February 26, 2020

Take Home Points 
  • No palpable pulse does not equal no perfusion. We aren't great at feeling pulses
  • Patients with moderate to severe signs and symptoms of lithium toxicity should be considered for hemodialysis
  • Always consider serious causes of back pain before simply treating with analgesics
  • Consider trauma as well as other toxic exposures (I.e. CO and CN) in patients with major burns

February 12, 2020

Take-Home Points
  1. Endocarditis can have vague and varied presentations and has high morbidity and mortality. Be on the lookout in patients with risk factors including: 
    1. Congenital heart disease
    2. Cardiac prosthesis or devices
    3. Immunocompromise
    4. IV drug use
    5. Recent invasive procedure
    6. Hx of prior IE
  2. Patients may present with fever, sepsis of unclear source or may have manifestations of emboli to the skin, eyes, brain, lungs, spleen or kidney.
  3. Diagnosis is based on the modified Duke Criteria and workup should include THREE good sets of blood cultures. 
  4. ED management includes consultation with ID and cardiothoracic surgery and starting antibiotics based on whether the patient has a native or prosthetic valve. Basic starting antibiotic regimen includes:
    1. For patients with native valve disease a good starting regimen is:
      1. Vancomycin 25-30 mg/kg IV loading dose followed by 15-20 mg/kg twice daily AND
      2. Cefepime 2 g IV TID
    2. For patients with prosthetic valve disease, we have to go a bit bigger:
      1. Vancomycin 25-30 mg/kg IV loading dose followed by 15-20 mg/kg IV twice daily AND
      2. Rifampin 300 mg PO/IV TID AND
      3. Gentamicin 1 mg/kg IV TID AND
      4. Some recommendations include the Cefepime 2 g IV TID

January 29, 2020

Take Home Points

  • When compared to 0.9% saline, lactated ringers is a more balanced solution and more closely resembles our serum.
  • SALT ED and SMART trials show normal saline may increase the occurrence of major adverse kidney events in comparison to a balanced solution like LR. For large volume resuscitations, LR is a better choice.
  • Certain medications cannot be run with LR in the same IV line. Ampicillin, Carbapenems, Phenytoin, Potassium Phosphate, Nicardipine
  • Ceftriaxone and LR should never be running at the same time in children less than 28 days old.

January 20, 2020

Definition: Acute infection of the ascitic fluid in a patient with liver disease without another source of infection

Epidemiology: (Runyon 1988, Runyon 1988, Borzio 2001)

  • Incidence
    • 10-25% risk of at least one episode per year
    • 20% risk in those with ascites admitted to the hospital
  • Historically, mortality ~ 50%

Pathophysiology:

  • Not completely understood
  • Increased portal systemic hypertension
    • Causes mucosal edema of the bowel wall
    • Increases transmural migration of enteric organisms into the ascitic fluid
  • Impaired phagocytic function in the liver
  • Impaired immunologic activity in ascitic fluid

January 15, 2020

Take Home Points 
  • Osteomyelitis is an infection in any part of a bone. It has a varied presentation including acute and chronic forms. Patients can present septic, or rather well appearing.
  • Patients may present with fever, chills, musculoskeletal pain, erythema, swelling or drainage from an ulcer.
  • Lab evaluation includes WBC, ESR and CRP, which we expect to be elevated in acute osteo, but less so in chronic.
  • MRI is the best imaging modality, but XR and CT may have some findings that suggest osteo.
  • Unstable patients should be started on broad spectrum antibiotics, usually vancomycin and cefepime, right away. Stable patients can be started on antibiotics in conjunction with your orthopedic consults.