Grand Rounds Recap 9.21.2022
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Clinical Knowledge: Acute Urinary Retention WITH Dr. Wolski
Incidence of Acute Urinary Retention (AUR)
Most common in men because most commonly 2/2 BPH
1 in 10 men in their 70s will experience AUR
1 in 3 men in their 80s will experience AUR
Catheters in escalating order
Foley first
Coude catheter
Silicone
Suprapubic- seldinger technique
Etiologies of acute urinary retention
Obstructive: BPH, neoplasm, bladder calculi, clots, (para)phimosis, urethral stricture, pelvic organ prolapse, gravid uterus, fecal impaction
Neurologic: Diabetic neuropathy, CVA, multiple sclerosis, cauda equina, Guillain-Barre, transverse myelitis, epidural abscess, spinal trauma
Infectious/inflammatory: cystitis/urethritis, prostatitis, vulvovaginitis, vaginal lichen planus or sclerosis, HSV or VZV, Lyme disease
Pharmacologic: antiarrhythmics, anticholinergics, antidepressants, antihistamines, antihypertensives, antiparkinsonians, antipsychotics, hormonal agents, muscle relaxants, sympathomimetics (alpha) and (beta)
Other: postpartum, epidural, trauma, general anesthesia, voiding dysfunction (pediatrics), pain, bladder overdistention, postoperative, psychogenic, bladder/urethral rupture
Physiologic Classification
Outflow obstruction: BPH, malignancy, stricture
Disruption of detrusor innervation: cauda equina, MS, Guillain-Barre, diabetes neuropathy
Bladder overdistention: general anesthesia/epidural, constipation, anticholinergics
Useful Diagnostics
History
Are they on any medications?
How long as the catheter been in place?
Any history of abdominal surgeries?
Physical Exam
Spinal tenderness?
Undress patients, evaluate for any GU infections
Rectal and/or pelvic exams
Lab tests
Urinalysis
CBC, BMP
Imaging
Bladder scan (urine volume >500ml)
Abdominal CT
Brain/spine MRI
Next steps
Observe for 2 hours: watch for post-obstructive diuresis, which can occur in up to 50% of acute urinary retention patients
>0.2L/hr for >3 hours: indicates post-obstructive diuresis which merits admission
Follow up in 3 days with urology, discharge on alpha blocker
Final tips
Empiric antibiotics after catheter placement? Not indicated
PSA? No
R2 CPC Myxedema Coma WITH Dr. Wright and Dr. Gawron
Patient: Elderly year-old male with unclear history presents to the ED after being found down. Fingerstick glucose noted to be 14. Given glucagon en route by EMS as unable to obtain IV access.
Diagnosis: Myxedema coma
Test of choice: TSH, Free T4
Epidemiology
Typically >60 years old
Often the first presentation of hypothyroidism
Underlying trigger: infection, medications, stroke, cold exposure
Pathophysiology
Vascular smooth muscle
Metabolism
Thermal regulation
Respiratory center
Coagulation
Typical presentation
Triad: hypothyroidism, mental status changes, hypoglycemia
Hypoventilation
Hyponatremia
Hypoglycemia
Hypotension
Elevated LFTs
Pericardial and/or pleural effusions
Management
Levothyroxine 4mcg/kg IV loading dose, then 75 to 100mcg daily until PO
T3 5-20 mcg IV, then 2.5 - 10mcg q8h
Hydrocortisone 100mg IV q8h
Give before levothyroxine
If bleeding, try desmopressin
Respiratory support as needed
Hemodynamic support
Volume resuscitate
Pressors unlikely to be helpful
Avoid active rewarming- can cause vasodilation if a patient is volume down
Identification and treatment of underlying trigger
Admit to ICU
Mortality rate as high as 60%
Empirically treat for sepsis with broad spectrum antibiotics
Summary
Myxedema coma is a rare, life-threatening presentation of severe hypothyroidism
Presents with hypothermia, hypoglycemia, and altered mentation
Identify underlying trigger
Treat with 4mcg/kg IV levothyroxine, steroids, antibiotics, and ICU admission
R1 Clinical Diagnostics: Global Parasitic Infections WITH Dr. Schor
Check out Dr. Schor’s infographics in the full post here
The Bot fly
Mode of transit
Primarily through mosquito bites
Female Bot fly lays eggs in vectors such as mosquitoes
The vector then bites humans and releases Botfly eggs into the host.
Self expulsion of the bot fly happens after about 5-10 weeks
Myiasis: infection of human tissue by fly larvae
Epidemiology
Endemic to Central and South America as well as Africa
Treatment
Larvae need to be stunned or encouraged to leave as they have spines and hooks that impede simple removal
Stunning can be completed by injection of lidocaine with epi into and around the larvae. Injecting more fluid at the base of the lesion can then force the larvae out
Engagement can be offered by causing asphyxiation of the larvae. This is accomplished through putting petroleum jelly over the area. After 3-24 hours the larvae will emerge seeking air.
Ascaris
Intestinal roundworm that is most common in warm tropical environments and is more likely to thrive in areas with poor sanitation.
Lifecycle
Eggs are ingested from contaminated soil or water. The eggs then hatch in the small intestine and the larvae migrate to the lungs. In the lungs they mature over ~10 days, climb out of the bronchus and are swallowed back into the gi tract. They mature in the GI tract. As long as male and female worms are present in the GI tract the female will cause fertilized eggs to pass in the stool.
Diagnosis
Stool O&P
Treatment
Single dose of albendazole 400mg
Malaria
What is it
This focuses on falciparum though vivax, ovale, malariae and knowlesi are also important
Spread by anopheles mosquito
Where is it
Present in a large swath of tropical and subtropical countries: Africa, South & Central America, Southeast Asia, and the Caribbean
Presentation
Non-specific but including tachycardia, chills, malaise, headache, cough, abdominal pain, nausea, vomiting, diarrhea, and sometimes cyclic fevers.
Diagnosis
Thick and thin blood smears + giemsa stain microscopy
Treatment
Amodiaquine/mefloquine/sulfadioxine-pyrimethamine for 3 days
Severe: IV Artesunate (through the CDC) for 24 hours plus a 3 day PO course
Babesiosis
What is it
Erythrocytic parasite that is spread by ixodes scapularis, the same deer tick that spreads Lyme disease
Where is it
Multiple species but primarily in the US it is seen in the northeast and upper midwest overlapping with Lyme disease
Presentation
Patients will have malaise, fevers, myalgias though it can also be subclinical. In asplenic patients it can result in anemia, jaundice and DIC.
Diagnosis
Blood smear showing maltese cross which is 4 parasites stuck in an erythrocyte.
Treatment
Mild (<4% parasitemia): atovaquone (750mg BID) + azithromycin (500-1000mg day one then 250-1000mg) for a total of 10 days
Severe (>4% parasitemia): Clindamycin (600mg PO q8h) +quinine (650mg TID) for a total of 10 days
Cryptosporidium
What
Protozoa generally found in unclean drinking or swimming water which is found around the world
Presentation
Immunocompetent patients have self limited disease with watery diarrhea that resolves in 2 weeks
Immunocompromised patients can have copious diarrhea passing over a gallon of stool in a day resulting in severe dehydration. It can also cause cause acalculous cholecystitis, cough and shortness of breath
Diagnosis
Stool acid fast stain showing oocysts and stool cultures showing protozoa
Treatment
Immunocompetent - likely no treatment needed but 500mg of nitazoxanide BID for 3d can be used if severe
Treatment is not approved for immunocompromised patients and starting ART is often best.
Chagas
Aka Trypanasoma cruzi which is a protozoa spread by the reduviid bug.
Transmission
The Reduuvid bugs often bite sleeping humans near the lips and eyes while defecating. Humans then scratch the areas and become inoculated.
Where is it
Endemic in the southern United States to the northern part of Argentina and Chile
How it Presents
Initially people will have signs of the initial bite from the Reduviid bug which will cause a chagoma(inflammation from the bite) and Romanas sign(orbital edema and conjunctivitis).
Long term chagas leads to chronic inflammation causing dilated cardiomyopathy, megaesophagus, and megacolon.
Diagnosis
Testing for antibodies for the parasite
Treatment
Benznidazole 5mg/kg/day for 60 days and nifurtimax 8-10mg/kg/day for 60-90 days)
