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

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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)

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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)

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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)

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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)

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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

• Approach to Thrombocytopenia (EM Clerkship)
• Treatment of Hemophilia (Hemophilia.org)

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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

• CDC Yellow Book (CDC Website)

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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

• Round 10 – Allergic Reaction (EM Clerkship)
• How to Use an EpiPen (YouTube)

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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

• Peds H- Hyperglycemia and Hypoglycemia (EM Clerkship)
• DKA Myths (REBEL EM)

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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

• Round 8 – Fall (EM Clerkship)
• Emergency Management of Hyperkalemia (EM Cases)