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