Category: Metabolic, Hematologic, Immunologic, Endocrine and Infectious Diseases

Common Fungal Infections

Most Life Threatening Fungal Infection
  • Mucormycosis
    • Black facial discharge
    • Cranial nerve dysfunction
    • Facial swelling
    • Eschar formation
When to Suspect a Fungal Infection
  • Immunocompromised (HIV, Diabetes, Organ Transplants, etc)
  • Not getting better on typical antibiotics
Other Fungal Infections
  • Aspergillus
    • Aspergilloma
    • Bronchopulmonary Aspergillosis
    • Invasive Aspergillosis
  • Coccidiomycosis
    • Southwestern United States
  • Histoplasmosis
    • North Central United States
  • Blastomycosis
    • Southeast United States
Additional Reading
  • Fungal infection archive and data sheets (CDC)

Nutritional Emergencies

Consider In High Risk Patients

  • Alcoholics
  • GI disorders
  • Eating disorders
  • Starvation/poor diet
  • Extremes of age

Thiamine (B1) deficiency

  • Causes damage to neurons and cardiac myocytes
  • Manifestations
    • Dry beriberi
      • Neuropathy
      • Paresthesias
    • Wernicke’s encephalopathy
      • Ophthalmoplegia
      • Ataxia
      • Altered mental status
    • Korsakoff syndrome
      • Ophthalmoplegia, ataxia, altered mental status
      • PLUS
      • Confabulation
      • Memory loss
    • Wet beriberi
      • Heart failure from cardiac damage
  • Treatment
    • High dose thiamine

Niacin (B3) Deficiency

  • “Pellagra”
  • Clinical Triad
    • Diarrhea
    • Dementia
    • Dermatitis
      • Scaly rash
        • Neck
        • Dorsum of hands
  • Treatment
    • Vitamin B3

Folate (B9) Deficiency

  • Megaloblastic anemia
  • Treatment
    • Folate

B12 Deficiency

  • Classically occurs in vegans (in addition to the previous high risk groups)
  • Manifestations
    • Megaloblastic anemia
    • PLUS
    • Neurologic complaints
      • Subacute combined (posterior and lateral column) degeneration of spinal cord
        • Posterior columns
          • Impaired vibratory sensation and propioception
        • Lateral columns
          • Sensory loss
          • Motor weakness

Additional Reading

  • Thiamine Deficiency: Pearls and Pitfalls (emDOCs)

Sepsis

Sepsis guidelines are constantly changing. Refer to your national guidelines or institutional protocol for most up to date treatment information.

Introduction

  • Sepsis is bad and needs to be treated aggressively
  • Confusion around multiple conflicting guidelines and requirements
    • Surviving Sepsis Campaign recommendations
    • CMS requirements
    • Sepsis-3
    • SOFA/SIRS/qSOFA
    • Institutional protocols

Sepsis-3 Proposed Recommendations

  • Screen for sepsis by applying qSOFA instead of SIRS criteria
    • qSOFA criteria
      • Altered mental status
      • Tachypnea
      • Hypotension
    • SIRS criteria
      • Tachycardia
      • Tachypnea
      • Leukocytosis
      • Hyper/hypothermia
    • qSOFA criteria miss cases of sepsis (too specific)
    • SIRS calls everything “sepsis” even if the patient is fine (too sensitive)
  • Change definition of “Sepsis” (no more SIRS plus source)
    • New definition
      • Source of infection
      • PLUS
      • Organ disfunction
        • Determined by SOFA score (different purpose than qSOFA)
  • Eliminate the term “severe sepsis” completely
  • Redefine “septic shock”
    • Persistent hypotension
    • OR
    • Lactic acid >4

Current Approach to Sepsis

  • Step 1- If the patient has SIRS plus source
    • Get labs including a lactic acid
  • Step 2- If the patient has organ dysfunction
    • Diagnose sepsis
  • Step 3- If the patient has sepsis
    • Order broad spectrum antibiotics
    • Order blood cultures
    • Needs to be completed in <3 hours
  • Step 4- If the patient has persistent hypotension or lactate >4
    • Diagnose septic shock
  • Step 5- If they have septic shock
    • Give 30ml/kg crystalloid bolus
    • Start vasopressers if hypotension doesn’t improve with bolus

Additional Reading

  • CMS Sepsis Core Measures (ACEP)
  • Sepsis-3 Recommendations (EMJ)
  • Surviving Sepsis Campaign (SCCM)

Thrombocytopenia

Clinical Presentation

  • Incidental finding on routing CBC
  • Petechiae/purpura
  • Mucosal bleeding
  • Epistaxis
  • Gingival bleeding
  • Hematuria
  • Vaginal bleeding

5 Major Causes of Thrombocytopenia

  • Thrombotic Thrombocytopenic Purpura (TTP)
    • Clinical presentation (pentad)
      • Thrombocytopenia
      • Fever
      • Microangiopathic hemolytic anemia
        • “schistocytes”
      • Neurologic abnormalities
      • Renal dysfunction
    • Physiology
      • Low ADAMTS13 results in impaired vWF breakdown
        • Widespread “platelet plugs”
    • Treatment
      • Plasma exchange
  • Hemolytic Uremic Syndrome (HUS)
    • Clinical presentation
      • Pediatric patient with bloody diarrhea
      • Renal dysfunction
      • Thrombocytopenia
    • Treatment
      • Supportive care
  • Heparin Induced Thrombocytopenia (HIT)
    • Clinical presentation
      • Recent heparin administration
      • Acute thrombocytopenia (<150) or 50% decrease in platelets
    • Treatment
      • Stop heparin and choose different anticoagulant
  • Disseminated Intravascular Coagulation (DIC)
    • Clinical presentation
      • Patient septic, severe trauma, or otherwise critically ill/injured
      • Multiple abnormal labs
        • Increased PT/PTT
        • Increased D-dimer
        • Increased fibrinogen degradation products
    • Treat underlying trigger
  • Immune/Idiopathic Thrombocytopenic Purpura (ITP)
  • Common condition
    • Relatively benign
  • Treatment
    • Steroids
    • Occasionally platelet transfusion
  • Other causes
    • HIV
    • Hepatitis
    • Heavy alcohol use

Additional Reading

  • Thrombocytopenia: An ED Approach (emDOCs)

Bleeding Disorders

These are most important in trauma patients!!!

Platelet Disorders

  • Symptoms of SUPERFICIAL bleeding
    • Mucosal bleeding
    • GI bleeding
    • Recurrent epistaxis
  • Thrombocytopenia
    • When the platelets ARE LOW
      • Refer to THIS episode
  • Von-Willebrand disease
    • When the platelets CAN’T BIND
    • Treatment
      • Desmopressin (DDAVP)
        • Causes increase in amount of von-willebrand factor (vWF) available
        • Also causes free water retention
          • Treatment of diabetes insipidus
      • Replace vWF
        • Transfuse factor VIII
          • Contains vWF (factor VIII binds vWF)
        • Transfuse cryoprecipitate

The Hemophilias

  • Symptoms of DEEP bleeding
    • Hemarthrosis
    • Hematomas
    • Intracranial Bleeding
  • Factor IX deficiency (Christmas disease)
    • Treat by replacing factor IX
      • Rate the “severity” of the bleeding on a scale of 1-100
        • Dosing equals the severity score in milligrams
          • For example
          • 25 = 25mg/kg factor = mild bleeding (mild hematuria with stable hemoglobin, painful but contained hemarthrosis)
          • 50 = 50mg/kg factor = moderate bleeding = (rapid nose bleeds, rapid bleeding that won’t resolve)
          • 75 = 75mg/kg factor = severe bleeding = (GI bleeds with dropping hemoglobin, retroperitoneal hematoma)
          • 100 = 100mg/kg factor = deadly bleeding = (intracranial hemorrhage)
  • Factor VIII deficiency (Hemophilia A)
    • Treat by replacing factor VIII
      • Dosing similar to factor IX but you take severity score and divide by 2
        • For example
        • 25 = 12mg/kg factor = mild bleeding (mild hematuria with stable hemoglobin, painful but contained hemarthrosis)
        • 50 = 25mg/kg factor = moderate bleeding = (rapid nose bleeds, rapid bleeding that won’t resolve)
        • 75 = 37mg/kg factor = severe bleeding = (GI bleeds with dropping hemoglobin, retroperitoneal hematoma)
        • 100 = 50mg/kg factor = deadly bleeding = (intracranial hemorrhage)

Additional Reading

Fever in a Returning Traveler

If a returning traveler has a fever, think malaria malaria malaria!!!

Step 1: Ask your patient if they have traveled within the last year

  • If yes… You should at least CONSIDER malaria

Step 2: If patient says yes, take a travel history

  • When did they go
  • Where did they stay
  • Where they exposed to anything concerning
    • Mosquitos
    • Animals
    • Weird foods
    • Sexual partners
    • Sick people
  • Where they in developed/tourist areas or “off the trail”

Step 3: Ask about prophylaxis

  • Did they see a doctor before leaving?
  • Did they take any immunizations or medicines prior to departure?
  • Did they continue prophylaxis as instructed?

Step 4: Go to the CDC website

  • Look up the country of concern
  • Will help establish your differential

Step 5: Test for malaria

  • If you are concerned that patient has malaria…
  • Order thick and thin blood smear

Additional Reading

Anaphylaxis

Airway and Epi! Airway and Epi! Airway and Epi!

Introduction

  • Anaphylaxis is caused by massive uncontrolled release of chemicals after exposure to “antigen”
  • The antigen causes extensive mast cell and basophil cross-linking/activation
  • Common antigens
    • Foods
    • Drugs
    • Insect venoms

Basic Approach

  • Step 1: Diagnose anaphylaxis
    • Consider anaphylaxis if the patient has TWO body systems involved
    • Dermatologic symptoms
      • Flushing
      • Rash
      • Urticaria
    • Pulmonary symptoms
      • Shortness of breath
      • Wheezing
    • Cardiovascular symptoms
      • Hypotension
      • Lightheadedness
    • Gastrointestinal symptoms
      • Nausea/Vomiting
      • Diarrhea
  • Step 2: Give epinepherine
    • A major pitfall in the treatment of anaphylaxis is delay of epinephrine!!!
    • Normal adult “EpiPen” contains 0.3mg epinephrine
    • Normal dosing of IM epinephrine is 0.01mg/kg
  • Step 3: Consider intubation
    • The second biggest pitfall in the treatment of anaphylaxis is delaying intubation until it’s extremely difficult to intubate!!!
  • Step 4: Give adjunct medications
    • H1 blocker
      • Diphenhydramine
    • H2 blocker
      • Ranitidine
    • Steroids
      • Prednisone, dexamethasone, etc
  • Step 5: Send the patient home with an EpiPen prescription
    • Education them on this
    • Articulate this part of the plan to your attending
  • Bonus
    • Refractory anaphylaxis
    • Beta-blockers?
      • Treat with glucagon

Additional Reading

Diabetic Ketoacidosis (DKA)

The blood sugar is NOT the emergency- Acidosis, Hypokalemia, and Dehydration are!!!

Signs and Symptoms

  • Vomiting
  • Abdominal pain
  • Polydipsia
  • Polyuria

Step 1: Test for DIABETIC-KETO-ACIDOSIS

  • Diabetes
    • Blood sugar
      • Typically notably elevated (>250 mg/dL)
      • Can be normal in certain circumstances
  • Ketones
    • Easiest test is a urinalysis
    • Serum ketones also can be obtained
  • Acidosis
    • Blood gas (arterial or venous)
      • pH <7.3

Step 2: Check Potassium Level

  • Patients frequently depleted of whole body potassium
  • Insulin administration will causes further drops in serum potassium level

Step 3: Replace Potassium

  • If potassium <3.3, do not give insulin
    • Replace potassium prior to insulin
  • If potassium >3.3 but <5.5
    • Consider supplementing potassium at this point
    • May continue insulin

Step 4: Give Fluids

  • Adult patients are frequently 3-6 LITERS depleted
  • 20 ml/kg NS during first hour

Step 5: Start an Insulin Drip

  • This accomplishes 2 things…
    • It decreases blood sugar
    • It also decreases acid production

Additional Reading

Hyperkalemia

Hyperkalemia = EKG… EKG changes = Calcium…

Step 1: Recheck the Potassium

  • Most common cause of hyperkalemia is PSEUDOhyperkalemia
    • Caused by too aggressive/fast of a blood draw
      • Causes RBCs to break open and falsely increase serum potassium

Step 2: Get an EKG

  • Earliest EKG change
    • Peaked T waves
  • Late EKG changes
    • Flattened P wave
    • Prolonged QRS
  • Critical/Emergent EKG changes
    • Sine wave

Step 3: Protect the Heart

  • EKG Changes = Give Calcium
    • Calcium gluconate (can be given IV)
    • Stabilizes the myocardium against dysrhythmia

Step 4: Shift Potassium Into Cells

  • Insulin (plus D50)
  • Albuterol

Step 5: Remove Potassium from Body

  • Kayexalate
    • Notorious for causing intestinal necrosis
    • Falling out of favor
  • Furosemide

Additional Reading

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