Pearls from Dr. David Chong
Necrotizing fasciitis: skin/soft tissue infection (SSTI) extending beyond epidermis/dermis/fat into fascia +/- muscle --> Poly- or mono-microbial (GAS, S. aureus, V. vulnificus-->immunocompromised/iron overload, C. perfringens-->myonecrosis)
- Red, tender, indurated w/ “pain out of proportion,” to other findings --> crepitus late and ominous
- LRINEC score (CRP, WBC, Hgb, Na, Cr, glucose) – sensitivity limited (80%)
- Imaging more sensitive: CT (subcutaneous air), MRI (fascial necrosis)
- Empiric abx: Vanc/Linezolid + Pip-Tazo/Cefepime+Flagyl/Meropenem, Clindamycin + PCN if suspect GAS or Clostridia
- Early surgical consult based on clinical suspicion --> definitive dx and treatment is debridement
- Streptococcal toxic shock syndrome: typically associated w/ GAS SSTI (but 50% no clear portal of entry) –-> consider with septic shock and no obvious source, consider IVIG in addition to abx
Posted 05/29/16 03:37:52 PM by Matthew Cummings
Sepsis-3 definitions (Feb 2016): re-conceptualize sepsis as infection-related organ damage (SOFA), thus “severe sepsis” no longer included
- Sepsis = 2/3 qSOFA (HAT): Hypotension (SBP<100), AMS (GCS<15), Tachypnea (RR>22)
- Septic shock = Sepsis + persistent hypotension (MAP<65) despite volume resuscitation (typically 20-30cc/kg) AND lactate ≥ 2 --> in-hospital mortality 40%
Posted 05/29/16 03:39:00 PM by Matthew Cummings
Resuscitation fluid: colloid vs. crystalloid
- SAFE (2004): 4% albumin vs. NS in ICU patients --> no difference in all-cause mortality, non-significant trend toward improved mortality w/ albumin in severe sepsis, follow-up meta-analysis conflicting
- SPLIT (2015): plasmalyte (balanced crystalloid) vs NS in SICU patients --> no difference in AKI or mortality (but low volumes given—median 2L)
Posted 05/29/16 03:39:45 PM by Matthew Cummings
For further reading...
Posted 05/29/16 03:44:48 PM by Matthew Cummings
For chronic thromboembolic pulmonary disease, CTA for PE is not a good test - V/Q scan is better and preferred
Posted 12/12/16 11:18:39 AM by Anna Krigel
- Scores calculated 24 hour after admission to the ICU and every 48 hours thereafter, the mean and the highest scores are most predictive of mortality
- Validated score with superior predictive validity of in-hospital mortality compared to SIRS
- qSOFA (quick SOFA) - proposed as a tool to identify sepsis in patients outside of the ICU, not yet prospectively validated
- RR > 22/min
- Altered mentation
- Systolic blood pressure less than or equal to 100mmHg
Posted 12/12/16 11:30:09 AM by Anna Krigel
- Immunocompromised State
- History of CNS Disease
- New Onset seizure (within 1 week of presentation)
- Focal Neurological Deficit
Posted 12/12/16 11:33:00 AM by Anna Krigel
Empiric Antibiotic Coverage for Bacterial Meningitis
- Third generation cephalosporin - good CSF penetration and activity against major pathogens including Strep pneumo, Neisseria, and Haemophilus
- Vancomycin - used for beta-lactam resistant strep
- Ampicillin - coverage for Listeria monocytogenes in adults over age 50
- Adjunctive dexamethasone - early IV steroids used to diminish neurologic complications of bacterial meningitis and decreased mortality in patients with strep pneumo meningitis
Posted 12/12/16 02:30:40 PM by Anna Krigel
Posted 12/12/16 02:32:57 PM by Anna Krigel
Subglottic stenosis - most common manifestation of tracheobronchial granulomatosis with polyangiitis (Wegener's granulomatosis)
Posted 12/12/16 02:37:10 PM by Anna Krigel
For further reading...
Posted 12/12/16 02:40:27 PM by Anna Krigel
Most common cause of asymmetric pleural effusion is heart failure, most commonly right sided.
Posted 07/05/17 10:16:27 AM by Emily Miller
If see a unilateral L sided pleural effusion think : 1) cancer 2) pancreatitis 3) post-pericardotomy syndrome
Posted 07/05/17 10:17:09 AM by Emily Miller
Albumin is not a great marker for nutritional status because half life is 30-40 days. Albumin is a good marker for inflammation. if total protein is normal, but albumin is low think that patient may be losing albumin.
Posted 07/05/17 10:18:28 AM by Emily Miller
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