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

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

12. Quiz

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

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

15. 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

16. Infective Endocarditis

17. Infective Endocarditis

18. Infective Endocarditis

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

20. Pulmonary Infections

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

23. 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

25. 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

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

27. Quiz

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

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

30. 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

31. 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

32. 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

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

34. Quiz

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

36. Bone & Joint

37. Quiz

38. 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)

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

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

41. Ophthalmologic Endophthalmitis Bacterial Fungal

42. 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

44. Quiz

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

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

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

48. Quiz

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

50. 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%)