Tips for the inpatient management of community acquired pneumonia

• The best scoring system is the Pneumonia Severity Index (PSI) for deciding on ICU admission and inpatient treatment. You can also use the CURB-65 score or the SMART-COP score but these are less sensitive.
• In general, PSI score of 4 or 5 tends to require ICU admission

• No, not really. Just try to do it as fast as you reasonably can do without over-treating

• Beta-lactam plus a macrolide or a quinolone alone. These work pretty well, cure rate around 90% or so

• You can stick with a beta-lactam plus a macrolide or quinolone in some cases but should be aware of certain issues
• Consider influenza now that we have entered the flu season
• Consider Staph aureus coverage for patients with influenza or those on chronic glucosteroids. Use linezolid or vancomycin for this.
• Consider P. aeruginosa coverage in patients with COPD or bronchiectasis.

• This can vary based on clinician preference but there is good data to support treating for around 5-7 days
• Longer treatment for Staph aureus or gram negative bacilli.   

Show References

Question

Patient presents with dyspnea & hypoxemia (pulse oximeter is 80%). The "stat" CXR is delayed, but ultrasound is not. What's the diagnosis and what are some differential diagnoses?

Show Answer

Show References

Management of Felons

• An abscess of distal finger that involves the pulp. 
• A difficult infection to treat due to the fibrous septa that divide the pulp into multiple small compartments. 
• These septa run from the periosteum to the skin increasing the risk of osteomyelitis
• Patients typically present with a lot of pain, redness, and swelling.
• Typically triggered by a puncture wound (i.e.: splinter)
• Incision and Drainage can result in a:
  • anesthetic finger tip
  • unstable finger pad
  • neuroma
• If you are going to drain one it is recommended that you do a volar longitudinal incision down the middle of the finger pad or a high lateral incision. 
• The high lateral incision should be at about 5 mm below the nail plate border. This distance is required to avoid the more volar neurovascular structures.

For good photos of the incision technique please visit the reference article listed.

Show References

A new population-based case-control study in older adults has linked the administration of trimethoprim-sulfamethoxazole (Bactrim, TMP-SMX) to increased risk of sudden death in patients also receiving angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB). [1]

Hyperkalemia is the suspected cause. [2] Compared to amoxicillin, TMP-SMX was associated with an increased risk of sudden death (adjusted odds ratio 1.38, 95% confidence interval 1.09 to 1.76) within 7 days of exposure to the antibiotic.

Practice Change

In older patients receiving ACE-Is or ARBs, TMP-SMX is associated with an increased risk of sudden death. When appropriate, alternative antibiotics should be considered.

Show References

Anisocoria, or unequal pupil sizes, is a common condition.  Approximately 20% of the normal population have physiologic anisocoria.  However, pathologic anisocoria indicates disease of the iris, parasympathetic pathway or sympathetic pathway.  A systematic approach to the evaluation of anisocoria can help differentiate between etiologies that range from benign to life threatening.

The most important question in the evaluation of anisocoria is whether both pupils are normally reactive to light or is one (or both) poorly reactive.  If both pupils are reactive, the smaller pupil is abnormal and the lesion is likely in the sympathetic pathway because pupillary constriction (parasympathetic pathway) is intact.  If one pupil is poorly or non-reactive (and there is no relative afferent pupillary defect), the larger pupil is abnormal and the lesion is likely in the parasympathetic pathway.

DDx of anisocoria with normally reactive pupils:

• Physiologic anisocoria
• Horner syndrome

DDx of anisocoria with poorly or non-reactive pupil:

• Iris sphincter damage (traumatic mydriasis)
• Pharmacologic blockade
• Tonic pupil
• Cranial nerve III palsy

Show References

Aminoglycosides in Critically Ill Patients

• Aminoglycosides remain an important class of antibiotics in critically ill patients, especially those infected with multidrug-resistant organisms (i.e., Klebsiella  and Pseudomonas spp.).
• Importantly, aminoglycosides are concentration-dependent antibiotics and a greatly affected by the increased volume of distribution and altered elimination commonly seen in the critically ill.
• As a result, recommended doses are often too low to be effective. 
• Initial doses of aminoglycosides should, therefore, be higher in critically ill patients.
  • Amikacin: 25-30 mg/kg
  • Gentamicin: 7-9 mg/kg
  • Tobramycin: 7-9 mg/kg
• Subsequent doses are based on drug level monitoring.

Show References

Question

Parasternal long-axis of two different patients. What is the:

1. structure labeled “A”
2. structure labeled “B”
3. diagnosis on the left?
4. diagnosis on the right?

Show Answer

Show References

Coronary Subclavian Steal Syndrome

Coronary subclavian steal syndrome (CSSS) is defined as coronary ischemia resulting from the reversal of flow in an internal mammary arterial graft usually secondary to subclavian stenosis.

Angiographic subclavian stenosis is defined as greater than 50% narrowing or greater than 20mmHg pressure difference across a lesion.

CSSS occurs in up to 4.5% of patients with prior CABG & common in older individuals with existing peripheral vascular disease.

CSSS most commonly manifests as stable angina, but frequently presents as unstable angina, acute myocardial infarction, acute systolic heart failure or even cardiogenic shock.

Screening for subclavian stenosis prior to CABG w/bilateral noninvasive blood pressure assessment, and a 15 mmHg or greater discordance should elicit further imaging.

Percutaneous revascularization is the first-line therapy for CSSS and has excellent long-term outcomes. 

Show References

Beware of spontaneous reduction masking the true injury!

Knee dislocations are rare due to supporting ligaments (MVCs, falls, sports)

but can be seen after minor trauma in obese patients.

Named by the direction of the displacement of the tibia relative to the femur

- Anterior and posterior are most common

Dislocations involve disruption of at least 2 of the major knee ligaments (ACL/PCL most common)

Usually associated with large hemarthrosis however capsular tearing may allow dissipation of the blood into adjacent soft tissue.

Consider a spontaneously reduced knee dislocation in those with a significant mechanism of injury in the setting of multidirectional instability,

Emergency Physician Bedside Ultrasound for Appendicitis

Why?

To reduce length of stay, improve patient care, and reduce radiation exposure in young patients.

How?

Start with pain medication so you get a better study. (Consider intranasal fentanyl for quicker pain relief and diagnostics in pediatrics.) Study results are also improved with a slim body habitus.

Place the patient supine

Use a high-frequency linear array transducer

Start at the point of maximal tenderness in the RLQ

Transverse and longitudinal planes "graded compression" to displace overlying bowel gas which usually has peristalsis (See Sivitz, et al article for images of "graded compression")

Appendix is usually anterior to the psoas muscle and iliac vein and artery as landmarks

Measure from outer wall to outer wall at the most inflamed portion of the appendix (usually distal end)

Example:

Positive study:

A non-compressible, blind-ending tubular structure in the longitudinal axis >6 mm without peristalsis (see second image above with 8.3 mm diameter measurement)

A target sign in the transverse view (see first image above)

Additional suggestive findings: appendiceal wall hyperemia with color Doppler, appendicoliths hyperechoic (white) foci with an anechoic (black) shadow, periappendiceal inflammation or free fluid

Negative study:

Non-visualization of the appendix with adequate graded compression exam in the absence of free fluid or inflammation.

Limitations for visualization and possible false negative result:

Retrocecal appendix and perforated appendix are difficult to visualize with US.

Pitfalls:

US has good specificity (93% in Sivitz et al article), but limited sensitivity (85% in Sivitz et al article), so trust your clinical judgement. You may need a MRI (pregnant/pediatrics) or CT as they have improved, but not perfect sensitivity.

Show References

Attachments

1411081818_Appendicitis_Blind_End_Pouch_US.jpg (1,372 Kb)

1411081818_Target_Sign_US_Appendix.jpg (1,461 Kb)

Digoxin-specific antibodies are produced in immunized sheep and have high binding affinity for digoxin and, to a lesser extent, digitoxin and other cardiac glycosides. The Fab fragment binds free digoxin and once the digoxin-Fab complex is formed, the digoxin molecule is no longer pharmacologically active.  The complex is renally eliminated and has a half-life of 14-20 hours (may increase 10-fold with renal impairment).  Reversal of signs of digoxin/digitalis intoxication usually occurs within 30-60 minutes, with complete reversal varying up to 24 hours.

Contraindication: None known.  Caution is warranted in patients with known sensitivity ot ovine (sheep) products.  Product may contain traces of papain and caution advised in patients with allergies to papain, papaya extracts, chymopapain.

Adverse effects: 

1) Monitor for potential hypersensitivity reactions and serum sickness

2) In patients with renal insufficiency and impaired renal clearance of dig-Fab complex, a delayed rebound of free serum digoxin levels may occur

3) Removal of the effect of digoxin/digitalis may exacerbate preexisting heart failure

4) Removal of digoxin/digitalis effect may cause hypokalemia

Laboratory interaction: Digoxin-Fab complex cross-reacts with the antibody commonly utilized in quantitative immunoassay techniques.  This results in falsely high serum concentrations of digoxin due to measurement of the inactive Fab complex.  Therefore, measure free digoxin levels, which may be useful for patients with renal impairment.

Dosing: Each vial of Fab product binds 0.5 mg of digoxin.

Digoxin-specific Fab (round up vial calculation)

# of vials = Digoxin concentration (ng/mL) x Pt Wt (kg)

                                               100

Background: The Centers for Disease Control and Prevention (CDC) classifies potential bioterrorism agents into three categories, with Category A the most deadly.

Category A: These are the highest priority agents/diseases because they:

• can be easily disseminated or transmitted from person to person;
• result in high mortality rates and have the potential for major public health impact;
• might cause public panic and social disruption; and
• require special action for public health preparedness.

Specific Category A Agents/Diseases:

• Anthrax (Bacillus anthracis)
• Botulism (Clostridium botulinum toxin)
• Plague (Yersinia pestis)
• Smallpox (variola major)
• Tularemia (Francisella tularensis)
• Viral hemorrhagic fevers (including filoviruses such as Ebola and Marburg, as well as arenaviruses such as Lassa)

Bottom Line: With the exception of smallpox, these disease still occur in various parts of the globe including the United States. As can be seen by the current Ebola epidemic in West Africa, the U.S. public health system and healthcare providers must be prepared to recognize and treat these agents.

Show References

Question

A patient presents post-motor vehicle crash with chest pain and dyspnea. The lung ultrasound is shown below. What's the diagnosis?

Show Answer

Show References

Back 2 Basics Series: Your Simple RSI Checklist - SOAP ME

The use of a checklist during high stress medical procedures is often recommended.  Rapid sequence intubation (RSI) is a classic situation where having a checklist can ensure adequate preparation however, if you don’t have a checklist – this simple mnemonic will make sure you are well prepared for a successful intubation.

The SOAP ME mnemonic is a quick and useful technique to remember only the basics of airway management and preparation.  Always remember to also assign roles to team members and communicate clearly to maximize your chances of success.  

Heart Failure & Pulmonary Hypertension (Part II)

- HFpEF-PH management guidelines recommend the treatment of symptoms of congestion and volume overload, targeting LV relaxation and co-morbidities; including the management of pulmonary congestion, ischemia, sleep apnea, atrial fibrillation, and diabetes.

- Both atrial/ventricular dysrhythmias contribute to the mortality associated with HF & control of particularly atrial fibrillation, is an essential part of the early pulmonary vascular remodeling process.

- Both endothelin receptor antagonists (ERA) and prostanoids have been effective for PAH & clinical trials utilizing these agents have also been attempted in treatment of PH due to left heart disease, but have proven to be either neutral or even detrimental.

- Selective dilation of the pulmonary vessels in patients with postcapillary PH, without simultaneously ensuring the unloading of the LV, can cause profound pulmonary venous congestion resulting in sudden pulmonary edema, which greatly increases the morbidity in patients with this form of PH.

- Currently, the most compelling published data for pharmacological treatment targeting PH in HFpEF involves phosphodiesterase (PDE) inhibitor sildenafil.

Show References

The cross-reactivity between cephalosporins and penicillins is significantly lower than the 10% figure many of us learned. In fact, the beta-lactam ring is rarely involved. So, when the warning pops up next time you order ceftriaxone in a penicillin-allergic patient, what should you do?

In a patient with a documented penicillin allergy, here is a simple chart to help determine when a cephalosporin is ok to use:

Common penicillins and cephalosporins with similar side chains include ampicillin/amoxicillin and cephalexin, cefaclor, cephadroxil, and cefprozil.

Show References

Background:

• There is a great deal of fear, media attention, and misinformation concerning Ebola.  
• As an emergency physician, you must be able to identify and appropriately manage individuals with possible Ebola presenting to your hospital. 
• ACEP's Ebola Expert Panel worked with the Centers for Disease Control and Prevention to help create a clear and concise algorithm in case someone presents with possible Ebola.

ED Algorithm For Patients with Possible Ebola

• Identify:
  • Do they have the right travel history (step 1)?
  • Do they have the right signs and symptoms (step 2)?

If yes to both identification questions, then:

• Isolate (step 3):
  • Place patient in private room or separate enclosed area
    • Private bathroom or covered, bedside commode
  • Only essential personnel should evaluate patient and provide care
  • Level of personal protective equipment should be determined
    • Based upon patient’s clinical status (signs and symptoms)
• Inform (step 4)
  • Immediately notify the hospital infection control program and other appropriate staff
  • Immediately notify the health department

• Further evaluation and management will depend on the patient’s clinical status and other potential diagnoses (step 5).

Bottom line:

Whether the patient has Ebola or not, a well-developed response is necessary for patient management and public health preparedness. The fear of the disease is much more widespread and impactful than the disease itself.

See the full algorithm, with more details at: http://www.cdc.gov/vhf/ebola/pdf/ed-algorithm-management-patients-possible-ebola.pdf

Attachments

1410290644_ed-algorithm-management-patients-possible-ebola.pdf (998 Kb)

Heart Failure & Pulmonary Hypertension (Part I)

~50% of patients with heart failure & preserved ejection fraction (HFpEF) develop pulmonary hypertension (PH)

HFpEF with PH portends reduced survival and increased hospitalization rates compared to those without PH

HFpEF-PH is often confused with idiopathic pulmonary hypertension (IPAH) given the similar hemodynamics; differentiating them is challenging and requires careful consideration of clinical, radiologic, and hemodynamic data

(Table reproduced from article)

Show References

Iliocostal syndrome aka iliocostal friction syndrome

Consider this entity in an elderly patient with osteoporosis with unexplained abdomen/flank or back pain.

Osteoporosis and/or vertebral compression fractures can result in a narrowing of the distance between .

the lowest anterior rib and the top of the iliac crest producing pain where this rib contacts the pelvis.

This can be perceived as side or back pain. This pain can restrict walking leading to a possible misdiagnosis of spinal stenosis. Treatment is with physical therapy and therapeutic injection.

http://www.caringmedical.com/wp-content/uploads/2013/09/iliocostalis.syndrome.jpg

Tetracycline has seen an increase in utilization due to its effectiveness in MRSA (check your local biogram). Remember its adverse effects/toxicity:

1) Photosensitivity 

2) Nephrogenic Diabetes Insipidus

3) Pseudotumor cerebri

4) Myopia

5) Deposits in calcifying bone/teeth - do not use in pediatrics