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EM Special Situations > EM Special 5: Injection Drug Users > Flashcards

EM Special 5: Injection Drug Users Flashcards

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
Q

Back pain features that suggest infection

A

Pain that does not resolve when lying down

Severe night time pain

Failure of pain to improve with conservative therapy

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26
Q

All cause mortality is 3x higher among this population if then are injection drug users

A

HIV +

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27
Q

Characterize endocarditis in injection drug users

A

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

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28
Q

Radiograph finding in injection drug users with infective endocarditis

A

Multiple opacities on chest radiograph consistent with septic pulmonary emboli (fig 296-1,2)

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29
Q

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

A

Pyuria and hematuria

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30
Q

Diagnosis of infective endocarditis requires?

A

Isolation of microbes in blood culture and or demonstration of typical lesions on echo

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31
Q

Classic findings of embolic phenomena

A

Janeway lesions

Roth spots

Not usually observed unless infection is advanced

Osler’s nodules are usually not seen with right sided endocarditis

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32
Q

Proper Blood culture collection in infective endocarditis

A

3 sets from separate sites

at least 1 hr wait between collection of first and last set BEFORE initiation of therapy

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33
Q

If an injection drug user engages in needle licking or uses saliva to reconstitute the drug, the antibiotic must cover?

A

Oral (streptococal and anaerobic) and skin flora

34
Q

Most common pulmonary infection in injection drug users

A

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
Q

Empiric antibiotic in patients without risk for Pseudomonas infection

A

IV quinolone + IV Ceftriaxone/Cefotaxime

until cultures return

36
Q

Determinants of risk for Pseudomonas infection

A

Structural lung disease, Malnutrition, Current or recent corticosteroid use and antibiotic use

37
Q

Empiric antibiotic in patients with risk for Pseudomonas infection

A

IV antipseudomonal B-lactamase agent (cefepime, imipenem, meropenem, pip-taz) + IV antipseudomonal fluoroquinolone

OR

Antipseudomonal B-lactamase agent, IV aminoglycoside and fluoriquinolone

38
Q

Most skin infections in IV drug users are caused by?

A

User’s own flora

S. aureus and Strep

39
Q

This drug contains large amounts of iodine and phosphorus that causes damage to skin, blood vessels, bone, and muscles

A

Desomorphine (Krokodil)

40
Q

Flesh-eating drug

A

Desomorphine (Krokodil)

41
Q

Cellulitis and abscesses are typically caused by?

A

S. aureus

Streptococcus

MRSA (community)

42
Q

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?

A

Clostridium botulinum

43
Q

Infections overlying venipuncture sits may produce?

A

Septic thrombophlebitis

Infected pseudoaneurysms

44
Q

Femoral vein injection = groin hit

Jugular vein injection =

A

Pocket shot

may lead to cutaneous abscess involving carotid triangle = airway obstruction, vocal cord paralysis, laryngeal edema

45
Q

Imaging in skin infections

A

Bedside US
Doppler US
Angiography (vasospasm, thrombosis, emboli, mycotic aneurysms)
Radiograph if suspecting air or foreign body
CT
MRI

46
Q

I&D is done in?

A

uncomplicated small abscesses, large furuncles, carbuncles

47
Q

All injection drug users with superficial cellulitis without systemic involvement with oral antibiotics to cover for?

A

Strep and MRSA

48
Q

Pain, Edema, Patchy mottling due to ischemia

A

Inadvertent arterial injection

Results to:
infection -> vasospasm, thrombosis, septic thrombophlebitis, venous and arterial psudoaneurysms, infected hematoma

49
Q

Consequence of persistent focal ischemia

A

Tissue necrosis and gangrene

50
Q

Limb edema and ischemia can progress to?

A

Compartment syndrome and complicated by rhabdomyolysis

51
Q

Venous pseudoaneurysms are usually secondary to?

A

septic phlebitis

sx: fever and painful mass

complications: hemorrhage, sepsis, claudication, ulcers, limb loss

52
Q

What differentiates a pseudoaneurysm and a abscess?

A

(+) pulsations and bruit in pseudoaneurysms

53
Q

All painful masses, especially in the groin should be imaged with?

A

Duplex US or Contrast CT

54
Q

Management of vascular infections in IV drug users

A

Antibiotics

Ligation and resection of psydoaneurysm

55
Q

Bone and Joint infections in IV drug users organisms

A

S. aureus
Strep
Candida (rare but occur in immunosuppresion)
Gram Neg
Mycobacterium
Eikenella

56
Q

True or false, osteomyelitis is more frequent in extremities in IV drug users

A

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
Q

Vertebral osteomyelitis is often accompanied by what condition?

A

Spinal epidural abscess (80%) of cases

58
Q

Organism likely present in injection drug users with bone and joint infections who like their needles prior to injection

A

Eikenella corrodens

59
Q

Candidal infections are likely hematogenous and are reported from?

A

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
Q

Sternal osteomyelitis organism

A

Aspergillus

61
Q

Imaging of choice in IV drug user bone and joint infection

A

MRI

delinates longitudinal and paraspinous extension of an abscess

CT not as specific, but reveals disk space narrowing and bony lysis

62
Q

True or False:
Antibiotic therapy should be withheld until culture results are obtained in non-toxic osteomyelitis patients

A

True

withhold UNLESS: Septic, focal neuro complaints, Endocarditis

63
Q

Aside from blood cultures, what do you need to obtain in epidural abscess?

A

CT guided needle biopsy
Bone sample culture

64
Q

Treatment duration in osteomyelitis

A

4-6wks

65
Q

Unstable IV drug users with osteomyelitis are treated with?

A

Vancomycin (s. aureus)
Ceftazidime (Pseudomonas)

66
Q

Septic arthritis in injection drug users usually involves what joints?

A

Hip or Knee

67
Q

What location of septic arthritis strongly suggests injection drug use?

A

Sternoclavicular septic arhtritis

68
Q

Radiographic findings in septic arthritis

A

Joint space widening
Articular surface erosion
Surrounding soft tissue infection

69
Q

What imaging modality can detect septic arthritis early?

A

CT or MRI

70
Q

Treatment of Septic arthritis

A

Immobilization
Empiric antibiotics (MRSA)
PT
Arhthrocentesis/washout
Open drainiage

71
Q

Type of hepatitis that can be obtained from IV drug use

A

A-E
Non-A through G

72
Q

Rise in what type of Hepatitis is attributed to injection drug use?

A

HCV

associated with more deaths in the US

73
Q

Admission criteria in hepatic IV drug use patients

A

Inability to tolerate oral intake
toxicity
prolonged prothrombin time

74
Q

Opthalmologic infections are primarily a result of what kind of seeding?

A

hematogenous

75
Q

Characterize bacterial endophthalmitis

A

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
Q

Most isolated organism on ophthalmologic IV drug user infeciton

A
  1. S. aureus
  2. Strep
77
Q

Treatment of opthalmologic infections

A

subconjunctival, intravitreal, systemic antibiotic tx, surgery, vitrectomy

78
Q

Fungal organisms on opthalmologic infections

A

Often candida or aspergillosis

rare: Torulopsis, Helminthosporium, Penicillium -> from Mexican black tar heroin injection

79
Q

organisms involved in HIV with eye infection

A

Cryptococcus
Mycobacterium avium-intracellulare

BOV, pain, poorly reactive pupil, dec VA

White cotton like lesions on choroid retina with vitreous haziness

80
Q

Aside from blood cultures, what should you obtain in ophthalmologic infections?

A

Vitreous culture

81
Q

Opthalmologic infection in IV drug user tx

A

Amphotericin B, Amphotericin lipid complex, fluconazole, +- antifungal therapy

early vitrectomy

82
Q

Appropriate antibiotics in admitted IV drug user patients with soft tissue infection

A

Penicillinase-resistant synthetic penicillin or vancomycin

+ Antipesudomonal aminoglycoside. antipseudomonal penicillin, or cephalosporin

EM Special Situations (13 decks)

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