A digest of Dr. Herbert’s monthly audio CME series
edited by Chris Feier, MD
1. Treatment of dyspepsia
The first priority, says Mel and Stuart, in any patient with abdominal symptoms is to address any possible life threat, namely acute coronary syndrome (ACS). 30% of ACS patients present with isolated GI complaints, therefore a screening EKG is strongly recommended. Next, look for the presence of red flags such as dysphagia, older age, weight loss, GI bleeding, and anemia that might signal patients requiring urgent endoscopy and possible admission. Only then, if the abdominal symptoms appear to be dyspepsic in etiology, empiric therapy can be initiated based on the classification of their symptoms (ulcer dyspepsia vs dysmotility dyspepsia). Treatment with lifestyle modifications, antacids, and H2 blockers is usually adequate in patients with mild symptoms. Proton pump inhibitors (PPIs) can be used in patients that fail a trial of H2 blockers or are found to be H. pylori positive. Patients that are refractory to medical therapies will require referral to a gastroenterologist for endoscopy and further testing.
2. Thrombolytics may be more effective than PCI for acute MI in certain populations
The goal in any patient with an acute MI is the restoration of myocardial blood flow and oxygenation as soon as possible. Thrombolytics may be beneficial in patients that present within 3 hours of their event, and especially if they present within one hour. This is because the average door to needle time (15-30 mins) is significantly shorter than the average door to balloon time (90 mins), thus limiting myocardial ischemic time. This allows for earlier reperfusion and limitation of myocardial injury. This benefit of early thrombolysis is not seen in patients with a delayed presentation of over 3 hours and PCI is likely more effective. Therefore, in the patient with an early presentation of MI, whichever method opens the vessel and allows reperfusion of the myocardium the quickest is likely the most beneficial. Source – Al Sacchetti MD and Randy Mintz MD
3. What is Community Acquired- MRSA?
CA-MRSA, which has increased from 29% in 2001 to 64% in 2004, has evolved separately from the well known hospital acquired MRSA. The accepted theory is that community strains of Staph aureus, now causing over half of all cellulitis cases, acquired resistance genes that subsequently allowed these strains to have a selective advantage of virulence and spread. The strength of CA-MRSA is that it carries the Panton–Valentine gene that produces leukocidin, a cytotoxin that has been associated with severe abscesses and necrotizing pneumonia. Unfortunately, there are no clinical or historical features that reliably predict MRSA etiology. Therefore, CA-MRSA should be suspected in most patients with skin infections. The good news is that, as compared with health care–associated MRSA isolates, community-associated MRSA isolates tend to be resistant to fewer antibiotics and can usually be treated with bactrim (100% susceptible), doxycycline or clindamycin (85% susceptible). Source – Dr. Greg Moran from UCLA/Olive. All-LA Grand Rounds Conference
4. Myths of Community Acquired Pneumonia
Myth: Typical and atypical pneumonias are easily differentiated.
Fact: History, physical, or x-ray are not good predictors
Pearl: Cover atypical pneumonia
Myth: Sputum gram stain and culture are required in CAP
Fact: Only a 50% likelihood of correlation.
Pearl: Us only in the case of HIV or TB
Myth: ED acquired blood cultures are often positive and change management
Fact: True positive rate may be as low as 7-10%, with false positives at 50%
Pearl: Use cultures only for complicated admissions, i.e. liver dz, hypo- or hyperthermic, tachycardic, uremic, altered WBC, hyponatremia
Myth: Antibiotics can be initiated upon admission to inpatient service
Fact: Mortality decreases with every hour less than 8
Pearl: Give antibiotics ASAP, not just within 4 hours.
Myth: Respiratory rate > 30 predicts impending respiratory failure
Fact: Healthy patients with good cardio reserve can tolerate substantial tachypnea
Pearl: Support with oxygen and look for multilobar or bilateral effusions as predictors of respiratory failure.
Myth: Pleural effusions associated with pneumonia can be safely observed over time.
Fact: Delay in thoracentesis is associated with longer hospitalization
pH has the predictive accuracy for complicated parapneumonic effusions
5. MRSA Pneumonia must be recognized early because of its high mortality rate
If you have a very sick, septic, or dying young person, suspect CA-MRSA pneumonia and treat empirically. That is the take home of this review. MRSA pneumonia is seen in young patients with an average age of 17-21. The mortality rate is over 60% and can kill rapidly- average symptom onset to death is 3.5 days. There is usually a preceding influenza infection and should be suspected in patients who present with cavitary infiltrates without risk factors for anaerobic aspiration pneumonia. Current IDSA/ATS guidelines recommend initiation of vancomycin or linezolid if CA-MRSA is a consideration, and should probably be initiated empirically in the septic, ill ICU patient. Source – Clinical Infectious Diseases 2007; 44:S27–72.
6. The CURB 65 score can help predict pneumonia severity and disposition
The Curb 65 score is an easy to use tool that can help with the disposition of pneumonia patients. Patients with scores of ≥ 2, admission to an inpatient facility should be strongly considered. Other prognostic tools such as the Pneumonia Severity Index (PSI) may have slightly better sensitivity and negative predictive values, but are also more cumbersome and difficulty to use. Also widely used, the PORT score is useful for predicting mortality but does not aid in the disposition of patients, which is what we as emergency physicians are concerned with. Objective criteria or scores are only one of many tools for the clinician and should not supplant their clinical assessment and determination of social factors, including the ability to reliably take oral medication and availability of outpatient support resources. Source – Peter Deblieux, MD
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