Peritonitis in peritoneal dialysis

19 Aug

Etiology

Due to contamination with pathogenic skin bacteria or catheter-related infection;

less commonly secondary peritonitis due to underlying GI tract pathology (cholecystitis, appendicitis, etc.)

 

Presentation

  • Abdominal pain (79-88%),
  • cloudy peritoneal effluent (84%),
  • fever (29-53%),
  • nausea (31-51%)

Patient with secondary peritonitis are more likely to have systemic manifestations of sepsis

 

Laboratory Findings

Peritoneal fluid cell count > 100 cells/mm3

*approximately 10% of patients with bacterial peritonitis have WBC counts below 100…among this group, >50% PMN strongly suggests peritonitis, independent of the WBC

Peripheral WBC often elevated as well

80-95% of cases have positive peritoneal fluid cultures, blood cultures are generally negative

 

Treatment

Typical organisms:

  • E. coli (43%)
  • Other strep (19%)
  • Klebsiella pneumonia (11%)
  • Miscellaneous (10%)
  • Streptococcus pneumonia (9%)

Antibiotic of choice = cefotaxime 2g IV q 8 hours (or other third generation cephalosporin)

Second line = Levofloxacin (doesn’t penetrate into ascites fluid to the same extent)

 

Submitted by Kelly Estes.

 

Reference: uptodate.com; picture

Understanding Insulin Pumps

14 Aug

Basic function:pump1

~200-300 units of short acting insulin is in the insulin reservoir. This connects through the tubing to be infused via the cannula to the subcutaneous tissue of the patient.

-Frequent BG monitoring is still required.  In fact more these patients check more frequently than patients without pumps d/t the possibility of pump problems.

-Patients have a basal rate they get continuously and then type in their desired bolus amount with meals.

-Patients need to move the needle site every 2-3 days (otherwise increased risk of infection and decrease in glycemic control)

 

pump2Complications:

  1. Local reactions to adhesive or insulin preparation
  2. Lipohypertrophy or lipoatrophy
  3. Cellulitis at the needle insertion site
  4. Pump failure. Any part of the device can fail- dead batteries, kinked/cracked tubing, depleted or broken reservoir…
  5. Air in tubing causing missed insulin
  6. Insulin leakage (at insertion site or infusion set connection site causing missed insulin

 

* Pumps frequently will not given any indication that there is a problem

* As the patient is getting only short-acting insulin, device failure can rapidly lead to DKA. 

 

Submitted by Heather Groth.

 

Sources:

Academic Life in Emergency Medicine

Pickup, John. “Insulin-Pump Therapy for Type I Diabetes Mellitus” N Engl J Med 2012; 366:1616-1624

UCSF Website: http://dtc.ucsf.edu/types-of-diabetes/type2/treatment-of-type-2-diabetes/medications-and-therapies/type-2-pump-rx/

Treatment of Primary Spontaneous Pneumothoraces

12 Aug

Definitions:ptx

-Primary= No apparent lung disease   vs   Secondary= Underlying lung disease

 -Spontaneous= No precipitating event (no traumatic/iatrogenic cause)

-The definition of a “small” pneumothorax can vary. For the most part, this means the distance between the lung and chest wall on CXR is <3cm. 

 

3 Senarios:

  1. Stable patient, small pneumothorax

-Give supplemental O2

-Observe in the ED 3-6 hours

-Repeat x-ray. If no progression and patient is asymptomatic, discharge with follow up in 12 hrs- 2 days.     Otherwise admit.

  1. Stable patient, large pneumothorax

                -Small-bore catheter (<14F/pigtail)    OR    16-22F chest tube and admit

Note: Some physicians have discharged patients with a chest tube in place and a Heimlich valve with follow up in 1-2 days if the patients refuse hospitalization but are reliable. This makes me nervous.

                VS

                -Needle aspiration

-There is pretty good data (multiple recent articles) behind needle aspiration of pneumothoraces instead of placing a chest tube. This is the recommended treatment in England but this is not in the American College of Chest Physicians guidelines.  A 2008 Annals review shows no difference in rate of failure/recurrence but lower rates of hospitalization, length of stay, comfort.  HRD has a prior blog post about this.

-You can watch a video of this procedure on the NEJM site under the article: Pasquier et al. “Needle Aspiration of Primary Spontaneous Pneumothoraces” NEJM 2013; 368:e24

  1. Unstable patient

                -Large chest tube.  Could use 16F-22F chest tube but will likely use 24F-28F chest tube as PPV is likely required.

 

Submitted by Heather Groth.


References
:

Baumann et al. “Management of Spontaneous Pneumothorax: An American College of Chest Physicians Delphi           Consensus Statement” Chest. 2001;119(2):590-602.

Bintcliffe et al. “Spontaneous Pneumothorax” BMJ 2014; 348:g2928

Pasquier et al. “Needle Aspiration of Primary Spontaneous Pneumothoraces” NEJM 2013; 368:e24

Tintinalli’s

Up to Date

Zehtabchi S, Rios C L. Management of emergency department patients with primary spontaneous pneumothorax: needle aspiration or tube thoracostomy? Annals of Emergency Medicine 2008; 51(1): 91-100.

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bleach ingestion

11 Aug

QUICK PEARLS:

Liquid bleach is dilute 3%-6% sodium hypochlorite with a pH of around 11 – and is minimally corrosive at household bleach levels. 

Small ingestions of household bleach usually results in no damage and patients are asymptomatic. 

It is most helpful if the family can bring the bottle or take a picture of the bottle to confirm that the material was solely household bleach. 

 

Industrial strength bleach on the other hand has much higher concentration of sodium hypochlorite and may result in gastric and esophageal necrosis. 

Emesis may lead to aspiration or chemical pneumonitis.

Industrial bleach may need admission, observation, and possible endoscopy. 

 

Household bleach patients without symptoms may be discharged with early follow up.

 

Submitted by J. Stone.

 

References: (Tintinalli’s Emergency Medicine 7th ed. Ch. 194 Caustics); picture

What is MELAS???

8 Aug

RAGING HYPOTHETICAL:

Otherwise healthy male in his 30’s presents to the ED very anxious-appearing with vague episodic neurologic complaints.  His neurologic exam is completely normal.  Later, his R index finger starts wiggling and he says he can’t control it. He then contorts his face saying he cannot control this. They both stop as you talk with him.  Then he tells you his mother died of MELAS and is worried about this.  You go back to your desk and Google MELAS…

 

What is MELAS???

Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-like episodes

(exact incidence unknown)

 
Cause:

-Mitochondrial genetic mutation affecting muscles and the nervous system

 

Symptoms:

-Usually presents in childhood 

-can include muscle weakness/pain, recurrent HA’s, loss of appetite, emesis, seizures

-Can present any time but usually affected people have stroke-like episodes before 40 y.o.

-Patients often times have elevated lactate causing pain, fatigue, muscle weakness, possible involuntary muscle spasms. Patients can also develop renal impairment and DM.

 

Diagnosis:

-Usually clinical with supporting lab work. Confirmation by mitochondrial DNA studies.

 

Treatment:

-No currently known specific treatment. Treatment is targeted to affected organ system/sx.  Various antioxidants and vitamins have been used without consistent success. This is a progressive and fatal diagnosis at this point.

 

Submitted by Heather Groth.

 

References:

-NLM/NIH website: http://ghr.nlm.nih.gov/condition/mitochondrial-encephalomyopathy-lactic-acidosis-and-stroke-like-episodes

-Thambisetty, et al. “A practical approach to the diagnosis and management of MELAS: a case report and review.” Neurologist. 2002 Sep;8(5):302-12.

-Up-to-date.com

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Tick Paralysis

7 Aug

Presentation

First 24 hours = reslesness, irritatbility, fatigue, paresthesias, myalgias

2-6 days tost tick attachment = unsteady gait, decreased deep tendon reflexes progressing to acute symmetric ascending flaccid paralysis.

*may involve cranial nerves: drooling, dysphagia, dysphonia, facial weakness

*involvement of respiratory muscles can lead to trouble without ventialtory support

 

Differential Diagnosis

Botulism, Guillain-Barre Syndrome, Myasthenia gravis, Lambert-Eaton syndrome, transverse myelitis, spinal cord compression, heavy metal poisoning, organophosphate poisoning

 

Risk Factors

Girls with long hair, < 8 years of age, spring and summer months.

Geography (Dermacentor andersoni: rocky mountain region, pacific northwest, southwest, Canada; Dermacentor variabilis: southeast; Ixodes holyclus: Australia)

 

Pathophysiology

The tick’s salivary glands produce a neurotoxin believed to decrease the presynaptic acetylcholine release at the neuromuscular junction (similar to botulinum toxin)

 

Diagnosis

Clinical findings + engorged tick

 

Treatment

Remove the tick! (duh)

Dermacentor ticks -> symptoms improve shortly after removal

Ixodes ticks -> symptoms may persist 1-2 days after removal

 

Submitted by Kelly Estes.

 

References:

Taraschenko OD1, Powers KM2. Neurotoxin-induced paralysis: a case of tick paralysis in a 2-year-old child. Pediatr Neurol. 2014 Jun;50(6):605-7. PMID: 24679414.

Chagnon SL1, Naik M, Abdel-Hamid H. Child neurology: tick paralysis: a diagnosis not to miss. Neurology. 2014 Mar 18;82(11):e91-3. PMID: 24638220.

picture 1, picture 2, picture 3

acute HIV syndrome

5 Aug

QUICK PEARLS:

Acute HIV syndrome usually follows exposure in 2-6 weeks.

Symptoms are nonspecific – fever, chills, myalgias, diarrhea, pharyngitis, malaise

presentation is similar to a mild viral syndrome and often the diagnosis is not considered or pursued. 

Rapid oral swab is now available for those in whom the diagnosis is suspected, and this may be performed in the ED.

If positive, this will need to be sent for a Western blot confirmation, as oral testing has a high sensitivity but there can be false positives.

Additionally, antibodies develop 2-8 weeks after initial infection so testing in this “window” period may give falsely negative results and patients should be referred for repeat testing in 2-3 months.  If you do the testing in the ED, you have to follow it up or arrange for a PCP to follow it up.

 

Submitted by J. Stone.

 

References: ( Rothman RE, et al. AIDS and HIV infection, in Marx JA et al: Emergency Medicine: Concepts and Clinical Practice, 7th ed. 2010  p1732-36.); picture

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