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Infectious Disease Emergencies Flashcards

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1
Q

Define sepsis

A
  1. A state of systemic inflammation triggered by infection
  2. Affects most or all organ systems
  3. Early recognition is essential to providing effective care
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2
Q

Define septic shock?

A

Severe sepsis w/ persistent hypotension despite adequate fluid resuscitation

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3
Q

What are the immediate ABC measures for sepsis?

A
  1. Maintain airway & ventilation
  2. Maintain SaO2 > 92%
  3. Pt’s w/ mental status changes or persistent hypoxia may require mechanical ventilation
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4
Q

Why is a central venous line inserted for sepsis?

A
  1. Allows rapid infusion of crystalloid
  2. Vasopressors
    A. NE or Dopamine
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5
Q

What is the CVP goal for sepsis?

A

Maintain CVP 8-12 mm H2O

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6
Q

What hx do you need for a sepsis pt?

A 
1. Onset & duration of sx’s
A. Change in rate of progression over time
2. Host factors
A. Alcoholism, IV drug use, DM, asplenia
3. Potential for systemic infection
A. Flu, trauma, burn
4. Exposure
A. Travel, pets, immunizations, sick contacts, sexual contacts, menses
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7
Q

What may be the general appearance of a septic pt?

A
  1. Agitated

2. Lethargic

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8
Q

What PE needs special attention?

A
  1. Skin & soft tissue exam
  2. Neurologic exam
  3. Mental status
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9
Q

What dx studies are indicated for sepsis?

A 
1. Blood Work
A. Blood cultures, urine C&S
B. CBC with diff
C. Electrolytes, BUN/Cr
D. LFT’s
2. CSF
A. Cell count, gram stain & culture, glucose, protein
3. CT / MRI
A. Evaluate focal abscess
4. Wound cultures
5. CXR
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10
Q

What is the allowable time for a dx test to delay treatment of a septic pt?

A

No diagnostic test should delay treatment for > 10 minutes

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11
Q

What abx should be given for sepsis?

A
  1. Appropriate abx should be given w/in the 1st hour after sepsis is recognized
  2. Empiric abx therapy
    A. Amox/clav + 3rd gen ceph,
    OR
    B. 3rd gen ceph + vanco
    C. Gm (+) > Gm (-)
  3. Obtain sample cultures BEFORE treatment is started
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12
Q

What are the abx treatment choices influenced by?

A
  1. Site of infection
  2. Pt’s age & immune status
    A. Alcoholism, HIV, DM, malnutrition
  3. Hospital acquired vs community acquired
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13
Q

What are the general characteristics for Sepsis Without an Obvious Focus of Primary Infection?

A
  1. Primary site of infection may not be identified initially

2. Bacteremia & shock evident

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14
Q

Who is at risk for Sepsis Without an Obvious Focus of Primary Infection?

A
  1. Asplenic pts
  2. Risk of sepsis ↑ throughout lifetime
  3. Streptococcus pneumoniae most common etiologic agent
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15
Q

What are the general characteristics for Sepsis with Skin Manifestations?

A
  1. Maculopapular rash is usually not emergent
    A. Can occur early in meningococcemia or rickettsial disease
  2. Petechiae
    A. Meningococcemia
    B. Mortality rate >90%, esp if pt presents w/ shock
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16
Q

What is meningococcemia asst with? Who is at the highest risk?

A
  1. Often asst w/ recent URI
  2. Most common in infants, w/ a 2nd peak around 18 yrs
    A. Outbreaks occur in schools & army barracks
  3. May be associated with other serious infectious illnesses
    A. Meningitis, sepsis, pneumonia, epiglottitis, pericarditis
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17
Q

What are the sxs of meningococcemia?

A
  1. Fever, petechial rash, hypotension, shock, meningismus, headache, photophobia
  2. Petechiae begin at ankles, wrists, axillae, mucosal surfaces
  3. Progress to purpura & Disseminated Intravascular Coagulation (DIC)
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18
Q

What are the complications from meningococcemia?

A
  1. Peripheral circulatory failure
    A. Gangrene, limb loss
  2. Ventricular dysfunction
  3. Brain damage
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19
Q

What are the dx studies for meningeococcemia?

A
  1. Blood cultures
  2. CBC w/ diff
  3. CMP, PT, PTT, fibrinogen, FSP’s (fibrin split products)
  4. LP
    A. CSF antigen for neisseria meningitidis, cell count, gram stain, culture, glucose, protein
  5. PCR (polymerase chain reaction) serology
    A. Gold standard for DX
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20
Q

What is the treatment for meningococcemia?

A
  1. Empiric Tx ASAP

A. Ceftriaxone (Rocephin) or cefotaxime (Claforan)

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21
Q

What is the prophylaxis for meningococcemia for the close contacts of pts?

A
  1. Prophylaxis for close contacts of those w/ invasive Dz (including HCP’s directly involved in care of pt)
  2. Oral rifampin 600 mg bid x 2 d or ciprofloxacin
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22
Q

What is included in the heading Neurologic Infections with or without Septic Shock?

A

Meningitis & Meningoencephalitis

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23
Q

What are the classic sxs of Meningitis & Meningoencephalitis?

A
  1. Fever
  2. H/A
  3. Nuchal rigidity
  4. Mental status change
  5. Photophobia
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24
Q

What are the sxs of Meningitis & Meningoencephalitis in an infant?

A
  1. Vomiting
  2. Lethargy
  3. Irritability
  4. Poor feeding
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25
What are the sxs of Meningitis & Meningoencephalitis in the elderly?
1. Low grade fever | 2. Delirium
26
What is the classic triad of bacterial meningitis?
Classic triad of H/A, neck pain & fever in 50-66% of pts
27
What type of HA is seen in bacterial meningitis?
H/A continuous throbbing, most common at occiput, ↑ by JV compression
28
What % of pts with bacterial meningitis have positive blood cultures?
50-60% of pts
29
What is death asst with from bacterial meningitis?
Death asst w/ coma, respiratory distress, shock
30
What are the characteristic of acute meningitis?
1. Signs & sx’s
31
What are the characteristic of chronic meningitis?
1. Signs & sx’s x 1-7 days 2. Bacteria, virus, fungal 3. Includes aseptic meningitis A. Viral etiology
32
What are the dx studies for meningitis?
1. CBC w/ diff 2. Serum glucose 3. Blood cultures 4. Immed. LP if no papilledema, focal neuro changes, bleeding disorder, etc. A. CSF Cell Count, Gram Stain, Cultures, Glucose, Total Protein B. ↑ WBC’s (> 1,000/ml): 85% WBC’s are Polymorphonuclear cells C. Glucose in CSF
33
How is acute meningitis treated?
1. Ceftriaxone + vancomycin in all age groups 2. Add ampicillin to neonates & pts > 50 yrs 3. Give first dose ASAP after cultures obtained 4. Dexamethasone 10 mg IV w/ Antibx (adults) Adjust dose in child >2 mo
34
How is subacute meningitis treated?
Based on results of gram stain Dexamethasone 10 mg IV w/ Antibx (adults) Adjust dose in child >2 mo
35
What is the treatment for meningitis if an abscess is seen on CT?
1. CT if suspected abscess A. IV Pen G + metronidazole OR B. IV 3rd gen. cephalosporin + metronidazole
36
What is the supportive care treatment for meningitis?
1. ABC’s 2. Seizure precaution 3. Avoid overhydration -> worsens cerebral edema
37
What causes necrotizing fasciitis?
1. Severe soft tissue infection by Group A streptococci or a mixture of aerobic & anaerobic bacteria A. Strep pyogenes B. Mixed aerobic & anaerobic bacteria C. Strains of MRSA 2. Usually occurs as a complication of surgery, injury, or infection
38
What is the pathophys of necrotizing fasciitis?
Edema & necrosis of subcu tissues w/ involvement of the fascia & widespread undermining of adjacent tissue
39
What are the rf for necrotizing fasciitis?
1. Minimal trauma 2. Surgical incision 3. Varicella 4. Comorbid conditions A. DM, PVD, IV drug use
40
What are the sxs of necrotizing fasciitis?
1. Bacteremia 2. Hypotension 3. Minimal physical findings compared to degree of pain 4. Fever & toxicity 5. Infected red, hot, shiny, exquisitely tender area 6. Progress to bullae, thrombosis & necrosis 7. As necrosis begins,↓ pain due to peripheral nerve destruction A. Ominous sign
41
What is the mortality rate for necrotizing fasciitis?
1. 100% without surgery 2. 70% in Toxic Shock Syndrome (TSS) 3. 25-30% overall
42
How is necrotizing fasciitis treated?
1. Emergent surgical exploration to deep fascia & muscle A. Remove necrotic tissue 2. IV Abx A. Acute -> Emperic Ceftriaxone in all age groups before cultures are back A. Add ampicillin to neonates & pts > 50 yrs 4. Subacute -> Based on results of gram stain 5. Mixed aerobes & anaerobes use Ampicillin + Clindamycin + Ciprofloxacin C. Gas Gangrene use Clindamycin + Pen G
43
Define Acute Bacterial Endocarditis
1. Infection of endothelial surface of heart, most often the cardiac valves 2. Acute 3. Subacute 4. Bacterial 5. Fungal in IV drug users
44
Who most often gets bacterial endocarditis?
Seen in pt’s w/ malignancy, DM, IV drug use, alcoholism
45
What are the pathogens asst with bacterial endocarditis?
1. Staph aureus (high mortality) 2. Streptococci (IV drugs users) 3. Aerobic Gm (-) Bacilli (IV drug users)
46
What are the sxs asst with bacterial endocarditis?
1. Fever, malaise 2. Murmur (left sided) 3. Night sweats, weight loss 4. Cough, SOB, CP -> CHF/ pneumonia 5. CVA -> emboli 6. Cold extremity -> emboli 7. Cutaneous lesions A. Conjunctival or palatal petechiae B. Splinter hemorrhage
47
Define osler nodes
Tender erythematous nodules w/ opaque centers that appear on pulp of fingers and toes
48
Define janeway lesions
Nontender red macules or nodules on palms & soles
49
Define roth spots
Pale oval area surrounded by hemorrhage near optic disc
50
What are the dx studies for bacterial endocarditis?
``` (+) blood cultures ↑ WBC ↑ ESR TEE is close to 100% sensitive for exam of native valves & 84-94% sensitive for prosthetic valves Urine C&S & sputum Cx if able ```
51
What is the treatment for bacterial endocarditis?
1. Empiric abx therapy AFTER pan- cultures are obtained A. IV Pen G or vancomycin -. Strep viridans & Group D strep B. Vanco or Gentamicin for IV drug users -Staph aureus, Pseudomonas sp, streptococci
52
what are the Common pathogens that cause pneumonia during neonatal period (birth – 2 weeks) ?
1. Group B streptococcus 2. Listeria monocytogenes 3. E. coli 4. Klebsiella pneumoniae 5. Sepsis or meningitis may accompany pneumonia
53
What are the sxs of pneumonia in neonates?
Poor feeding Irritability Grunting Tachypnea
54
What dx studies are used for pneumonia in infants?
``` CBC w/ diff UA, Urine C&S Blood cultures CSF CXR ```
55
What are the rx of pneumonia in neonates?
IV Ampicillin
56
What is the most likely pathogen for pneumonia in infants 1-3 months?
RSV or influenza common pathogens If WBC > 15,000 suspect bacteria Chlamydia pneumoniae Strep pneumonia
57
What are the pneumonia sxs for infants 1-3 months?
Tachypnea, cough, grunting, rales, wheeze presenting sx’s Fever variable Dehydration complication
58
What is the treatment for pneumonia in infants age 1-3 months?
Erythromycin or Amoxicillin
59
What is the most likely pathogen for pneumonia in children 3 months-5yrs?
RSV or Influenza common path Mycoplasma pneumonia Chlamydia pneumonia Strep pneumonia
60
What is the sxs for pneumonia in children 3 months-5yrs?
Tachypnea, cough, rales, wheeze | Fever variable
61
What is the rx for pneumonia in children 3 months-5yrs?
Macrolide or Amoxicillin
62
What are the common pathogens for pneumonia in children 5-18?
Mycoplasma pneumonia common pathogen (Strep pneumonia)
63
What are the common sxs for pneumonia in children 5-18?
Fever, abd pain, cough, rales, wheezing, bullous myringitis
64
What are the tx for pneumonia in children 5-18?
Macrolide
65
What are the common pathogens for pneumonia in adults?
Strep pneumonia most common cause CAP in adults Mycoplasma pneumonia or chlamydia pneumoniae common in young adults Legionella pneumonia is associated w/ profuse diarrhea Gram (-) pneumonia Elderly, nursing home pts, alcoholics, pts w/ lung disease, immunosuppressed pts

Gen Med: Emergency Med (13 decks)

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