Episode 22b: Whistler Update in Emergency Medicine Conference 2012

In this bonus episode, our second installment of the highlights from Whistler’s Update in Emergency Medicine Conference 2012, we have Dr. David Carr updating us on infectious diseases, Dr. Dennis Scolnick giving us the low down on pediatric urological emergencies, Dr. Anil Chopra reviewing the pearls and pitfalls of managing shock states, and much more. In these conference highlights our experts answer such questions as: Which oral antibiotics can replace IV antibiotics in the majority of bacterial infections? What are the most recent recommendations for pelvic inflammatory disease management? Which patients with mammalian bites require antibiotics? How can we best counsel our patients with potential exposure to HIV? Does every child with a painful scrotum require an ultrasound? What is the role of treatment with Bicarb in shock? What are the best antibiotic choices in patients suspected of septic shock? When are steroids indicated for patients in shock? How should you decide between the different vasopressors for shock? and many more…….

 

INFECTIOUS DISEASE UPDATE

David Carr

  • High bioavailability antibiotics – eg, fluoroquinolones, TMP‐SMX, linezolid, doxycycline, metronidazole and clindamycin can be used po to replace IV drugs in most non‐lifethreatening infections
  • Nitrofurantoin has poor bioavailability, which is exactly why you want to use it in simple UTIs (it goes to the urine, not to the tissues), but not in pyelonephritis

Pelvic inflammatory disease (PID)

  • Lower abdominal/pelvic pain in sexually active woman + adnexal tenderness, cervical motion tenderness or uterine tenderness = PID until proven otherwise
  • Outpatient treatment for mild disease as per CDC: Ceftriaxone 250mg IM x1 (or Cefoxitin 2g IM + Probenecid 1g PO concurrently) for gonorrhea, PLUS doxycycline 100mg PO BID x14d for chlamydia (Azithromycin 1g PO x1 can be used for uncomplicated chlamydial infection, not for PID), WITH OR WITHOUT Metronidazole 500mg PO BID x14d for bacterial vaginosis (which is often associated)

Skin infections

  • Consider MRSA in spider bites, furuncles, carbuncles, and health care workers – prevalence increasing rapidly in Canada in all groups, but still lower than the U.S.
  • Fist line MRSA Rx = TMP‐SMX; also condiser doxycycline, clindamycin, linezolid or vancomycin if severe/treatment failure
  • Prophylactic antibiotic treatment is NOT required for mammalian bites except in immunosuppressed patients and for human bites – antibiotic of choice is Clavulinic acid x5d for prophylaxis, and Pip‐tazo for infected wounds
  • HIV transmission – Highest risk is receptive anal intercourse; contact with bodily fluids (feces, urine, saliva, tears and vomiting) is low‐risk unless tainted with blood
    • In counselling patients, remember that HIV prophylaxis therapy has 1/5,000 risk of serious adverse events, and 1/50,000 risk of death

 

emcases-updateUpdate 2016: Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV— United States, 2016 Full PDF

 

PEARLS & PITFALLS IN MANAGEMENT OF SHOCK

Anil Chopra

  • Patients in shock need aggressive fluid resuscitation (if >50% IVC collapse with inspiration on ultrasound, more fluid needed), even if it means leading to pulmonary edema, and vasopressors won’t work unless the tank is full
  • High oxygen demands associated with increased respiratory effort, so consider intubation, sedation and paralysis in severe sepsis, even if not a respiratory cause
  • HCO3‐: No human evidence of improved outcomes, and animal evidence that it may hurt – alkalinizes urine but paradoxically acidifies intracellular milieu; also shown to decrease oxygen delivery at tissues (more tightly bound to hemoglobin) and worsen ventricular contraction (due to decreased ionized calcium levels)

Antibiotic choices in shock

    • 25% of infections are respiratory in origin (mostly S. pneumo) – treat with Imipenem, Pip‐tazo or Cefipime AND Levofloxacin or Azithromycin, WITH Vancomycin if suspect MRSA or patient is very sick
    • 25% of infections are urinary in origin (mostly E. coli) – Ceftriaxone AND Fluoroquinolone (Levofloxacin or Ciprofloxacin)
    • 15% of infections are skin in origin (Strep or Staph) – treat with , WITH Vancomycin if suspect MRSA (eg, pacemaker or central line) or a joint is involved, which is present in 35‐40% of cases
    • 15% of infections are abdominal in origin (mostly E. coli, enterococcus, Bacteroides fragilis), and often have GI comorbidity or had prior abdominal surgery – treat with Imipenem or Pip‐tazo AND Metronidazole
    • Unknown source: Vancomycin AND Ceftriaxone AND Metronidazole

     

  • Steroids not required early on in the management (ie. in the ED), unless patients are adrenally deficient (eg, Addison’s disease) or steroids dependent
  • Vasopressors:
    • Norepinephrine (0.05‐0.2μg/kg/min) and dopamine (5‐20μg/kg/min) have no difference in outcomes, but dopamine leads to higher rates of tachydysrhythmias and is less effective in cardiogenic shock
    • Consider adding dobutamine (5‐20μg/kg/min) in poorly perfused patients, or epinephrine (2‐10μg/min) in refractory shock

     

  • Lactate clearance is prognostically related to survival, and can be used as a marker of perfusion instead of mixed central venous saturation
  • Anaphylactic shock:
    • Epinephrine always given IM initially, but in very sick patients consider epinephrine IV 25‐50mcg boluses until infusion can be arranged
      • IV Epinephrine RECIPE: Take 10cc out of a 50cc NS bag, and put in 10cc of 1:10,000 epinephrine (1mg amp) – result will be 10mcg/cc, and can give 5cc boluses prn

       

  • Toxic shock syndrome:
    • Group A Strep or Staph (tampons and post‐op) are usual etiologies
    • Treatment: Clindamycin (which decreases production of endotoxins but bacteriostatic) AND Vancomycin (bacteriocidal)
      • Consider immune globulin, which also kills the toxins

 

PEDIATRIC UROLOGIC EMERGENCIES

Urinary Tract Infections

    • Febrile children up to 36mo old should have consideration for urinalysis even when another focus of infection has been found, especially if the fever has lasted 48‐72hrs (12.5% UTIs, versus 5% if fever has lasted <24hrs)
    • Toddlers may initially have a bag urine because the negative predictive value is good, but infants probably up to 8mo old (definitely up to 3mo old) NEED a culture (clean catch, catheter or suprapubic aspiration) because dipstick may be negative in this patient population
    • Oral antibiotics of choice: Cephalexin or nitrofurantoin (NOT Amoxicillin); always treat for 10 days and always admit ALL children
    • True positive results in young children mean they require follow up ultrasound (for abnormal anatomy), and consideration for voiding cystourethrogram (VCUG – for vesicoureteral reflux), although it is controversial whether or not vesicoureteral reflux requires preventative antibiotics

     

PEDIATRIC SCROTAL PAIN

  • DDx: testicular torsion, epididymitis (pain localized to postero‐lateral testicle, and treated with NSAIDs only if no concomitant UTI), torsion appendix testis (blue dot sign), hernia in scrotum, direct trauma, Henoch‐ Schonlein Purpura, Kawasaki’s, tumor, hydrocele (transillumination)
  • Testicular torsion is defined by (a) sudden onset of (b) excruciating pain that is (c) felt over the whole testicle, (d) often starting during exercise, with (e) high‐riding or sideways testicle, and (f) absent cremasteric reflex
    • Fever is also often present, and pain will decrease with “opening of the book” – temporizing measure until surgery
  • Balanitis = inflammation of the penis glans only, vs. balanoposthitis = infammation of glans and foreskin in uncircumcised males
    • Treatment: sitz baths BID, gently milking foreskin (but no retraction), NSAIDs ± hydrocortisone ointment; Cephalexin ONLY IF cellulitis
  • Paraphimosis: forcibly retracted foreskin and strangling glans; treatment: apply pressure from top‐down to squeeze edema out while pulling foreskin, for 5‐10min; provide pain relief and sedation PRN
  • Inguinal hernia in female = ovaries until proven otherwise (get ultrasound)
  • Vomiting NYD child needs to be undressed to prevent missing “silent” systems – CNS (hemorrhage, tumor, AVM) and GI/GU (volvulus, testicles)

 

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About the Author:

Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.

One Comment

  1. Abu Zeid October 19, 2018 at 4:53 am - Reply

    Thank you so much for these cutting-edge pearls.

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