Carolinas Emergency Medicine Residency

June 02nd, 2016

6/2/2016

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URIs are common in children... acute sinusitis is not. Approximately 6-8% of children with URI symptoms meet criteria for acute bacterial sinusitis

Diagnostic criteria for acute bacterial sinusitis have been revised in the last few years. There are three clinical courses that constitute a diagnosis acute bacterial sinusitis...

- persistent symptoms without improvement
- severe onset of symptoms
- worsening clinical course

So that means, we don't diagnose sinusitis in children with imaging studies.
However, if you are worried about orbital or CNS involvement, it is recommended to evaluate with contrast CT or MRI.
It is most often caused by S. pneumoniae, H. influenzae, and M. catarrhalis. S. aureushas not been identified as a major etiology.

Antibiotic treatment should take into account S. pneumoniae resistance patterns and beta lactamase production of H. influenzae and M. catarrhalis - high dose amoxicillin (90mg/kg/day BID) or Augmentin (90mg amoxicillin/kg/day BID) are first line choices.

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STDs in 2016 - Dr. Callahan

3/23/2016

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CDC 2015 recommendations include screening all patients age 13-64 for HIV, especially if they have another STD in opt out approach. We need to consider working towards doing this here at CMC and wherever you go practice.
Managing sexual partners: options include patient referral, provider referral, expedited partner therapy (EPT). EPT based on multiple RCTs appears to be superior and involves sending prescription with patient to give to partner.
Sexual Assault victim: treat with rocephin, azithromycin, flagyl, hepatitis B vaccine. CDC with algorithm for HIV prophylaxis. If significant exposure and presents within 72 hours treat with zidovudine for 28 days.
PID: spectrum from cervicitis to TOA and peritonitis. Strongly consider ultrasound as first line imaging. 50 % STD related. Treat uncomplicated with rocephin and 2 weeks doxycycline. TOA, pregnancy, ill appearing admit for IV antibiotics/OB GYN consultation.
Epidydimitis: Consider US also. Less than 35 or STD exposure-treat rocephin, 2 weeks doxycycline.
Complications of gonorrhea: PID, septic arthritis, Fitz Hugh Curtis, disseminated gonococcemia, meningitis, conjunctivitis. Neonates-day 2-5, full sepsis workup and admit for IV antibiotics.
Complications of chlamydia: infertility, PID, Reiter syndrome. Recommend treating with PO azithromycin 1 g including pregnancy.
Syphillis: treat with penicillin, different regimens depending on stage. Ocular and neurosyphilis requires CSF, admission, IV antibiotics.
Less common STDs include Chancroid, Lymphogranuloma Venereum, Donovanosis. Treat with rocephin and doxycycline.

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Carolinas Case Conference - Dr. Young

9/3/2015

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Myocarditis:
- broad spectrum of disease, high level of suspicion is essential
- myocarditis can mimic STEMI and Wellens syndrome among others
- EKG, echo, and cardiac enzymes cannot rule in/out the diagnosis
- No hesitation to consult Peds Cards

NAT:
- no discrimination, occurs in all people groups
- history, exam, and physical findings may raise suspicion for abuse.
- must place child in gown.
- make sure story matches up... loose ends must be tied

Marfan and PTX:
- Must be personally knowledgeable about equipment associated with procedures (ie: suction device for chest tubes)
- Pigtail catheters equivalent to thoracostomy tubes for uncomplicated PTX with decreased pain - http://pedemmorsels.com/pigtail-catheter/

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Necrotizing Fasciitis - Dr. El-Kara

3/12/2015

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Keep clinical suspicion high
Wide range of presentation - can be challenging!
Early surgical intervention is life saving
Consider the LRI-NEC Score for equivocal cases
Add Clindamycin to decrease mortality

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Meningitis - Dr. Winters

9/18/2014

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Steroids in meningitis
    - All cause meningitis - reduction in hearing loss and neuro sequelae ; nonstatistical reduction in mortality
        *** Pediatric - reduction in hearing loss and neurologic seuelae in Hflu; no recs in neonates
        *** Adult - decrease in mortality in strep pneumo

    - Steroids are thought to reduce CSF penetration of antibiotics
        *** Can be bad in resistant bugs

    - Don't give steroids after you give antibiotics

Not everyone needs CT before LP
IDSA rec CT - Age > 60, history of CNS disease (stroke, focal infection, mass lesion), immunocompromise, papilledema, altered level of consciousness, focal neuro deficit, new onset seizure within one week of presentation - may be too sensitive

Newer data - documented normal CT that herniated after LP > newer recommendations - no LP if evidence of impending herniation

Chemoprophylaxis for meningitis
- Household contacts, school or daycare contacts, direct exposure to patients secretions - first line is rifampin, second line is cipro

HSV meningitis - affects limbic structures of temporal and frontal lobes

- 70% mortality untreated > 20% if treated with acyclovir
- New psych symptoms or behavioral symptoms, cognitive deficits are more common
- Seizures
- CSF findings - pleocytosis with lymphocytic predominance, elevated RBC, elevated protein,
     > Beware that the CSF - can be normal in early disease process, can have neutrophil predominance, can have normal RBC, and glucose can be reduced

Tuberculosis
  - Common in HIV patients
  - Indolent course then rapid progression
  - Suggestive CSF - clear appearance, lower pressure, < 50 PMN in kids, >30% lymphocytes in adults
  - Def give steroids in these patients

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Rocky Mountain Spotted Fever - Dr. Schneider

5/29/2014

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School-aged kids are the most likely to get RMSF!
North Carolina has the most cases in the USA.
Summer time + Headache + Fever +/- rash / exposure = Just treat, because time is of the essence.
You can perform LP or not. Depends on your index of suspicion for other forms of meningitis. CSF is not helpful in the diagnosis of RMSF, but it can help rule-out other conditions.
Doxy is not the Devil! Children can have a full course of doxycycline and not ruin their teeth.

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Patrick Jackson - Rocky Mountain Spotted Fever

9/7/2013

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Remember RMSF happens year round, even though 90% of cases occur between April and Sept.
Think RMSF for patient presenting with “flu-like” illness in summer time in endemic area.
Only 50% of people with RMSF remember a tick bite or exposure.

Classic triad is rarely, if ever, present in initial patient encounter.
Patients with mainly viral gastroenteritis symptoms are the ones most commonly missed with RMSF.
10-15% never develop a rash. Rocky Mountain Spotless Fever.
Rash starts as macular, then progresses to maculopapular, then petechial (rash 2-4 days after fever onset)

Workup is clinical: Normal WBC, no thrombocytopenia, few physical exam findings.
Do NOT place too much emphasis on serology results (takes minimum 7-10 days for positive serology conversion).

Doxycycline is the first line treatment for all patients (including pregnant and pediatrics)
Empiric therapy is recommended if: Febrile, endemic area, April-Sept, and headache or other constitutional symptoms.
Include doxycycline in your empiric coverage of patients suspected for meningitis/RMSF.
Prescribe Doxycycline monohydrate CAPSULE (cheapest).

Asymptomatic tick exposure does not get prophylaxis.

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June 02nd, 2016

STDs in 2016 - Dr. Callahan

Carolinas Case Conference - Dr. Young

Necrotizing Fasciitis - Dr. El-Kara

Meningitis - Dr. Winters

Rocky Mountain Spotted Fever - Dr. Schneider

Patrick Jackson - Rocky Mountain Spotted Fever

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