Rosen & Barkin's 5-Minute Emergency Medicine Consult (188 page)

• Transcutaneous pacing for unstable type II 2nd- or 3rd-degree block
  
• Atropine:
  
  • Avoid with type II 2nd-degree block because it may precipitate 3rd-degree block.
    

• Stabilize airway, breathing, and circulation:
  
  • Correct fluid, respiratory, electrolyte, and glucose abnormalities.
    
  • Bronchodilators/steroids if wheezing.
    
• Pneumothorax:
  
  • Observe if <5–10%.
    
  • Thoracostomy
    
• Consultation with the primary CF physician or pulmonary specialist
  
• Right heart failure:
  
  • Diuretics
    
• Hemoptysis:
  
  • Blood products as indicated (check INR)
    
  • Ventilatory support
    
• DIOS:
  
  • Usually requires surgery
    
• Hematemesis:
  
  • Packed RBCs
    
  • Blood products for coagulation abnormalities
    
  • Early consultation with endoscopist
    
• Intussusception:
  
  • Correct with barium/air enema
    
  • May require surgery
    
• Rectal prolapse:
  
  • Manual reduction
    
  • Consider surgical consult
    
• Respiratory care:
  
  • Pulmonary toilet/physical therapy
    
  • Mucous thinning inhaled agents
    
• Antibiotics for pneumonia:
  
  • Based on culture and sensitivity
    
  • S. aureus (MSSA):
    
    • Cephalothin or Nafcillin
      
  • S. aureus (MRSA):
    
    • Vancomycin or linezolid
      
  • P. aeruginosa:
    
    • (Tobramycin or amikacin or colistin) + (piperacillin/tazobactam or ticarcillin/clavulanate or ceftazidime or imipenem/cilastatin or meropenem)
      
  • S. aureus (MSSA) and P. aeruginosa:
    
    • (Piperacillin/tazobactam or ticarcillin/clavulanate or cefepime or imipenem/cilastatin or meropenem) + (tobramycin or amikacin or colistin)
      
  • S. aureus (MRSA) and P. aeruginosa:
    
    • (Vancomycin or linezolid) + coverage for Pseudomonas alone
      
  • B. cepacia:
    
    • Trimethoprim–sulfamethoxazole and/or meropenem and/or cipro and/or minocycline and/or chloramphenicol
      
  • H. influenzae
    :
    
    • Cefotaxime or ceftriaxone
      
  • Sinusitis
    
  • Based on cultures and sensitivities
    

Note: Ciprofloxacin may replace the aminoglycoside if sensitive pseudomonas

• CFTR modulation: Ivacaftor
  
  • Repair of protein function
    
• Restore airway surface liquid:
  
  • Nebulized hypertonic saline
    
• Mucous alteration:
  
  • Dornase alpha to thin mucus in lungs
    
• Future directions:
  
  • Gene therapy: Compacted DNA
    
  • Anti-inflammatory: High-dose ibuprofen
    
  • Anti-infective agents:
    
    • Inhaled tobramycin, aztreonam, colistin
      
    • Continuous vancomycin infusion
      
  • Transplantation: Inhaled cyclosporine
    
  • Nutrition and exercise
    

• Amikacin: 7.5–10 mg/kg IV q8h
  
• Cefazolin: 100 mg/kg/d IV (max.: 6 g/d)
  
• Cefepime: 50 mg/kg IV q8h (max.: 2 g/8hr)
  
• Ceftazidime: 50 mg/kg IV q8h (max.: 6 g/d)
  
• Colistin: 2.5–5 mg/kg/d IV, div. BID–QID
  
• Imipenem/cilastatin: 15–25 mg/kg IV q6h
  
• Meropenem: 40 mg/kg IV q8h (max.: 2 g/8hr)
  
• Nafcillin: 25–50 mg/kg IV q6h (max. 2–3 g q6h)
  
• Piperacillin/tazobactam: 350–450 mg/kg/d IV (max.: 4.5 g q6h)
  
• Ticarcillin/clavulanate:300–400 mg/kg/d IV q6h
  
• Tobramycin: 2.5–3.3 mg/kg/dose IV q8h
  
• TMP–SMX: 5–10 mg/kg IV q12h (max.: 160 mg TMP q12h)
  
• Vancomycin: 15 mg/kg q6h (max.: 1 g q6h)
  
• Note: Because many patients are undernourished, pharmacokinetics of antibiotics (especially aminoglycosides, penicillins, and cephalosporins) may be altered, requiring careful monitoring.
  

FOLLOW-UP

• Pulmonary exacerbation with significant deterioration from baseline, hypoxemia, resistant bacteria, failure of outpatient therapy
  
• Pneumothorax
  
• Hemoptysis
  
• Hematemesis
  
• Intussusception or unexplained abdominal pain or bowel obstruction
  
• Hyperglycemia
  

• Close follow-up to verify the sensitivities of culture results and change therapy as needed
  
• Avoid hot weather.
  
• Oral salt supplement when profuse sweating
  

All patients followed by a pediatric pulmonary center. Consultation during acute exacerbations.

• Team approach of specialists
  
• Breathing treatments, chest PT, exercise programs, antibiotics, replacement of pancreatic enzymes
  

• With CF patients in respiratory distress, always consider pneumothorax: Obtain CXR.
  
• For CF patients with abdominal pain/vomiting, always consider DIOS and intussusception
  

• Hoffman LR, Ramsey BW. Cystic fibrosis therapeutics: The road ahead.
  Chest.
  2013;143:207–213.
  
• Ryan G, Jahnke N, Remmington T. Inhaled antibiotics for pulmonary exacerbations in cystic fibrosis.
  Cochrane Database Syst Rev.
  2012
  .
  
• Willey-Courand DB, Marshall BC. Cystic Fibrosis. AAP
  : Pediatric Care Online
  2013,
  www.pediatriccareonline.org
  .
  

CODES

• 277.00 Cystic fibrosis without mention of meconium ileus
  
• 277.02 Cystic fibrosis with pulmonary manifestations
  
• 277.03 Cystic fibrosis with gastrointestinal manifestations
  

BASICS

• Dacryoadenitis and dacryocystitis are inflammatory conditions affecting the lacrimal system of the eye:
  
  • Dacryoadenitis is inflammation or infection of the lacrimal gland from which tears are secreted.
    
  • Dacryocystitis is an infection within the lacrimal drainage system.
    
• Dacryoadenitis may be a primarily inflammatory condition or an infectious process resulting from contiguous spread from a local source or systemic infection.
  
• Dacryocystitis is a suppurative infection involving an obstructed lacrimal duct and sac.
  

Dacryoadenitis is an uncommon disorder more commonly seen on the left:

• Acquired:
  
  • Uncommon
    

Dacryocystitis is a more common disorder most often occurring in adult females >30 yr old but may be seen in infants

Etiology—Dacryoadenitis

• Most commonly caused by systemic inflammatory conditions:
  
  • Autoimmune diseases
    
  • Sjögren syndrome
    
  • Sarcoidosis
    
  • Crohn's disease
    
  • Tumor
    
• Infectious causes may be primary or may occur secondary to contiguous spread from bacterial conjunctivitis or periorbital cellulites
  
• Acute, suppurative:
  
  • Bacteria most common cause in adults:
    
    • Staphylococcus aureus
      
    • Streptococci
      
    • Chlamydia trachomatis
      
    • Neisseria gonorrhea
      
• Chronic dacryoadenitis:
  
  • Nasal flora > ocular flora
    

• Viruses most common cause in children:
  
  • Mumps
    
  • Measles
    
  • Epstein–Barr virus
    
  • Cytomegalovirus
    
  • Coxsackievirus
    
  • Varicella-zoster virus
    
• Slowly enlarging mass may be dermoid
  

Etiology—Dacryocystitis

• Under normal conditions, tears drain via pumping action at the lacrimal duct, moving tears to lacrimal sac and then into middle turbinate/sinuses.
  
• Symptoms begin when duct to lacrimal sac becomes partially or completely obstructed:
  
  • In acquired form, chronic inflammation related to ethmoid sinusitis is a commonly implicated cause but many nasal and systemic inflammatory conditions have been correlated with this process:
    
    • May also occur secondary to trauma, a dacryolith, after nasal or sinus surgery or by any local process that might obstruct flow
      
  • Stasis in this conduit results in overgrowth of bacteria and infection.
    
  • Infection may be recurrent and may become chronic:
    
    • Most common bacteria: Sinus > ocular flora
      
    • S. aureus
      is the most common organism
      

Complications may include formation of draining fistulae, recurrent conjunctivitis, and even abscesses or orbital cellulitis

• In congenital form, presentation occurs in infancy as a result of dacryocystoceles
  
• High morbidity and mortality associated with this form:
  
  • Caused by systemic spread of infectious process or bacterial overgrowth in a partially obstructed gland
    
• The most common organism is
  Streptococcus pneumonia.