Bites Stings and other emergency things 8282014 Ifedolapo Sulyman Olanrewaju MD PGY3 Alexandria FMRP LSU Health Shreveport 1 introduction Family physicians are an essential part of the emergency medicine safety net and without this contribution large areas of the ID: 737182
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Slide1
emergency and urgent care review
“…Bites, Stings and other emergency things…”
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
1Slide2
introduction
“Family
physicians are an essential part of the emergency medicine safety net, and without this contribution, large areas of the country would be without adequate emergency medical care.”Critical Challenges for Family Medicine: Delivering Emergency Medical Care - “Equipping Family Physicians for the 21st Century” (Position Paper
) – The Future of Family Medicine Project“40% of family physicians provide emergency medical services, and many family physicians have made lifelong careers in emergency medicine.”
Bullock,
K.
Turf Wars: Emergency Medicine and Family Physicians; AFP 54:4 pgs. 1201-6 (Sept. 15, 1996)“Most primary care physicians report at least one emergency presenting to their office per year. ”Toback, SL. Medical Emergency Preparedness in Office Practice. Am Fam Physician. 2007 Jun 1;75(11):1679-1684.
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
2Slide3
Learning objectives
Recognize and manage acute allergic reactions
Recognize and determine which toxicology emergencies require specific antidotes
Evaluate and manage environmental injuriesAppropriately manage a variety of animal bitesAssess and manage pit viper bitesRecognize spider and other insect bites and determine treatment
Review current ACLS guidelines
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport3Slide4
Acute Allergic reactions
AnaphylaxisAnaphylactoid reactions
AngioedemaBee stingsScombroid
Poisoning8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
4Slide5
Acute Allergic reactions
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
5
Type of reaction
Mechanism
Representative Examples
Type 1 – Anaphylactic
IgE- & IgG4 –mediated immediate hypersensitivity
Anaphylaxis
Urticaria
Angioedema
Type 2 – Cytotoxic
IgG- or
IgM
Abs
against cell antigens with complement activation
Blood transfusion reaction
AIHA
ITP
Type 3 – Immune Complex
Ag-Ab (immune)
complex deposition & complement activation
Serum
sicknessPost-strep GNVasculitisType 4 – Cell-mediatedActivated T-cells against cell surface-bound antigensContact dermatitis – Poison IvyPPDPhotosensitivity dermatitis
Gell
and
Coomb’s
ClassificationSlide6
Anaphylaxis
Systemic reactionDevelops rapidly over seconds to minutes
Life-threatening Early recognition and treatment may avert death
by airway obstruction or vascular collapseU. S. incidence rate: 49.8 cases per 100,000 person-yearsLifetime prevalence ≈ 2 percent, with a mortality rate of 1 percent
The risk of
anaphylaxis is
doubled and tripled in patients with mild and severe asthma respectively!8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
6Slide7
Anaphylaxis - Classification
Immunologic Allergic
IgE-mediatedImmune-complex-complement-mediated
Cytotoxic-mediatedNon-immunologicNonallergic anaphylaxis (anaphylactoid)
Idiopathic
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
7Slide8
Anaphylaxis - triggers
Immunologic
Foods - egg, fish, food additives, milk, peanuts, sesame, shellfish, tree nuts
Hymenoptera stings Medications – Abx (beta-lactams)Latex rubberBlood products
Non-immunologic
Radiocontrast
mediaMedications – vancomycin, NSAIDs, ACEIsHemodialysis
Physical factors – cold, heat, exerciseIdiopathic
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
8Slide9
Anaphylaxis - manifestations
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
9
Dermatologic/mucosal
Respiratory
CardiovascularGastrointestinalNeurologic
GeneralSlide10
Anaphylaxis - manifestations
Milddermatologic
Moderate Dermatologic + cardiorespiratory compromiseSevereDermatologic + cardiorespiratory compromise
Neurologic compromise8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
10Slide11
Anaphylaxis – differential diagnosis
Vasovagal syncope
Myocardial ischemiaPulmonary embolism
Foreign body aspirationAcute poisoningHypoglycemiaSeizure
Red man syndrome
Shock states
MastocytosisScombroidosisFlushing syndromes8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
11Slide12
Clinical criteria for anaphylaxis – 1
Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (e.g., generalized hives; pruritus or flushing; swollen lips, tongue, or uvula), and
at least one of the following:
Respiratory compromise (e.g., dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia)Reduced blood pressure or associated symptoms of end-organ dysfunction (e.g., hypotonia [collapse], syncope, incontinence)
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
12
Source: Sampson HA, Muñoz-Furlong A, Campbell RL, et al. Second Symposium on the Definition and Management of Anaphylaxis: summary report—second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium
. Ann Emerg Med. 2006;47(4):374.Slide13
Clinical criteria for anaphylaxis – 2
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
13
Two
or more of the following that occur rapidly (minutes to several hours) after exposure to a
likely allergen for that patient:Involvement of the skin, mucosal tissue, or both (e.g., generalized hives; pruritus or flushing; swollen lips, tongue, or uvula)Respiratory compromise (e.g., dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia)Reduced blood pressure or associated symptoms (e.g., hypotonia
[collapse], syncope, incontinence)Persistent gastrointestinal symptoms (e.g., abdominal cramps, vomiting
)
Source: Sampson
HA, Muñoz-Furlong A, Campbell RL, et al. Second Symposium on the Definition and Management of Anaphylaxis: summary report—second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium
. Ann
Emerg
Med
. 2006;47(4):374
.Slide14
Clinical criteria for anaphylaxis – 3
Reduced blood pressure that occurs rapidly (minutes to several hours) after exposure to a
known allergen for that patientInfants and children: low systolic blood pressure (age-specific)* or a more than 30 percent decrease in systolic blood pressure
Adults: systolic blood pressure of less than 90 mm Hg or a more than 30 percent decrease from that person's baseline8/28/2014
Ifedolapo
Sulyman
Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport14
Source: Sampson HA, Muñoz-Furlong A, Campbell RL, et al. Second Symposium on the Definition and Management of Anaphylaxis: summary report—second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium
. Ann Emerg Med. 2006;47(4):374.Slide15
Anaphylaxis – Lab testing
Anaphylaxis is a clinical
diagnosis!
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
15Slide16
Anaphylaxis-management
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
16
Continuous
noninvasive hemodynamic monitoring
pulse
oximetry
monitoring
urine output monitoringSlide17
Anaphylaxis-management
Adjuncts to careAlbuterol
H1 antihistamineH2 antihistamine
GlucocorticoidBiphasic/rebound reaction may occur up to 72hrs after 1o episode in 1 – 20% of patients
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
17Slide18
Anaphylaxis-management
In refractory cases
Start epinephrine infusion2 to 10 micrograms per
Add other vasopressors as neededGlucagon1 to 5 mg IV over five minutes, followed by infusion of 5 to 15 micrograms per minute
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
18Slide19
Anaphylactoid reaction
Non-IgE
-mediatedClassically caused by radiocontrast media
Management is the same!8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
19Slide20
Urticaria
and angioedema
Localized reactions to allergensIgE and non-IgE
mediated: Medications – ACEIs, NSAIDsOther non-immunologic mechanisms InfectionsAutoimmune diseaseInsect bites
Rx: eliminate triggers
supportive
H1 & H2 receptor blockersIf concomitant anaphylaxis – we know what to do!
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
20Slide21
Bee stings
Hymenoptera
species bees, wasps, yellow jackets, hornets, and imported fire ants
Uncomplicated local reactioncold compressesLarge local reactionshort-course of systemic steroids Allergic reactions —
Anaphylaxis!
Prevention:
EpiAutoInjector/Allergy referral & testing/Consider LT Venom Immunotherapy (VIT)8/28/2014Ifedolapo Sulyman
Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
21Slide22
Scombroidosis
(Scombroid poisoning)
Ingestant-related reaction
Spoiled fish (tuna/mackerels/skip-jack/bonito) – presence of sulfites or histidinesKept above 4oC for upto 3hrsSweese cheese
Signs and symptoms of
scombroid
toxicity usually begin within an hour of eating contaminated fishRapid response to antihistamines!flushing of the face and neck urticarial
rash - face and upper torsoDiarrheaHeadachePerioral burning or itchingDizziness
palpitations, tachycardiaRarely, severe cardiorespiratory compromise may occur, especially in patients with underlying cardiorespiratory heart disease
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
22Slide23
Scombroidosis – differential diagnosis
Allergic
reactions to seafood can mimic scombroid poisoning
Myocardial ischemia or infarctionStaphylococcal enterotoxin-induced food poisoningOther types of marine foodborne poisoning
ciguatera
poisoning
shellfish poisoningpufferfish poisoning8/28/2014Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
23Slide24
Scombroidosis
- management Primarily, antihistamines – PO versus IV
Notify local health department officials
Education on rapid chilling of fish below 4°C (40°F), immediately after being caught!8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
24Slide25
Environmental injuries
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
25Slide26
Heat-induced injury
Heat-related
illness affects a diverse group of individualsAt risk populations include
older persons, children, and persons who perform strenuous outdoor activities. Persons with cardiopulmonary disease, chronic mental disorders, and
individuals taking
medications that interfere with salt and water balance are also at increased
riskMortality increases as the heat index increases ( > 95°F (35°C)Severity correlates with elevation of temperature and duration of the heat
Early recognition and
rapid cooling are crucial, because heat stroke is a medical emergency!
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
26Slide27
Heat-induced injury
Heat Exhaustion
Presents with HA, N/V, dizziness, weakness, irritability ± cramps
Diaphoresis, Postural hypotensionCore temp – normal-to-increasedRxCool environmentRestFan evaporationIsotonic fluid replacement
Heat
Syncope
Variant of postural hypotensionCommonly seen with exercise in a hot environmentPeripheral vasodilatationVenous pooling
Transient LOCRapid recovery once supine!Rx: rest, cool envt
. & fluid repletion
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
27
*Core temp: < 104
o
F (40
o
C)Slide28
Cardinal featuresHyperthermia
Altered mental status CNS involvement tends to be earlyCerebellar symptoms/signs: ataxia.
Seizures
Differential DiagnosisMalignant hyperthermiaNMSAnticholinergic toxicitySympathomimetic toxicitySevere hyperthyroidismSepsis
Meningitis/Encephalitis
Hypothalamic dysfunction
Brain abscessCerebral malaria8/28/2014Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
28
Heat stroke
*Core temp: > 104
o
F (40
o
C)Slide29
Heat stroke
Diagnostic testing
LabsCBCD, CMP, PT/PTT, FDPs,
Serum CPKABGsUAEKGImagingHead CTConsider LP
Treatment
Immediate cooling
ice-water cooling versus tepid sprayingIce water sheetsIce water submersion
Cold fanIce packs to major points of heat transferAntipyretics/Dantrolene
sodiumContinuous core temp monitoringGoal to drop temp to 102.2oF (<39oC) within 30mins. Physiologic cooling thereafter. Monitor and treat complications – hypotension,
rhabdomyolysis
/AKI, ARDS
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
29Slide30
Cold-induced injury
Most commonly described among homeless populations
Major determinants of InjuryAbsolute
temperature Duration of exposure
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
30Slide31
Cold-induced
injury-Predisposing factors
Substance abuse
Poor nutritionDehydrationDiabetesPeripheral vascular diseasePeripheral neuropathy
Hypothyroidism
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
31Slide32
Cold-induced injury
4 Major forms
ChilblainsImmersion Injury (Trench Foot)
Frostnip (Superficial frostbite)Deep FrostbiteHypothermia
***
***cold-related emergency
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
32Slide33
Frostsnip
Superficial FrostbiteInvolves skin and subcutaneous tissues
Level of skin involvementFirst-degreeSecond-degree
Rx of ChoiceRapid rewarmingImmerse body in part in water for 15 – 30 minutesHeals within 3 – 4 weeks
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
33Slide34
Deep Frostbite
Involves deeper skin layers
Exposure at < 44oF for 7 – 10 hours
Third-degree (Skin, Subcut + muscle)Fourth-degree (+ deep tendons, bones)Clinically, tissues appear frozen, hard with capillary filling on rewarmingHemorrhagic blistersEschars
Autoamputation
Rx
Rapid rewarming AnalgesicsElevate extremityPrevent weight-bearingSeparate affected digits wit hcotton woolUpdate tetanus immunization
Early surgical intervention is not indicatedRole of Abx is unclear
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
34Slide35
Toxicology emergencies
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
35Slide36
Overdoses – principles of management
Overdoses are common in the ED but are rarely fatal
AAPCC indicates 2 million exposures and 1,146 fatalities in 2010
Clin Toxicol
49 (10):910)
Early recognition and management guided by sound physiologic principles is key to good outcomes!
5 toxidromes
are recognized based on clinical presentation s
ympathomimetic |
cholinergic
|
anticholinergic
|
opiate
|
sedative-hypnotic
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
36Slide37
medication od
toxidromes
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
37
SLUDGE Syndrome/CNS symptoms
a
ntimuscarinic
syndrome
r
esp
depression is not a significant feature of BZD OD (PO)Slide38
Overdoses
– diagnostic evaluation
Undifferentiated or mixed exposure is not uncommon.Diagnostic testsR
BGBMP ± LFTsVBG/ABGSerum Drug Screen – APAP, salicylate, EtOH ± TCAUrine Drug Screen – high FP+FN rates!
cocaine, & THC screens – fairly sensitive
Amphetamines –
x OTC cold medsPCP – x dextromethorphan, ketamine, diphenhydramineEKGRole of imaging: consider KUB – CHIPES (chloral hydrate, heavy metals, iron, phenothiazines, EC preparations, SR preparations)
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
38Slide39
Overdoses – Treatment
Prevention of absorption
No “stomach pumping” – IPECACActivated Charcoal – mainstay
Best results - < 1 hr. after ingestionWhole-bowel irrigationPEG at 1 - 2L/hr. till clear rectal effluentsSR preps, body packing, heavy metals
Cathartics
“GI Rx” – contraindicated in patients with airway compromise, persistent vomiting , ileus, bowel obstruction or perforation
Enhanced EliminationForced diuresis
Urinary alkalinization
Urinary acidificationHemodialysis and hemoperfusion
Antidotes
Disposition
psychiatric evaluation
outpatient
obs
versus inpatient versus ICU care
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
39Slide40
Acetaminophen toxicity
Leading cause of toxicologic
fataities in the US.APAP-induced hepatotoxicity - most frequent cause of ALF
Leading indication for liver transplantation.Risk factorsDecreased glutathione stores – fasting state, malnutrition, anorexia nervosa, chronic alcoholism, febrile illness, chronic disease statesCYP450 enzyme inducers – EtOH, INH, phenytoin, barbiturates, cigarette smoking
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
40Slide41
Acetaminophen toxicity
4 clinical stages
Asymptomatic (stage 1 – 1st
24hrs.)Hepatotoxic (stage 2 – 24 – 48 hrs.)Fulminant hepatic failure (stage
3 –
2 – 4 days
)Recovery (stage 4 – 4 – 14 days)History : reliable time of ingestion is crucial to management!In addition – amount, what form, and over what period of time.Any co-
ingestantsPhysical: ABCs, mental status evaluation
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
41Slide42
Acetaminophen toxicity
Diagnostic Criteria
Obtain APAP level at 4hrs post-ingestion and plotRumack-Mathew
nomogramAssess risk for progressive hepatic failureKing’s College Hospital(KCH) CriteriapH < 7.3 (at 48hrs)
PT
>
100Cr > 3.3mmol/LGrade 3 -4 hepatic encephalopathyOther labs: CMP (AST vs. ALT), PT/INR, VBG, serum lactate, serum phosphate
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
42Slide43
Acetaminophen
toxicity - treatment
Prevent absorptionActivated charcoalReplenish glutathione
N-acetylcysteine (NAC)PO vs. IV administrationAC – NAC co-administration not recommended – give 2 hours apart.Indications for NACacute poisoning with toxic APAP levels
Delayed presentation > 8hrs with pending APAP levels
Delayed presentation > 24hrs with detectable APAP levels + ↑AST
Chronic APAP OD exposure with associated transaminitisFulminant hepatic failure Monitor & treat complications - hypoglycemia, electrolyte & metabolic disturbances, GI bleeding, cerebral edema, Infections, AKIGI/Hepatology consult – notify transplant center – arrange early transfer!
8/28/2014
Ifedolapo
Sulyman
Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
43Slide44
Animal bites
Principles of Management of Bite Wounds
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport44Slide45
Bite wounds - management
Copious irrigation
Culture when visibly infectedConsider imaging
To exclude fracture, foreign body and/or joint space involvementAvoid primary closureException: lesions on the faceElevate extremity
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
45Slide46
Bite wounds - management
Antibiotic Rx
For overt infectionProphylaxis for high-risk bite wounds
Location: hands, genitalia, close proximity to jointsType of Injury: puncture, crush injurySeverity: moderate-to-severe
Bite Source: cat bites
Immune status: DM,
asplenia, immunosuppression Choice: Amoxicillin-clavulanate 875/125 PO BID x 3 – 5 daysMost effective when wound > 8 hrs Tetanus and Rabies prophylaxis as indicated
Arrange surgical consultation and out-patient f/u as appropriate
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
46Slide47
Bite wounds
– specific considerations
Dog BitesMost common bite wounds (80%), not commonly infected (5%)
P. multocida, Strep, Staph, C.canimorsusAmoxicillin-clavulanate or Ciprofloxacin + clindamycinCat Bites
High infection rates – 80%
P.multocida
, S. aureusAmoxicillin-clavulanate always – Cephalosporins
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
47Slide48
Bite wounds – human bites
Pediatric wounds
Generally trivialIntercanine distance > 3cm suggests adult bite – red flag for child abuse
Clenched fist injuryHigh infection risk – raises concern for significant deep soft tissue/bone/joint infectionsLate presentation – very common!Virus transmission riskHepatitis B – consider PEPHIV, HCV transmission rates are low (blood in saliva?!)
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
48Slide49
Bite wounds – human bites
Common organismsViridans strep
Bacteroides spp
Fusobacterium sppPeptostreptococciEikinella corrodensProphylaxis is recommended in most cases
Amoxicillin-
clavulanate
875/125 PO BID x 5 daysInfected wounds: IV Rx recommendedAmpicillin-sulbactam, Ticarcillin-clavulanate, Cefoxitin x 1 - 6 weeks
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
49Slide50
Insect bites
Tick-Borne Infections
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport50Slide51
Tick-borne infections
Common in summer months
Prevalence is a function ofVector tick populationAnimal reservoirs
Co-infection with multiple TBIs can occurOutdoor activity rather than report of tick bite correlates better with presentation8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
51Slide52
Lyme borreliosis
Most common vector-borne disease in the USEndemic regions include
Northeastern coastal regionsUpper MidwestNorthern California
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
52Slide53
Lyme borreliosis
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
53Slide54
Lyme
borreliosis
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
54Slide55
Lyme borreliosis
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
55Slide56
Current ACLS guidelines - review
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
56Slide57
Q & a section
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
57Slide58
q1
Which one of the following accurately describes the classic rash of erythema
migrans?A) Scattered individual purple macules on the ankles and wristsB) An annular rash with a bright red outer border and partial central clearing
C) A dry, scaling, dark red rash in the groin, with an active border and central clearingD) A diffuse eruption with clear vesicles surrounded by reddish maculesE) A migratory pruritic, erythematous, papular eruption
8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
58Slide59
q2
72-year-old male is brought to your office by a friend because of increasing confusion,irritability, and difficulty walking. This began shortly after the patient’s car broke down in a
rural area and he had to walk a mile to get to a phone and call the friend. The temperature outdoors has been near 100°F. On examination the patient has a rectal temperature of 39.5°C (103.1°F), a pulse rate of 110beats/min, and a blood pressure of 100/60 mm Hg. His shirt is still damp with
sweat.
Which
one of this patient’s findings indicates that he has heatstroke rather than heat exhaustion?A) ConfusionB) SweatingC) His temperatureD) His heart rateE) His blood pressure8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
59Slide60
q3
A 42-year-old female has a 3-day history of an intensely pruritic rash on her arm, shown below.Which one of the following is most likely to have caused these skin lesions?
A) Balsam of PeruB) BedbugsC) NeomycinD) NickelE) Poison ivy
8/28/2014Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
60Slide61
q4
A 45-year-old obtunded male is brought to the emergency department by ambulance. Slow
, shallow respirations are noted. His wife tells you that he is being treated by a local painspecialist for chronic back pain stemming from a severe workplace injury 2 years ago. A
urine immunoassay drug screen is negative for opioids.Which one of the following opioid medications would NOT be detected by this drug screen?A) CodeineB) FentanylC) HydrocodoneD) Hydromorphone
(
Dilaudid
)E) Morphine8/28/2014Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
61Slide62
q5
What is the specific antidote used to treat methanol poisoning?A) Ethanol
B) HaloperidolC) Lorazepam (Ativan)D) NaloxoneE) Thiamine
8/28/2014Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
62Slide63
q6
A 3-year-old male is brought to your office the day after he was stung by a honeybee.
He developed a significant local reaction, with redness and swelling around the site of the sting on his forearm. He also had some swelling of his lips which lasted 2–3 hours. He was treated
with oral diphenhydramine (Benadryl) at home and now his symptoms have completely resolved.Which one of the following should be recommended for this patient?A) An epinephrine autoinjector (EpiPen)
B) Corticosteroids as needed for stings
C) Immunotherapy for 1–2 years
D) Reassurance only8/28/2014Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
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references
Jang JL. Cheng S. Fluid and Electrolyte Management. The Washington Manual of Medical Therapeutics. Godara et al. Eds. 34
th Edition. Multiple Uptodate
ResourcesAmerican Family Physician8/28/2014
Ifedolapo Sulyman Olanrewaju, MD PGY-3 Alexandria FMRP, LSU Health Shreveport
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