Treatment assess the severity of illness, have a low threshold for treat- ment as septic sh ock (b p480). If signs of infection, consider broad- spectrum antibiotics (b p179) until cu lture results known. Repeat septic screen if new rise in temp >38 C even if already commen ced on antibi- otics. Symptom management paracetamol (1g/6h PO) ibuprofen (400mg/6h PO) f or pyrexia; an electric fan may also produce symptomatic relief. Give adequate analgesia (b p86) and ensure adequate hydration (consider IV fl uids if nauseated or NBM); supplementar y O2 if sats <94%. Request early senior review if in doubt of diagnosis or patient unwell. 1 This may be true, but the cardiologists may take a good deal of persuading. OHFP.indb 482 OHFP.indb 482 30/05/2014 16:18 30/05/2014 16:18 483 PYREXIA The septic screen In many patients the likely source of a fever will be obvious, and invest igations and management can be tailored specifi cally towards that; in others it is less cl ear, and a more widespread approach is required. History a thorough history can sometimes s hed new light on the potential cause or highlight the potential for immunocompromise. Exami nation of all the patient \200\231s systems and a top to toe examination of the skin and jo ints may reveal a source of infection. All line sites should be inspected and changed if ol d or infl amed \200\223 send the tips of removed lines to microbiology for culturing. Inve stigations see box. Septic screen \200 FBC (repeat every 2d) \200 Infl ammatory markers, ESR, CRP (repeat e very 2 \200\2234d) \200 Urine culture (separate samples from any nephrostomies/urostomies ) \200 Sputum culture, if indicated \200 Blood cultures (3 sets at 6 \200\2238h interva ls from diff erent veins; additional sets from any central lines) Microbiology swabs of wounds/pressure areas/cannula or central line sites \200 CXR if pro ductive cough or abnormal clinical signs present. If infectious source still not identifi e d, consider: \200 Procalcitonin (will be negative if non-infective cause, b p480) \200 Stopping all antibiotics (if stable) and repeating all cultures after 48h \200 Echocardio gram if new murmur or new stigmata of bacterial endocarditis \200 Check sickle-cell statu s \200 Blood fi lm for parasites (if malaria is suspected) \200 Lumbar puncture if CNS infection suspected or needs excluding (CT fi rst). Pyrexia of unknown origin (PUO) (OHCM9 b p388) Classically defi ned as a recurrent fever (T >38.3 C), persisting for >3wk, without obvious cause despite >1wk of in-patient investiga tions. Causes include infection (30%), malignancy (30%), non-infectious infl ammatory disea se (eg connective tissue disease, vasculitis; 20%), and drug reactions. Always repeat a det ailed history and examination, clearly summarize all inves- tigations and results so far an d discuss with an infectious disease physician. Despite your best eff orts, in 710% of case s a cause is never found. Iatrogenic causes of pyrexia \200 Transfusion reactions (b p402) \200 Infected lines: cannula, central lines, arterial lines, urinary catheters, long-lines, etc. Drug-induced (most due to hypersensitivity reactions): antibiotics (eg erythromycin, nitrofurantoin, isoniazid, penicillins) \200 cardiovascular medications (eg atropine, hydralazine, nifedipine) \200 malignant hyperthermia (eg anest hetic agents) \200 neuroleptic malignant syndrome (eg antipsychotic drugs) \200 miscell aneous (eg aspirin, allopurinol, phenytoin, opioid withdrawal). Post-operative: atelectasis (often 24h post-op). _OHFP.indb 483 _OHFP.indb 483 30/05/2014 16:18 30/05/2014 16:18 484 CHAPTER 15 Emergency department Urinary tract infection, including pyelonephritis (OHCM9 b p292) Worrying signs dBP/shock ( b p480), temp >40 C, new renal impairment. Elderly patients can be afebrile or hypothermic but heavily bacteraemic. Symptoms cystitis urinary frequency, dysuria, urgency, pyuria, ha ematuria, suprapubic pain; pyelonephritis fever, rigors, vomiting, loin pain. Risk factors 5, sexual intercourse, catheterisation, DM, immunosuppression, pregnancy, structural abnorm alities of urinary tract, stones, elderly. Signs warm peripheries, vasodilation, tachycardi a, suprapubic/loin pain. Investigations Urine dipstick (see box and b p590) C+S if clinical suspicion of UTI and in all pyrexial/vomiting children; blds FBC (iWCC, iN \230), U+E (iur ea, icreatinine if outfl ow tract obstruction b p377), iinfl ammatory markers, iglu- cose ( ?DM); bld cultures if itemp or systemically unwell. Acute treatment (UTI) if dBP/shock trea t as septic shock (b p480); other wise paracetamol (for fever) and consider empirical antib iotic therapy (eg trimeth- oprim 200mg/12h PO, or co-amoxiclav 1.2g/8h IV if septic) whilst awaiting sensitivities; ioral fl uid intake. Treat for 3d (simple infection in 5) or 7d (i f structural urinary tract abnormality, immunosuppressed or 4). Acute treatment (pyelonephr itis) if dBP/shock treat as septic shock (b p480); admit for IV antibiotics if septic, preg nant, frail elderly, immunosuppressed or structurally abnormal urinary tract. Give paraceta mol and start empirical antibiotic therapy (eg co-amoxiclav 625mg/8h PO or 1.2g/8h IV) whil st awaiting sensitivities; ioral fl uid intake. Treat for 7 \200\22310d. Further investigat ion consider renal USS referral to urology if: failure to respond to treatment, recurrent UTIs (especially in 4), pyelonephritis (after 1st episode in 4, 2nd episode in 5), Proteus species isolated or microscopic haematuria persisting after resolution of symptoms. haemat uria persisting after resolution of symptoms. Simple measures to prevent urinary tract infections \200 Voiding before bedtime and after sexual \200 Drink >2l fl uid day \200 Voiding at 2 \200\2233h intervals \200 Wipe fr ont to back after micturition (5). \200 Double voiding intercourse Recurrent urinary tract infections \200 Avoidance of constipation \200 Drinking cranber ry juice1 1 Kontiokari, T. et al. BMJ 2001 332:1571 available free at (cid:27)www.bmj.com Antibiotic prophylaxis (eg trimethoprim) \200 Avoidance of irritants in bathwater (bubble (prevents outfl ow obstruction) bath etc). Just how useful is a urine dipstick? A MSU culture demonstrating a urinary pathogen at >105 CFU/ml is the gold standard test in suspected UTI. Dipsticks allow \200\230near patient \200\231 testing for various markers that may allow for a modest improvement in clinical di agnosis: \200 Nitrites many uropathogens reduce nitrate to nitrite; +ve in 730% confi rme d UTIs, but highly specifi c. False \210\222ves occur with organisms that do not reduce ni trate or polyuria \200 Leucocyte esterase a marker for pyuria; will be positive in 780 \200\22390% confi rmed UTIs; false-positives occur with contamination from eg vagina \200 Blood +ve in 770 \200\22380% confi rmed UTIs; false +ves occur with contamination from eg menstrual bleeding, renal stones \200 Protein refl ect organisms and cells in urine; +ve in 750% confi rmed UTIs. Study data from UK primary care2 show that where clinical suspicio n of a UTI exists, the presence of nitrites, leucocytes or blood can support a diagnosis, b ut that evalu- ation of protein provides no additional information. Combining test results increases sensitivity, but decreases specifi city. Even when all tests are \200\223ve, 24% of symptomatic women will have a UTI confi rmed by MSU culture. If UTI suspected, send an MSU. 2 Little, P. et al. Health Technol Assess 2009 13(19) available free at (cid:27)www.jo urnalsli- brary.nihr.ac.uk/hta/volume-13/issue-19 OHFP.indb 484 OHFP.indb 484 30/05/2014 16:18 30/05/2014 16:18 485 PYREXIA Endocarditis (OHAM3 b p96) Symptoms fatigue, anorexia, weight loss, fever, night sweats, dy spnoea. Risk factors prosthetic valve, valvular lesion (aortic >mitral), congenital cardiac defect, pacemaker/central line, mural thrombus (post-MI), recurrent bacteraemia (IV drug u sers, severe dental disease), atrial myxoma. Signs fever (90%), new murmur (85%), neurologi cal defi cit (40%), splinter hemorrhages, Janeway lesions, Osler \200\231s nodes, Roth spot s, conjunctival hemorrhage, tachycardia, warm peripheries, CCF, evidence of IVDU. Investiga tions for diagnostic criteria see below; blds FBC (iWCC, iN \230, dHb), U+E, LFT, iESR/CRP; bld cultures take 3 sets (prior to commencing ABx) from diff erent sites at intervals of > 1h; ECG non-specifi c changes, new AV block if aortic valve disease; CXR pulmonary oedema, septic pulmonary emboli if tricuspid disease; echo valvular lesion/vegetation (sensitivity 90% for transoesophageal; 60% for transthoracic); V/Q scan if pulmonary emboli suspected; u rine dipstick blood protein. Acute treatment try to obtain at least 3 sets of blood cult ures prior to com- mencing antibiotics even if patient unwell. Empirical treatment should i nclude a penicillin (benzylpenicillin or fl ucloxacillin) and gentamicin, vancomycin if ? MRSA. Give O2 as needed, paracetamol and other supportive measures (anti-emetics, IV fl uid s if dehydrated, diuretics if CCF). Further treatment give antibiotic therapy for at least 4 \200\2236wk, targeted according to microbiology advice. Valve replacement may be indicate d in refractory CCF, aortic root abscess (lengthening PR interval, RBBB), failure of prosth etic valve, persistent sepsis despite antibiotics. Complications valve destruction, cardiac failure, AV block, intracardiac abscess, embolism (to brain, limbs, lungs), septicaemia, d eath. Duke criteria for infective endocarditis (IE)1 Defi nite IE \200\223 2 major, or 1 major a nd 3 minor, or 5 minor criteria Possible IE \200\223 fi ndings fall short of \200\230defi nite \200\231 but not \200\230rejected \200\231 Rejected IE \200\223 fi rm alternative d iagnosis or resolution within <4d of therapy. Major criteria \200 Blood cultures: +ve for typical organism on \211 2 separate occasions2 \200 +ve for organism consistent with IE on 2 occasions >12h apart \200 +ve for organism consistent with IE on 3/3 or 3+/4 cultures taken >1h apart Evidence of endocardial involvement defi ned as +ve echocardiogram.3 Minor criteria \200 Predisposing heart condition or drug use \200 Fever >38 C \200 Vascular phenomena (sep tic emboli, Janeway lesion, intracranial or conjunctival hemorrhage) Immunologic phenomena (glomerulonephritis, Osler \200\231s nodes, Roth spots, +ve rheumatoid factor) Microbiological evidence (+ve blood cultures failing to meet major criteria) \200 Echocar diographic fi ndings (consistent with IE but not meeting major criteria). 1 Durack, D.T. et al. Am J Med 1994 96:200 (subscription required). 2 Streptococcus viridan s, Streptococcus bovis, HACEK group (Haemophilus sp, Actinobacilius actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella sp). S. aureu s or Enterococci in absence of 1 \232 focus. 3 Evidence of an intra-cardiac vegetation or abscess, new valvular regurgitation, or dehisc ence of prosthetic valve. _OHFP.indb 485 _OHFP.indb 485 30/05/2014 16:18 30/05/2014 16:18 486 CHAPTER 15 Emergency department Neutropenia Neutrophil counts <1 x 109/l increase susceptibility to infection. Severe neutr openia (<0.5 x 109/l) necessitates urgent assessment for infection. Causes of neutropenia t ypically seen following marrow suppression from chemotherapy (usually 7 \200\22310d later) for an underlying malignancy. Other causes of neutropenia present less often to hospital, b ut include several rare congenital syndromes, infections (viral, brucellosis, TB), a large number of drugs (eg amiodarone, penicillins, cephalosporins, carbimazole, propylthiouracil, ACEi, antipsychotics, anticonvulsants, sulphonylureas), hypersplenism (eg Felty syndrome) or anti-neutrophil antibodies and marrow failure secondary to either infi ltration or B12/f olate defi ciency. 3Febrile neutropenia requires prompt medical action \200\223 see box an d Table 15.16. Non-febrile neutropenic patients without any signs of infection, are still immunocompromise d; question if hospital is appropriate as they may be safer at home. If admission is necess ary, ensure a clean side-room is used and the patient should have reverse barrier nursing t o prevent staff introducing infection. Check for a cause of neutropenia and look at FBC to exclude a signifi cant pancytopenia. Discuss prophylactic antibiotics with hematology and m icrobiology. Remove unnecessary IV cannulae, central lines or urinary catheters; if left in , change IV cannulae every 48h. 3Febrile neutropenia (OHAM3 b p690) Neutropenia: N \230<0.5x109/l (or <1.0x109/l and predicted to d) \200 Pyrexia: >38.3 C a t any point or >38 C sustained >1h Defi nitions beware the possibility of normo/hypothermia in the very sick, or those on steroids or NSAIDs Often not clear clinically; consider: mouth/teeth/gums, Source of infection sinuses, URTI/LRTI, diarrhea, Hickman/central line, urine, skin, perianal. Microbiological diagnosis made in only about 40% of cases Investigations \200 Monitor FBC and diff erential, clotting, U+E, LFT, glucose Culture blood (peripheral and from central lines), urine, sputum \200 Swab central line p orts and skin folds \200 Consider stool and CSF cultures; CMV and aspergillus PCR \200 CXR \200 Repetitive clinical examination to identify source of infection \200 Resuscita te (O2, IV fl uids; if in septic shock, see b p480) \200 Commence antibiotics early (see Table 15.16) \200 Early involvement of hematology and microbiology \200 Consider antifu ngal prophylaxis Treatment Table 15.16 Empirical antibiotic therapy for febrile neutropenia Early discussion with microbiology is advised (check your local policy guidelines) 1st line 2nd line 3rd line Tazocin 4.5g/8h IV + gentamicin 5mg/kg/24h IV Add in vancomycin 1g/12h IV if known or sus pected MRSA Consider adding in amphotericin if fever not settling. Further therapy, including the use of recombinant granulocyte-colony stimulating factor (G- CSF) will be advised by hematology: low risk patients who remain apyrexial at 48h may be sw itched to oral therapy and antibiotics stopped as the neutrophil count recovers. OHFP.indb 486 OHFP.indb 486 30/05/2014 16:18 30/05/2014 16:18 487 PYREXIA Noti \201 able diseases Noti \201 cation of a number of diseases (see box) is mandatory u nder the Health Protection (Notifi cation) Regulations 2010 and the Public Health (Control of Disease) Act 1984. The statutory requirement for notifi cation of certain infectious dis eases was introduced over 100 years ago to help identify and stem outbreaks and epidemics o f certain infectious diseases (initially cholera, diphtheria, smallpox, and typhoid). This remains the primary purpose of the legislation today. If a patient has been diagnosed with a notifi able disease, or is strongly suspected of having a notifi able disease, a notifi c ation certifi cate should be completed and sent to the \200\230Proper Offi cer \200\231 of the local authority (or discussed by telephone if the case is urgent). Seek advice from mi crobiology if you have any concerns. Ensure you know the patient \200\231s address, home ci rcumstances, any foreign travel and their clinical history before referring the case. UK Noti \201 able diseases \200 Anthrax \200 Botulism \200 Brucellosis \200 Choler a \200 Diarrhea (infectious, bloody) \200 Diphtheria \200 Encephalitis (acute) \200 Food poisoning \200 Haemolytic uraemic syndrome \200 Invasive group A streptococcal di sease \200 Legionnaires \200\231 disease \200 Leprosy \200 Malaria \200 Measles \200 Meningitis: all types \200 Meningococcal septicaemia \200 Mumps Paratyphoid fever \200 Plague \200 Poliomyelitis (acute) \200 Rabies \200 Rubella \200 SARS \200 Scarlet fever \200 Smallpox \200 Tetanus \200 Tuberculosis \200 T yphoid fever \200 Typhus fever \200 Viral haemorrhagic fever \200 Viral hepatitis: al l types \200 Whooping cough \200 Yellow fever. Disease surveillance is carried out nationally by the Health Protection Agency (HPA) who pu blish a very interesting and informative weekly report of the numbers and location of the v arious notifi able diseases. These reports, and further information on notifi cation can be found at: (cid:27)www.hpa.org.uk/infections/topics_az/noids/menu.htm HIV is not a notifi able disease, but it is often voluntarily reported to the HPA, typicall y by a senior clinician or laboratory scientist. Infections covered elsewhere b p276 b p412 b p307 b p507 Meningitis/Encephalitis b p360 b p461 Tonsilitis b p295 Cholecystitis b p465 Sexually trans mitted Pneumonia Cellulitis Gastroenteritis Endometritis _OHFP.indb 487 _OHFP.indb 487 30/05/2014 16:18 30/05/2014 16:18 488 CHAPTER 15 Emergency department Recurrent/unusual infections Patients reattending with recurrent infections may be identifi ed by their GP. In hospital, isolation of an unusual pathogen will usually trigger further investigation, and a microbiologist will often suggest further investigations, as well as treatment. Opportunistic infections are commonly seen in HIV (b p490) and other immunocompr omised states (see Table 15.17, p489). Identifi cation of an unusual pathogen does not infe r immunocompromise, it merely makes it more likely. Equally, immunocompromised patients wil l also develop \200\230standard \200\231 infections with \200\230standard \200\231 pathog ens. Causes of immunocompromise are diverse and diagnosis requires meticu- lous history taking, examination and investigation (mostly blood-based), from which microbiology and infectious disease physicians will be able to off er advice. DM, iage, steroids (b p177) and immunosup pressants can cause a relative increase in susceptibility to infections, though less so tha n neutropenia. Malaria (OHCM9 b p394) A common cause of fever in the tropics, malaria is the most deadly v ector- borne disease in the world, found in Central/South Americas, sub-Saharan Africa, Ind ia, Southeast Asia and parts of the Middle East. Consider malaria in any traveler who prese nts with fever or unexplained illness within 1mth of travel to these endemic areas, regardl ess of prophylaxis. Plasmodium falciparum, vivax, ovale and malariae all cause human malari a. Transmission is through the bite of an infected female Anopheles mosquito, which typical ly occurs at night. The use of bed nets, mosquito repellents, long-sleeved clothing, and pr ophylaxis all reduce (but do not eliminate) the risk of infection. Presentation is with fev er, typically a few weeks after infection, though incubation periods vary according to the species of Plasmodium, as well as the patient \200\231s previous exposure. The classic cycl ical fever, peaking every 2 \200\2233d is rare. Other symptoms include headache, vomiting, fatigue, and arthralgia/myalgia. Severe forms of malaria include cerebral (dGCS), severe an emia, renal and respiratory failure. All are more common with P. falciparum. Diagnosis requ ires identifi cation of parasites on \211 3 thick and thin blood fi lms drawn 12 \200\2232 4h apart. Thick fi lms are more sensitive and allow quantifi cation of parasitaemia, whilst thin fi lms aid identifi cation of species. Many labs will off er rapid and sensitive test s based upon immunohistochemical identifi cation of parasite antigens, or PCR. Treatment de pends upon species. P. falciparum is typically resistant to chloroquine (which is used for other species); alternatives include artesumate, mefl oquine and Malarone ; discuss with i nfectious diseases. Prophylaxis should be encouraged in all travelers to endemic areas. Cho ices include chloroquine, proguanil, doxycycline, mefl oquine and Malarone . Further advic e is available in the BNF section 5.4.1. OHFP.indb 488 OHFP.indb 488 30/05/2014 16:18 30/05/2014 16:18 489 PYREXIA Table 15.17 Opportunistic pathogens in the immunocompromised (OHCM9 b p477) Candidiasis Ubiquitous fungus, typically causing white oral plaques (thrush), though can form in skin f olds, genitalia and esophagus; in severe cases causes septicaemia. Treated locally with nys tatin or systemically with fl uconazole or amphotericin B Most common in HIV+ patients. Red uction in visual acuity, blindness. \200\230Mozzarella pizza \200\231 appearance on fund oscopy. Treated with ganciclovir or foscarnet Encapsulated yeast, causing eye infections, b ut most commonly meningitis, often without neck stiff ness. India ink stains help identify organism; confi rm on culture. Amphotericin B ( fl ucytosine) followed by fl uconazole is used to control, though cure in HIV+ patients is rare Cold sores/genital lesions. More seri ous CNS infections (meningitis/encephalitis) require high-dose IV aciclovir The most common opportunistic infection seen in HIV+ patients, this unicellular fungus typically causes a severe pneumonia. Also seen in patients with leukemia and following bone marrow transplanta tion. Suspect in any immunocompromised patient with fever, dyspnoea, and non-productive cou gh. CXR typically shows diff use bilateral infi ltrates, but may be normal. Diagnose based upon culture of induced sputum or bronchoalveolar lavage samples. Treat with co-trimoxazole (trimethoprim + sulfamethoxazole). HIV patients with CD4+ counts <200 should receive this as prophylaxis or secondary prophylaxis following PCP CMV retinitis Cryptococcus neoformans Herpes simplex virus (types 1 or 2) Pneumocystis jiroveci (formerly carinii) Tuberculosis (TB) This is the commonest of the mycobacteria which present clinically. Frank pulmonary TB in the immunocompromised may result from primary infection or reactivation of a primary infection many years prior. Treatment should be aggressive with quadruple therap y (b p491). Compliance is crucial and should be emphasized. Always consider MDR-TB M. avium and M. intracellulare are 2 ubiquitous nontuberculous species of mycobacterium that cause disseminated infection in HIV+ patients with CD4+ counts <50; pulmonary infection is also s een in those with chronic lung disease. Prolonged combination antituberculous therapy is re quired Fungal skin infections are common in the healthy, but more so in the immunocompromis ed. Treat with topical agents (nystatin, clotrimazole, terbinafi ne) unless more invasive d isease (b p416) Mycobacterium avium intracellulare Tinea corporis Toxoplasma gondii Protozoal infection, associated with eating undercooked meat or food contaminated with cat feces. Usually subclinical, unless HIV+ patient, where causes chorioretinitis, meningitis/ encephalitis or intracerebral abscesses. Treat with sulfadiaz ine and pyrimethamine. Secondary prophylaxis required Can cause severe cutaneous manifestat ions (chickenpox and shingles, b p414), pneumonitis or encephalitis in immunocompromised. R equires high-dose IV aciclovir or foscarnet. Urgent ophthalmology input if ophthalmic shing les Varicella-zoster virus _OHFP.indb 489 _OHFP.indb 489 30/05/2014 16:18 30/05/2014 16:18 490 CHAPTER 15 Emergency department HIV/AIDS1 Probably arising from primates in Africa, and fi rst described in 1981, the HIV e pi- demic spread rapidly and silently around the globe in the absence of understanding or t esting. 1% of the adult population are now infected, with 3 million new infec- tions and 2 million deaths a year. Transmission blood-borne; mother to child (during birth or breastfee ding), sexual intercourse, IV drug users, needle-stick injuries, blood products. Stages of infection \200 Acute seroconversion 2 \200\2236wk after infection; 50% will develop sympt oms: sore throat, fever, malaise, maculopapular rash, lymphadenopathy Asymptomatic a symptom-free period lasting 8 \200\22310yr; may have persistent generalized lymphadenopathy Symptomatic as the immune system fails and the virus mutates, the patient becomes more susceptible to common pathogens (eg colds, gastroenteritis); constitutional sy mptoms include weight loss and fatigue \200 AIDS diagnosis with an AIDS-defi ning illness (see box). Symptoms often asymptomatic (+ve HIV test); may present with Kaposi \200\231s s arcoma or opportunistic infection(s) (see box): cough, shortness of breath, weight loss, le th- argy, recurrent fever, confusion, headaches, diarrhea, abdominal pain, dysphagia. Signs rashes (Kaposi \200\231s sarcoma is a red/purple, slightly raised papule or plaque often o n the head, neck, trunk or mucous membranes); wasting, generalized lymphadenopathy, oral/ge nital candidiasis. Counseling always obtain consent prior to any HIV test and discuss how t he result will be communicated; length counseling is rarely required.1 Never give a result to a 3rd party. Investigations HIV antibody tests used for diagnosis: can take up to 3mth t o give a positive result after infection; HIV PCR used to monitor treatment; more sensitive than the antibody tests and give a viral load to quantify infection; CD4 count used to mon itor and plan treatment. Label all bodily fl uid samples as \200\230high risk \200\231 if HIV is suspected. Treatment with a combination of drugs (HAART: Highly Active Anti-Retrovir al Therapy) should be led by a GUM or infectious disease specialist, and guided by the CD4 count. Treatment is usually initiated with 2 nucleoside reverse-transcriptase inhibitors (N RTI) + 1 non-nucleoside reverse transcriptase inhibitor (NNRTI). 2 NRTIs + 1 protease inhib itor (PI) is a 2nd-line therapy. Multiple new classes of drug are coming to market. Co-trim oxazole and isoniazid are used as prophylaxis against Pneumocystis jirovecii and TB. Ensure appropriate vaccinations given,1 but caution with live vaccines (eg BCG, MMR, yellow fever ). Post-exposure prophylaxis (PEP) healthcare workers exposed to potential infection, or in dividuals attending the emergency department after a high-risk exposure, may be off ered PE P, pending serological testing; seek local guidance. Prognosis untreated mortality >90% wit h progression to AIDS in 8 \200\22310yr; appro- priate treatment, where available, dramatic ally improves survival. Common AIDS-de \201 ning conditions Kaposi \200\231s sarcoma Pneumocystis jirovecii pneumonia (PCP) CMV retinitis Chronic mucoc utaneous herpes Mycobacterium avium intracellulare Miliary or extrapulmonary TB Oesophageal candidiasis Chronic cryptosporidial diarrhea Progressive multifocal leucoencephalopathy Recurrent non-typhi salmonella septicaemia Cereb ral toxoplasmosis Cryptococcal meningitis Non-Hodgkin \200\231s lymphoma Primary cerebral l ymphoma HIV-associated wasting HIV-associated dementia 1 Range of useful British HIV association guidelines (including on testing) available at (c id:27)www. bhiva.org/Guidelines.aspx OHFP.indb 490 OHFP.indb 490 30/05/2014 16:18 30/05/2014 16:18 491 PYREXIA Tuberculosis (TB)1,2 Responsible for 2 million annual global deaths, and latently infecting 3 billion people, TB was in decline in the UK through most of the 20th century. Rates bega n to increase in the 1990s, mostly in London and major cities. Transmission by air droplets generated by a person with infectious stage TB. Risk factors immunocompromise (eg HIV+ve), social deprivation, migrants from, or travel to, high prevalence countries (eg South-East Asia, Africa). Outcomes of exposure \200 Immune destruction of inhaled bacilli by a compe tent immune system \200 Primary TB infection may be asymptomatic, or cause cough, fever, etc \200 Latent TB after primary infection most patients become asymptomatic with the mycobacteria dormant within a tubercule; CXR may show apical fi brosis Active TB disease in a specifi c organ (see Table 15.18) or throughout the body (miliary); usually reactivation of latent TB (eg due to immunocompromise) or a rarely conti nuation of primary TB. Table 15.18 Sites of active TB Pulmonary Meningeal Genitourinary Bone Skin GI Miliary Commonest (80%): cough, fever, breathlessness, weight loss Sub-acute meningitic symptoms: f ever, headache, dGCS Frequency, dysuria, loin pain, haematuria; 4epididymitis; 5PID, infert ility Back pain, stiff ness; paraspinal abscess or cord compression Jelly-like nodules/ulce rs on face and extremities (lupus vulgaris) Aff ects any part of GI tract \200\224typically ileocaecal; weight loss, abdo pain Hematological spread to multiple tissues: liver, spleen , lungs, marrow Symptoms and signs see Table 15.18; systemic features include fever, night sweats, weight l oss, anorexia, lethargy, erythema nodosum. Isolation if you suspect TB and patient requires admission to hospital, isolate patient in \210\222ve pressure side room until 3 sputum sa mples have been urgently tested for mycobacteria. All visitors/staff must wear face masks; if the patient is moved through the hospital they should wear a mask. If mycobacteria are i dentifi - able on initial urgent sputum smears, these so-called \200\230smear +ve \200\231 patients must remain isolated; retest after 2wk of treatment: they should no longer be inf ectious. Investigations CXR consolidation (often apical), cavitation, fi brosis, calcifi ca tion, hilar lymphadenopathy, pleural eff usion; sputum 3 early morning cultures for Ziehl \200\223Nielsen (ZN) stain for acid-fast bacilli (AFB), takes 3 \200\22312wk; sputum may be induced with nebu- lised saline; bronchoscopy with lavage and biopsy may be necessary in t hose with high index of suspicion; Mantoux tuberculin skin test based upon hypersensitivity response to intradermal mycobacterial antigens: may be false \200\223ve if immunocompromi sed, whilst result may be +ve in latent infection or after BCG vaccine; interferon-G releas e assays eg T-SPOT TB: sensitive and specifi c; do not reliably diff erentiate active and latent infection; HIV consent all patients with TB for testing; drug sensitivity testing p revi- ously performed in culture over several weeks, now based upon rapid genetic testing. Treatment initial phase (2mth) standard therapy involves rifampicin, isoniazid, pyrazinamid e and ethambutol; continuation phase (4mth) rifampicin and iso- niazid are continued for fu lly sensitive isolates. Resistant organisms will require alternative regimens; side eff ect s are common eg hepatitis (all antibiotics), neurop- athy (isoniazid), visual changes (etha mbutol). Full compliance is essential: Directly Observed Therapy (DOT) is recommended where risk of poor compliance. Drug resistance multi-drug resistant TB (MDR-TB) is resistant to isoniazid and rifampicin; consult with infectious disease specialists early. Contact tracin g all individuals who have shared an enclosed space with someone with active TB should have further testing guided by risk and previous vaccination.2 Vaccination BCG (Bacillus Calmet te \200\223Gu rin) is a live vaccine that decreases the risk of developing TB by between 5 0 and 70%; it used to be given in the UK to everyone at 13yr but is now given at birth to a t-risk groups only. 1 See (cid:27)www.who.int/tb for useful information and educational res ources. 2 NICE guidelines available at (cid:27)guidance.nice.org.uk/CG117 _OHFP.indb 491 _OHFP.indb 491 30/05/2014 16:18 30/05/2014 16:18 492 CHAPTER 15 Emergency department Overdose emergency Check airway is patent; consider maneuvers/adjuncts If no respiratory eff ort \200\223 CAL L ARREST TEAM If no palpable pulse \200\223 CALL ARREST TEAM If GCS \211 8 \200\223 CALL anesthetist Airway Breathing Circulation Disability Drug overdoses are often deliberate but can happen accidentally at home or in a hospital. T he emergency management is the same. 3Call for senior help early if patient unwell or deter iorating. \200 Lie patient down ask a colleague to observe for vomiting and be ready to turn them onto their side Assess respiration RR, O2 sats, O2 requirement, consider blood gas: \200 call anesthetist if poor respiratory eff ort, it will only get worse Assess CVS HR, BP, consider fl uid resuscitation (b p381) \200 Venous access, take bloods : FBC, U+E, LFT, salicylate, paracetamol, glucose, PT/APTT \200 Monitor pulse oximeter, BP cuff , defi brillator ECG leads if unwell \200 Take brief history to establish the medica tion(s), quantity and timing \200 Consult the Toxbase/Poisons service (b p493) for info o n the specifi c overdose Consider gastric lavage if <1h since overdose \200 Examine patient condensed CVS, resp, a bdo and neuro exam \200 Repeat set of observations and ECG \200 Consider: urine toxicology \200 urinary catheter \200 ABG Follow management plan from Toxbase/Poisons service (b p493) If patient deteriorating: \200 call for senior help \200 reassess starting with A, B, C \200 Life-threatening causes Paracetamol \200 Other overdoses b p495 Check Toxbase/Poisons service (b p493) OHFP.indb 492 OHFP.indb 492 30/05/2014 16:18 30/05/2014 16:18 493 OVERDOSE AND DELIBERATE SELF-HARM Overdose and deliberate self-harm 1 Worrying features violent method, intention to die, ongoing wish to die, previous attempts, preparation, concealment. Think about emergency psychosis, acute suicidal intent; common depression, grief, stressful situations, relationship breakdown. Ask about medical medications taken, dose, number of t ablets, time- frame, ingestion of alcohol, symptoms (vomiting, tinnitus, dizziness, abdo pa in), mechanism of injuries; psychiatric events leading to overdose, expected outcome, inten t (eg call for help, to kill themselves), suicide note, extent of planning/preparation (eg spontaneous), circumstances of seeking help, expectation of being found, current intent (eg still suicidal), alcohol intoxication prior to events, recent stresses (relationships, wor k, money, family, legal); PMH previous suicide attempts and methods, psychiatric care, chro nic illness; risk factors for paracetamol toxicity (if paracetamol over- dose, b p495); DH regular medications, alternative medicines (eg St John \200\231s wort), tetanus status, all ergies, alcohol intake, substance abuse; SH who do they live with? Who is at home? Relation ships, family, friends, employment. Obs temp, HR, BP, RR, GCS, glucose. Look for1 medical o rientation, conscious level, pupil size, refl exes, tone, tremor, sweating, agitated, abdo tenderness, sweating, nutritional state; psy- chiatric (mental state examination once medic ally stable and not intoxicated, see b p160) neglect, scars on wrist/forearms, eye contact, withdrawn, abnormal posture or movements, anxiety, paranoia, fl at aff ect, speech form an d content, thought form and content including delusions, percep- tion including hallucinati ons, concentration, memory, insight into actions. See Table 15.19. Investigations2 paraceta mol and salicylate levels in all overdoses (ideally 4h post-overdose); consider blds glucos e, FBC, U+E, LFT, PT/ APTT ECG; ABG. Management2 Severe overdose stabilize the patient acco rding to b p492 and get senior help early. Severe trauma call the trauma team and see b p23 2. Paracetamol see b p495. Other trauma see b p434. Risk assessment (b p494) this determine s the psychiatric management of the patient. Once medical problems are resolved the patient must be discussed with the on-call liaison psychiatrist. They will recommend further in-pa tient psychiatric assessment or discharge home with appro- priate psychiatric follow-up. Ac utely suicidal patients must not leave the hospital without psychiatric assessment. If nece ssary they can be restrained or sedated (b p364) under the Mental Health Act (1983); always seek senior advice and help. 1 NICE guidelines available at (cid:27)guidance.nice.org.uk/C G16 2 Guidance on specifi c overdoses can be obtained from the UK National Poisons Informat ion Service at (cid:27)www.toxbase.org (all UK NHS emergency departments should have a logi n). _OHFP.indb 493 _OHFP.indb 493 30/05/2014 16:18 30/05/2014 16:18 494 CHAPTER 15 Emergency department Table 15.19 Features of common overdoses Symptoms and signs Vomiting, iRR, tinnitus, vertigo, sweating Investigations Salicylates (aspirin) Respiratory alkalosis then metabolic acidosis; idglucose, isalicylate levels Acidosis, prol onged PR, QRS and QTc heart block, ventricular dysrhythmias Dysrhythmias, ST depression ( \200\230reverse tick \200\231 shaped, b p259); eff ects more severe if dK+ Respiratory acid osis, opioids on urine toxicology Respiratory acidosis (mixed acidosis if excess alcohol); blood and urine toxicology Urine toxicology; ECG abnormalities (dysrhythmia, ischaemia) Tricyclic antidepressants (TCAs) Digoxin Dilated pupils, blurred vision, seizures, dGCS, dysrhythmia, tachycardia Nausea, confusion, hallucinations, yellow haloes around lights, anorexia Pinpoint pupils, dRR, dGCS dGCS, dBP , dtone, drefl exes Opioids Benzodiazepines, barbiturates, alcohol Ecstasy, amphetamines, cocaine Thirst, confusion, agitation, tremor, dilated pupils iHR, iBP, itemp Assessing risk after suicide attempts This is a diffi cult judgment that requires experienc e; making the wrong decision could result in a preventable death. All cases should be discu ssed with the on-call psychia- trist.The mnemonic \200\230SAD PERSONS \200\231 was origina lly developed to teach medical stu- dents to assess suicide risk; this has been modifi ed i nto a validated scoring system for use in the emergency department setting (Table 15.20).1 It is by no means foolproof; trust your instinct and ask for help if you are in any doubt Table 15.20 Modi \201 ed \200\230SAD PERSONS \200\231 score Sex: Male Age <19yr or >45yr Depressed or hopeless Previous suicide attempts or psychiatric care Excessive alcohol or drug use Rational thinking loss: psychotic or organic illness Se parated, widowed or divorced Organized or serious attempt at suicide No social support Stat ed future intent (determined to repeat or ambivalent) Score +1 Score +1 Score +2 Score +1 Score +1 Score +2 Score +1 Score +2 Score +1 Score +2 Interpreting the score Score <6 Score 6 \200\2238 May be safe to discharge, depending upon circumstances Probably requires psychiatric assess ment Score >8 Likely to need admission and urgent psychiatric assessment Other important risk factors include stressful life-events, unemployment or retire- ment, i dentifying with others who have committed suicide, chronic illness (medical or psychiatric) and availability of lethal weapons or drugs (eg farmers or vets). 1 Hockberger et al. J Emerg Med. 1988 6:99 (subscription required). OHFP.indb 494 OHFP.indb 494 30/05/2014 16:18 30/05/2014 16:18 495 OVERDOSE AND DELIBERATE SELF-HARM