REVIEWS IN URGENT CARE. Anne Koster FNP Tricia Beveridge FNP Nurse Practitioners of Idaho Conference 2013

Transcription

1 REVIEWS IN URGENT CARE Anne Koster FNP Tricia Beveridge FNP Nurse Practitioners of Idaho Conference 2013

2 CASE STUDY 1 CJ 4 yr old brought to the urgent care with difficulty breathing Hx: Patient had just eaten a cookie with possible nuts in it and his mother says he has a peanut allergy. The symptoms started 15 minutes ago, he was at a friends house and ate a cookie then started having coughing and mom noticed a few hives and immediately put him in the car and drove here because we are the closest clinic. Patient has vomited one time. They have not given him anything. They do have an epi pen but didn t use it yet. He is fairly agitated and crying. Physical: Vitals: Oxygen 95%, HR 110, RR 24, BP do not have yet, afebrile What is happening and how do you proceed?

3 Allergic reaction? Anaphylaxis?

4 Anaphylaxis Defined A serious allergic reaction that is rapid in onset and might cause death Mechanism: IgE-mediated immune response Most typically, an immediate systemic reaction caused by rapid, IgEmediated immune release of potent mediators from mast cells and peripheral blood basophils

5 CAUSES OF ANAPHYLAXIS

6 DIAGNOSTIC CRITERIA Onset minutes to hours Skin or mucosa 80-90% - hives, pruitis, flushing, angioedema PLUS one of the following Respiratory 70% - wheezing, stridor, hypoxia, muffled or hoarse voice, dyspnea Reduced BP or associated symptoms such as syncope GI 45% - vomiting, abdominal pain CNS- 15% - irritability, CNS depression

7 TREATMENT Epi, Epi, Epi Epinephrine 1:1, mg IM Pediatric dose 1:1, mg/kg max dose 0.3mg IM Use their own epipen if available May be repeated every 5-15 minutes if refractory or rebounds. IV fluids, Oxygen, Monitor Benadryl 25-50mg IV, pediatric 2mg/kg IV or IM Ranitidine 50mg IV, pediatric 1mg/kg max 50mg IV Methylprednisone mg IV adult, pediatric 2mg/kg IV/IM Albuterol or duonebs Racemic Epi?

8 SITE AND ROUTE DO MATTER

9 TOP REASONS WHY PEOPLE DON T USE EPINEPHRINE Failure to recognize sx (atypical presentations) Rationalization & denial Spontaneous recovery last time Reliance and belief in antihistamines The clinic/er was nearby Fear re: use of epinephrine (side effects) Fear of needles 2 words: Fear and denial 1 word: Fear

10 CJ Treatment? Admit? Home? How long for observation? 4-6 hours, biphasic can occur up to 72 hours Admit criteria, hypotension, repeated doses of epi, rural location, high risk ie asthma Instructions for home Written plan Script for Epipen or Epipen jr with refills, instructions on when to use Referral to allergist if first attack or unsure allergen Medic alert bracelet

11 CASE STUDY 2 35 year old male presents with a redness and pain to his leg Onset 3 days ago started with area that looked like a pimple now is bigger and more painful. He tried to drain it on his own but nothing came out. He thinks he was maybe bitten by a spider He is otherwise healthy Offender? Treatment?

12 CELLULITIS OR MRSA

13 CELLULITIS MRSA Classically caused by strep or staph There usually is not a fluctant area IE no abscess A small percentage will have MRSA, those are the ones that we send home on Keflex then see back in a few days with noted abscess Hx of trauma? Open areas? At risk? Exam: erythematous area, warm, tender, edema CA-MRSA Typically fluctant area with abscess. There can be other presentations that can mimic, cellulitis, impetigo, erysipelas Get family history as well as patient history Exam: abscess with or without surrounding cellulitis, may be deeper abscess, muscle

14 non-b hemolytic strep 4% other 8% unknown 9% B-hemolytic strep 3% MSSA 17% MRSA 59% Moran NEJM 2006; 355:

15 OUTPATIENT TREATMENT OF NONPURULENT CELLULITIS Drug Adult Dose Cephalexin 500 QID Dicloxacillin 500 QID Clindamycin* TID Linezolid* 600 BID *Also have activity against CA-MRSA Copyright Infectious Diseases Society of America (IDSA) 2011

16 Incision and drainage is the primary treatment (AII). For simple abscesses or boils, I&D alone likely adequate Loop drainage is newer method Do antibiotics provide additional benefit? Multiple, observational studies: high cure rates with or without abx 3 RCTs of uncomplicated skin abscesses; 2 large NIH trials ongoing

17 LOOP VESSEL I+D

18 ANTIBIOTIC TREATMENT OF MRSA Severe, extensive disease, rapidly progressive with associated cellulitis or septic phlebitis Signs & sx of systemic illness Associated comorbidities, immunosuppressed Extremes of age Difficult to drain area (e.g. face, hand, genitalia) Failure of prior I&D

19 TREATMENT OF CA-MRSA TMP-SMX 1-2 DS BID AII Doxycycline, Minocycline 100 BID AII Clindamycin TID AII Susceptiblity to bactrim and doxycycline remains high 90% for most community aquired infections. Duration for I+D plus antibiotics can be 3-5 days, benefits are marginal.

20 CHILDREN Cellulitis: MSSA PCN, Augmentin, if allergic clindamycin which would also cover MRSA or azithromycin Children with abscesses larger than 5cm were found to have larger number of treatment failures of only I+D. These may do better with antibiotics. Another reason is not aggressive I+D with kids. Make sure you drain the abscess adequately.

21 CASE STUDY 2 Treatment I+D, either with loop drainage or traditional open and pack Antibiotics? Send culture

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26 Presentation Diagnosis / Evaluation X-Rays?

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32 CASE STUDY 3 30 yr old female CC: migrane Onset: yesterday HX: long history of migranes, photophobia, nausea, occasional vomiting, not worst headache of life, no fever, no thunderclap Exam: photophobia, nausea and vomiting, no focal neurologic findings Tx in the urgent care?

33 AURA Visual phenomena, such as seeing various shapes, bright spots or flashes of light Vision loss Pins and needles sensations in an arm or leg Speech or language problems (aphasia) Less commonly, an aura may be associated with limb weakness (hemiplegic migraine). ATTACK Pain on one side or both sides of your head Pain that has a pulsating, throbbing quality Sensitivity to light, sounds and sometimes smells Nausea and vomiting Blurred vision Lightheadedness, sometimes followed by fainting

34 MIGRANES Migraine is a clinical diagnosis. Diagnostic investigations are performed for the following reasons: Exclude structural, metabolic, and other causes of headache that can mimic or coexist with migraine Rule out comorbid diseases that could complicate headache and its treatment Establish a baseline for treatment and exclude contraindications to drug administration

35 DIFFERENTIAL DIAGNOSIS Bleed The first or worst headache of the patient's life, especially if rapid in onset. Intracranial Pressure TIA, CVA Precipitation of the headache with Valsalva maneuvers (id coughing, sneezing, bearing down). The presence of associated neurologic signs or symptoms (eg, diplopia, loss of sensation, weakness ataxia) Temporal arteritis Meningitis Mass Onset of headaches after the age of 55 years. Headache accompanied by stiff neck or fever New progressive headache that persists for days.

36 DIFFERENTIAL DIAGNOSIS Glaucoma Iritis Head Trauma Atypical history or unusual character that does not fulfill the criteria for migraine Inadequate response to optimal therapy

37 CBC, BMP, SED RATE, CRP Non-contrast head CT LP?

38 URGENT CARE TREATMENT Sumatriptan 6mg SC or Maxalt 10mg dissolvable tab (use only if recent onset of headache) DO NOT give if patient uses Ergots or other triptans in the last 24 hours. Don t give to those with CAD, uncontrolled hypertension, PVD, pregnant. Toradol 30mg IV or 60mg IM if no GI bleed or renal issues IV fluids 1 liter normal saline, some medications can cause some hypotension Benadryl 25-50mg IV Thorazine (chlorpromazine) 10mg very effective in aborting severe migranes, akathisia most likely side effect but reduced with administration of Benadryl. Compazine ( prochlorperazine) 10mg IV/IM. In a large retrospective analysis by the Headache Society of America in 2012 it outperformed placebo, toradol, magnesium, valproate and sumatriptan. PROBLEM: shortage Headhache Society of America 2012

39 MIGRANE TREATMENT Steroids such as dexamethasone 10mgIV/IM or PO or Solumedrol 500mg IV, may help with staving off recurrent headache. DHE, most don t have in clinic My starting cocktail Toradol 30mg IV, Benadryl 25-50mgIV and Compazine 10mg IV. Works best all together than spread out. You can substitute phenergan which most of us have in clinic. Read the chart. Past treatment may be helpful to know what worked in past. How many visits? I will use narcotics only last resort. Sit and wait, explain that will not fix all of headache but should help reduce symptoms. Explain expectations of visit.

40 DISCHARGE Discharge home when symptoms are starting to wane. They can follow up with PCP if have not tried any preventatives or abortives in the past. If they have tried multiple medications in past referral to neurology may be helpful. Avoid sending home on narcotics or Fiorcet. These can end up causing misuse and overuse headaches. Headache diary, triggers, treatments, NSAIDS as abortive at beginning of a headache.

41 CASE STUDY 4 4 year old CC: Ear Pain They are waiting when you open the Urgent Care doors at 8am. Onset: Mom states that M.J. has been up all night screaming and tugging at the left ear. Mild runny nose and congestion, no fever, or cough. No history of recent swimming in natural water or pools. Hx: Sporadic ear infections, otherwise healthy. Exam: You look in the left ear and see

42 AM E R ICAN ACAD EMY OF PEDIATRICS,

43 ACUTE OTITIS MEDIA Guidelines for management and diagnosis of AOM American Academy of Pediatrics 2013 Guidelines Over the age of 23 months practitioner should diagnose AOM with rapid onset of symptoms with severe to moderate bulging of the TM or with new onset otorrhea that is not related to acute otitis externa. Treatment of pain is always recommended. If the symptoms are severe, 48 hours with temp above 39 C and ongoing otalgia. Treatment with antibiotics are recommended. Pneumatic otoscopy strengthens the diagnosis. Under 23 months of age with mild symptoms and less then 48 hours of temperature of greater than 39 C should be treated with antibiotic therapy. AM E R ICAN ACAD EMY OF PEDIATRICS,

44 ACUTE OTITIS MEDIA American Academy of Pediatrics recommend in non-severe older children (>23 months) or nonsevere younger children. Antibiotic Therapy OR Observation over the next hours. This is a discussion to have with your families. AM E R ICAN ACAD EMY OF PEDIATRICS,

45 ACUTE OTITIS MEDIA AM E R ICAN ACAD EMY OF PEDIATRICS,

46 AOM PATHOGENS S. pneumoniae Haemophilus influenzae Moraxella catarrhalis

47 MANAGEMENT OF AOM First Choice Amoxicillin High Dose 80-90mg/kg/day Alternative dose 40mg/kg/day Consider modifying with ß-lactamase if the patient had received amoxicillin in the last 30 days. Avoid if allergy AM E R ICAN ACAD EMY OF PEDIATRICS,

48 MANAGEMENT OF AOM Alternative antibiotics Cefdinir 14mg/kg/day daily or twice daily dosing. (Can be used with PCN allergy if allergy is not severe). Azithromycin (But has poor coverage for H. influenzae) AM E R ICAN ACAD EMY OF PEDIATRICS,

49 CASE STUDY 5 9 year old boy CC: Tummy pain Onset: Ongoing for the last 3 days Exam: Child walks into office unable to stand up straight, splinting right lower abdomen. Mild fever and had some diarrhea yesterday. Some rebound tenderness. Pain radiates to the umbilical area. Hx: Constipation.

50 APPENDICITIS

51 CT OR NOT TO CT CT in appendicitis gives a window of 24 hours. But pain and symptoms may be more telling. When on the fence opt for US and a CBC, if these tests can be obtained in a reasonable amount of time. Pediatric surgeons may never get the CT before surgery, but always want a CBC.

52 QUESTIONS?