Sepsis– Dr Rashmi Koul

  • Sepsis screening depends on SIRS criteria
    • 4 components: WBC, temp, HR, RR
    • All nonspecific criteria that can be present in non-infected patients
  • SOFA and qSOFA criteria can be used to evaluate organ dysfunction
  • When patients present with undifferentiated vital sign abnormalities present ensure you thoroughly evaluate for all sources of infection
  • Lab workup– start with basic labs, lactate, +/- coags, blood culture, UA and culture
    • Consider obtaining CSF, joint, intra abdominal cultures as applicable
  • Fluid resuscitation in sepsis
    • Consider balanced fluids when available (plasmalyte and LR)
    • Consider other factors that may influence volume status prior to administration
  • BP control
    • Traditional goals set for MAP >65, new evidence to suggest lower MAP goals in elderly patients
  • Administration of antibiotics within 3 hours demonstrates mortality difference
  • In patients with refractory hypotension, end organ dysfunction consider stress steroids
    • Can consider a 5 day course of hydrocortisone 200mg
  • BMC guidelines
    • Bundle includes- antibiotic administration, fluid administration, lactate, blood cultures
  • Evidence regarding sepsis guidelines
    • 2019 ACEP guidelines pushed back on initial surviving sepsis guidelines (30cc/kg, antibiotics, lactate, etc.)
    • Loosened guidelines to reinforce differences between patients and lack of evidence behind various parts of the sepsis bundle
  • Resources

HIV Related Emergencies– Dr Juliia Isaacson

  • Transmission of HIV comes through bodily fluids
    • Highest risk populations are those participating in anal intercourse and sharing needles
    • At BMC there have been an increasing amount of diagnoses related to IVDU and immigration
    • Those using IV drugs should get tested annually
    • Anyone presenting requesting STI testing ought to also receive HIV and syphilis testing
  • PrEP– medications that can be taken to prophylactically protect patients
    • Takes 21 days to take full effect
    • Truvada and Descovy are the two most common options
    • There is a large disparity between white and minority patients in being on PrEP
  • PEP– post exposure prophylaxis
    • Offered within 72 hours of high risk exposure
    • Truvada and raltegravir/dolutegravir for 28 days, stop if source HIV negative
    • There are 3 day starter packs from the ED
  • Patients are most at risk for infection/transmission during acute infection
    • Have a low threshold to test as initial symptoms can be vague
  • IRIS– immune reconstitution inflammatory syndrome
    • Hyper inflammation starting after initiation of treatment leading to reactivation of latent pathogens
    • Most common- TB, MAC, crypto, CMV
    • Continue HIV treatment and treat supportively
  • Estimating CD4– (WBC*lymphocyte %) <1000 means CD4 < 200
  • AIDS- CD4< 200 or presence of an AIDS defining illness
  • Remember that patients with HIV are at a higher risk for common pathogens as well
  • Respiratory infections
    • Consider adding fungal testing, LDH for eval for PCP, consider MAC as dx
    • PCP- occurs w CD4< 200, bibasilar/bat sign CXR, elevated BD glucan and LDH
      • Treat with bactrim and add prednisone if hypoxic or AA gradient >35
    • Histoplasmosis- CD4 <200, HSM with bony/joint pain/rash, CXR with hilar LAN
      • Treat with itraconazole (mild), amphotericin and steroids (severe)
    • Coccidioides- CD4 <250, chest paiin/night sweats/weight loss
      • Treat with -azoles or amphotericin
    • TB- substantially increased risk with HIV
      • Look for CXR findings and sputum findings as quant gold can be unreliable
  • Occular infections
    • CMV-typically causes retinitis with low CD4 counts <50
      • Consult ophtho for vision changes/pain
  • Abdominal infections
    • Large variety of sources with cryptosporidium being most commonly associated
    • Consider testing for all GI/stool pathogens including c diff
  • Oral infections
    • Candida (most common), HSV, and CMV can all cause infectious esophagitis
  • CNS infections
    • Need opening pressure on your LP and add on cryptococcal studies
    • Cryptococcal meningitis
      • Occurs in patients with CD4 <100
      • Treatment with amphotericin and flucytosine followed by fluconazole
    • Toxoplasma
      • CD4< 100 with ring enhancing lesions, carried by cats
      • Will have active lesions visible on CT
    • CMV encephalitis
      • MS changes with atypical sx, dx via MRI and CSF
      • Treatment with gancyclovir
    • CNS lymphoma
      • AIDS defining illness associated with EBV
    • PML
      • Reactivation of JC virus (latent) w multifocal demyelination
      • Treat with optimization of ART
  • Resources

Fever in the Returning Traveler– Dr Elissa Perkins

  • Different populations are at risk for different illnesses
    • For immigrants there are certain conditions that deem people inadmissible to the US
    • Visiting friends and relatives are often times higher risk than traditional tourists to the area
    • Keep in mind that adventure travelers will have different exposures than typical tourists
    • Remember some patients will go abroad to receive planned healthcare (surgery, routine health visits, etc.)
  • Remember where people have traveled to assess risk for various diseases
    • Mosquito borne illnesses often seen in equatorial countries in South America and Africa
    • Consider exposure to fresh water while traveling
  • Timing affects risk of infection
    • Increased risk of infection with increased LOS
    • Less likely to manifest after 12 months from travel
    • Different incubation periods are present for different illnesses
  • Undifferentiated fever
    • Short incubation- malaria, dengue, rickettsia, leptospirosis, typhoid, brucellosis, HIV
    • Malaria is the most common etiology of fever in returning travelers even those on ppx
      • Mild- present with fevers and anemia
      • Severe- anemia, jaundice, seizure, pulmonary edema, renal failure, etc.
      • Testing- antigen and blood smears available at BMC
      • Treatment can be complex and will often require and ID consult
        • Chloroquine if sensitive or atovaquone proguanil for other infections
    • Dengue- often times presents with fever, arthralgia, and rash (white spots within a red area of skin- white islands within a red sea)
      • Tourniquet test can be used to evaluate for petechia
      • Considered to be one of the hemorrhagic viruses (yellow fever, ebola, typhoid, rickettsia, meningococcal disease)
      • If longer than 2 weeks have passed since exposure it is not dengue
      • Second infection with different serotype can lead to hemorrhagic fever and shock
      • Hemorrhagic fever- confusion, conjunctival injection thrombocytopenia, capillary leak (pleural effusions, ascites, etc.)
      • Treat with supportive care
    • Typhoid fever
      • Fecal oral transmission
      • Initial presentation will often be subtle and can present with rash and fever
      • Most commonly seen in travel to India
      • Can progress to GI bleeding
      • Can diagnose with blood and stool cultures but may be negative
      • Treatment with third generation cephalosporin
    • Leptospirosis
      • Hemorrhagic fever with hyperbili, LFT elevations, INR elevation, conjunctival suffusion
      • Transmitted via urine to mucous membranes
      • Septic phase presents initially then progresses to vasculitis, pulmonary complications, Weil’s disease (fever, jaundice, purpura)
      • Seen in patients with heavy water exposure
      • Diagnosed via abnormal US demonstrating intrinsic renal injury
      • Can consider 3rd gen cephalosporin in moderate to severe
    • Rickettsial disease- often presents with necrotic eschar
      • Treat with doxycycline
    • HAV- fever, jaundice, RUQ pain
      • Most common vaccine preventable travel disease w 1 month incubation
    • Flow chart for ddx
      • Are hemorrhagic manifestations present?
        • Consider hemorrhagic viruses
        • Will need isolation
      • Is malaria possible based on travel?
        • If yes obtain malaria testing with smears
        • If no need to evaluate for other infections
  • Resources

Decompensating Patients and Transitions of Care– Dr Jaion Griner

  • Patients who are signed out from the ED are ED patients until they go upstairs
    • Boarding patients are under the care of the inpatient team and once signed out the inpatient team can immediately take over care
    • Inpatient teams cannot place orders on admitted patients with beds assigned until the patient leaves the ED
  • No resources for this lecture, but be mindful of who the care teams for the patient when in the ED

Chief Talk– Dr Lance Shaull

  • The emergency department is not about diagnosis but about determining what the patient needs
  • Cognitive offloading
    • Our job is hard and it can be difficult to process everything simultaneously
    • It can be helpful to find ways to unload your active working memory
    • Develop a list of things NOT TO DO
    • Try not to get lost in the details and focus on the necessary steps
    • Know that sometimes there are a lot of right answers and you can always consult your patients
  • Try to feel comfortable with discomfort
    • Load your toolbelt and approach patients as individuals when going through care options
  • Treat yourself as a leader in the department because you are
    • Think about yourself, your situation, leading up, leading across, and leading in your space
    • Own your domain
  • Resources