Chris Arnold’s July E-shift!

1. What is the optimal outpatient treatment for uncomplicated UTI?

UTI is a common issue faced in the ED, with a broad spectrum of presentation. There are many options for treatment; however, each medication provides advantages and disadvantages. The microbial spectrum of uncomplicated cystitis and pyelonephritis consists mainly of E. Coli 75-95% with Proteus, Klebsiella and Staph. saprophyticus. As the other causes are rare local susceptibility to E. coli should be considered when selecting empirical treatment for UTI.

Treatment of Cystitis

1. Nitrofurantoin 100 mg BID x 5 days
   1. Do not use in early Pyelonephritis as it concentrates in urine
   2. Caution with elderly (cause confusion), and renal disease, CrCL < 60 ineffective
2. Bactrim DS 1 tab BID x 3 days
   1. Do not use if treated for UTI w/ Bactrim in last 3 months
   2. Consider other Abx if local resistance is > 20% (30% at SJH)
3. Fosfomycin 3 g single dose
   1. Less effective than Bactrim and Nitrofurantoin
4. Floroquinolones x 3 days
   1. Not a first line treatment
   2. Local E Coli resistance 34%
   3. Longer treatment regimens did not improve cure rates but did increase side effects.
5. B-lactam agents 3-7 days
   1. Augmentin, cefdinir, cefaclor are all acceptable
   2. Keflex is less well studied but can be used
   3. Amoxicillin and Ampicillin should never be used as they are ineffective.

Treatment of Pyleonephritis

1. Ciprofloxacin 500 mg BID x 7 days
   1. One time IV dose of Cipro shows no added benefit
   2. If reisitance patterns to fluoroquinolones > 10% a long acting IV abx such as Ceftriaxone 1 gram should be given. (34% at SJH)
2. Bactrim DS 1 tab BID x 14 days
   1. Only to be used if pathogen is known to be sensitive to Bactrim
3. Oral B- lactam 10-14 days
   1. Should be given 1 gram Ceftriaxone in ED
   2. Less effective than other options

 

2. If and when is the use of stress dose steroids indicated in the treatment of Sepsis in the ED?

The use of stress dose steroids is a controversial one. Studies have shown overall benefit and a quicker resolution of shock, but no mortality benefit at 28 days. Current guidelines recommend the use of hydrocortisone 100mg q8 for 7 days in patients who require vasopressor support despite adequate fluid replacement. This should also be considered for any critically ill patient taking more than 5 mg of Prednisone for greater than 3 weeks. The rationale behind this is that patients with relative adrenal insufficiency (defined as a post-ACTH cortisol increase <9ug/dl) showed significant shock and mortality reduction in one large multicenter RCT (1).   Further smaller studies have shown significant effects on shock reversal (2-3). Current AAEM guidelines recommend that stress dose steroids be given to any patient requiring vasopressor support (septic shock); they should not be used in patients without evidence of shock. I found some recommendations for increasing the dose by 2-3 fold of daily steroids in patients on a maintenance dose > 5mg of Prednisone with minor infections.

(1) Annane D, Sebille V, Charpentier C, et al: Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 2002;288:862–871

(2) Briegel J, Forst H, Haller M, et al: Stress doses of hydrocortisone reverse hyperdynamic septic shock: A prospective, randomized, double-blind, single-center study. CritCare Med 1999; 27:723–732

(3) Bollaert PE, Charpentier C, Levy B, et al: Reversal of late septic shock with supraphysiologicdoses of hydrocortisone. Crit Care Med 1998; 26:645–650

 

 

3. What is the procedure for and emergent C-section in the ED?

The possibility of being required to perform an emergent C-section in a dead or critically ill mother is one that you might face depending on where you choose to practice. Time is of the essence as a C- section must be preformed within 5 minutes if the baby is to survive. Below is the entire procedure, although some steps will be unnecessary in most instances where we would be performing a C- section.

The book first mentions using 0.5% lidocaine w/ epinephrine to either side of midline from the symphysis pubis to 5 cm above the umbilicus being careful not to pierce the peritoneum or uterus. Ketamine can also be used at a dose of 0.5 mg/kg if analgesia is required for the mother, avoid narcotics or sedatives as they adversely affect the baby. Place patient with R side up to displace uterus to the left

1. Prep patient from below breast to mid thight
2. Enter abdomen through a lower midline incision
3. Identify and incise the peritoneal reflection of bladder transversely and create a bladder flap to retract the bladder
4. Carefully incise the uterus transversely across the lower uterine segment (where the uterine wall thins)
5. Once the amniotic membranes are visible or opened extend the incision laterally bluntly or with bandage scissors careful to advoid the uterine vessels laterally. If necessary extent the incision at one or both of the lateral margins in J fashion with a vertical incision
6. Elevate the fetal part into the incision with an assistant providing fundal pressure
7. Deliver the fetus, suction the nose and mouth, clamp then cut the cord and hand off infant for further care
8. Apply gental traction to the placenta, massage the uterus and begin oxytocin
9. Using gauze sponge clean inside of uterus and vigorously massage fundus to help uterus contract.
10. Close the incision with larger (size 0) absorbable sutures, single layer running is adequate
11. Close the fascia and abdomen once hemostasis is assured.

 

4. What is the treatment for Acute Angle- Closure Glaucoma?

I tend to struggle with eye complaints. I had a patient recently who had acute angle closure glaucoma and wanted to review the treatment. Acute angle closure glaucoma results from sudden increase in IOP from blockage of the anterior chamber outflow channels by the iris root. This causes intraocular vascular insufficiency that may lead to optic nerve or retinal ischemia and can lead to permanent visual loss within hours. It is characterized by sudden onset of blurry vision followed by pain, halos around lights, photophobia, frontal headache and nausea/vomiting.   Exam findings can include red eye with fixed or sluggish mid-dilated pupil, shallow anterior chamber, hazy cornea, and IOP will be greater than 30 mmHg.

Treatment involves reducing the IOP by one or more of the following means.

1. Timolol 0.5% one drop in affected eye
2. Pilocarpine 2% Two drops q15 min for 2-3 hours
3. Mannitol 20% 250-500 ml IV over 2-3 hours
4. Acetazolamide 500 mg PO or 250 mg IV

The patient should also receive an emergent ophthalmologic consultation