Principles of Appropriate Antibiotic Use for Acute Respiratory Infections

Principles of Appropriate Antibiotic Use for Acute Respiratory Infections

Principles of Appropriate Antibiotic Use for Acute Respiratory Infections

The CDC recently convened a multi-disciplinary expert panel to produce evidencebased practice guidelines for the appropriate use of antibiotics in acute respiratory
infections. The guidelines were published in full in the March 20, 2001 issue of the Annals of Internal Medicine.

Principles of appropriate antibiotic use for treatment of nonspecific URI in adults:

1) The diagnosis of nonspecific upper respiratory tract infection should be used to
denote an acute infection in which sinus, pharyngeal, and lower airway symptoms,
although frequently present, are not prominent. These infections are predominantly
viral in origin, and complications are rare.
2) Antibiotics should not be used to treat nonspecific upper respiratory tract
infections in previously healthy adults.
3) Purulent secretions from the nares or throat (commonly observed in patients with
uncomplicated upper respiratory tract infection) predict neither bacterial infection nor
benefit from antibiotic treatment.

Principles of appropriate antibiotic use for treatment of acute sinusitis in adults:
1) Sinus radiography is not recommended for the diagnosis of uncomplicated
sinusitis.
2) Acute bacterial sinusitis does not require antibiotic treatment, especially if
symptoms are mild or moderate.
3) Patients with severe of persistent moderate symptoms and specific findings of
bacterial sinusitis should be treated with antibiotics. Narrow-spectrum antibiotics are
reasonable first-line agents. In most cases, antibiotics should be used only for
patients with specific findings of persistent purulent nasal discharge and facial pain
or tenderness who are not improving after 7 days or those with severe symptoms of
rhinosinusitis, regardless of duration. On the basis of clinical trials, amoxicillin,
doxycylcine, or trimethoprim-sulfamethoxazole are the favored antibiotics.

Principles of appropriate antibiotic use for treatment of acute pharyngitis in adults:
1) Clinically screen al adult patients with pharyngitis for the presence of the four
Centor criteria: history of fever, tonsillar exudates, no cough, and tender anterior
cervical lymphadenopathy.
2) Do not test of treat patients with none or only one of these criteria. These
patients are unlikely to have GABHS infections.
3) For patients with two or more criteria, the following strategies are appropriate: a)
Test patients with two, three, or four criteria by using a rapid antigen test, and limit
antibiotic therapy to patients with positive test results; b) test patients with two or
three criteria by using a rapid antigen test, and limit antibiotic therapy to patients
with a positive test result or patients with four criteria; c) do not use any diagnostic
tests, and limit antibiotic therapy to patients with three or four criteria
4) Do not perform throat cultures for the routine primary evaluation of adults with
pharyngitis or for confirmation of negative rapid antigen tests when the test
sensitivity exceeds 80%. Throat cultures may be indicated as part of investigations
of outbreaks of GABHS disease, for monitoring the development and spread of
antibiotic resistance, or when such pathogens as gonococcus are being considered.
5) Administer appropriate analgesics, antipyretics, and supportive care to all patients
with pharyngitis.

Principles of appropriate antibiotic use for treatment of acute bronchitis in adults:
1) The evaluation of adults with an acute cough illness or a presumptive diagnosis of
uncomplicated acute bronchitis should focus on ruling out serious illness, particularly
pneumonia.
2) Routine antibiotic treatment of uncomplicated acute bronchitis is not
recommended, regardless of duration of cough.
3) Patient satisfaction with care for acute bronchitis depends most on physicianpatient
communication rather than whether an antibiotic is prescribed.

Concussion Parameters: Guidelines For Return to Competition

Concussion Parameters: Guidelines For Return to Competition


Grade 1 Concussion
Definition: Transient Confusion, no loss of consciousness, and a duration of
mental status of < 15 minutes

Grade 2 Concussion
Definition: Transient Confusion, no loss of consciousness, and a duration of
mental status of > 15 minutes

Grade 3 Concussion
Definition: Any loss of consciousness, either brief (seconds) or prolonged
(minutes)


MANAGEMENT

Grade 1: may return same day if postconcussive
symptoms resolve within 15 minutes
Multiple Grade 1 concussion: 1 Week

Grade 2: 1 Week
Multiple Grade 2: 2 Weeks

Grade 3 brief (seconds) loss of consciousness: 1 Week
Grade 3 prolonged (minutes): 2 Weeks
Second Grade 3 Concussion: A minimum of one month. Any
abnormality on CT/MRI consistent with edema, contusion, or other intracranial pathology should result in termination of the season and return to play in the future should be seriously discouraged.

When comparing a non-Q-wave myocardial infarction with a Q-wave infarction, which of the following statements is true?

a. Non-Q-wave infarctions have a much better 1-year survival profile.
b. Because non-Q-wave infarctions are considered a small infarction, they have a much lower chance of a reinfarction.
c. Non-Q-wave infarctions occur predominantly in the inferior wall; Q-wave infarctions occur predominantly in the anterior wall.
d. Because non-Q-wave infarctions tend to be smaller infarctions, left ventricular function plays no role in prognosis.
e. The mortality associated with non-Q-wave infarctions occurs later when compared to patients with Q-wave infarctions.

E

nonQ MI is generally extensive multiple vessel disease
recurrent reinfarction and ischemia.
good early Px. and poor late Px.

A 52-year-old woman with rheumatoid arthritis (RA) is seen for persistent arthritis. She has a 5-year history of RA now involving her hands, shoulders, and feet. Current medication includes diclofenac 75 mg b.i.d, prednisone 7.8 mg daily, methotrexate 17.5 mg weekly, and folic acid 1 mg daily. In the past she had been treated with hydroxychloroquine (Plaquenil) and minocycline. Examination shows swelling and tenderness in her proximal interphalangeals (PIPs), metacarpalangeals (MCPs), and wrists. The next step in therapy should be:

a. Increase prednisone to 15 mg.
b. Change methotrexate to 1M gold.
c. Begin on Enbrel.
d. Administer IV pulse cyclophosphamide.

The correct answer is c.
c. This patient is relatively refractory to current therapy. In efforts to control the symptoms of these patients more combination therapy has been used. Targeting specific mechanisms of inflammation has been a goal of therapy in RA. Enbrel (etanercept) is a fusion protein formed from soluble tumor necrosis factor (TNF) receptors and the FC portion of an antibody molecule. TNF appears to be a central cytokine in the inflammation of RA. This agent administered subcutaneously has led to improvement in 65% of patients with 15% achieving 70% improvement. Currently, combination therapy with methotrexate represents the best available therapy in many patients.

short course of corticosteroids(20mg/day prednisone initially, with a rapid taper over 5days) may be effective for controlling disease flares and for bridging treatment periods in which DMARDs have not yet controlled disease.
virtually, the clinical effectiveness of gold is disappointing and MTX to alternative DMARD is difficult to regain disease control.

A 75-year-old man presents with a complaint of right hip pain that occurs mainly when he lies on his right side and when he stands with his weight on the right leg. On physical examination, there is no groin tenderness, and there is full range of motion of the hip.
The most appropriate next step in management of this patient is:

a. Perform a straight leg-raising maneuver.
b. Palpate the soft tissues of the lateral thigh.
c. Obtain an erythrocyte sedimentation rate.
d. Obtain a radiograph of the right hip.

B

1. Trochanteric bursitis occurs frequently, but it is often undiagnosed. Patients frequently describe it as hip pain, and they may complain of symptoms that suggest radiculopathy. The diagnosis is made by eliciting localized tenderness on palpation of the soft tissues overlying the greater trochanter.

Which of the following statements about seronegative rheumatoid arthritis (RA) is true?

a. It is frequently associated with extraarticular disease.
b. It rarely causes joint erosions.
c. It carries a worse prognosis than seropositive RA.
d. In the elderly, it may mimic polymyalgia rheumatica.
e. All of the above

The correct answer is d.
d. Ten to thirty percent of adults who meet diagnostic criteria for RA do not exhibit serum rheumatoid factor. These patients rarely have extraarticular disease but do develop erosive disease. A small subset of patients with polymyalgia rheumatica may present with hip and shoulder pain, making these two conditions difficult to distinguish clinically

Overall these patients have a better prognosis and a better survival rate.
Fewer extraarticular manifestations are seen, but erosive disease may still be present nevertheless.
One should always look out for other possible diagnoses such as systemic lupus erythematosus, psoriatic arthritis, and for the presence of microcrystalline deposits such as those seen in gout or pseudogout.

Which of the following food- or waterborne bacteria responsible for diarrheal illness has the LONGEST incubation period (time from ingestion to illness)?

A Clostridium perfringens
B Staphylococcus aureus
C Bacillus cereus
D Campylobacter jejuni
E Vibrio parahaemolyticus

The answer is D
Bacteria that cause diarrhea via elaboration of toxins generally are associated with a shorter time from ingestion to illness than are invasive strains. For example, enterotoxigenic E. coli (the most common cause of traveler's diarrhea), C. perfringens (associated with poorly cooked meat or poultry), S. aureus (associated with improperly refrigerated dairy foods), and B. cereus (associated with grossly contaminated uncooked rice) all have incubation periods of 24 h or less. Even though the pathogenesis may depend on direct mucosal damage, V. parahaemolyticus, which is present in inadequately cooked seafood, can cause a diarrheal illness within 6 to 48 h after consumption of a contaminated food. Ingestion of water contaminated with the intestinal flora of wild or domestic animals may cause infection with C. jejuni, a common cause of acute, sometimes bloody diarrhea. The incubation period for this invasive bacterium is 2 to 6 days, longer than that associated with other pathogens. Therapy is usually supportive, though erythromycin will shorten the duration of illness.

An 19-year-old man is brought to the emergency department because of a bicycle accident. He was riding with a group of friends who noted that the patient's bike hit a rock, the bike tumbled, and the patient's head hit the pavement. Unconsciousness lasted about 30 s. It is now approximately 1 h after the accident. At this time the patient is alert, though he has thrown up once and complains of difficulty in concentration and blurred vision. Furthermore, he is complaining of a severe frontal headache. The physical examination is notable for the absence of blood at the tympanic membranes and the mastoid processes and a completely nonfocal neurologic examination. Skull x-rays and MRI are normal. The most appropriate course of action at this point is to

A obtain a neurosurgical consultation
B admit the patient to the hospital for observation
C administer phenytoin and admit the patient to the hospital for observation
D perform an electroencephalogram
E discharge the patient home in the care of his friends

The answer is E
Concussion, the transient loss of consciousness consequent to blunt impact to the skull, is believed to occur because of electrophysiologic dysfunction of the upper midbrain as a result of sudden movement of the brain within the skull. About 3 percent of those with concussions also have an associated intracranial hemorrhage, but the absence of a skull fracture decreases the risk. Amnesia for events just prior to the trauma is common, as are a single episode of emesis, severe bilateral frontal headache, faintness, blurred vision, and problems with concentration. However, minor injuries are characterized by an absence of neurologic signs, normal skull x-ray, and normal CT or MRI scans. In the absence of persistent confusion, behavioral changes, decreased alertness, or focal neurologic signs, patients may be discharged to be observed by responsible individuals. Several more worrisome clinical syndromes may accompany more severe head injury. Such symptoms are characterized by (1) delirium and wishing not to be moved, (2) severe memory loss, (3) focal deficit, (4) global confusion, (5) repetitive vomiting and nystagmus, (6) drowsiness, and (7) diabetes insipidus. Positive findings on CT scan or EEG would be common with these types of postconcussive syndromes, neurosurgical evaluation would be required, and prophylactic phenytoin, glucocorticoids, and haloperidol could be considered.

Which of the following is the best predictor of hemodialysis efficacy?

a. Pretreatment BUN
b. Interdialytic weight gain
c. Urea reduction ratio (URR)
d. Serum potassium
e. Hemoglobin level

The correct answer is c.
c. The pretreatment BUN was once considered a reasonable guide; however, it can be affected by protein intake as well as efficiency of treatment. Most physicians now accept the URR as the best indicator. Urea modeling is a standard component of the monthly laboratory work evaluated in dialysis patients, with a value of 65% to 70% or greater seen as adequate for hemodialysis. These values have been associated with improved long-term survival rates.

A 26-year-old man with 1-year status postcadaveric transplant presents for routine follow-up. He has no complaints. His BP is 180/95. He is afebrile. Examination is unremarkable except for a renal allograft in the right iliac fossa. Review of his laboratory work from the last four visits shows his creatinine at 1.4, 1.5, 1.7, 1.8 mg/dL. Today his creatinine is 2.0 mg/dL, his urine shows 2+ protein, and his cyclosporine A (CSA) level is at the lower end of the acceptable range.
The most likely diagnosis of this patient is

a. CSA nephrotoxicity
b. Acute rejection
c. Chronic rejection
d. Benign nephrosclerosis

The correct answer is c.
c. The slow rise in the creatine kinase over a period of 5 months, hypertension, and proteinuria all suggest chronic rejection. CSA toxicity is not likely, given that the level was in the low therapeutic range. Acute rejection is ruled out by the slow progression and also is less likely to occur 1 year after transplantation, although this can happen. Benign nephrosclerosis is a process that occurs in native kidneys over many years and is not pertinent to this case.

in hypertensive patient, benign urinary sediment (but in this case,,,protein 2+generally less than 1g/day in benign nephrosclerosis, no chronic lead intoxication history..)..
so i am leaning toward c

Which of the following statements about acute interstitial nephritis (AIN) is true?

a. In children, it is usually due to a drug reaction.
b. It can be ruled out by the absence of eosinophils in the urine.
c. It generally requires treatment with steroids for complete resolution.
d. The triad of fever, rash, and eosinophilia is found in less than 33% of cases.
e. It is rarely associated with gross hematuria.

The correct answer is d.
d. In adults, AIN is usually due to drugs; in children it most often follows an infection. The finding of eosinophils in the urine supports the diagnosis of AIN; however, their presence has been variable and their absence should never be used to rule out the diagnosis. Although there is a role for the use of steroids in treating cases of AIN that are particularly severe or longstanding, the mainstay of therapy is removal of the offending agent. Generally, steroids are not necessary. AIN has frequently been reported to cause gross hematuria. Although eosinophilia has been reported in 80% of cases, fever in about 75%, and rash in up to 50%, the entire triad is present in less than 33% of cases. It is uncommon in AIN due to use of nonsteroidal antiinflammatory drugs.

Urinalysis reveals nonnephrotic-range proteinuria, commonly with microscopic hematuria. Gross hematuria has been reported, although the sediment in about 75% of patients shows only moderate amounts of red and white

blood cells. White cell casts can be observed (in the absence of infection), but red cell casts are so uncommon that their presence should suggest an alternative diagnosis of glomerulonephritis.

hematuria, proteinuria, and pyuria are present in over 80% of cases,
the hematuria -90% microscopic
the role of corticosteroid in this disorder is uncertain, however a relapse may occur as the prednisone is being discontinued
eosinophiluria (wright's stain)
skin rash : 30-50% of cases
eosinophilia : 30-60% of cases
as different picture of NSAID induced AIN , there is frequently no eosinophilia or eosinophiluria and nephrotic range proteinuria and edema may also be present

40 yrs old diabetic male came in ER following a MVA with spinal injury and lost his cremesteric reflex. Rest of the reflexes are normal. This is due to:

a) Partial spinal shock
b) injury at the level of T7-12
C) Injury at the level of L1-2
d) Diadetic neuropathy
e) Injury at the level of S3-4

C

absent of cremasteric reflex is good indicator of testicular torsion

A 45 years old woman with history of DM and mild Hypertension with occational history of seizure for last 6 month came to your office with H/O 6 hours headach, right sided partial ptosis, pain in lower half of face and neck rigidity. What would be the cause?

a)Trigeminal neuralgia
b)SAH of Post communicating artery
c)SAH of ICA
d)Brainstem glioma
e)Lacunar stroke

60 years old female h/o chronic Diabetes & Hypertension with a left sided stroke came in ER 3 month ago with repeated attack of seizure. There she was given some anti-seizure medication for chronic control. But last two months she developed incontinence with no urinary symptoms. The most likely cause is

a)UTI
b)Phenytoin therapy
c)Carbamazapine
d)Valproic acid
e)BHP

D

incontinence without urinary sx. like enuresisis one of the side effects of valproate


carbamazepine: hypersensitivity, BM suppression, skin side effect
additionally, urinary incontinence due to drug side effect : diuretics, anticholinergics, alpha adrenergic agent, narcotics, psychotropics

A 52-year-old woman complains of recurrent sudden attacks of vertigo and tinnitus for 4 years. She notes that her hearing has become progressively worse. She is asymptomatic during the time of examination. Neurologic examination shows decreased hearing for low tones. She has no nystagmus and no facial sensory loss or facial asymmetry. The balance of the neurologic examination is likewise normal.
The most likely diagnosis of this patient is

a. Acute labyrinthitis
b. Acoustic neuroma
c. Mnire's disease
d. Benign positional vertigo
e. Brainstem transient ischemic attacks

C

This patient has a triad of symptoms considered to be classic for Mnire's disease. This triad consists of vertigo, tinnitus, and hearing loss. Attacks are recurrent, and the patient is usually asymptomatic between bouts of Mnire's disease. Vertigo is usually severe and occurs suddenly. Hearing loss is sensorineural in type, with decreased perception of low tones. Hearing loss becomes increasingly severe and eventually leads to severe cochlear damage and total deafness.

A genital ulcer without inguinal adenopathy would most likely be

a. Granuloma inguinale
b. Chancroid
c. Syphilis
d. Lymphogranuloma venereum
e. Gonorrhea

The correct answer is a.
a. Granuloma inguinale is a sexually-transmitted disease that is caused by Calymmatobacterium granulomatis. The incubation period ranges from 2 weeks to 3 months. The initial genital lesion may be a papule, a nodule, or an ulcer. The inguinal swelling, or pseudobubo, may look like a lymph node, but true inguinal adenopathy is unusual.

A 17-year-old man has a tender ulceration on the penis with inguinal lymphadenopathy. A smear from the ulcer shows chains of bacilli in a 'school of fish' arrangement. The best treatment for this condition is

a. Amoxicillin
b. Benzathine penicillin
c. Ceftriaxone
d. Acyclovir
e. Tetracyline

The correct answer is c.
c. Chancroid is a sexually transmitted disease characterized by painful genital ulcers with inguinal lymphadenopathy. The causative organism, Hemophilus ducreyi, a gram-negative coccobacillus, may be seen on Gram stains of the ulcers. Either ceftriaxone (one dose of 250 mg intramuscularly) or oral erythromycin (500 mg 4 times per day for 7 days) is very effective treatment.

In an adult male who is allergic to penicillin, the treatment of choice for syphilis is

a. Erythromycin
b. Cephalexin
c. Clindamycin
d. Tetracycline
e. Rifampin

D

In penicillin-allergic patients with syphilis, tetracycline is the treatment of choice. Erythromycin can be given, but failures may occur with this drug.

A 35-year-old woman presents with obesity, proximal muscle weakness, mild hypertension, and a blood glucose of 156 mg/dL. Physical examination reveals slight roundness of the face and abdominal striae. Which of the following tests would be best to confirm or rule out your clinical impression?

a. Measurement of 24-hour urinary-free cortisol
b. Computerized tomography (CT) scan of the pituitary gland
c. Overnight dexamethasone suppression test
d. Measurement of morning adrenocorticotrophic hormone (ACTH) and serum cortisol level
e. Cosyntropin stimulation test

The correct answer is a.
a. An overnight dexamethasone suppression test may be falsely positive (failure to suppress in a patient who does not have Cushing's syndrome), especially in an overweight person. Measurement of a 24-hour urinary-free cortisol will take into account body weight and is not affected by many of the drugs that can interfere with the dexamethasone suppression test. CT of the pituitary gland should be done only after a diagnosis of Cushing's syndrome has been made chemically; you are looking for the cause of the Cushing's syndrome. Nonfunctioning adenoma of the pituitary is relatively common. ACTH levels may be elevated in certain causes of Cushing's syndrome but not in all. Random cortisol levels are not useful in making a diagnosis of Cushing's syndrome because a random level may not be elevated, or it may be elevated because of reasons other than Cushing's syndrome, such as stress. A 24-hour urinary-free cortisol provides a much better idea of the total day's production of cortisol.

Which of the following statements regarding diabetes insipidus is true?

a. It presents with low plasma sodium.
b. The plasma and urine osmolality are equal.
c. Plasma osmolality is greater than 295 mOsm/kg.
d. Treatment is fluid restriction.
e. Urine osmolality is greater than 295 mOsm/kg, and plasma osmolality is less than 295 mOsm/kg.

The correct answer is c.
c. In patients with intact thirst mechanism, the plasma sodium is normal to slightly increased. The urine osmolality is less than plasma osmolality, less than 295 mOsm/kg. The plasma osmolality is greater than 295 mOsm/kg. Urine volume is high, generally more than 3 L per 24-hour period. DDAVP (desmopressin acetate) is the best treatment for chronic central diabetes insipidus.

which is the cost effective trt for H pylori?
1.Aoc- Amox, Omepaera, clarithromycin
2.MOC- metro, omeparo, clarithro
3. RBCC- ranitidine, bismuth, calrithro
4.rani, bismuth, falgyl, tretacycline

what is the intial step?

in treating the new onset pud, what is the first approcach
1. trial of ppi
2. barium swallow
3. endoscopyin treating the new onset pud, what is the first approcach
1. trial of ppi
2. barium swallow
3. endoscopy

what is the best approach

you are treating a patient with pud. the patient compliants are 85% reduced. He was taking medications for 4wks. now to test for hpylori after the trt , what is the best method ?
1. breth urease test.
2. clo test
3. culture
5. stool antigen test
6. serology test for hp

stool antigen test

urea breath test

good for diagnosis and follow up
antibody to H.pylori -unsuitable for follow up

empiric antiulcer therapy for 4-6weeks, ant then failure to respond by 2weeks or recurrence of sx.necessitates further evaluation

amoxicillin,omeprazole,clarithromycin

Prophylaxia endocarditis

Preoperative antibiotics is recommended for patients who have which of the following
a. Hx of CABG
b. Hx of Kawasaki disease
c. Hypertrophy cardiomyopathy
d. cardiac pacemaker
e. an implanted defibrillator

C

1. IE prophylaxis is recommended for the following conditions:
   Prosthetic heart valves
   Previous hx of IE
   Congenital heart malformations
   Acquired valvular dysfunction (as with rheumatic heart disease)
   Hypertrophic cardiomyopathy
   Mitral valve prolapse with valvular regurgitation or thickened leaflets
   Surgically constructed systemic pulmonary shunts or conduits
   
   B. IE prophylaxis is recommended for the following procedures:
   Various dental procedures known to induce gingival/mucosal bleeding (including
   professional cleaning)
   Tonsillectomy or adenoidectomy
   Surgery of intestinal or respiratory mucosa
   Bronchoscopy with a rigid (not flexible) scope
   Sclerotherapy for esophageal varices
   Esophageal stricture dilation
   Endoscopic retrograde cholangiography with biliary obstruction
   Biliary tract surgery
   Surgical operations which involve intestinal mucosa
   Cytoscopy
   Urethral dilation
   Urethral catheterization with UTI present
   Urinary tract surgery with UTI present
   Prostatic surgery

ANAPHYLAXIS-a pt. presents to the ER with severe sob after exposure to some food( i dont recall the type of food this pt. ate.)After the initial stabiliztion i admitted the lady to the icu.She continued to have tachycardia though other sxs resoved.Which medications are good for the tachycadia.? cardizem,beta blockers etc.?

airway
epi
volume expasion, tachycardia may be a sign of shock
albuterol nebulizer
benadryl
prednison

close monitoring

prevention in the future

check washington manual

Never beta-blocker

She could have bronchoconstriction as one of the manifestations of condition

YOU DONT TREAT TACHYCARDIAIT IS NORMAL RESPONSE DUE TO SHOCK


Definition/Pathophysiology

A systemic reaction (usually life-threatening) that occurs secondary to an IgE mediated antigen induced reaction (allergen) or exposure to mast cell degranulating agents (anaphylactoid). Both reactions cause mediator release (histamine, leukotrienes, PAF, etc.) which produce the symptoms. While there is often a history of prior exposure to a given antigen, in the non-IgE mediated (anaphylactoid) reactions, symptoms may occur during the first exposure.


Clinical Course

Symptoms usually occur within seconds to 60 min. of Ag exposure.

Variable: Initial symptoms may be mild or life threatening. Generally, the earlier the onset, the more severe the reaction.

Symptoms - cutaneous (urticaria/angioedema, pruritus), respiratory (bronchospasm, stridor, pulmonary edema, laryngeal edema), rhinitis, cardiovascular (hypotension, arrhythmias, myocardial ischemia, vasodilation, flushing), gastrointestinal (nausea, emesis, diarrhea, pain), asymmetric swelling of a limb or perioral area.

Most Common Etiologic Agents

Antibiotics (for instance penicillin, although any could be involved)

Insect (hymenoptera) stings

Foods (nuts, eggs, seafood)

Immunotherapy

Non-IgE (Anaphylactoid) mediated mast cell degranulation:

Morphine

Codeine

Polymyxins

Radiocontrast dye

Risk Factors:

Personal history of previous allergic reaction.

Positive skin test.

Sick patient on multiple medications.

Therapy

ABCs

Establish airway if significant compromise.

May need intubation or trach. if no relief with epi.

Oxygen if respiratory distress or hypotension.

Stop antigen administration - if insect bite or allergy shot, isolate antigen site with tourniquets and inject 0.01 cc/kg epi. (1:1000) SQ into site after tourniquet applied. Flick off (do not squeeze) any stinger present.

Epinephrine:

Mainstay of treatment

SQ or IM 0.01 cc/kg of 1:1000 soln, max 0.3 cc, may repeat

Rarely IV 1:10,000 by drip and titrate to achieve response, begin at drip of 0.1 mcg/kg/min (only in refractory hypotension requiring CPR).

Immediate IV placement with IVF (LR/NS, bolus 20 cc/kg as needed for shock).

Continue to observe for 24 hrs, as symptoms may recur.

Subjective: SOB, anxiety.

Objective: stridor, retractions, wheezing, cyanosis, pallor.

BP: q 5-10 min initially, then q 1 hr.

Continuous EKG monitor or A-line as needed.

Other drugs as needed (NOT a substitute for epi.).

H1 Antihistamine - Benadryl 0.5-1.0 mg/kg po or slow IV push.

Steroids - 1-2 mg/kg methylprednisolone to prevent late phase response.

Cimetidine IV 5-10 mg/kg given over 5 min - given in association with H1 antihistamines may reverse profound hypotension unresponsive to fluids/pressors (this is controversial).

Glucagon may be effective in reversing hypotension in rare cases, especially if beta-blockade is present. (Dose: < 10 kg: 0.1mg/kg IM, > 10 kg: 1 mg/dose IM).

For cardiorespiratory arrest, continue with BCLS/ACLS algorithms.

Differential diagnosis includes:

Insulin reaction

Vasovagal syncope

Arrhythmias

Hereditary angioedema

SICKLE CELL CRISIS- a 5 y.o .aa male present to the clinic with severe right arm and chest pains.No family h/o sickle and no history of ss was mentioned in the initial presentation.Vitals i think showed a moderate fever.I ordered stat xray of the arm which was normal.
i ordered stat ekg and cbc with diff. which showed sickle cells in the p. smear,hemoglobin of 3.5, low mcv but normal plts.Pt. was sent to the ER.where i.v.fluids was initiated plus iv morphine and antibiotics,cardiac monitor.The ekg results look very weird.He improved well so i admitted him to picu.He continued to do well and all his sxs resolved.