
  • Ingestion
  • Munchausen

– Obtain critical sample during hypoglycemic <50 episode

– for metabolic disorders

Fatty oxidation

• Can crump quick when glycogen depleted
• Test carnitine

Insulin mediated

Ketotic hypoglycemia

• Glycogen storage disorders
• Hormone deficiency
  • hypopit
• Idiopathic (kids grow out of this by 6-8)

Disorders of gluconeogenesis

• Glactosemia
• Fructose disorders

Tx – Rule of 50

• D10 = 5ml/kg
• D50 = 1ml/kg
• Consider steroid
• Glucagon?
  • Only helps with insulin mediated diseases bc they need preexisting hepatic stores of glycogen

Hyperglycemia

• DKA
  • New onset
    • p/w weight loss, polyuria, polydipsia, vomiting
    • Look for kussmaul  breaths
  • Glucose >200
  • pH <7.3
  • Ketones
• Tx
  • Correct acidosis, dehydration, glucose
  • Fluid resuscitation
    • Aggressive
    • 10-20 cc/kg bolus LR or NS
    • Add potassium due to shifts intracellularly
      • <3.5 = bolus
      • Defer if >5.5
        
    • Inulin 0.05 – 0.1 ug/kg
• Complications
  • Cerebral edema
  • Avoid bicarb
  • Could be from hypoperfusion from dehydration
  • Usually develops first 12hrs
  • Tx, mannitol

Shaw; Acid Base

Look at pH (primary disorder) >  check for compensation 

Respiratory

Metabolic

Metabolic acidosis is usually complicated by compensation

Winters = paCO2 = 1.5 (HCO3) + 8 +- 2

Anion gap = Na – Cl – HCO3

NAGMA = GI vs renal bicarb loss 

• Body takes in chloride

MUDPILES

Excess anion gap

• If change in anion gap > change in bicarb then too much bicarb = less acidotic
• AG – 12 + serum bicarb
  • >30  = 
  • <30 = underlying NAGMA (too  much Cl)

Use base deficit to predict resuscitation goals

VBG for people that don’t need exact pCO2, pulse ox accurate

ABG for people in shock

R acidosis – minute ventilation

R alkalosis – treat underlying cause

M alk – stop offending agent, consider CA inhibitor

M acidosis – treat underlying cause

Bicarb- need control or respirations to make sure co2 is blown off

• Otherwise benefits are primarily from Na and fluid replacemen t
• Na blocker overdose

Thomas; DKA/AKA

Gluconeogenesis/ glycogenolysis not as efficient glycolysis

Gluconeo breaks down fats and proteins

• Fat breakdown = ketones
• Happens in the liver primarily

Glyco

• No ketones
• Happens in muscle and liver

T1DM no insulin production

T2DM insulin resistance

Insulin = store

Glucagon = burn

T1DM more likely to have DKA

AKA

Wide gap acidosis in chronic drinkers

• Following a binge
• Abrupt stoppage of drinking prior to ED

Due to shift of carb metab due to malnutrition

Alcohol w no glucose

• Fasting state = glucagon secretion > gluconeogenesis (mainly lipolysis)
  • If functioning liver

S/Sx 

• N/V/abd pain
• Tachycardic, tachypnea

Labs 

• Etoh often negative
• Anion gap
• Usually w LFT abnormality

Does not need to be acidotic 

• 15% normal ph
  • compensation

Padget

Alcoholic ketoacidosis

Presents; n, v, dehydration, ams

Suspect in poor po + alcoholism

Alcohol increases NADH/NAD+ = higher ketones and lactic acidosis

• Malnutrition presents compensation
• p/w other metabolic derangements

Dx overlaps to some degree w starvation ketosis, DKA

• Correlate clinically

Tx

• Thiamine  (WK)
• Fluids
• D5LR preferred, thiamine before
• Can treat glucose >250 w insulin
• Supportive care otherwise
• Beware CIWA

If lactic >4 something else going on

Disposition; resolution in symptoms, acidosis = home

Rizzo; small group 

Case 1 – HyperK

• Ddx; medicines, renal disease, diet, rhabdo

• Ekg changes, spectrum, peaked t wave – prolonged qrs – sinusoidal 
• Tx, insulin, glucose, Ca, lasiks, albuterol, fluids, dialysis
  • Ca
    • Gluconate through PIV
    • Chloride in codes, central lines
  • Dialysis
    • K refractory to treatments

Case 2 – HypoK

• Ekg changes – U waves
• Ddx; diet, DM, GI loss, medicines
• Tx;
  • Mg, repletion
  • K repletion
    • 10meq = .1 increase

Case 3 – HypoNa

• Ddx; Polydipsia, SIADH, polypharm, CKD, aldosterone deficiency

• Tx; Replete w hypertonic 150mg / 10-20min
  • Can use x2-3 amps bicarb 
• <120 = ICU
• Don’t correct too quickly

Case 4 – HyperCa

• Ddx; exogenous, PTH, genetic disorder, bone resorption, addison, pagets, malignancy, polypharm
• Tx; Fluids, supportive, Ca binders, bisphos, dialysis
• EKG changes = osborne J wave, shortened QT

Case 5 – HypoMg

• Ddx; malnutrition, alcohol, gi loss, renal loss
• Ekg changes – prolonged qtc, risk for ventricular arrhythmia
• Tx; replete
  • Beware of rapid infusion – respiratory depression, hyporeflexia, hypotension

Ross; Small group

Case 1 – thyroid storms

• Precipitant; trauma, infection, contrast, medicines
• Burch and Wartofsky score to sound smart to endocrinology 

• Tx
  • Ptu vs methimazole (avoid in 1st trimester pregnancy)
  • Propranolol vs esmolol (beta selective)
  • Iodine, can substitute Li if allergic
  • Steroid
  • Cholestyramine
• Avoid, amio, asa

Hashimoto – low thyroid

Exogenous – dont need ptu, methimazole

Case 2 – HTN emergency (pheo)

• Ddx; pheochromocytoma, substance use, idiopathic, kidney disease, carcinoid, angina
• If pheo/cocaine avoid beta blockade
• Plasma metanephrines for pheo, urine catacholamines
• Tx;
  • Phentolamine
  • Oral doxazosin if stable
  • Cardine
  • Nitroprusside
• Imaging – CT scan w adrenal protocol
• Associated w MEN2, neurofibromatosis, von hippel lindau
• Reglan, TCA, steroids can exacerbate
• Common sx; palpitation, diaphoresis, HA

Case 3 – Myxedema coma

• Ddx; hypothermia, sepsis, chf, trauma, renal
• Tx;
  • Levothyroxine, consider T3 too (if TSH> 10)
    • T4 preferred in old people, significant CAD
  • Hydrocortisone if c/f concomitant adrenal insufficiency
  • Passive rewarm
  • Beware of pericardial effusion – low voltage ekg
    • Get an echo

Bequer/Baker; US

Fascia Iliaca Block

Blocks femoral/obturator/lateral cutaneous nerves

Indications 

•  femoral head/neck/trochanter fractures
• Anterior thigh lac/abscess

Careful on anticoagulated pts

Ropivicaine/bupivicaine preferred (longer acting)

Use linear probe

2 person procedure

• X2 syringe
• Threeway stopcock

Enter laterally between fascial planes