Meningitis

  • CNS infection should be considered in all patients with a headache, neck stiffness, fever, altered sensorium, or diffuse or focal neurological findings.
  • pneumoniae is one of the two leading causes of bacterial meningitis in adults. Mortality from S. pneumoniae is 30%.
  • pay close attention to cranial nerves 2, 3, 4, and 6
  • Altered mental status in a patient with suspected meningitis can be a sign of increased ICP or encephalitis.
  • You’ve got to get the LP! Only true way to assess for meningitis
  • Early initiation of empirical antimicrobial therapy is recommended in cases of suspected acute CNS infection. Antibiotic administration should not be delayed for CSF analysis or performance of neuroimaging studies.
  • Antibiotic chemoprophylaxis should be assured for close contacts of patients with meningitis resulting from N. meningitidis or H. in uenza.
  • Concomitant CNS infection should be strongly considered in any symptomatic patient with another severe systemic infection, such as urinary tract infection or pneumonia.
  • First line treatment for bacterial meningitis is ceftriaxone plus vancomycin.
  • Acyclovir is recommended for patients with suspected meningoencephalitis.
  • Dexamethasone is recommended prior to treatment with antibiotics in adults (controversial)

 

Retropharyngeal Abscess

  1. What is the differential for a sore throat?
  2. What would make you consider retropharyngeal abscess?
  3. What are the upper airway signs that signify an impaired airway (and the need to intubate)?
  4. How do you diagnose retropharyngeal abscess? 
  5. What is the management of a retropharyngeal abscess? 

 

Knee Dislocation

  1. Up to 50% of true knee dislocations will spontaneously reduce prior to arrival. Be suspicious of a dislocation in any patient who describes the joint moving out of place or if they have significant swelling, joint effusion or ecchymosis despite normal X-rays
  2. In all patients with suspected dislocation, perform a neurovascular exam immediately as popliteal artery injury is common. If they’ve got an absent Dorsalis Pedis or Posterior Tibial pulse, reduce immediately and get a CT angiogram as quickly as possible to assess for popliteal injuries
  3. If distal pulses are intact, you can either do Ankle Brachial Indices (ABIs) and if normal, observe and repeat them or get a CT Angiogram (CTA). If the ABI is abnormal or the patient had an absent or decreased pulse at any point, get the CTA

 

T-Waves

  • Hyperacute T-waves are often the first manifestation of complete vessel occlusion; they are wide, bulky and prominent.
  • Hyperacute T-waves are not necessarily tall, and small T-waves can still be hyperacute when paired with a low-amplitude QRS complex.
  • De Winter T-waves represent LAD occlusion (a STEMI equivalent) requiring immediate revascularization.
  • Previously inverted T-waves can appear normal and upright in the setting of acute vessel occlusion. This is known as pseudonormalization.
  • The tall T-waves associated with hyperkalemia are sharp, pointy, symmetric, and have a narrow base.
  • When in doubt, get serial ECGs (every 15 minutes) and use adjunctive information.

 

Herpes Zoster

  • Classically, herpes zoster will present with rash and pain in a dermatomal distribution
  • Immunocompromised patients are at greater risk for significant complications of zoster, including visceral dissemination and zoster ophthalmicus
  • Appropriate therapy includes antiviral therapy within 72 hours of onset of symptoms and analgesia for acute neuritis
  • Disseminated zoster and zoster ophthalmicus threatening sight should be treated with IV antivirals