Emergency Medicine EOR

HACEK

HACEK: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella (hard to culture)

HACEK organisms in endocarditis present when

native valves in community acquired

tx of HACEK endocarditis

ceftriaxone

MCC of endocarditis, valve, and when it occurs

Streptococcus viridans, *mitral valve

*usually as late complication of valve replacement

MCC of bacterial endocarditis in IVDU and MC valve

- staph aureus - causes smaller vegetations

- tricuspid valve

stroke + fever think

think endocarditis!

patient has vegetation on the aortic or mitral valve the vegetation breaks off goes up to the brain causes the stroke. They will have the fever from the endocarditis and the vegetation in brain causing the stroke.

MCC of bacterial endocarditis in prosthetic valve

Staphylococcus epidermidis (within 60 days) or staph aureus

candida endocarditis

- slow-growing organism

- most common source is a contaminated line

- typically causes large vegetations in endocarditis.

- Large vegetation endocarditis in the early post-valve replacement period (2 months post-surgery) is most likely due to fungus, that is, Candida infection

what causes subacute bacterial endocarditis

Indolent (slow moving) infection of abnormal valves with less virulent organisms (S. viridans)

osler nodes

PAINFUL raised lesions on palms and soles with endocarditis

(O = ouch!)

*result from deposition of immune complexes

Janeway leisions

PAINLESS macule on palms/soles

what cause Osler nodes and Janeway lesions

emboli that lodge in small blood vessels in the skin.

4 classic peripheral findings of bacterial endocarditis

Janeway lesions, Osler nodes, Roth spots, Splinter hemorrhages

other physical signs of bacterial endocarditis

Petechiae: These are small, flat hemorrhages on the skin. They are caused by bleeding from small blood vessels.

Purpura: These are larger, raised hemorrhages on the skin. They are also caused by bleeding from small blood vessels.

Clubbing: This is a thickening of the fingertips and/or toenails. It is caused by a decrease in the amount of oxygen in the blood.

Splenomegaly: This is an enlargement of the spleen. It is caused by an increased number of white blood cells in the spleen.

Hepatomegaly: This is an enlargement of the liver. It is caused by inflammation or infection of the liver.

Hematuria: Due to emboli or glomerulonephritis.

Neurologic findings consistent with CVA, such as visual loss, motor weakness, and aphasia

who needs prophylaxis in endocarditis

1. Prosthetic heart valve 2. Heart repair using prosthetic material 3. Prior history of endocarditis 4. Congenital heart disease

diagnostic study of endocarditis

- 3 sets of blood cultures 1 hour apart

- EKG

- echo

- CBC

gold standard diagnosis of bacterial endocarditis

transesophageal echocardiogram

How to qualify for endocarditis based off of Duke criteria

2 major OR 1 major + 3 minor OR 5 minor

Major duke criteria

1. sustained bacteremia (2 positive cultures)

2. endocardial involvement --> positive echo showing vegetations or NEW valvular regurgitation

Minor duke criteria

1. predisposing condition (IVDU)

2. Fever (over 100.4)

3. vascular/embolic phenomena: janeway lesion, septic emboli, ICH

4. Immunologic phenomena: Osler nodes, Roth spots, positive RF, acute glomerulonephritis

5. positive blood culture not meeting major criteria

6. positive echo not meeting major criteria

empiric therapy for native valve bacterial endocarditis

PCN/ampicillin + gentamicin + vanco (in IVDU)

(IV ampicillin+ nafcillin + gentamicin)

empiric therapy for prosthetic valve bacterial endocarditis

Vanco + gentamicin + rifampin

tx of endocarditis in IVDU

IV nafcillin

abx prophylaxis for endocarditis

2 g of Amoxicillin 30-60 minutes before the procedure

tx of fungal endocarditis

Amphotericin B, caspofungin

- if severe --> valve replacement

how long to treat bacterial endocarditis

4-6 weeks

tx of laryngitis

self-limited

- oral and IM steroids for vocal performers to hasten recovery

tx of bacterial laryngitis

erythromycin, cefuroxime, or Augmentin

MC bugs of acute otitis media

strep pneumo, h. flu, moraxella catarrhalis

diagnosis of AOM

1) bulging of the tympanic membrane or 2) other signs of acute inflammation (e.g., marked erythema of the tympanic membrane, fever, ear pain) and middle ear effusion

AOM diagnosis for children under 2

limited mobility of the TM with pneumotoscopy

- they will usually be tugging at the ear

what does tuning fork show for AOM

bone conduction > air conduction

acute otitis media timeline

under 3 weeks

tx timeline for AOM

< 2 y for 10 days

> 2 y for 5-7 days

complications of AOM

Mastoiditis and bullous myringitis

tx of AOM

- amoxicillin

- 2nd line= amox-clav

- PCN allergy = azithro, Bactrim

tx of chronic or recurrent otitis media

myringotomy with ventilation tube

tx of auricular hematoma (to prevent cauliflower ear)

- evacuate clot

- cephalexin to prevent infection

centor criteria for strep pharyngitis

1. fever >100.4

2. pharyngotonsillar exudates

3. tender anterior cervical lymphadenopathy

4. absence of cough

0-1, nothing needed

2-3, throat culture

4-5, give abx (PCN)

tx of strep pharyngitis

PCN *prevent rheumatic fever*

- erythromycin if allergy

most cases of pharyngitis are due to

viral - adenovirus

tx of pharyngitis

- symptomatic = fluids, warm saline, lozenges

- fungal = clotrimazole, nystatin

non-resolving pharyngitis + sexually active, consider

gonorrhea pharyngitis

inhaled steroid use + pharyngitis, consider

fungal pharyngitis

3/4 Centor criteria met ---> get _____ --> if negative, get _____

rapid strep test ---> throat culture (gold standard)

what causes GABHS pharyngitis

S. pyogenes

tx of fungal pharyngitis

clotrimazole, miconazole, or nystatin

tx of Gonococcal pharyngitis

ceftriaxone IM

what can happen if you do not treat strep pharyngitis

scarlet fever, glomerulonephritis, acute rheumatic fever, abscess formation

diagnosis of bullous pemphigoid

skin biopsy with direct immunofluorescence exam shows deposition of IgG and C3 basement membrane

bullous pemphigoid s/s

- Tense pruritic blisters, widespread bullae, usually in lower trunk, itchy, dense, symmetric

- negative Nikolsky sign

- does not effect mucus membranes

what is bullous pemphigoid

chronic autoimmune condition that is IgG produced, usually in pts over 60

tx of bulls pemphigoid

steroids

major burn characterized as

>25% TBSA adult, >20% young/old, >10% full thickness burn, burns involving face, hands, perineum, feet, cross major joints/circumferential

who needs fluid resuscitation with a burn

children with TBSA over 10%, adults with over 15%

1st degree burn

Erythema of involved tissue, skin blanches with pressure, the skin may be tender

tx of burns

Monitor ABCs, fluid replacement, irrigate chemical burns for 20mins, wrap fingers and toes individually, and sulfadiazine

cervical sprain s/s

stiffness, paarspinal muscle tenderness, spasm, + spurling test

cervical sprain tx

cervical collar for 2-3 days, NSAIDs, ice/heat

muscle relaxant for back strain

cyclobenzaprine, could also use benzodiazepine

back strain caused by

lifting, twisting, or strenuous activity --> is the MCC of back pain

non septic olecranon bursitis

acute trauma or repetitive trauma causes inflammation of the olecranon bursa

olecranon septic bursitis

- infection from microorganisms transferred via trauma to the skin overlying the bursa -- MC = staph aureus

- Pain or fever may suggest an infectious etiology - R/O septic or gout - aspirate

what could be helpful to treat bursitis and tendonitis

steroid injections (not in patellar though!!)

treat olecranon bursitis

PT, rest and ice, systemic antibiotics based on culture if septic, NSAIDS, injected corticosteroids and joint, operative bursectomy

when to aspirate bursitis?

septic, fever, DM, immunocompromised

tx of septic bursitis (normal and MRSA)

dicloxacillin or cephalexin

MRSA = bactrim or clindamycin

Pre-patellar bursitis (housemaid's knee)

- due to increased pressure on knee

- swelling over the patella

- common in wrestlers - concern for septic bursitis

tx of pre patellar bursitis

compressive wrap, NSAIDs, +/- aspiration, and immobilization

Patellofemoral Pain Syndrome

"runner's knee", which refers to anterior knee pain that worsens while going up or down stairs, walking hills, or prolonged sitting with knees flexed

*sunrise view on xray

pes anserine bursitis

MEDIAL knee pain; secondary to overuse

subacromial bursitis

superior surface of the supraspinatus tendon from the overlying coracoacromial ligament, acromion, and coracoid (the acromial arch) and from the deep surface of the deltoid muscle

*pain not associated with trauma usually

s/s of subacromial bursitis

pain with motion and at rest can cause fluid to accumulate. The presentation is very similar to what you would see with subacromial impingement

when to aspirate subacromial bursa

fever, diabetic or immunocompromised

features of tendonitis

pain with movement, swelling, impaired function; resolves over several weeks but recurrence common

patellar tendonitis

- "jumper's knee"

- Activity-related anterior knee pain associated with focal patellar tendon tendernes

Basset's sign

tenderness to palpation at the distal pole of the patella in full extension and no tenderness to palpation at the distal pole of the patella in full flexion --> patellar tendonitis

tx of patellar tendonitis

Ice, rest, activity modification, followed by physical therapy. Surgical excision and suture repair as needed

diagnosis of patellar tendonitis

History and physical examination are usually sufficient for diagnosis of infrapatellar tendinitis

- MRI can show the extent of the injury

what is C/I in patellar tendonitis care

steroid injections --> risk of tendon rupture!

presentation of bicep tendonitis

- pain in the biceps groove

- Anterior shoulder pain - may have pain radiating down the region of the biceps, symptoms may be similar in nature and location to the rotator cuff or subacromial impingement pain

- Pain with resisted supination of the elbow

Popeye deformity

biceps tendon rupture

MRI of biceps tendonitis

thickening and tenosynovitis of proximal biceps tendon - increased T2 signalaround the biceps tendon

tx of bicep tendonitis

NSAIDs, PT strengthening, and steroid injections

special tests for bicep tendonitis

Speed test and Yergason's test

speed test

*biceps tendonitis

- Pain elicited in the bicipital groove when the patient attempts to forward elevate shoulder against examiner resistance while the elbow extended, and forearm supinated

- Positive if the pain is reproduced

- May also be positive in patients with SLAP lesions

Yergason's test

- Elbow flexed 90 degrees, wrist supination against resistance -Positive if the pain is reproduced.

what is cauda equina syndrome

midline disk herniation that compresses nerve roots usually at L4-L5 level

dx of cauda equina

MRI - new onset urinary symptoms with associated back pain/sciatica

tx of cauda equina

urgent surgical referral --> laminectomy to decompress

Costochondritis s/s

pain and tenderness on the breastbone, pain in more than one rib, or pain that gets worse with deep breaths or coughing

risk factors for costochondritis

age >40, high-impact sports, manual labor, allergies, rheumatoid arthritis, ankylosing spondylitis, reactive arthritis

pain with costochondritis

reproduced with palpation of the chest wall area

(if not, think of another diagnosis)

tx of costochondritis

- Tylenol, NSAIDs

- Applying heat

-PT, local steroid injection

what more serious condition may mimic costochondritis

Pulmonary embolism

Tietze syndrome

costochondritis + palpable edema; inflammatory process

tx of proximal humerus fx

sling

splint for distal or shaft humerus fracture

sugar tong splint (distal) and coaptation splint (shaft)

complication of distal/shaft humerus fracture

radial nv injury = wrist drop

complication of proximal humerus fracture

axillary nv injury --> avascular necrosis or deltoid paresthesia