WikEM - User contributions [en]

Meningitis

2014-06-12T21:10:51Z

Teachmd: /* Acute Treatment */

== Background ==
*Microbiology
**Bacterial meningitis:
***Pneumococcus (60%), meningococcus (15%), GBS (15%), H flu (7%), listeria (2%)
**Viral meningitis
***Echo, coxsackie, entero (85%)
***HSV, CMV
*Pathophysiology
**Hematogenous spread via respiratory tract
**Contiguous spread (otitis media, sinusitis, brain abscess)

=== Risk Factors ===
#[[Otitis Media]]
#[[Sinusitis]]
#Immunosuppression/splenectomy
#[[Alcoholism]]
#[[Pneumonia]]
#[[Diabetes Mellitus]]
#CSF leak
#[[Endocarditis]]
#Neurosurgical procedure / head injury
#Indwelling neurosurgical device / cochlear implant
#Malignancy

=== Classification ===
#Acute (<24hr)
##Usually bacterial in origin (25%)
#Subacute (1-7d)
##Viral or bacterial
#Chronic (>7d)
##Viral, TB, syphilis, fungi, carcinomatous

== Clinical Features ==
*Almost all patients present w/ at least 2 of the following:
**[[Headache]]
**[[Fever]]
**Neck stiffness
**[[Altered Mental Status]]
*Also may have:
**Photophobia
**Vomiting
**Prodromal URI
**Focal neuro sx (e.g. CN deficit)
**[[Seizure]] (25%)
*Jolt Test (~100% Sn)
**Have pt rapidly shake head L and R; if does not bother pt unlikely to have meningitis

===[[Lumbar Puncture]] Diagnosis===
{{Lumbar Puncture Diagnosis}}

== Differential Diagnosis ==
{{Headache DDX}}

== Work-Up ==
#CBC
#Chem
#Blood cx
#?CT head: See [[CT Before Lumbar Puncture]]
#CXR (50% of pts w/ pneumoccocal meningitis have e/o pna on CXR)
#CSF studies
##Glucose and protein (Tube 1)
##Gram stain and culture (Tube 2)
##Cell count and differential (Tube 3)
##Special studies if indicated (HSV PCR, india ink) - Tube 2
##Hold (Tube 4)

==Management==
===Acute Treatment===
#Abx
##Give as soon as possible (if LP performed w/in 2hr of abx CSF culture will not be affected)
##Guidelines
###Age 18-50y
####[[Ceftriaxone]] 2gm IV q12hr + [[vancomycin]] 15mg/kg q8-12hr
#####(vancomycin is for resistant pneumococcus)
###Age >50y
####[[Ceftriaxone]] 2gm IV q12hr + [[vancomycin]] 15mg/kg q8-12hr + ampicillin 2gm IV q4h
#####(Ampicillin is for listeria)
###CSF leak w/ history of closed head trauma
####[[Ceftriaxone]] 2gm IV q12hr + [[vancomycin]] 15mg/kg q8-12hr
###History of recent penetrating head injury, neurosurgery, CSF shunt
####(Ceftazidime 2gm IV q8hr or cefepime or meropenem) + vanco 25 milligrams/kg load
###Meningitis due to sinusitis
####[[Ceftriaxone]] + metronidazole
###Meningitis with severe PCN allergy
####chloramphenicol 1g IV q6h + [[vancomycin]] 15mg/kg q8-12hr
#Dexamethasone
##Only give prior to or w/ first dose of abx
##10mg IV q6hr x4d
#Mannitol
##For marked cerebral edema
#Acyclovir
##Consider for pts w/ suspected viral meningitis who present w/ neuro deficits
##10mg/kg IV q8hr (Obese patients should be dosed using ideal body weight)

===Prophylaxis===
*For meningococcus exposure
**Indications:
***Household contacts
***School or day care contacts in previous 7d
***Direct exposure to pt's secretions (kissing, shared utensils or toothbrush)
***Intubation without facemask
**Meds
***Rifampin 600mg PO BID x2d OR [[ceftriaxone]] 250mg IM x1 OR ciprofloxacin 500mg PO x1

==Disposition==
#Bacterial meningitis
##Admit w/ droplet precautions
#Viral meningitis
##Admit for empiric abx until culture results return OR
##Discharge w/ 24hr f/u

==See Also==
*[[Meningitis (Peds)]]

== Source ==
Tintinalli,
Lexicomp

[[Category:ID]]
[[Category:Neuro]]

Rapid sequence intubation

2012-06-03T09:51:43Z

Teachmd:

==Agents==
===Premedication===
*[[Atropine]]
**0.02 mg/kg, minimum dose 0.1 mg
**Prevents bradycardia & dries secretions
**Indications:
***Intubation in child < 1 yr old
***Intubation in child 1-5 yrs old using succinylcholine
***Intubation in child > 5 yrs old using second dose of succinylcholine
*[[Lidocaine]]
**1.5 mg/kg
**Lowers ICP
*Fentanyl
**3 mcg/kg
**Blunts sympathetic response to intubation (pretreat if concern for inc ICP/BP, i.e. ICH, aortic dissection)
**Should be the last agent given

===Induction===
*Etomidate 0.2-0.4 mg/kg
**Onset - 1 min
**Duration - 30-60 min
*Versed 0.2-0.3 mg/kg (max 5 mg)
**Onset - 1 to 2 min
**Duration - 30-60 min
*[[Propofol]] 1-3 mg/kg
**Duration - 10-15 min
*[[Ketamine]] 1-2 mg/kg IV or 3-4 mg/kg IM
**Duration - 30 min
===Paralytics===
*[[Succinylcholine]]
**1.5 mg/kg (>10 y/o)
**2.0 mg/kg (< 10 y/o)
**4mg/kg IM if no line
**Onset - 45s
**Dur - 10-15 min
*Rocuronium
**1.2 mg/kg (intubate)
**0.6mg/kg (paralyze)
**Onset - 60s
**Dur - 25-60 min
*Vecuronium
**0.3 mg/kg (intubate)
**0.1mg/kg (paralyze)
**Onset - 60-90 s
**Dur - 90 min

==7 Ps==
===1. Preparation===
*SOAPME: (Suction, oxygen, airway, pharmacology, monitoring, equipment)
===2.Preoxygenation===
*Nitrogen wash-out
**100% NRB for 3-5min or 8 VC breaths (BVM) w/ high-flow O2
===3. Pretreatment===
*Ischemic heart dz/dissection: Fentanyl 3-5mcg/kg
*Incr ICP: Fentanyl 3-5mcg/kg (+/- lidocaine 1.5mg/kg (some think drop in MAP not worth it))
*Reactive Airway Dz: [[Lidocaine]] 1.5mg/kg (suppresses cough reflex)
*Peds (age <1): Atropine 0.01-.02mg/kg (min 0.1 mg, max 0.5 mg)
**Controversial

===4. Paralysis with induction===
*INDUCTION
**Etomidate (0.3mg/kg)
***Especially good for hypotensive/trauma patients
***Hemodynamically neutral, lowers ICP
***Lowers seizure threshold in patients with known sz disorder
***Does NOT blunt sympathetic reaction to intubation (no analgesic effect)
***Adrenal suppression is likely irrelevant with one-time dose
**[[Ketamine]] (1-4mg/kg)
***Agent of choice for asthmatics
***Available in IM form
***Sympathomimetic
****Avoid in pt with incr. ICP AND HTN
****Consider in pt with incr. ICP AND hypotension or normal BP
**Midazolam (0.2 mg/kg)
***Consider in pt with CHF (nitro-life effect --> decr. vent filling pressure)
***Consider in pt in status epilepticus (anti-seizure effect)
***May decrease MAP, especially if pt hypovolemic
**[[Propofol]] (1.5 to 3 mg/kg)
***Consider in pt with bronchospasm
***Decreases MAP, CPP
*PARALYSIS
**[[Succinylcholine]]
***1.5 mg/kg - better to overdose than to underdose
***2mg/kg - neonates/infants
**Contraindications
***Stroke <6 months old, MS, muscular dystrophies
***ECG changes c/w hyperkalemia
***OK to use in crush injury, acute stroke as long as within 3 days of occurrence
**Rocuronium
***1-1.2mg/kg
===5. Protection and positioning===
*Sniffing position

===6. Pass Tube===
*[[Intubation]]
*End-tidal CO2 detection is primary means of ETT placement confirmation
*Cola-complication: need CO2 detection for at least 6 ventilations

===7. Postintubation management===
*CXR
*Pain control/sedation
**Fentanyl gtt
**Midazolam 0.05mg/kg spot boluses

==See Also==
*[[Intubation]]

==Source ==
Harwood & Nuss, UpToDate

[[Category:Airway/Resus]]
[[Category:Drugs]]

Streptococcal pharyngitis

2012-03-12T14:58:15Z

Teachmd: /* Source */

==Background==
*Strep pharyngitis
**Peak in 5-15yr old
**Rare in <2yr of age
**Accounts for only 15-30% of pharyngitis

==Diagnosis==
===Clinical Features===
*Sore throat
*Painful swallowing
*Fever
*N/V
*Tonsillar exudate

===Centor Criteria===
#History of fever
#Absence of cough
#Lymphadenopathy
#Tonsillar exudate or swelling

==DDx==
#Causes
##Viral pharyngitis
##Retropharyngeal abscess
##[[Infectious Mononucleosis‎|EBV pharyngitis]]
##CMV pharyngitis
##Gonococcal pharyngitis
#Others
##[[PTA]]
##[[Retropharyngeal Abscess]]
##[[Ludwig's Angina]]
##[[Epiglottitis]]

== Treatment ==

=== Treatment Algorithm by Centor Criteria ===

{| cellspacing="1" cellpadding="1" border="1" style="width: 333px; height: 129px;"
|-
| '''Points''' 
| '''Treatment''' 
|-
| 4 
| Rx without testing
|-
| 3 
| Rapid Strep Test
|-
| 2 
| Rapid Strep Test
|-
| 1 
| Do not test/treat
|-
| 0 
| Do not test/treat
|}

*Likelihood of streptococcal pharyngitis in pts presenting with sore throat
**4 criteria = 50% PPV
**3 criteria = 40% PPV
**0 criteria - 80% NPV

=== Treatment Medications ===

*Abx
**Tx can be delayed for up to 9 days and still prevent major sequelae
**Choices
***Penicillin
****250mg BID x 10d (child) or 500mg BID x 10d (adolescent)
***Bicillin
****25-50Kmg/kg IM x 1 (max dose = 1.2million)
***PCN Allergic
****Cephalosporin (e.g.: Cefuroxime 10mg/kg PO QID x 10d (child) or 250mg PO BID x 4d)
****If hx of PCN anaphylaxis: clindamycin 7.5mg/kg PO QID x 10d (child) or 450mg PO TID x 10d
****Azithromycin 12mg/kg QD (child) or 500mg on day 1; then 250mg on days 2-5 [resistance rates as high as 15% in US]
*Steroids
**Single dose of dexamethasone shortens duration of pain

==See Also==
*[[Peritonsilar Abscess]]

==Source==
*Tintinalli
*Rosen's
*Logan LK, McAuley JB, Shulman ST. [Macrolide treatment failure in streptococcal pharyngitis resulting in acute rheumatic Fever]. Pediatrics. 2012 Mar;129(3):e798-802. Epub 2012 Feb 6.
[[Category:Peds]]
[[Category:ENT]]
[[Category:ID]]

Streptococcal pharyngitis

2012-03-12T14:54:09Z

Teachmd: /* Treatment Medications */

==Background==
*Strep pharyngitis
**Peak in 5-15yr old
**Rare in <2yr of age
**Accounts for only 15-30% of pharyngitis

==Diagnosis==
===Clinical Features===
*Sore throat
*Painful swallowing
*Fever
*N/V
*Tonsillar exudate

===Centor Criteria===
#History of fever
#Absence of cough
#Lymphadenopathy
#Tonsillar exudate or swelling

==DDx==
#Causes
##Viral pharyngitis
##Retropharyngeal abscess
##[[Infectious Mononucleosis‎|EBV pharyngitis]]
##CMV pharyngitis
##Gonococcal pharyngitis
#Others
##[[PTA]]
##[[Retropharyngeal Abscess]]
##[[Ludwig's Angina]]
##[[Epiglottitis]]

== Treatment ==

=== Treatment Algorithm by Centor Criteria ===

{| cellspacing="1" cellpadding="1" border="1" style="width: 333px; height: 129px;"
|-
| '''Points''' 
| '''Treatment''' 
|-
| 4 
| Rx without testing
|-
| 3 
| Rapid Strep Test
|-
| 2 
| Rapid Strep Test
|-
| 1 
| Do not test/treat
|-
| 0 
| Do not test/treat
|}

*Likelihood of streptococcal pharyngitis in pts presenting with sore throat
**4 criteria = 50% PPV
**3 criteria = 40% PPV
**0 criteria - 80% NPV

=== Treatment Medications ===

*Abx
**Tx can be delayed for up to 9 days and still prevent major sequelae
**Choices
***Penicillin
****250mg BID x 10d (child) or 500mg BID x 10d (adolescent)
***Bicillin
****25-50Kmg/kg IM x 1 (max dose = 1.2million)
***PCN Allergic
****Cephalosporin (e.g.: Cefuroxime 10mg/kg PO QID x 10d (child) or 250mg PO BID x 4d)
****If hx of PCN anaphylaxis: clindamycin 7.5mg/kg PO QID x 10d (child) or 450mg PO TID x 10d
****Azithromycin 12mg/kg QD (child) or 500mg on day 1; then 250mg on days 2-5 [resistance rates as high as 15% in US]
*Steroids
**Single dose of dexamethasone shortens duration of pain

==See Also==
*[[Peritonsilar Abscess]]

==Source==
*Tintinalli
*Rosen's

[[Category:Peds]]
[[Category:ENT]]
[[Category:ID]]

Streptococcal pharyngitis

2012-03-12T14:43:28Z

Teachmd: /* Treatment Medications */

==Background==
*Strep pharyngitis
**Peak in 5-15yr old
**Rare in <2yr of age
**Accounts for only 15-30% of pharyngitis

==Diagnosis==
===Clinical Features===
*Sore throat
*Painful swallowing
*Fever
*N/V
*Tonsillar exudate

===Centor Criteria===
#History of fever
#Absence of cough
#Lymphadenopathy
#Tonsillar exudate or swelling

==DDx==
#Causes
##Viral pharyngitis
##Retropharyngeal abscess
##[[Infectious Mononucleosis‎|EBV pharyngitis]]
##CMV pharyngitis
##Gonococcal pharyngitis
#Others
##[[PTA]]
##[[Retropharyngeal Abscess]]
##[[Ludwig's Angina]]
##[[Epiglottitis]]

== Treatment ==

=== Treatment Algorithm by Centor Criteria ===

{| cellspacing="1" cellpadding="1" border="1" style="width: 333px; height: 129px;"
|-
| '''Points''' 
| '''Treatment''' 
|-
| 4 
| Rx without testing
|-
| 3 
| Rapid Strep Test
|-
| 2 
| Rapid Strep Test
|-
| 1 
| Do not test/treat
|-
| 0 
| Do not test/treat
|}

*Likelihood of streptococcal pharyngitis in pts presenting with sore throat
**4 criteria = 50% PPV
**3 criteria = 40% PPV
**0 criteria - 80% NPV

=== Treatment Medications ===

*Abx
**Tx can be delayed for up to 9 days and still prevent major sequelae
**Choices
***Penicillin
****250mg BID x 10d (child) or 500mg BID x 10d (adolescent)
***Bicillin
****25-50Kmg/kg IM x 1 (max dose = 1.2million)
***Azithromycin (penicillin allergic)
****12mg/kg QD (child) or 500mg on day 1; then 250mg on days 2-5
****High resistance rates; consider cephalosporin or clindamycin
*Steroids
**Single dose of dexamethasone shortens duration of pain

==See Also==
*[[Peritonsilar Abscess]]

==Source==
*Tintinalli
*Rosen's

[[Category:Peds]]
[[Category:ENT]]
[[Category:ID]]

Streptococcal pharyngitis

2012-03-12T14:41:58Z

Teachmd: /* Centor Criteria */

==Background==
*Strep pharyngitis
**Peak in 5-15yr old
**Rare in <2yr of age
**Accounts for only 15-30% of pharyngitis

==Diagnosis==
===Clinical Features===
*Sore throat
*Painful swallowing
*Fever
*N/V
*Tonsillar exudate

===Centor Criteria===
#History of fever
#Absence of cough
#Lymphadenopathy
#Tonsillar exudate or swelling

==DDx==
#Causes
##Viral pharyngitis
##Retropharyngeal abscess
##[[Infectious Mononucleosis‎|EBV pharyngitis]]
##CMV pharyngitis
##Gonococcal pharyngitis
#Others
##[[PTA]]
##[[Retropharyngeal Abscess]]
##[[Ludwig's Angina]]
##[[Epiglottitis]]

== Treatment ==

=== Treatment Algorithm by Centor Criteria ===

{| cellspacing="1" cellpadding="1" border="1" style="width: 333px; height: 129px;"
|-
| '''Points''' 
| '''Treatment''' 
|-
| 4 
| Rx without testing
|-
| 3 
| Rapid Strep Test
|-
| 2 
| Rapid Strep Test
|-
| 1 
| Do not test/treat
|-
| 0 
| Do not test/treat
|}

*Likelihood of streptococcal pharyngitis in pts presenting with sore throat
**4 criteria = 50% PPV
**3 criteria = 40% PPV
**0 criteria - 80% NPV

=== Treatment Medications ===

*Abx
**Tx can be delayed for up to 9 days and still prevent major sequelae
**Choices
***Penicillin
****250mg BID x 10d (child) or 500mg BID x 10d (adolescent)
***Bicillin
****25-50Kmg/kg IM x 1 (max dose = 1.2million)
***Azithromycin (penicillin allergic)
****12mg/kg QD (child) or 500mg on day 1; then 250mg on days 2-5
*Steroids
**Single dose of dexamethasone shortens duration of pain

==See Also==
*[[Peritonsilar Abscess]]

==Source==
*Tintinalli
*Rosen's

[[Category:Peds]]
[[Category:ENT]]
[[Category:ID]]

Streptococcal pharyngitis

2012-03-12T14:41:32Z

Teachmd: /* Centor Criteria */

==Background==
*Strep pharyngitis
**Peak in 5-15yr old
**Rare in <2yr of age
**Accounts for only 15-30% of pharyngitis

==Diagnosis==
===Clinical Features===
*Sore throat
*Painful swallowing
*Fever
*N/V
*Tonsillar exudate

===Centor Criteria===
#History of fever
#Absence of cough
#Lymphadenopathy
#Tonsillar exudate or Swelling

==DDx==
#Causes
##Viral pharyngitis
##Retropharyngeal abscess
##[[Infectious Mononucleosis‎|EBV pharyngitis]]
##CMV pharyngitis
##Gonococcal pharyngitis
#Others
##[[PTA]]
##[[Retropharyngeal Abscess]]
##[[Ludwig's Angina]]
##[[Epiglottitis]]

== Treatment ==

=== Treatment Algorithm by Centor Criteria ===

{| cellspacing="1" cellpadding="1" border="1" style="width: 333px; height: 129px;"
|-
| '''Points''' 
| '''Treatment''' 
|-
| 4 
| Rx without testing
|-
| 3 
| Rapid Strep Test
|-
| 2 
| Rapid Strep Test
|-
| 1 
| Do not test/treat
|-
| 0 
| Do not test/treat
|}

*Likelihood of streptococcal pharyngitis in pts presenting with sore throat
**4 criteria = 50% PPV
**3 criteria = 40% PPV
**0 criteria - 80% NPV

=== Treatment Medications ===

*Abx
**Tx can be delayed for up to 9 days and still prevent major sequelae
**Choices
***Penicillin
****250mg BID x 10d (child) or 500mg BID x 10d (adolescent)
***Bicillin
****25-50Kmg/kg IM x 1 (max dose = 1.2million)
***Azithromycin (penicillin allergic)
****12mg/kg QD (child) or 500mg on day 1; then 250mg on days 2-5
*Steroids
**Single dose of dexamethasone shortens duration of pain

==See Also==
*[[Peritonsilar Abscess]]

==Source==
*Tintinalli
*Rosen's

[[Category:Peds]]
[[Category:ENT]]
[[Category:ID]]

Aortic ultrasound

2012-01-25T07:36:34Z

Teachmd:

==Technique==
*Transverse
**Start in epigastrium (below diaphragm) with indicator at 9 o'clock (aorta on left/IVC on right)
**use liver as window
**identify vertebral body (shadowing)
**rock/jiggle the probe to move bowel gas from view
** Scan from celiac to bifurcation (near umbilicus)
** Capture and measure the largest diameter

*Sagittal
**Rotate indicator to 12 o'clock (aorta on top/vertebra on bottom of screen)
**make sure you're looking at aorta and not IVC (aorta may pulsate/IVC may be compressible)
** Scan from bifurcation to celiac
** Capture and measure sagittal views, including the largest diameter
*Measurements
**Normal is <3cm
**measure outer wall to outer wall (make sure to include thrombus)
**watch out for saccular aneurysms

==Findings==
*[[Abdominal Aortic Aneurysm]]
** >3cm diameter (transverse or saggital)
**look for free fluid
**try to reproduce pain with probe
**if clot, confirm flow with doppler
*[[Aortic Dissection]]
**double lumen separated by intimal flap
**confirm with doppler

==See Also==
*[[Ultrasound (Main)]]
*[[AAA]]

==Source==
1. Sonosite

[[Category: Cards]]
[[Category: Rads]]

Aortic ultrasound

2012-01-25T07:32:41Z

Teachmd:

==Technique==
*Transverse
**Start in epigastrium (below diaphragm) with indicator at 9 o'clock (aorta on left/IVC on right)
**use liver as window
**identify vertebral body (shadowing)
**rock/jiggle the probe to move bowel gas from view
** Scan from celiac to bifurcation (near umbilicus)
** Capture and measure the largest diameter

*Sagittal
**Rotate indicator to 12 o'clock (aorta on top/vertebra on bottom of screen)
**make sure you're looking at aorta and not IVC (aorta may pulsate/IVC may be compressible)
** Scan from bifurcation to celiac
** Capture and measure sagittal views, including the largest diameter
*Measurements
**Normal is <3cm
**measure outer wall to outer wall (make sure to include thrombus)
**watch out for saccular aneurysms

==Findings==
*Abdominal Aortic Aneurysm
** >3cm diameter (transverse or saggital)
**look for free fluid
**try to reproduce pain with probe
**if clot, confirm flow with doppler
*Aortic Dissection
**double lumen separated by intimal flap
**confirm with doppler

==See Also==
*[[Ultrasound (Main)]]
*[[AAA]]

==Source==
1. Sonosite

[[Category: Cards]]
[[Category: Rads]]