8:00 Resident Lecture Competition - "Rabies" by Dr. Dan Witkewitz

1885 1st vaccine by L Pasteur
2-3 cases per year in USA
Skunks, bats, foxes, racoons, bobcats – 90%
Organ transplantation can be a cause
Prophylaxis is highly effective – nearly 100%
Negative stranded RNA virus
Transmission from saliva in bites, incubation period weeks to years, average 1-3 months

Clinical:
Prodrome – flu-like sxs. May have paresthesia from wound radiating proximally, percussion myoedema.
Travels to CNS by root ganglia.
Hydrophobia, aerophobia, contraction of facial muscles, ascending paralysis, altered mental status, autonomic instability. Death from respiratory paralysis.

Testing: skin, saliva, CSF, serum
Vaccination: Ig
Treatment: pre-exposure prophylaxis is often given empirically.
Post-exposure prophylaxis: 0, 3, 7, 14, 28 days. If one dose is missed, you have to start over.

Questions to ask: Was animal provoked? Strange aggressive behavior in animal? Ability to observe animal? Vaccination status of the animal?

"Dermatologic Emergencies" by Dr. Nicole Lucas

2 questions to ask: Is there MM involvement? IS there Nikolsky sign?

Diffuse Erythema:

Erythema Multiforme – symmetric, target lesions, palms and soles, drugs/HSV/mycoplasma. No MM, no Nikolsky sign. Not an emergency.
Steven Johnson syndrome – more aggressive, + MM, + Nikolsky’s sign, painful, + palmes and soles, + conjunctivitis. Look at surface area affected – usually <10%. Drugs, HSV. Admit to burn unit.
Toxic Epidermal Necrosis – even more aggressive, + MM, + Nikolsky’s sign, >30%, surface area drugs. Treat with IVF by Parkland formula, admit to burn unit. 40-50% mortality.

Scalded Skin Syndrome – erythema and blisters, palmes and soles, flaccid bullae, kids 6+ years, post-infectious, No MM, + Nikosky. Admit, + Abx, no steroids!

Vesicles and bullae:

Pemphigus vulgaris:
Oral lesions, painful mucosal blisters, flaccid bullae, rupture of them – erosions. + MM, + NIkolsky
Steroids, Parkland formula

Bullous pemphigoid:
Deeper involvement, tense bullae that will not rupture, older pts, no MM, no Nikolsky
Self-limiting, steroids

"Steven was Vulgar, so he got scolded" – SJS, emphigus vulgaris, SSS

"Hantavirus" by Dr. Zachary Athing

Deadly, 20 species that cause human disease, Sin Nombre Virus is in USA, reservoir in deer moose, virus is shed in rodent urine, saliva, droppings.
Strict zoonosis: cleaning (basement, garages, abandoned buildings, etc), housecleaning of mice stuff, work-related exposure
HCPS (Hantavirus cardiopulmonary syndrome)
38% fatality
Western USA

Incubation period: 2-3 weeks
Prodrome: F/N/V/D, weakness, cough but no other URI sxs. Flu-like illness
Cardiopulmonary phase: rapid onset of cough, capillary leak into pulmonary bed, non-cardiac pulmonary edema, hemodynamic compromise, lasts 24-48 phase. Can be deadly in a short time.
Convalescent phase

Treatment: Supportive
No steroids, no antivirals

Rapid urbanization = opportunity for rodents
CDC warns it will increase in prevalence due to rapid urbanization of the world. Contrapest: rat birth control.

Board pearls: Southwestern US, aerosolized droppings/urine (shed, garage, abandoned buildings), general malaise, N followed by abrupt respiratory failure

PEGs by Dr. Melvin Thomas

Complications of PEG placements:
Pneumoperitoneum – self-limiting
Gastro-colo-cutaneous fistulas – PEG is accidentally put through bowel to stomach
Abd wall bleeding – after placement, can tighten external bumper
Injury to colon, liver, etc
Infected G-tube – stoma site with erythema/tenderness/purulent drainage
Clogged tube – 45%, frequent water flushes prevents it. Unclogging attempt with water, carbonated beverages, pancreatic enzymes. Replace the tube if no success.
Buried bumper – excessive tension between internal and external bumper – leads to ulceration. Need to be fixed by GI
Displacement – takes 1 month for track to fully mature and be replaced safely in ED

Can always use Foley if PEG cannot be found.
Verify placement of PEG by using contrast infusion and X-ray.

9:00 am Case conference by Dr. Kevin Kammel

Intern in hot seat: Dr. Masood Khalid
Life line senior: Dr. Mike Torre

CC: Fever

Neutropenic Fever

ANC = WBC x (segs% + bands%) x 10

Normal: ANC 1500 to 8000
Neutropenia: ANC <1000
Severe neutropenia: <500
Profound neutropenia: <100

ANC nadir typically occurs 5-10 days after chemotherapy

Fever definition:
Single oral temp >100.9 or multiple temps >38 separated by an hour

3 fever syndromes:
Microbiologically documented infection
Clinically documented infection
Unexplained

Measuring temp: avoid rectal temp – local mucosal damage causes bacteremia

Clinically may have no symptoms due to suppressed immune response.
PE must be meticulous to find the source of infection
Chemotherapy typically causes severe mucocytis

Treatment:
Many pts have central lines – can be a source in itself
Bacterial: Staph, Strep, Pseudo monas, Enterocolitis
Fungal infections can be common (Candida and Aspergillus)
Viral infections are common (HSV)

Load then with Abx asap! Don’t wait for test results, etc.

Clinical Score predictors:
MASCC, CISNE

11:00 am "Hem/Onc Emergencies" by Dr. Enkhtsetseg Purev

Metabolic Emergencies:

Tumor Lysis Syndrome

Life-threatening condition after cellular destruction of rapidly growing tumors
HyperK, hyperuricemia (AKI), hyperphosphatemia (N/V/D/lethargy, seizrues, AKI), hypocalcemia (muscle cramps, tetany, hypotension, dysrhythmias, AKI)

Hypercalcemia

25% cancer patients
Complex mechanism: humoral osteolytic activity via PTHrP, local osteolytic activity:
Sxs:
Neuro: altered MS, weakness, depression, delirium, decreased DTRs
Renal
GI – N/V/constipation, abd pain, pancreatitis
CV – ECG changes
Musculoskeletal
Treatment: depends on sxs. If mild, just observe and treat underlying cancer. If symptomatic and Ca >14, admit, IVF, monitor, calcitonin, diuresis, steroids.

Structural emergencies:

SVC syndrome – compression or invasion of SVC, 3-4% of cancer patients (mostly from lung, NHL, thyroid cancers)
Early signs: facial edema, edema on neck/thorax, dilated veins (spider veins), facial plethora, Horner syndrome
Late signs: Cyanosis, absent peripheral pulses, CHF, BP, syncope, Chest pain/SOB/resp. distress, Hoarseness, stridor, Mental status changes, seizure, coma

Management:
CT with IV contrast
Tissue Dx
Radiation/chemo
Steroids
Surgery
Thrombolytics,/

Infusional emergencies:

Infusion reaction, especially of immunologic agent as part of chemotherapy
Hypersensitivity reactions, IgE or non-IgE- mediated reactions
Wide variety of clinical sxs
Skin rash (welts, urticaria, pruritis)
Anaphylactoid reactions
Management:
Prevention – pre-medication with Benadryl and Tylenol
Treatment – slow down of rate of infusion, Benadryl, steroids, epinephrine if anaphylactoid

Infusional vesicant extravasation reaction (Doxyrubicin)
DNA and non-DNA binding agents
Management:
Stop infusion, but do not remove line to avoid further damage
Assess site and clean it, draw back from line but don’t flush it
CT/US to assess the extent of damage
Usually ICU admission
Some antidots are available, consult Hem/Onc for choice

DIC
Mortality 80% for APL patients in the 1st 2 weeks
Hem/Onc emergency that develops secondary t underlying pathologic condition, bleeding and clotting at the same time.
Management: …….

Neutropenic fever
Start Abx within 30 min
Fever is the only sign of infection in these patients sometimes
Mortality 30-50% in septic patients with cancer
G -: E.coli, Klebsiella, Pseudomonas – most dangerous
G+ bacteria – not as bad
Fever >38 on 2 occasions 1 hour apart
PE is very important, because presentation may be subtle, need to look for source of infection meticulously.
Management: Abx asap!!!!
Cefepime 2 gr or Meropenem 1 gr or Zosyn 3.375gr
PLUS
Vancomycin

CAR T-cell therapy toxicity:

CRS (Cytokine release syndrome):
Causes severe flu-like reaction, can affect any organ, causes multi-organ failure.

Mediated by IL-6
Symptoms: F/N/hypotension/confusion, hypoxia, dypnea, capillary leak, hepatic failure
Treatment: Tocilizumab – it’s an anti-IL-6 receptor monoclonal Antibody. Now it is FDA-approved antidot for CRS

Neurotoxicity
Another side effect of immunotoxicity
It’s a toxic encephalopathy – most common sxs is pt is unable to speak, then confusion, seizure, death due to brain swelling and herniation
If survive the acute phase, then survive without sequelae.
Treatment: Steroids

The information on these pages is provided for general information only and should not be used for diagnosis or treatment, or as a substitute for consultation with a physician or health care professional. If you have specific questions or concerns about your health, you should consult your health care professional.

The images being used are for illustrative purposes only; any person depicted is a model.

 
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