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EM Special Situations > 12 Injection drug users > Flashcards

12 Injection drug users Flashcards

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1
Q

Most Harmful Type of Drug Abuse

A

Opioids

Higher risk of fatal and non-fatal overdose
Higher risk of infection

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2
Q

Of people who inject illicit drugs, 1.6M are affected with ___ and 6.1M are affected with ___

A
  1. HIV 2. HepC
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3
Q

Injection drug users are at risk for?

A

Infection (HIV, Hepatitis B and C, Kaposi’s sarcoma herpes virus, Tetanus, TB, STD

Trauma

Partner violence

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4
Q

Vaccine for Injection Drug users

A

HIV and Hep B

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5
Q

Non-treponemal syphilis test

A

False positive

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6
Q

Coombs test

A

Positive

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7
Q

Vaccination

A

Low measured antibody response

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8
Q

Street names

A
  1. H
  2. Skag
  3. Tar
  4. Bud light
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9
Q

A patient comes in with fever, tachypnea, tachycardia, abdominal pain, and inflammatory retinal nodules. CXR noted pulmonary granulomata. The companion divulges that the patient has a history of drug abuse. What condition should you suspect?

A

Cotton Fever

Flulike syndrome hours after injection with drugs suspensions filtered through cotton balls

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10
Q

Type of pneumonia typical in injection drug users

A

Community acquired

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11
Q

Causes of dyspnea in injection drug users

A

Aspiration from intoxication
Infection (TB, Pneumonia, etc)
Foreign body
Septic pulmonary emboli, right sided endocarditis

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12
Q

Noninfectious causes of dyspnea in injection drug users

A

Pulmonary edema, Pneumothorax, Hydrothorax, Toxic reaction to injected substances, Hypersensitivity, Foreign body granulomatosis, Exacerbation, septic emboli, air emboli, needle fragment emboli

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13
Q

What is pocket shooting

A

Drug users inject into supraclavicular fossa to access:
1. subclavian vein
2. Jugular vein
3. Brachiocephalic vein

high risk for pneumothorax/hemothorax

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14
Q

What is Talc Lung

A

Syndrome:
1. Progressive respiratory distress
2. Diffuse interstitial infiltrates

due to injection of talc adulterant

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15
Q

Usual presentation of heroin and cocaine injection with hypersensitivity

These patients typically respond with?

A

Cough and wheezing

inhaled B-agonist therapy

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16
Q

Noncardiogenic pulmonary edema drug user presentation

A

Dyspnea + Desat
diffuse alveolar infiltrates

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17
Q

Origin of CNS infections in injection drug users

A
  1. contiguous spread of overlying soft tissue infection
  2. Embolic complications of distant infection (endocarditis)
  3. extension of local infection (vertebral osteomyelitis)
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18
Q

Common Neuro infections in injection drug users

A

Epidural abscess, bacterial and fungal meningitis

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19
Q

Common causes of bacterial meningitis

A
  1. Meningococcus
  2. Pneumococcus
  3. S. aureus bacteremia from endocarditis
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20
Q

A patient presents with cranial nerve deficits, altered mental status, and progressive symmetric paralysis. What do you suspect?

A

Tetanus and botulism

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21
Q

Injection drug user with HIV and CD4 <100/mm3. Give an example of an opportunistic organism that may be present in this patient.

A

Toxoplasma

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22
Q

Low-flow states during heroin intoxication result to:

A

Stroke syndromes

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23
Q

Drugs that cause hypertensive hemorrhage

A
  1. amphetamines
  2. phencyclidine
  3. cocaine
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24
Q

Non-Traumatic focal back pain in febrile or nonfebrile injection drug users usually requires what imaging study?

A

MRI

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25
Back pain features that suggest infection
Pain that does not resolve when lying down Severe night time pain Failure of pain to improve with conservative therapy
26
All cause mortality is 3x higher among this population if then are injection drug users
HIV +
27
Characterize endocarditis in injection drug users
Typically right sided (57-86%) Mostly involve the tricuspid valve (55-94%), then the mitral and aortic valves (20-40%) Minority (5-14%) involve both sides of the heart
28
Radiograph finding in injection drug users with infective endocarditis
Multiple opacities on chest radiograph consistent with septic pulmonary emboli (fig 296-1,2)
29
These findings may also be present in infective endocarditis in injection drug users due to glomerulonephritis from immune complex deposition, embolic renal infarction, perinephric abscess
Pyuria and hematuria
30
Diagnosis of infective endocarditis requires?
Isolation of microbes in blood culture and or demonstration of typical lesions on echo
31
Classic findings of embolic phenomena
Janeway lesions Roth spots Not usually observed unless infection is advanced Osler's nodules are usually not seen with right sided endocarditis
32
Proper Blood culture collection in infective endocarditis
3 sets from separate sites at least 1 hr wait between collection of first and last set BEFORE initiation of therapy
33
If an injection drug user engages in needle licking or uses saliva to reconstitute the drug, the antibiotic must cover?
Oral (streptococal and anaerobic) and skin flora
34
Most common pulmonary infection in injection drug users
Community acquired cause bye Strep pneumoniae and H. influenzae also high risk for S. aureus, MRSA, Klebsiella, Aspiration pneumonia, TB HIV: pneumocystis jiroveci, CMV, Atypical mycobacteria
35
Empiric antibiotic in patients without risk for Pseudomonas infection
IV quinolone + IV Ceftriaxone/Cefotaxime until cultures return
36
Determinants of risk for Pseudomonas infection
Structural lung disease, Malnutrition, Current or recent corticosteroid use and antibiotic use
37
Empiric antibiotic in patients with risk for Pseudomonas infection
IV antipseudomonal B-lactamase agent (cefepime, imipenem, meropenem, pip-taz) + IV antipseudomonal fluoroquinolone OR Antipseudomonal B-lactamase agent, IV aminoglycoside and fluoriquinolone
38
Most skin infections in IV drug users are caused by?
User's own flora S. aureus and Strep
39
This drug contains large amounts of iodine and phosphorus that causes damage to skin, blood vessels, bone, and muscles
Desomorphine (Krokodil)
40
Flesh-eating drug
Desomorphine (Krokodil)
41
Cellulitis and abscesses are typically caused by?
S. aureus Streptococcus MRSA (community)
42
An injection drug user that uses mexican black tar heroin engages in skin poppin. What is the most likely organism involved in his skin infeciton?
Clostridium botulinum
43
Infections overlying venipuncture sits may produce?
Septic thrombophlebitis Infected pseudoaneurysms
44
Femoral vein injection = groin hit Jugular vein injection =
Pocket shot may lead to cutaneous abscess involving carotid triangle = airway obstruction, vocal cord paralysis, laryngeal edema
45
Imaging in skin infections
Bedside US Doppler US Angiography (vasospasm, thrombosis, emboli, mycotic aneurysms) Radiograph if suspecting air or foreign body CT MRI
46
I&D is done in?
uncomplicated small abscesses, large furuncles, carbuncles
47
All injection drug users with superficial cellulitis without systemic involvement with oral antibiotics to cover for?
Strep and MRSA
48
Pain, Edema, Patchy mottling due to ischemia
Inadvertent arterial injection Results to: infection -> vasospasm, thrombosis, septic thrombophlebitis, venous and arterial psudoaneurysms, infected hematoma
49
Consequence of persistent focal ischemia
Tissue necrosis and gangrene
50
Limb edema and ischemia can progress to?
Compartment syndrome and complicated by rhabdomyolysis
51
Venous pseudoaneurysms are usually secondary to?
septic phlebitis sx: fever and painful mass complications: hemorrhage, sepsis, claudication, ulcers, limb loss
52
What differentiates a pseudoaneurysm and a abscess?
(+) pulsations and bruit in pseudoaneurysms
53
All painful masses, especially in the groin should be imaged with?
Duplex US or Contrast CT
54
Management of vascular infections in IV drug users
Antibiotics Ligation and resection of psydoaneurysm
55
Bone and Joint infections in IV drug users organisms
S. aureus Strep Candida (rare but occur in immunosuppresion) Gram Neg Mycobacterium Eikenella
56
True or false, osteomyelitis is more frequent in extremities in IV drug users
False More frequent in axial skeleton 50% of cases involve the vertebral column particularly the lumbar segments 18% sternoclavicular joint 17% sacroiliac, extremities, hip and knee joints
57
Vertebral osteomyelitis is often accompanied by what condition?
Spinal epidural abscess (80%) of cases
58
Organism likely present in injection drug users with bone and joint infections who like their needles prior to injection
Eikenella corrodens
59
Candidal infections are likely hematogenous and are reported from?
Use of contaminated reconstituted lemon juice to mix drugs initial flu lke syndrome (3-4days) -> metastatic lesions in skin, eye (chorioretinitis, endophthalmitis), bones, joints
60
Sternal osteomyelitis organism
Aspergillus
61
Imaging of choice in IV drug user bone and joint infection
MRI delinates longitudinal and paraspinous extension of an abscess CT not as specific, but reveals disk space narrowing and bony lysis
62
True or False: Antibiotic therapy should be withheld until culture results are obtained in non-toxic osteomyelitis patients
True withhold UNLESS: Septic, focal neuro complaints, Endocarditis
63
Aside from blood cultures, what do you need to obtain in epidural abscess?
CT guided needle biopsy Bone sample culture
64
Treatment duration in osteomyelitis
4-6wks
65
Unstable IV drug users with osteomyelitis are treated with?
Vancomycin (s. aureus) Ceftazidime (Pseudomonas)
66
Septic arthritis in injection drug users ***usually involves*** what joints?
Hip or Knee
67
What location of septic arthritis ***strongly suggests*** injection drug use?
Sternoclavicular septic arhtritis
68
Radiographic findings in septic arthritis
Joint space widening Articular surface erosion Surrounding soft tissue infection
69
What imaging modality can detect septic arthritis early?
CT or MRI
70
Treatment of Septic arthritis
Immobilization Empiric antibiotics (MRSA) PT Arhthrocentesis/washout Open drainiage
71
Type of hepatitis that can be obtained from IV drug use
A-E Non-A through G
72
Rise in what type of Hepatitis is attributed to injection drug use?
HCV associated with more deaths in the US
73
Admission criteria in hepatic IV drug use patients
Inability to tolerate oral intake toxicity prolonged prothrombin time
74
Opthalmologic infections are primarily a result of what kind of seeding?
hematogenous
75
Characterize bacterial endophthalmitis
Pain, redness, lid swelling, dec visual acuity anterior and posterior chamber inflammation White centered, flame shaped embolic hemorrhages (roth spots), cotton-woll exudates, macular holes
76
Most isolated organism on ophthalmologic IV drug user infeciton
1. S. aureus 2. Strep
77
Treatment of opthalmologic infections
subconjunctival, intravitreal, systemic antibiotic tx, surgery, vitrectomy
78
Fungal organisms on opthalmologic infections
Often candida or aspergillosis rare: Torulopsis, Helminthosporium, Penicillium -> from Mexican black tar heroin injection
79
organisms involved in HIV with eye infection
Cryptococcus Mycobacterium avium-intracellulare BOV, pain, poorly reactive pupil, dec VA White cotton like lesions on choroid retina with vitreous haziness
80
Aside from blood cultures, what should you obtain in ophthalmologic infections?
Vitreous culture
81
Opthalmologic infection in IV drug user tx
Amphotericin B, Amphotericin lipid complex, fluconazole, +- antifungal therapy early vitrectomy
82
Appropriate antibiotics in admitted IV drug user patients with soft tissue infection
Penicillinase-resistant synthetic penicillin or vancomycin + Antipesudomonal aminoglycoside. antipseudomonal penicillin, or cephalosporin

EM Special Situations (13 decks)

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