Author: Susan Brion, M.D.
Dr. Brion enlightens us on the ever-evolving standard of sepsis management.
Category: Infectious Disease
Podcast #219: History of Sepsis
Author: Chris Holmes, M.D.
Educational Pearls
- “Sepo’ is a term from Homer (author of The Iliad and The Odyssey), and means “I rot”.
- Hippocrates in 400 BC identified sepsis as a “dangerous decay within the body”.
- Galen in 200 AD believed pus was “laudable”.
- The Greeks and Romans used the term “myasma” to describe the smell of swamp and rotting flesh.
- Dr. Emmanuel Rivers in Detroit did one of the the first big studies about sepsis and was an advocate for goal-directed therapy.
- Now, Vitamin C cocktails are in use, but new sepsis treatments should be investigated carefully before implementation.
References: Funk, Duane J. et al. Sepsis and Septic Shock: A History. Critical Care Clinics , Volume 25 , Issue 1 , 83 – 101
Podcast #195: How to Properly Inject Heroin
Author: Don Stader, M.D
Educational Pearls:
- It is important for providers to know how to use IV drugs properly so that they can instruct their patients on how to avoid injury. Heroin use is increasing.
- Hepatitis, HIV and infection are possible complications of improper IV drug use
- The first step of heroin use is to dissolve the solid heroin in water using heat – a spoon and lighter are often used for this step. Next, the heroin is drawn into the syringe through a filter (cotton is often used).
- Heroin concentration often varies widely – counsel patients to test their heroin first.
- Sterility of the needle, water, cooker, cotton and syringe is paramount. Refer patients to a needle exchange program where they can get clean supplies.
- Hepatitis C can live outside the body for 4 days – NEVER share ANY supplies.
- Sterile procedure is important – needles should not be licked.
References: http://drugsense.org/flyers/10_tips_for_safer_use.pdf
Podcast #188: Monoarthritis
Author: Peter Bakes M.D.
Educational Pearls:
- Some common causes of monoarticular arthritis include: crystal arthropathies (gout and pseudogout), infection (septic joint), reactive arthritis and acute presentations of chronic arthritides.
- Lyme disease usually presents with a targetoid lesion associated with constitutional symptoms
- The common triad of symptoms associated with reactive arthritis (aka Reiter’s Syndrome) consists of conjunctivitis, urethritis, and arthritis
- Reactive arthritis commonly presents with a history of a GU infection (often chlamydia) or GI infection (Shigella, Campylobacter, Yersinia, Salmonella). It is more common in men and those between 20 and 40 years old.
- Treatment for reactive arthritis is usually supportive.
References: www.emedicine.medscape.com/article/331347-overview
Podcast #187: Mumps
Run Time: 4 minutes
Author: Gretchen Hinson M.D.
Educational Pearls:
- The key imaging of a mumps patient is “chipmunk cheeks” or parotitis.
- The swelling can extend almost to the ears and can be extremely painful – in about 25% of cases the swelling is unilateral.
- Other organs can be involved as well including: testicles, ovaries, breast tissue, other salivary glands, and the brain/spinal cord.
- Mumps is transmitted through droplets in the air.
- Two immunizations will get you 88% probability immunity and one immunization will get you 78% probability of immunity. Yet, immunity can wane and there can be viral strains not covered by the immunization.
- Mumps outbreaks are common in the winter season because of close quarters.
- You can test for Mumps using an IGM blood test, (more likely to see a spike in this if the patient is not vaccinated) Buckle swabs, & Urine test.
References: https://www.cdc.gov/mumps/index.html
Podcast #169: Lyme Disease
Run Time: 7 minutes
Author: Greg Burcham M.D.
Educational Pearls:
- Case presentation: A 48 year-old male cyclist travels to new england for a race. Afterwards he is sore, tired and fatigued, but 1 week later back in Colorado he is still sore, tired, and fatigued, and he also noticed a rash that started after a few days. The patient presents to the ED after a syncope with HR in the low 40s.
- This patient has Lyme Disease. Hallmarked by the rash that he has, known as erythema migrans – a migrating red rash.
- Symptoms usually present 1-2 weeks after a tick bite, and generally start as nonspecific – fever, myalgias, headache, arthralgias, malaise. 80% of patients present with the rash that starts as a small red lesion that enlarges with a bright red border.
- A smaller percentage of patient get early disseminated disease. The most concerning complications are cardiac – Atrioventricular Block, bradycardia, and syncope – or a meningitis presentation.
- Late disseminated findings include chronic joint and muscle arthralgias, seizures, paresthesias, memory and cognitive changes. Amy Tan – author of The Joy Luck Club – has chronic lyme and she loses memory if she is off her antibiotics for any period of time.
- Lyme Disease is increasing by more than 10% per year for several years due to the destruction of habitat of predators, leading to mice population explosion, and global warming.
- Each stage of the tick life cycle require a blood meal – larva to nymph to adult. Normally larva find it hard to get a blood meal in the fall after they hatch in the late summer. The larva go dormant until spring when they are able to find a blood meal and eventually become adults so the life cycle can start over on an annual basis.
- As the climate has warmed a higher percentage of larvae are feeding earlier in the year, with a greater frequency in the New England area.
- The bacteria that causes Lyme Disease needs time to replicate in the host, but due to asynchronous feeding between the mice and ticks there is a higher concentration of the bacteria in both the mice and the ticks.
Link to Podcast: http://medicalminute.madewithopinion.com/lyme-disease/
References: http://rstb.royalsocietypublishing.org/content/370/1665/20140051
Podcast #162: Jaw Infections
Run Time: 3 minutes
Author: Suzanne Chilton M.D.
Educational Pearls:
- Patient presentation: 2 weeks of mouth pain, no recent dentist visit, low grade fever, and muffled or hot potato voice.
- Patient exam: swollen tongue that is located up and back in the mouth, edema under tongue, diffuse erythema, and rancid breath.
- This patient has Ludwig’s Angina – a potentially life-threatening cellulitis of the lower jaw space.
- The infection starts from a dental infection – most commonly between the 2nd & 3rd molar because roots of these teeth go into a space between the muscles of the head and neck that can reach down to the anterior neck.
- The most serious complication for patients is maintaining their airway. Patients should be placed in a room with advanced airway management and a cricothyrotomy kit near by.
- Treatment is broad spectrum antibiotics that targets anaerobes, and oral flora such as clindamycin or unasyn with flagyl.
- Steroids will help with the swelling – patients have a 65% less chance of intubation if they are given steroids.
Link to Podcast: http://medicalminute.madewithopinion.com/jaw-infections/
References: http://www.ncbi.nlm.nih.gov/pubmed/18952475
Podcast #142: Botulism from Black Tar Heroin
Run Time: 2 minutes
Author: Michael Hunt M.D.
Educational Pearls:
- The first case of skin botulism from the use of black tar heroin in Colorado was documented in July of 2016.
- Botulism is most deadly toxin known to man and originates from the genus of tetanus and difficile – Clostridium botulinum.
- Characteristics of botulinum, bulbar palsies of the cranial nerves causes a descending paralysis from the head down.
- Neurologic symptoms start as decreased facial sensation, EOMI problems, difficulty controlling airway, skeletal muscle dysfunction, and diaphragm dysfunction.
- Patients with botulism from heroin use need to be admitted to the ICU. Treatment includes airway support and management, then administration of the antitoxin from the CDC.
Link to Podcast: http://medicalminute.madewithopinion.com/botulism-from-black-tar-heroin/
References: http://www.tchd.org/DocumentCenter/Home/View/3591
https://www.cdc.gov/botulism/index.html
Podcast #134: Rabies
Run Time: 4 minutes
Author: Susan Brion M.D.
Educational Pearls:
- Rabies causes 61,000 deaths per year worldwide, mostly in Africa and Asia, and associated with dog bites. In the US there are 2 fatal rabies cases per year, all associated with bats.
- Dogs in the US: the only concern is if you are bitten along the US/Mexico border, there are actually more documented cases of rabies in cats in the US than in dogs.
- All 49 continental states have documented rabies cases with bats. Even if a patient woke up in a room with a bat, the patient is a child, has developmental delay, or is intoxicated they should be treated prophylactically.
- There are no documented case of rabies in small rodents, no documented transmission of rabies from infected patients to providers.
- Theoretically rabies can be transmitted from human to human, but it is not well documented.
- BOTH immunoglobulin AND vaccine are given for prophylaxis. Wound cleaning reduces chance of transmission by 90%. Dosing is 20 int units /kg.
- It is recommended to give as much of the immunoglobulin as feasible at the site of the wound, the rest is given IM. If there is no obvious wound the immunoglobulin is given IM.
- Prophylaxis is given on days 1, 3, 7, 14.
Link to Podcast: http://medicalminute.madewithopinion.com/rabies/
References: http://www.cdc.gov/rabies/medical_care/
Podcast #124: Nets and Malaria
Run Time: 4 minutes
Author: Eric Miller M.D.
Educational Pearls:
- The WHO in 2000, set a goal of reversing incidence of mosquito deaths by 2015.
- One billion insecticide coated nets were given for free in areas of high malarial incidence in Africa. Each net costs 2-3 dollars.
- In 2000, there were 1 million deaths due to malaria per year. In 2015, there were about 400,000 deaths due to malaria per year showing a 60% decrease in deaths.
- From 2000 to 2015 the incidence of new malaria infections also decreased from 200 million new cases to 50-60 million new cases of malaria.
- While this was a great success in terms of decreasing death and incidence of mortality there are unintended consequences. In communities by water, 87-90% of the nets distributed are being used for fishing. This causes issue as the insecticide on the nets are being directly introduced into the water sources. As a result malaria rates in fish have also decreased precipitously but the fish all taste like “OFF!” (just kidding…pesticides and fish shouldn’t mix).
Link to Podcast: http://medicalminute.madewithopinion.com/nets-and-malaria/