Heparin à no renal metabolism (helpful in patients with renal failure)
Thrombocytopenia, HIT, heparin resistance, hyperkalemia from aldosterone suppression
Half-life 30-60 minutes, immediate onset
IV administration for VTE, must be administered inpatient
Careful monitoring required
Enoxaparin (Lovenox, LMWH)
Derived from heparin
3-5 hour onset, no monitoring required, patients may self-administer
Similar outcomes compared to heparin with regards to recurrent VTEs, some data suggest lower bleeding risk
Renal clearance, avoid in renal dysfunction
Similar precautions as heparin
Lower incidence of HIT, but still contraindicated in patients with HIT
Subcutaneous dose for VTE
Apixaban (Eliquis)
Factor Xa inhibitor
Half-life 9-14 hours, BID dosing
Renal clearance, caution in renal insufficiency
Rivaroxaban (Xarelto)
Factor Xa inhibitor
Half-life 5-19 hours, daily dosing
Must be taken with food to be effective
Renal clearance, caution in renal insufficiency
Dabigatran (Pradaxa)
Direct thrombin inhibitor
Half-life 12-14 hours
VTE dosing after 5 days of bridging, BID dosing
2020 AHS Guidelines on Management of VTE suggests using DOACs over Warfarin
Does not apply to all patients
AMPLIFY à Eliquis non-inferior to standard therapy (Warfarin, LMWH), less bleeding complications
EINSTEIN DVT/PE à Xarelto non-inferior to standard therapy
Does not recommend one DOAC vs. another, recommend using patient specific factors to guide clinical decision making
Recommends home treatment for patients with uncomplicated DVT
2020 AHS guidelines recommend considering home treatment for patients with low-risk PE (PESI Score risk stratification), conditional recommendation
Extremely important to counsel patients when being discharged on these high-risk medications, ensue follow-up and understanding of risks and return precautions
Pneumomediastinum (Dr. Alia)
Presence of free air in the mediastinum
Spontaneous (idiopathic, tobacco use, recreational drug use) vs. secondary (i.e. traumatic, iatrogenic) etiologies
30% have normal chest x-rays à CT Chest is preferred diagnostic modality
“Continuous diaphragm sign” on XR
Management:
Treat underlying cause
Supportive care à typically resolves spontaneously in 1-2 weeks
Disposition:
Primary à discharge with PCP follow-up
Secondary à management of underlying cause, typically will require admission
Lung Abscess, Parapneumonic Effusion, Empyema or (Dr. Edwards)
Typically polymicrobial, affected tissue at risk for necrosis and cavitation
Diagnosed via CXR vs. CT Chest (also recommended following XR diagnosis)
Ultrasound helpful for evaluation of effusions and for procedure guidance
Obtain blood and sputum cultures (blood cultures frequently negative in empyema)
Treatment à empiric antibiotics with anaerobic coverage
Empyema, effusions require drainage
VATS for complicated effusions and empyema
Thoracentesis provides definitive diagnosis for empyema (distinguishes between effusion and empyema) à body fluid cultures and diagnostics must be obtained
Pneumonia for EM Residents (Dr. Eisenstat)
CAP à everything not HAP or VAP
HAP à >48 hours from time of admission, previous admission within 90 days
Cover for pseudomonas and MRSA
VAP à >48 of intubation time, recent previous intubation
Cover for pseudomonas and MRSA
Therapy tailored based on sensitivities and culture results
Normal vital signs and normal respiratory examination have good negative predictive value in most patients
Procalcitonin à good predictor of blood culture positivity
Hypoglycemia, lactate à predictors of 28-30 day mortality
2-view chest XR recommended
Flu test patients with CAP during flu season
Give antibiotics to all patients clinically suspected to have CAP regardless of procalcitonin
Clinical judgement + decision tool is best (PSI > CURB-65)
Healthy, outpatient à amoxicillin vs. doxycycline vs. macrolide (if local resistance is <25%)
Comorbidities, outpatient à Augmentin vs. cephalosporin (cefpodoxime, cefuroxime) AND macrolide vs. doxycycline
Monotherapy with respiratory fluoroquinolone also acceptable, but consider risk factors
Inpatient treatment of CAP in adults without risk factors for MRSA or Pseudomonas
Combination therapy with Beta-lactam + macrolide or doxycycline
Coverage of anaerobic pathogens not necessary in admitted patients who are suspected to have aspiration PNA
Inpatient treatment of patients with risk factors for MRSA and Pseudomonas à vancomycin or linezolid for MRSA, Zosyn/cefepime/meropenem for Pseudomonas
Corticosteroids are unnecessary unless used in patients persistently hypotensive despite IVF and vasopressors (i.e. surviving sepsis guidelines) but evidence is not conclusive
Give Tamiflu to patients with CPA who test positive for flu (regardless of inpatient vs. outpatient or duration of symptoms), give antibiotics regardless of flu positivity
Antibiotic treatment duration for outpatient treatment of CAP à 5-7 days
No follow-up CXR necessary in adults who are improving following treatment
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