All,
In case you haven’t heard, we’re in the midst of a Hepatitis A outbreak in Louisville (there’s been much larger ones elsewhere, including San Diego). I apologize if this is a long post and will try to keep organized but want to get this out sooner rather than later. Some things I think you should know:

• It’s transmitted via the fecal-oral route (hence why food handlers with HepA should not be working)
• High risk patients include Homeless patients, IV drug users, and Men who have sex with men (so a big portion of our patients)
• Consider Hepatitis in patients with: Fever, malaise, N/V/D, abdominal pain + either jaundice or elevated AST or ALT.
• It requires reporting to the Health Dept
• Patients should be placed in contact/enteric isolation (similar to C. Diff).
• Hands must be washed with soap and water (hand sanitizer isn’t good enough)!
• Rooms must be cleaned by EVS with Bleach. Please clean your stethoscopes as well.
• The incidence of fulminant hepatic failure is <1% (it’s higher in those with liver disease and with concomitant Hep B or C)
• Treatment is generally supportive, with hydration and electrolyte replacement as needed. Infection with Hepatitis A generally leads to immunity, thus do not need to vaccinate those with a diagnosis of Acute Hepatitis A.
• Patients are contagious until ~1 week after appearance of jaundice
• Patients and family members should be counseled on the route of transmission and should receive a dose of the Hepatitis A Vaccine (they can be directed to the Louisville Metro Dept of Public Health and Wellness at 400 E. Gray St.)
• There is no chronic Hep A State.
• The Acute Hepatitis Panel checks for HAV IgM, HepB Core Antibody, IgM, HepB Surface Antigen, and Hepatitis C antibody (thus can tell you if Acute A, and maybe B, but not whether Hep C is acute or chronic). You can order the specific Hep A IgM in Cerner, though it’s probably good to know whether B or C is present also.
• Those with Altered sensorium, INR > 1.5, a PT > 5 seconds above normal or with concomitant illnesses may require admission.
•  One of the recommendations is to administer the vaccine to our at risk populations, but PLEASE wait on this until I have further info on our stock/supply of the vaccine.
• The attached PDF has a questionnaire that the health dept is requesting be filled out and sent to them in order to reduce the spread of HAV, so please be aware of it and remind the nursing staff to try to get it filled out. If they’re unsure about it discuss with charge nurse to get the form.

Sorry this is so long but hope this helps. For any issues just email me and I’ll try to sort it out.

*See the attached PDF for information from the Health Dept/ULH. as well as the CDC link on Hepatitis A

Hep A Provider Recommendations 12.2017

https://www.cdc.gov/hepatitis/hav/havfaq.htm

Hey Everybody,
Not sure if you’ve heard of the Emergency Medicine Cases blog (it’s good), but they have a “Just the Nuggets” segment that they will email you and covers a wide range of topics but summarizes them down to the most important aspects of different illnesses (current segment is on GI Bleeds). Just thought I’d share the link for you to check out and decide if you’d want to subscribe to it (I have no ties to the blog).

New EM Cases Feature: Just The Nuggets

Great Blog Posts reviewing LVAD & its complications/management.

Left Ventricular Assist Device

https://lifeinthefastlane.com/ccc/ventricular-assist-device/

Blog Post on REBOA from Life in the Fast Lane:
https://lifeinthefastlane.com/ccc/resuscitative-endovascular-balloon-occlusion-aorta-reboa/

Attached is Dr. Steve Smith’s article for his Equation for Subtle LAD STEMI.

Subtle Stemi- Stephen Smith 2010

Currently, we are using approximately 20 bags/day and at this rate, we have estimated a 14-17 day supply. At this time, please follow the recommendations listed below. We would like to avoid restricting this medication while on shortage. However, a restriction to dedicate remaining supply may be necessary and released as early as mid-next week. The Pharmacy Team is looking at all purchasing options each day. We are buying allocations when they are available and avoiding loaning our current supply.

Please work with your team to facilitate the below options. Please also be aware that, at this time, there is no automatic medication switches or discontinuations. All actions need to be approved with team, except for automatic IV to PO conversions meeting criteria.
PLAN:
Share shortage news with your teams
Be extra diligent with IV to PO/per tube conversions (po metronidazole is available at this time) – Please make this a high priority!
Discontinue unnecessary IV metronidazole and/or duplicate anaerobic coverage
Consider alternative IV anaerobic coverage agents, if needed (examples below – some helpful suggestions)
Anaerobic coverage (non-CNS): IV clindamycin **Reminder: Clindamycin does not penetrate CNS like metronidazole
Hospital acquired infection needing anaerobic coverage (non-CNS): Piperacillin/tazobactam, cefepime + clindamycin
Non-Pseudomonas risk infection needing anaerobic coverage (non-CNS): Ampicillin/sulbactam, cefoxitin, ceftriaxone + clindamycin, fluoroquinolone + clindamycin
Clostridium difficile: PO vancomycin
Please try to reserve IV metronidazole to those with:
CNS abscess
Clostridium difficile treatment in patients with high risk/no gut absorption requiring IV
We would like to avoid using carbapenems, but they are alternatives if the shortage worsens
Contact the ID Pharmacist or ID Team with any questions on substitution or alternatives

Details known on shortage:
Reason for the shortage: Manufacturer delays
Estimated resupply dates: BBraun and Claris are unable to estimate a release date; Pfizer estimates some additional allocation mid-September (not guaranteed)

All,
On the line of anticoagulation, if you are wishing to send a patient out on Rivaroxaban (Xarelto) or Apixaban (Eliquis), on their website they (or you) can have a card downloaded and printed that can get their first 30 days free. It does require filling out some basic demographic info so you’d have to go through that with the patient.

So if there are any financial/timing issues, this may be an option. Keep in mind that may not fix any financial issues a month later, but could allow them enough time to get that sorted out.

Quick Price Comparison from GoodRx (without these cards):
Cost of 30d of Coumadin (plus ~5d of Lovenox to start): $40-$60 (Coumadin alone for 30d is $4-$10)
Cost of 21d Starter Pack of 15mg Rivaroxaban: $564
Cost of ~28d of Apixaban: $477
Cost of 30d of Lovenox 80mg: $285

https://www.xarelto-us.com/carepath/savings-program
https://www.eliquis.bmscustomerconnect.com/afib/savings-and-support#copaynew

Hope this helps.

All,
Good 3-5 min read on something I think we see a decent amount of. Keep these points in mind when you’re managing your next patient with Hyperkalemia.

https://www.aliem.com/2015/04/hyperkalemia-management-preventing-hypoglycemia-from-insulin/

Follow up from ENT lecture this morning, see algorithms below.

As promised,
Several links with videos on the process of fiberoptic as well as topicalization. Lots of variations on strategies here, some of which of course are really more applicable for awake Anesthesia patients and may not fit our population but definitely helpful.
The Life in the Fast Lane has a good written summary as well. Hope these help. Email or talk with me for questions!

Good video of topicalization process for awake nasal and oral

Dr. Gallagher discussing the gist of fiberoptic intubation

Rich Levitan’s Video of Fiberoptic Intubation

https://www.youtube.com/watch?v=rljSPu7-vZA
20 min video from Anesthesiolgoist on Fiberoptic- decently covers range of topics

https://lifeinthefastlane.com/ccc/awake-intubation/
LIFTL summary with a couple different videos both on awake intubation and also fiberoptic

https://www.youtube.com/watch?v=c9pAQ3DUKVM
Dr. Ali Diba using aScope on Awake patient—uses spray as you go technique

Narrated Talk on Topicalization: They do both Nasal and Oral for an Oral Fiberoptic for some reason. Also used both viscous Lidocaine and Ointment then sprayed cords.

Video on the LMA MADgic

Good 3-5 minute read on Critical Care time complements of ALiEM- what qualifies, time frames, procedures, etc.

https://www.aliem.com/2017/07/charting-coding-critical-care-time/

See below: The gist is, 40mg IV Pantoprazole (Protonix) on shortage until August or so. Consider using Pepcid instead.

Medical Staff,

Pantoprazole 40mg inj vials is on national backorder. The anticipated availability is in early August. To ensure continuity of patient care, Pharmacy, supported by P&T plan to substitute pantoprazole 40mg IV push daily to famotidine 20mg IV push BID for the indication of stress ulcer prophylaxis. And pantoprazole IV push to esomeprazole IV push for all other indications.

Pantoprazole 40mg inj vials will be reserved for existing PPI drip protocols.

The good news is that we do not have to adjust existing protocols or infusion pump library settings. Pharmacist will manually change the order from pantoprazole to alternative upon verification. We expect that this shortage will be relatively short.

Please call pharmacy with any questions or Michael Nnadi at 336-817-5265.

Hey All,
Saw this recent post on REBEL EM and wanted to post it as a follow up to Dr. Bosse’s lecture this past week on Salicylates. Will take ya 5 minutes or less.

Acute Salicylate Toxicity, Mechanical Ventilation, and Hemodialysis

As a follow up to Dr. Dennison’s presentation yesterday: see this link if you’d like to watch a couple videos on replacement/troubleshooting. They go through passing a new Trach over an airway exchange catheter as well as a Bougie.

http://www.tracheostomy.org.uk/Templates/Videos.html

This link is the algorithms for both Tracheostomy and Laryngectomy: http://www.tracheostomy.org.uk/Templates/Algorithms.html