POTD: Neutropenic Fever Part I

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Clinical Scenario: 35 yo F with hx of breast cancer currently on chemotherapy, last treatment a week ago, presents for fever, weakness, nausea but no vomiting.  She is febrile to 102F in the ED with HR120, BP 110/70, RR16, O2Sat 99%RA.  Her exam is unremarkable aside from dry mucous membranes.  You start her on IVF, antipyretic and antiemetic.  Her labs return and the CBC is concerning for neutropenia.
 
Question: How do you calculate the absolute neutrophil count and what value matters?
Absolute Neutrophil Count (ANC) = 10 x WBC in the 1000s x (%PMNS+%Bands)
E.g. 10 x 1.5 x (37%+13%) = 10 x 1.5 x 50 = 750/mm3
Neutropenia is usually defined as ANC <1500/mm3, with severe neutropenia defined as ANC<500/mm3.  The Infectious Diseases Society of America (IDSA) defines neutropenia as ANC <500/mm3 or an ANC expected to decrease to <500/mm3 in the next 48 hours.
*Note that areas overlooked during routine exams of febrile neutropenic patients are: the oral cavity, the perianal area, and IV sites*
 
Want to read more?
Alison G. Freifeld, Eric J. Bow, Kent A. Sepkowitz, Michael J. Boeckh, James I. Ito, Craig A. Mullen, Issam I. Raad, Kenneth V. Rolston, Jo-Anne H. Young, John R. Wingard; Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 Update by the Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 52, Issue 4, 15 February 2011, Pages e56–e93, https://doi.org/10.1093/cid/cir073
Stapczynski J. Emergency Complications of Malignancy. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109386926. Accessed January 22, 2018.
[To be continued... Neutropenic fever Part II will be released on Thursday!]
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POTD: Benzodiazepines

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Clinical Scenario:  30 yo M with hx of EOTH abuse BIBA after being found on the street, reports drinking alcohol a few hours ago.  At bedside, patient appears tremulous and vital signs are notable for tachycardia and hypertension.  You are concerned about alcohol withdrawal and ask the nurse to give the patient a benzodiazepine.  How do you decide which benzo to give?  

Adapted from Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e, 2016; Table 183-1

Generic Name Time to Peak Effect Elimination Half-Life Duration of Action Active Metabolite Half-Life Oral Dose Equivalents in Milligrams to Diazepam 10mg
Midazolam

(short acting)

 IV 1-2 min 3-6 hours IV 2 hours Yes 5
IM 10-15 min IM 4-6 hours
PO 30 min-1 hour PO 4-6 hours
Lorazepam

(intermediate acting)

 IV 5-20 min 9-16 hours 6-8 hours No 1
IM 20-30min
PO 30 min-1 hour
Diazepam

(long acting)

 IV 1-5 min 20-50 hours IV 15min-1 hour Yes (36-200 hours) 10
PO 15-45min PO 12-24 hours
Chlordiazepoxide

(long acting)

 PO 2 hours 5-30 hours 5-30 hours Yes (36-200 hours) 25

 

Want to read more?

Bernstein E, Bernstein JA, Weiner SG, D'Onofrio G. Substance Use Disorders. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109448503. Accessed January 19, 2018.

Quan D. Benzodiazepines. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109414024. Accessed January 19, 2018.

https://emedicine.medscape.com/article/2172250-overview

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POTD: The Different Realities…

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The International Meeting on Simulation in Healthcare (IMSH) 2018 was held this past weekend into early this week in Los Angeles, California.  One thing that was noticeable in the expo hall is that virtual and augmented reality is making its way into simulation education.  There were many vendors and so much cool gear!  So what is virtual and augmented reality?  

Virtual reality (VR) is a computer generated environment that allows one to experience a different reality.  This fully immersive experience is usually attained with a head-mounted display in our current consumer market.

 

Augmented reality (AR) uses the existing real world environment and adds digital information over it.  Think Pokémon Go.

 

And then there is mixed reality (MR), where one can interact with physical and virtual environments.

 

Check out this link for some of the companies that were at the expo (and watch some videos!):

http://www.healthysimulation.com/14505/imsh-2018-year-of-the-vr-a-breakdown-of-new-vr-training-opportunities-from-the-exhibit-hall/

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