Questions of the Week for 7/18/2023
Author: Christian Gerhart
A 75 yo male presents with massive hemoptysis. He is intubated and is resuscitated with MTP. He continues to have bleeding from his ET tube. What imaging should be considered?
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A CTA of the chest can be helpful in finding the source of bleeding if the patient is stable enough to tolerate CT. Massive hemoptysis is usually from the bronchial arteries, which are branches from the aorta (NOT pulmonary artery) and therefore can be imaged with an arterial phase CTA (different than PE protocol). This can potentially give IR or another specialist a target to embolize or intervene on. Bedside bronchoscopy is an important investigation as well and has the advantage of being possibly therapeutic and can be performed on more unstable patients compared to CT. They both have advantages and disadvantages and should probably both be done as soon as feasible.
You are taking care of a 23 yo female who presented for lower abdominal pain. Her hCG is negative. After evaluating her you think she probably has PID and decide to treat her as an outpatient since she well appearing with an otherwise reassuring workup. What antibiotic therapy would you use?
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Ceftriaxone 500mg IM x1, Doxycycline 100mg BID x14 days and Metronidazole 500mg BID for 14 days. The main difference between PID and cervicitis treatment is the addition of metronidazole and the longer course (14 days). Systemically ill patients, those with abscess or TOA, patients with inability to tolerate PO or who are refractory to outpatient antibiotics, and pregnant patients with PID are generally admitted.
A 51 yo male presents with headache, fever and confusion. His non contrast head CT is normal. You have a high suspicion for meningitis/encephalitis and decide to start empiric treatment while you work on your LP. What treatment should be initiated?
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Ceftriaxone 2g q12, vancomycin 15-20mg/kg, ampicillin 2g q4 hours, acyclovir 10mg/kg q4 hours, and probably dexamethasone 0.15 mg/kg. Ampicillin is indicated as the patient is over 50. Given his altered mental status HSV encephalitis is possible, and acyclovir can be started then peeled off if testing negative. Steroids are indicated if there is a high suspicion for bacterial meningitis, which in this case there is.
A patient with an 8-0 Shiley cuffed trach presents with respiratory distress. The trach was placed over a year ago. You have them on the monitor and RT is at bedside. They are saturating 91% on the NRB mask that EMS placed over the trach. RR is 28. List your initial interventions.
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You can start by oxygenating through the mouth (unless they had a laryngectomy) and over the trach. It is common for trachs to become occluded with debris or mucous. The inner cannula can be removed and the airway suctioned through the trach. If the suction passes then the trach is likely patent. If not, then the next step is usually to remove the trach and replace it. If you have a fiberoptic scope, you can use this to examine the airway and ensure the new trach you insert is in the correct position. This should be confirmed with end tidal CO2. You can intubate from above if the patient does not have a laryngectomy history. If the patient is still in respiratory distress and you now have a patent trach or ETT that you know is in the trachea with end tidal CO2, you can place them on the ventilator for positive pressure support while you obtain a workup such as a chest x ray, EKG, etc.
How should specimens be collected when assessing for STIs vs. UTI?
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When assessing for UTI, a mid-stream sample should be obtained to avoid contamination and evaluate for bladder infection. For STIs in females, a vaginal swab is superior to urine sampling. This can be done with a self-swab if the patient prefers. If the patient refuses a vaginal swab and urine testing is obtained then a first catch urine is preferred. For males a first catch urine is the method of choice for STI testing.
What laboratory abnormalities, clinical findings and risk factors should prompt treatment of febrile neonates with acyclovir?
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Risk factors: maternal history of genital HSV lesions or fever 48 hours before or after delivery
Exam: seizure, hypothermia, vesicles or mucous membrane ulcers on exam
Labs: CSF pleocytosis with negative Gram stain, leukopenia, thrombocytopenia, elevated ALT
A patient with a cuffed trach is evaluated for a speaking valve. How should the cuff be managed while the speaking valve is in place?
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The patient's cuff MUST BE DEFLATED while the speaking valve is in place. Speaking valves are one-way valves that allow air to enter through the trach but force it to escape through the patient's mouth instead of out of the trach. Therefore, if the cuff is up, the patient would not be able to exhale, which could lead to asphyxiation and cardiac arrest.
A patient presents with fever, and headache. He is found to have a brain abscess. What is the preferred antibiotic regimen?
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Vancomycin, Cefepime and Metronidazole. Ceftriaxone instead of Cefepime may be adequate for some patients without pseudomonas risk factors and low suspicion for otogenic primary source of infection. Though Pipericillin-Tazobactam is a commonly used agent for gram negative and anaerobic coverage, it is not ideal for CNS infections given its poor penetration into the CNS. It is probably fine for spinal epidural abscess since the infection is superficial to the dura unless there is concomitant meningitis.