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Emergency Medicine Special Situations: IV Drug Users Transplant Patients Palliative Care

This conference discusses the overview and specific infections associated with intravenous drug users, including HIV, infective endocarditis, pulmonary infections, skin and soft tissue infections, vascular complications, and more.

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Emergency Medicine Special Situations: IV Drug Users Transplant Patients Palliative Care

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  1. Emergency Medicine Special Situations:IV Drug UsersTransplant PatientsPalliative Care Thomas Vu Resident Weekly Conference 07/03/19

  2. IV Drug Users • Overview • Specific Infections • HIV • Infective Endocarditis • Pulmonary Infections • Skin and Soft Tissue • Vascular • Bone & Joint • Ophthalmologic

  3. Quiz

  4. Street Names (not all-inclusive)

  5. IV Drug Users • Overview • Specific Infections • HIV • Infective Endocarditis • Pulmonary Infections • Skin and Soft Tissue • Vascular • Bone & Joint • Ophthalmologic

  6. Overview - IVDU • IV Drug use (such as heroin) and subesequent ED visits are on the rise • Places users at increased risk of complications • Associated with immune dysregulation (fever, wbc/ESR elevation not always present) • Fever: infectious, drug reaction, withdrawal, “cotton fever” • Dyspnea: aspiration, TB, opportunistic, ptx (pocket shot), hypersensitivity reactions, noncardiac pulm edema • AMS/Neuro: infectious, trauma… • Back Pain: epidural abscess, vertebral osteomyelitis, trauma

  7. Quiz

  8. Quiz Dr. Ekmel Bermek – Welcome to Brookdale!

  9. IV Drug Users • Overview • Specific Infections • HIV • Infective Endocarditis • Pulmonary Infections • Skin and Soft Tissue • Vascular • Bone & Joint • Ophthalmologic

  10. HIV

  11. Quiz

  12. Quiz Dr. Joseph Rauscher– Welcome to Brookdale!

  13. IV Drug Users • Overview • Specific Infections • HIV • Infective Endocarditis • Pulmonary Infections • Skin and Soft Tissue • Vascular • Bone & Joint • Ophthalmologic

  14. Infective Endocarditis • Incidence rising among IVDU, and consequently in N America • 8% of febrile IVDU hospitalized with “fever without a source” • #1 = S. aureus (MRSA 1/3), Eikenella, H. parainfluenzae, Bacteroides, Neisseria • 20% = polymicrobial • R-side heart (tricuspid) dominant • As opposed to Mitral Valve for non IVDU • Respiratory complaints: dyspnea, cough, hemoptysis • Findings: multiple CXR opacities, pyuria/hematuria

  15. Infective Endocarditis

  16. Infective Endocarditis

  17. Infective Endocarditis

  18. IV Drug Users • Overview • Specific Infections • HIV • Infective Endocarditis • Pulmonary Infections • Skin and Soft Tissue • Vascular • Bone & Joint • Ophthalmologic

  19. Pulmonary Infections

  20. IV Drug Users • Overview • Specific Infections • HIV • Infective Endocarditis • Pulmonary Infections • Skin and Soft Tissue • Vascular • Bone & Joint • Ophthalmologic

  21. Skin and Soft Tissue • **Most common cause of infections among IVDU • Cellulitis, SubcutAbsces, Septic Phlebitis, NecFasc, Fournier’s, Gas Gangrene, Pyomyositis • S. aureus, strep • Pseudomonas, candida if drugs contaminated (tap/toilet water, saliva) • Clostridium botulinum (skin poppers) • Tetanus higher incidence • Desomorphine (aka Krokodill) • Synthetic morphine derivative • Contains iodine, phosphorous • Serious damage to skin, blood vessels, bone • Long term users: limb amputation (“flesh-eating drug”) • Retained needles – nidus of infection

  22. Skin and Soft Tissue - Imaging Beside US • Underlying Abscess Doppler US • Pulsatile Mass Plain Films • Radiopaque FB, ST gas CT • Dilineates other structures, exten of abscesses • Helpful in neck region CT Angiogram • Vasospasms, thrombosis, emboli, mycotic aneurysms

  23. Skin and Soft Tissue Treatment • Similar to non-IVDU • Outpatient if no systemic signs • I&D, packing for abscesses

  24. Quiz

  25. Quiz Dr. Matt Skea– Welcome to Brookdale!

  26. IV Drug Users • Overview • Specific Infections • HIV • Infective Endocarditis • Pulmonary Infections • Skin and Soft Tissue • Vascular • Bone & Joint • Ophthalmologic

  27. Vascular • Inadvertent arterial injection: • Resultant vasospasm, thrombosis, septic thrombophlebitis, venous/arterial pseudoaneurysms, infected hematomas • Major occlusive pain, edema, mottling, ischemia • Persistent ischemia - tissue necrosis, gangrene Limb Ischemia • **Vascular surgery consult – determine if surgical or intra-arterial thrombolysis • Majority = distal vessels, limited to AC/supportive care • Limb edema can progress to compartment syndrome rhabdomyolysis

  28. Vascular Infected Pseudoaneurysm • Accidental/intentional intra-arterial drug injection • Most often reported femoral artery (followed by radial, brachial) • Similar appearance to abscess • Fever, painful mass • Can result in life-threateninghemorrhage, sepsis, post-traumatic ulcers, limb loss • All painful groin mass – needs US or CT with contrast

  29. Vascular Infected Pseudoaneurysm • Abx as per endocarditis • Surgery: limited/reserved • Localized ligation, resection without revascularization (risk of claudication, eventual limb amputation) • Ligation w/o revascularization then excision/drainage and selective revascularization w/ grafting

  30. IV Drug Users • Overview • Specific Infections • HIV • Infective Endocarditis • Pulmonary Infections • Skin and Soft Tissue • Vascular • Bone & Joint • Ophthalmologic

  31. Quiz

  32. Quiz Dr. Adam Rutz– Welcome to Brookdale!

  33. Bone & Joint

  34. Quiz

  35. Bone & Joint Osteomyelitis • Axial, tibia, prior fracture sites • Candidal can be due to contamination with lemon juice • Vertebral – localized pain/ttp over bone; palpable soft tissue mass • Can co-exist with epidural abscess • Sx for days (bacterial), weeks (fungal) • Lack of ESR/CRP/WBC elevation does not exclude Imaging • MRI preferred • CT – can show space narrowing, bony lysis (not as sens/spec) Treatment • Early Ortho/NSGY consult, CT guided biopsy for vertebral • Antimicrobials: per biopsy results; needed for 4-6 weeks; Vanc and Ceftazidime for unstable/septic patients (can’t wait for biopsy results)

  36. Bone & Joint Septic Arthritis • Usually hip or knee • Coexists with osteomyelitis 16% of cases • Sternoclavicular septic arthritis suggests drug use

  37. IV Drug Users • Overview • Specific Infections • HIV • Infective Endocarditis • Pulmonary Infections • Skin and Soft Tissue • Vascular • Bone & Joint • Ophthalmologic

  38. Ophthalmologic Endophthalmitis Bacterial Fungal

  39. Ophthalmologic • 2/2 Hematogenous seeding (Endocarditis) or Opportunistic Infections associated with HIV Fungal Endophthalmitis (#1 Candida, #2 Aspergilliosis) • Common black tar heroin (lemon juice dissolvent) • White cotton-like lesion • Treatment: Ampho B, Voriconazole Bacterial Endophthalmitis • Pain, redness, lid swelling, decreased visual acuity • Inflammation anterior/posterior chambers – Roth spots, cotton-wool exudates • S. aureus = #1 • Treatment: subconjunctival + systemic antibiotics, potential surgical/ophtho treatment • Poor visual prognosis HIV Co-Infection • CMV, Toxoplasmosis Retinitis, Choroidal Cryptococcus, MAV should be considered as well

  40. Quiz

  41. Quiz Dr. Ernest Rin – Welcome to Brookdale!

  42. Transplant Patients • Overview • Post Transplant Infections • Graft-Versus-Host Disease • Acute GVHD • Transfusion Associated GVHD • Specific Types of Transplantation • Renal • Liver • Lung • Cardiac • Corneal

  43. Transplant Patients • Overview • Post Transplant Infections • Graft-Versus-Host Disease • Acute GVHD • Transfusion Associated GVHD • Specific Types of Transplantation • Renal • Liver • Lung • Cardiac • Corneal

  44. Quiz

  45. Quiz Most commonly transplanted organ? • Kidney (58%) • Liver (21%) • Heart (8%) • Lung (5%) • Pancreas (5%)

  46. Overview • Most require lifelong immunosuppression • Acute Life Threatening Emergencies 1. Transplant Infection 2. Meds Side Effect 3. Rejection 4. Graft vs. Host 5. Organ Physiologic Changes • Common ED Presentations- Infection (39%)- GI/GU pathology (15%)- Dehydration (15%)- Electrolyte Disturbances (10%)- Cardiopulm Pathology (10%)- Injury (8%)- Rejection (6%)

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