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HACK. these are a few of my favourite respiratory infections Brendan Munn Emergency Residents’ Academic Day August 13 2009 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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Objectives 1.review common respiratory infections 2.myths and just enough EBM 3.provide an approach to the above 4.discuss some cases 5.minimize powerpoint CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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Respiratory Tract Infections CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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Respiratory Tract Infections CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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Approach 1.is this pneumonia? 2.what tests should i order? 3.is this pneumonia special? 4.what f*ing antibiotic(s?) should i start? 5.should this patient be admitted? CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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case 1 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS HPI : 64F with cough, fever x 1 week O/E : febrile, RR 32
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CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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“Does this patient have Community Acquired Pneumonia? Diagnosing Pneumonia by History and Physical Examination” Metlay JP, Kapoor WN, Fine MJ. JAMA. 1997 Nov 5;278(17):1440-5. NO specific symptoms for dx pneumonia NO fever, tachypnea, tachycardia is Sn
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Special Populations CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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Special Populations CALGARY EMERGENCY MEDICINE TEACHING ROUNDS CAP VAP HAP HCAP HIV TB ASPIRATION AECOPD
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case 2 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS HPI : 64F with cough, fever x 1 week O/E : febrile, RR 32, LLL crackles PMHx : nil
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Sputum Cultures - Evidence CALGARY EMERGENCY MEDICINE TEACHING ROUNDS only 20% yield no correlation C&S with gram or with BC misses atypicals nosocomial risk does not change antibiotics or outcome ATS07 guidelines : for all “complicated” Roson B, Clin Infect Dis 2000
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CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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Disposition - Evidence CALGARY EMERGENCY MEDICINE TEACHING ROUNDS (1)Pneumonia Severity Index (PSI) online calculators available limitations - 20 factors, CAP Fine, MJ. NEJM, 1997 Jan
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CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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curb 65 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS CConfusion UUremia >7mmol/L RRespiratory Rate > 30 BBP > 90 (S) or >60 (D) 65 Age >65 Lim, WS. Thorax, 2003 May
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case 3 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS HPI : 64F with L THA O/E : febrile, RR 32, LLL crackles
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Blood Cultures - Evidence CALGARY EMERGENCY MEDICINE TEACHING ROUNDS <10% yield in CAP 50% false positive in ED only 2% positive once antibiotics limited data for inpatient if immune N ATS07 guidelines : for all “complicated” Corbo J, BMJ 2004
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case 4 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS HPI : 64F diabetic receiving daily foot wound care at home with cough, fever x1 week O/E : febrile, RR 32, LLL crackles
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HCAP RF CALGARY EMERGENCY MEDICINE TEACHING ROUNDS hospitalization >2d in preceding 90 days long-term care facilit resident home infusion or wound care therapy chronic dialysis family member with drug resistant bug
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MDR RF CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Antibiotics within the preceding 90 days Current hospitalization of ≥ 5 days High frequency of antibiotic resistance in the community or in the specific hospital unit Immunosuppressive disease and/or therapy Presence of risk factors for HCAP
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case 5 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS HPI : 28M with cough x 6 weeks, worsening SOB O/E : febrile, RR 32
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CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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case 7 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS HPI : 64F alcoholic w cough, fever x 1 week O/E : febrile, RR 32, RLL opacity
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case 8 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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Review 1.is this pneumonia? hx/phys poor, gestalt and a monkey, CXR 2.what tests should i order? good empiric abx > sputum and blood cx 3.is this pneumonia special? know your categories and risk factors if VAP/HCAP/HAP evaluate MDR risk always consider HIV, TB
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CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Review 4.what f*ing antibiotic(s?) should i start? empiric coverage of common organisms 5.should this patient be admitted? use the PSI or at worst use CURB65 and feces
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CALGARY EMERGENCY MEDICINE TEACHING ROUNDS References 1.Tintinalli 2.Up To Date 3.EMRAP 4.ATS CAP and HAP Guidelines 2007
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