Mad Mondays: the meningitis edition

Meningitis: a few morsels

* Symptoms: 

- HA 90% occurence w/ meningitis

- Fever 80%

- AMS 70%

--> TWO of HA/fever/meningismus/AMS = 95% occurrence rate

* Peds vs Adults: 

- Sick kids are sick until proven otherwise

- BGM BGM BGM BGM BGM BGM BGM

- Peds more likely to show first with myalgia, cold or mottled extremities --> rapidly spreading purpura/AMS/hemodynamic instability

= TREAT IMMEDIATELY

= DO NOT WAIT FOR LP (talk to your attending)

- Consider CSF-CRP to help determine viral vs bacterial meningitis; early evidence shows it might help in stain negative samples

- With moderate suspicion, if WBC and/or ESR is elevated, treat immediately (EBM recommendation; consider this in context)

* Diagnosis:

- CSF gram stain only 60-90% sensitive

 

 

* Treatment:

- Steroids?? 

= Highly controversial. EBMedicine says consider giving to adults if HIGH SUSPICION ofpneumococcal infection  (only if you can give with first dose abx too)

- Ceftriaxone, fluids; add other abx prn

- Close contacts: rifampicin (routine) or cipro (women on OCP)

Thrilling Thursday: Peri-intubation crashing

Let's talk some peri-intubation hazards and what you should be thinking about in this setting, focusing on hypotension. If you want to really reinforce it, highly recommend the recent EmCrit podcast (a little dense but helpful) and the RebelEM adjunct (http://rebelem.com/critical-care-updates-resuscitation-sequence-intubation-hypotension-kills-part-1-of-3/).

Peri-intubation crashing:

First and always the P's

In the addition to the thorough process of P's prior to intubating a patient, consider the HOPs:

* hypotension-- we.ll focus here today

* hypoxia

* acidosis

Hypotension

* ETT/vent --> positive pressure ventilation --> increased RA pressure --> decreased venous return --> decreased preload

* most of these patients are already under a lot of stress with a huge catecholiamine surge propping up the system but also nearly depleting their stores.

* you take this away with induction; this makes ketamine often a better agent

* in shock, paralytics may take longer to work; make sure they're actually circulating

* even if starting with just a soft BP, target a  higher number than you might otherwise

* push dose pressor administration vs drip prior to intubation will help prevent peri-intubation crashing;

* epinephrine is the preference for direct cardiac effect

Wellness Wednesday: the Recap and more!

We all listened to a great case this morning about a very sick patient who ultimately was found to have sepsis and DKA secondary to Fournier's gangrene. Broadly, we discussed:

* early, aggressive and critical fluid resuscitation in DKA and sepsis

* early recognition of a patient's severity of illness and potential to decompensate (also early consideration of what interventions ie. central line may be necessary to keep the patient safe as inpatient)

* early and appropriate consultation (especially of Surgery) by all possibly involved parties

* along those lines, urological emergencies are often also surgical ones

So, to discuss further:

Urological emergencies: a sampling

 

To pick some big ones:

Penile trauma:

* corpus cavernosum tears

* "pop", pain and swelling --> eggplant deformity (look it up)

* 10-20% occur with urethral trauma

* ultrasound! Or MRI

* surgical repair significantly decreases chances of erectile dysfunction and chronic pain

Urethral trauma: in pictures!

* 10-20% of pelvic fractures have urethral injury!

Bladder injury:

* intraperitoneal rupture is a surgical emergency; retroperitoneal will drain on its own; you can have both at once

* direct blunt trauma to inflated bladder, penetrating, pelvic fracture

* 10-30% of posterior urethral injuries also occur with bladder injury!

* high rates in children

Paraphimosis:

* foreskin caught behind glans --> swelling --> blister-like distension of penis tip --> necrosis and ulceration into urethra

* suspect in ALL ages

* infection risk in DM, immunoxompromise

* pain control

* reduceable at bedside but POSSIBLE need for OR (http://emedicine.medscape.com/article/143885-overview)

***Also consider testicular torsion, testicular rupture, renal injuries, and urinary retention.***