Respiratory Pharmacy Lecture – Zacharry Dougherty PharmD

Community Acquired Pneumonia (CAP)

• ATS/IDSA guidelines for treatment of adults with CAP
• Typical organisms include strep pneumoniae, H. Influenzae, M. pneumoniae
• Be aware if the patient has a history of MRSA / Pseudomonas colonization
• Risk stratify patients with a calculator such as Pneumonia Severity Index (PSI) to determine inpatient vs outpatient treatment.

Outpatient:

• With vs without comorbidities
• Without (Single agents): Amoxicillin 1000mg TID, Doxy 100mg BID, Azithromycin 500mg daily for 3 days.

Azithromycin monotherapy not recommended due to local S. pneumoniae resistance rates

• With: Augmentin 875mg BID plus doxy or azithromycin for 7 days
• Cefpodoxime 200mg BID or Cefuroxime 500mg BID plus doxy or azithromycin for 7 days
• Levofloxacin 750mg daily for 7 days

Clinical success is highest with cephalosporins.

Cefdinir technically has appropriate coverage, however some strains of these bacteria have resistance to this, and for this reason, it is not recommended by the ATS/IDSA

Multi Drug Resistant (MDR) Coverage:

• Doxycyline 100mg BID for MRSA coverage and Levofloxacin 750mg daily for p. aeruginosa

Always consult your hospital antibiogram

Inpatient (Nonsevere vs Severe CAP):

Nonsevere:

• Ceftriaxone 2g Daily + Azithromycin

If Prior culture, or recent hospitalization, add MRSA coverage with Vancomycin

If Prior culture, for pseudomonas change ceftriaxone to cefepime.

Severe:

• Cefepime 2g Q8 or Zosyn 4.5g Q6 (plus vancomycin and azithromycin)

Anaerobic Infections:

• Less common, however lung abscess, empyema, and necrotizing pneumonia make this more likely to occur.

Room 9 Follow-up – Madelyn Huttner MD

Age 60s F found down at home confused by family with black sputum. Hx of suspected IBS. Seen initially in room 9. HR 100, BP 100/60, 94% NRB, afebrile. GCS 14, pale, dried black emesis and stool covering her body.

Orders:

• CBC, CMP, Type and cross, Lipase, Coags, UA, CXR, ABG, Lactic Acid

Consider CTA A/P – was not obtained in this case

Medications:

• Protonix, Octreotide, Ceftriaxone, IV Fluids, Blood products

Consider reversal of anticoagulation

Procedures:

• Intubation, Central line, A line

Consider Minnesota tube

Anticipate significant blood in the airway

SALAD (Suction Assisted Laryngoscopy) Technique

ABG 7.3 / 29 / 45 / 14. Hgb 11.6

Na 130, K 3.2, Cl 96, BUN 46, Cr 2.2

Lactic 4.4

GI and MICU consulted from room 9. Patient found to have a history of excessive NSAID use.

Taken for emergent EGD with GI. Found to have significant esophagitis, diffusely ulcerated gastric mucosa and duodenitis.

Overview of Lithuanian Healthcare System – Simona and Deimante

Universal coverage throughout Lithuania. Patients can choose private insurance, however emergency care is fully covered. Private care is used for elective care, and faster access to care, but not common for emergency care. Can show your ID and have no-copay emergency care throughout Europe.

ED systems are based in public hospitals in major centers in Vilnius, Kaunas, and Klaipeda.

Country has a shortage of emergency medicine specialists. General practitioners are gatekeepers to other specialists.

Vilnius and Kaunas are tertiary care centers and trauma centers.

Gallbladder / Biliary Disease – Tim Price MD

30s Male with 4 days of abdominal pain. Pain is consistent and has been steadily worsening. Described as a dull pain. Located in the upper abdomen. If he lays on his back and holds his hands up, his pain is relieved. Has had regular bowel movements but has some nausea a small amount of emesis 3 days ago, as well as decreased appetite. Denies fevers or chills. Has taken hydrocodone which did help somewhat. Denies dysuria.

Differential: Cholecystitis, Choledocolithiasis, Biliary colic, Pancreatitis, Pyelonephritis, Nephrolithiasis, Hepatitis, ACS, Gastroenteritis, AAA, Cannabis hyperemesis

Labs: Elevated tbili on labs. Normal leukocyte count with neutrophil predominance

POCUS Gallbladder US: Gallstone present without pericholecystic fluid. No anterior gallbladder wall thickening. +Sonographic murphy sign.

CT – Significantly enlarged gallbladder wall

Disposition to Baptist for surgery

Rescue Task Force and Tactical Medicine – Dr. O’Brien

• Tactical Combat Casualty Care (TCCC) “cold zone” vs “warm zone” vs “hot zone”
• Rescue task force allows for a coordinated response to a situation which cannot be completely handled by a single first response agency
• (S)MARCH –(S.ecurity) M.assive hemorrhage, A.irway, R.espirations, C.irculation, H.ypothermia
• Hemostatic gauze: radiopaque, used when not able to apply tourniquet
• Care Under Fire Priority List
• Casualty Movement Rescue Plan
• “High and tight is always right” (for tourniquets)

ABEM Certifying Exam – Dr. Platt

• Steps
  • Program Director Approval
  • Apply (register May 9 – Oct 9. 
  • Qualifying exam November 3-12, 305 questions
  • Certifying Exam, brand new exam that assesses more competencies than oral exam. In Raleigh, NC. 
    • Half day sessions with 2 case types, clinical care cases and communication and procedures
    • Will be offered 9 times a year
    • Sample cases on ABEM website

• Central Venous Access – Drs. Stults and Wells
  • Locations: IJ (R 15cm, L 18cm), Subclavian(R 14cn, L 17cm), Femoral
  • Procedure SIM
• “To Pee or Not to Pee?” – Dr. Williams
  •  Rhabdomyolysis
    • Muscle breakdown – Meds, toxic ingestion, increased muscle activity
    • UA with positive heme/blood without RBCs
    • CK > 5000
    • Electrolyte abnormalities
    • McMahon Score
    • Treat by removing precipitating factors, Rehydrate as needed, treat electrolyte abnormalities, maybe dialysis
  • Acute Kidney Injury (AKI)
    • KIDGO Criteria
    • Staging (stage 1-> stage 3)
    • Pre-renal, Intra-renal, Post-renal
    • Screening/Labs: Electrolytes, CMP, BMP, CK, UA, Renal US, FENa
  • Uremic Encephalopathy
    • Cerebral dysfunction from accumulation of eremic toxins in acute or chronic renal failure
    • Delirium, fatigue, anorexia, nausea, asterixis/myoclonus, seizures
    • Often with GFR <15L/min
    • CMP/BMP. CBC, EEG, CT Head/MRI Brain
    • Treated with dialysis (must evaluate for other causes of delirium)
  • Hepatorenal Syndrome
    • Advanced cirrhosis causes systemic dilation, to compensate for low BP and SVR body releases endogenous catecholamines and activates RAAS
    • AKI
    • Diagnosis of exclusion (takes 2 days of albumin therapy to diagnose)
    • Treat with albumin
• US Image Review – Drs Baker and DiMeo
  • Vitreous detachment
  • Retinal Detachment
  • Nerve Block
• Introduction to Observation Medicine (OLOU) – Dr. Kuzel
  • Trial of therapy, Continued Diagnostic work up, risk stratification, Optimization before discharge home, assessment of acute psychosocial needs
  • Patient can be discharged within 24 hours
  • Specific inclusion and exclusion criteria, protocol based
  • NOT an ambiguity or continued decision unit
  • NOT an additional annex for ED holding patients
  • NOT for patients admitted to other services
  • Soft Launch of ULOU on Feb 3
    • Maximum number of 5 obs patients at a time

• Nephritis/Nephrosis – Dr. Samuels
  • Nephritic vs Nephrotic
    • Nephritic Syndromes
      • Hypertension
      • Decreased Urine Output
      • Proteinuria +/-
      • RBC casts
      • Examples:
        • PSGN
        • Rapidly Progressive Glomerulonephritis
        • IgA Nephropathy
    • Nephrotic
      • >3.5 grams protein excreted per 24h
      • Hypoalbuminemia >lipid formation
      • Edema/anasarca
      • Hypercoagulable state (loss of antithrombin III, protein C & S)
      • Examples:
        • FSGS (focal segmental glomerulosclerosis)
        • Membranous Nephropathy
        • Diabetic Nephropathy

• Urinary Infections – Dr. Stanforth
  • Urinary Tract Infections
    • Pathophys
      • Bacteria ascend through the urethra
      • Complicated vs uncomplicated
      • Relapse = recurrence of symptoms within 1 month despite treatment (typically same organism)
      • Reinfection = symptoms develop 1-6 months after treatment (typically different organs mim)
    • Risk factors
      • Anatomical abnormalities
      • Advanced age (men)
      • Nursing home residency
      • Neonatal
      • Diabetes, sickle cell disease
      • Pregnancy
      • Immunosuppression
      • Advanced neurologic disease
    • General workup
      • UA
        • WBC >5 w/ symptoms is diagnostic
      • Urine culture
      • Consider labs: CBC, CMP, lactic
      • Blood cultures not always indicated as cultured organsmi will typically match urine culture (97%)
    • Types
      • Renal
        • Pyelonephritis
          • Flank pain, fevers, chills, nausea, vomiting
            • CVA tenderness alone could be referred pain from cystitis
          • Complications
            • Bacterial Nephritis
            • Renal/perinephric abscess
            • Emphysematous pyelonephritis
      • Ureteral
        • Infected stone (8-15% of stones have co-infection)
        • Systemic symptoms: urology consult, close follow-up
        • Obstruction with infectious symptoms -> urologic emergency
        • Imaging considerations
      • Cystitis
        • Infection of bladder
        • Complicated
          • Symptoms >7 days
          • DM
          • UTI in previous 4 weeks
          • Men
          • > 65years old
          • Women using spermicides or diaphragm
          • Relapse
          • Pregnancy
        • Treatment
          • Refer to system/community based antibiogram
      • Urethritis
        • UA, Urine GC/Chlamydia, M. genitalium and trichomonas testing
        • Treatment: Empirically cover gonorrhea and chlamydia
        • Partner treatment
      • Prostatitis
        • E. coli makes up about 80% of cases
        • Enterococcus, Staph. N. gonorrhoeae, Chlamydia
        • Prostate manipulation: increased risk of pseudomonas infections
      • Management:
        • Prolonged antibiotic course
    • Asymptomatic bacteriuria
      • Do not treat unless immunocompromised or pregnant

• PEM: Renal Disorders – Dr. Lund
  • Pediatric Renal/GU
    • UTI
    • UTI: Diagnosis
      • Culture showing leukocyte esterase or pyuria AND …
        • 1,000 CFU SPA
        • 50,000 CFU catheterized specimen
        • 100,000 CFU clean catch
      • 2-24 months first febrile UTI or recurrent UTI in older child needs RBUS
    • UTI: Treatment
      • Cephalexin 25 mg/dose TID (max 1000mg/dose)
      • https://uticalc.pitt.edu/
  • PIGN
    • One of the most common causes of acute glomerulonephritis in children
    • PSGN: Clinical features
      • M>F
      • 4-14 y/o, rare before 2 y/o
      • Latency 1-2 weeks for pharyngeal infections and 3-5mfor skin infection
    • Acute nephritic syndrome
      • Hematuria
      • Hypertension
      • Edema
      • Oliguria
    • PSGN: Treatment
      • Treat underlying infection
      • Treat nephritic syndrome, if needed
        • Diuretics
        • Antihypertensives
        • RRT
  • Hemolytic Uremic Syndrome
    • Triad of microangiopathic hemolytic anemia, thrombocytopenia and acute kidney injury
    • Many etiologies with most common being shiga-toxin producing E. coli (STEC)
    • Treatment
      • pRBC
      • Fluid/electrolyte anagment
      • Dialysis
      • Platelets
  • Henoch Schonlein purpura
    • IgA depositions in blood vessel walls – kidneys, GI tract, skin, joints
    • Clinical manifestation
      • Palpable purpura
      • Joint pain
      • GI complaints
      • Renal involvement
      • Cerebral vasculitis
      • Testicular hemorrhage
      • Interstitial pulmonary  hemorrhage
    • Pathogenesis
      • Preceding URI
      • IgA complexes deposit in the small vessels in the skin joints, kidneys and GI tract. 
    • Diagnosis
      • Mandatory criterium:
        • Purpura or petechiae with lower limb predominance
      • Minimum Criteria(1 of 4)
        • Diffuse abdominal pain with acute onset
        • Arthritis or arthralgia of acute onesie
        • Renal involvement in the form of proteinuria or hematuria
        • Histopathology showing leukocytoclastic vasculitis or proliferative glomerulonephritis, with predominant immunoglobulin A deposits
    • Treatment
      • Non renal involvement -> symptomatic treatment
      • No consensus on HSP nephritis/severe complications
        • Steroids
        • Cyclosporine, mycophenolate, cyclophosphamide, rituximab, dapsone 
    • Approach to Hematuria
      • Pathophysiology
        • Glomerular
          • Disruption of the glomerular basement membrane with leakage of RBS and protein
          • RBC casts 
          • Brown, smoky coca-cola colored
        • Non-glomerular
          • Renal papillae
          • Sickle cell disease, trait
          • Tubules are site inflammation caused by NSAIDs and antibiotics
          • Pink, bright red with ot without clots more likely lower in urinary tract
          • Increased vascularity from infection or chemical irritation
      • Evaluation
        • Confirm blood in urine
        • Detailed patient and family history
        • Life Threatening causes
          • Trauma
          • Acute glomerulonephritis
          • HUS
          • Renal stones with obstruction
          • Tumor
          • Hematologic disorders
          • toxin/xenobiotic
      • Trauma
        • Hematuria is “cardinal marker of renal injury, with magnitude of hematuria paralleling the severity of renal injury (except renal pedicle injuries, which may have no associated hematuria
        • Presence of gross hematuria or significant microscopic hematuria (>50 RBCs/HPF) along with mechanism point to emergent imaging

• Testicular Infections/STI – Dr. Scott
  • Sexually Transmitted Infections
    • Ulcerative
      • Painful Ulcers
        • HSV
          • HSV-2
            • Multiple painful lesions
            • Starts as blisters
            • Clinical Dx
            • Acyclovir 400 mg q8h x7-10 days or valacyclovir 1 g q12h x 7-10 days
        • Chancroid
          • H. ducreyi
          • Begins as chancre -> unilateral painful inguinal lymphadenopathy forms (buboes)
          • Can form abscess
          • Azithro 1 g PO x1 dose
      • Painless
        • Syphilis
          • Chancre painless
          • Secondary
            • Maculopapular ras on trunk and extremities
            • CSF involvement (40%) 
          • Late
            • Most commonly neuro, associated with HIV
            • Gummas
            • Cardiovascular
          • Diagnosis
            • RPR or VDRL -> antibody if reactive
            • Antibody test -> RPR or VDRL
          • Tx:
            • Penicillins
            • Doxycycline
            • Ceftriaxone if neurosyphilis
            • Jarish-Herxmeier reaction: fever. Chills, myalgias, headache
        • LGV
          • Chlamydia trachomatis
          • Associated with HIV
          • Primary: painless ulcer x2-3 days
          • Secondary: painful ulcer 2*6 weeks later
            • Fever, mylagia, malaise
        • Gonorrhea chlamydia/chlamydia
          • Arthritic, PID
          • Urine culture
          • Ceftriaxone/doxy
        • Epididymitis
          • <35, GC/chlamydia
          • >35 (or anal intercours): e. Coli, pseudomanas, TB, enterovacrer, syph
            • Scrotal elevation
            • Pain relief
            • GC/Chlamydia treatment
        • Orchitis
          • Testes inflammation
          • Most commonly mumps
          • GC, chlamydia, E. coli

• Torsion – Dr. Gosser
  • Ovarian torsion
    • Most common in reproductive-aged females but is found in females of any age
    • Risk factors
      • Ovary > 4cm
      • Pregnancy
      • Patients undergoing IVF, patients after tubal ligation
    • Mechanism: enlarged ovary rotates on the axis of its ligaments leading to twisting of the ligaments restricting lymphatic outflow, swelling that will inhibit venous return that in-turn compromises arterial blood flow. 
    • Requires emergent OB/Gyn consult for operative management
  • Testicular torsion
    • Bimodal incidence
      • Peaks in first year of life and in puberty
    • Risk Factors
      • Mechanical: exertional/exercise, trauma
      • Testicular masses
      • Undescended testicle
      • Bell-clapper deformity
    • Evaluation
      • Emergent urology consult
      • UA
      • US for equivocal cases
      • TWIST Score
    • Mechanism
      • Twisting of the testis on its blood supply
      • Tunica vaginalis is secured to the scrotal wall on the posterolateral side, prevents movement of the testis
        • If this attachment occurs too superiorly, this can lead to torsion
    • Treatment
      • Manual detorsion (temporizing measure)
        • Medial to lateral rotation (open book)
      • Urological consultation for detorsion and orchipexy
      • Salvage rates
        • 100% at 6 hours
        • 20% at 12 hours
        • Little to no salvageability at >24 hours
• ITE Tox Review – Dr. Eisenstat
  • Toxicology ITE Prep
    • self-review
• Renal Emergencies – Dr. Thomas
  • Hyperkalemia and Emergent Hemodialysis
    • Causes of hyperkalemia
      • The Kidney
        • Renal insufficiency
        • ARF
        • Addison’s Disease, Adrenal insufficiency
        • ACEs
        • ARBs
      • Intake
        • Excessive K+ supplementation
        • Excessive K+ in diet
        • Dehydration
          • Prerenal cause of insufficiency
          • Causes shift in electrolytes with more K+ now extracellular
      • Tissue Damage
      • Endocrine
      • The Lab/Phlebotomy
    • Hyperkalemia
      • Generally >5 or 5.5
      • The serum concentration of K+ is important
      • The rate of change in the concentration of serum K+ is MORE important
      • EKG changes
        • Mild 5.5-6.5  – Peaked T Waves and or Prolonged PR segment
        • Moderate 6.5-8 – Loss of P Wave, Prolonged QRS complex, ST-Segment elevation, Ectopic beats
        • Severe >8.0 – Progressive widening of the QRS, Sine wave morphology, V-fib, Asystole, axis deviations, BBB, Fascicular blocks
    • Therapy
      • Calcium
      • Insulin/dextrose
      • Albuterol
      • Bicarb
        • Only really worthy of consideration in setting of metabolic acidosis
      • Diuretics
      • GI elimination
        • NOT RAPID
        • NOT FOR EMERGENCY TREATMENT
      • Hemodialysis
    • Emergent Hemodialysis
      • AEIOU
        • Acidosis
          • pH ,7.1
        • Electrolytes
          • Refractory hyperkalemia
        • Intoxication/Ingestions
          • Toxic alcohols, salicylates, lithium, etc
        • Overload
          • Congestive Heart Failure
        • Uremia
          • Uremic pericarditis, uremic encephalopathy
      • I STUMBLED (Toxins removed by HD)
        • I – INH, Isopropyl alcohol
        • S – Salicylates
        • T – Theophylline, Tenormin (atenolol)
        • U – Uremia
        • M – Methanol
        • B – Barbiturates
        • L – Lithium
        • E – Ethylene glycol
        • D – Dabigatran, Depakote