Approach to the IDU in the ED from the CFN

[Featured Image: Creative Commons, danielleellis55 on Flickr.]

First off here’s a video I recorded for the CEM FOAMed network on “approach to the injecting drug user“. Be sure to subscribe on iTunes and check out the site. There’s a podcast feed and a blog feed, so be sure to get both.

CEM FOAMed widget

[Direct Download ]]

 

Injecting Drug User (IDUs) are frequent attenders at EDs for lots of reasons. While there is no doubt that there are a lot of social factors involved in these attendances, we can all too easily forget that these patients get really sick and often get left in the bottom of the queue of patients waiting to be seen. I think “the approach to the IDU” would make a great chapter for Rosen’s but it’s not in there yet. Harwood Nuss is the only one I’ve seen with a good chapter on it.

Complications of injection drug use

Hardwood-Nuss 5th edition p1398

I find this population of patients perhaps the most fascinating to treat. Generally ostracised by society in the way homeless people usually are.  Usually undertriaged at the front door (“just another junkie”) I frequently find them in the waiting room with fairly dramatic vital signs. Without doubt injection drug use is usually not compatible with a stable and productive lifestyle and low grade criminality abounds. Certain aspects of the doctor patient relationship can be challenging here but they aren’t always drug seeking the way we expect they are.

And if your waiting room is anything like mine by the time they’ve waited 12 hrs to be seen then they’ve usually gone into withdrawal and it’s easy to blame all their symptoms and abnormal vital signs on withdrawal (even though their symptoms and abnormal vital signs all occurred prior to their withdrawal…)

All this to say that we approach them with so many cognitive biases and good old fashioned prejudices that it’s no wonder we fail to diagnose lots of the really interesting illnesses they bring with them.

Soft tissue infections

  • Probably higher incidence of MRSA
  • Most tentanus and wound botulism these days is associated with IDU
  • Necrotising fascitis is a much higher risk
  • Pyomyositis is a nice complication

Vascular

  • DVT
  • Arteriovenous malformations
  • Pseudo aneurysm
    • Here’s a quote “any mass over a vascular territory may actually be a pseudo aneurysm and should be approached with caution”
    • I know a number of people with great stories of enthusiastic junior surgeons incising and draining these with impressive and unexpected results
  • Associated abscess
  • All 4 of the above in the same leg as I saw once…
  • Those lovely cutaneous groin sinuses that descend to dear knows where.
  • Mycotic aneurysms, typically with infectious endocarditis

 Pulmonary

  • ‘Pocket shooting': injecting into the supraclvaicular space in the hope of finding a vessel. Can result in pneumo, haemo, hydropneumo and the wonderfully titled pyopneumothorax
  • Dissolving tablets and injecting them can result in what I’ve heard called trash lung or talc lung. [Check out BroomeDocs podcast with @dreapadoirtas on this]
    • This can cause granulomas in the pulmonary and even retinal vasculature (in fact looking at the retinas for talc might be better CXR or pulmonary function tests)
    • Restrictive and obstructive dysfunction can occur. I suspect this is commoner than we suspect. I see a lot of IDUs with lowish sats and it gets blamed on something like COPD from smoking.
    • Chronic pulmonary hypertension can result

 Skeletal

  • Osteomyelitis and septic arthritis can be local or haematogenous
  • Commonest is vertebral osteomyelitis usually lumbar which may have associated disc it is with or without the even more emergent spinal epidural abscess
    • Pain is often chronic (as has been in the cases I have seen)
    • Don’t expect fever (unless you’re the admitting doctor in which case it can’t possibly be vertebral osteo without a fever…)
  • Joint involvement is axial. Think sacroiliac, sternoclavicular, hip and pubic symphysis. (Mainly fibro cartilaginous joints if you’re into the anatomy of it all)
    • This is really important as no one will consider septic arthritis in someone with tender central chest pain.

Central nervous system

  • Meningitis both fungal and bacterial
  • Various sites for epidural abscesses
  • Brain abscesses
  • CNS aspergillosis
  • Cerebral murcomycosis (even when HIV negative)
    • Headache, fever, cranial and motor deficits
    • Apparently basal ganglia lesions on CT are the key

 Fungal endophthalmitis

  • Decreased acuity, eye pain
  • White vitreal exudate on fundoscopy

Blood Born Viruses

  • Hep C (almost ubiquitous amongst IDU. >80% in our population)
  • Hep B (up to 80% become seropositive over lifetime)
  • HIV (about 10% in our local population)

Endocarditis

  • (lifetime incidence of 5%)
  • Classic signs are rare
  • Mainly right sided

Cotton fever

  • A brief, febrile episode following injection when the solution is filtered through cotton balls
  • No way to distinguish this in the ED from the other more serious occult causes of fever in the IDU

It might be easier is to think about common clinical presentations and then apply appropriate IDU pathologies

IDU with stroke

  • Brain abscess
  • Subdural empyema
  • Botulism
  • Mycotic aneurysms
  • Good old fashioned stroke

Groin pain

  • Abscess
  • AV fistula
  • DVT
  • Pseudo aneurysm
  • And I suppose it could be just a hernia

Chest pain

  • Pneumonia
  • PE (esp in groin injectors)
  • ACS (chronic inflammatory states like HIV lead to accelerated atherosclerosis. Never mind the cocaine use)
  • Sternal joint osteomyelitis

Headache

  • Brain abscess
  • Meningitis
  • SAH (remember all the cocaine use that goes with the heroin)
  • Complications of associated HIV
    • Toxoplasmosis
    • Lymphoma
  • And yes it could just be a migraine too i suppose…

 Back pain

  • Epidural abscess
  • Discitis
  • Vertebral osteomyelitis
  • And yes it could just be good old fashioned back pain too I suppose

Fever

  • Endocarditis
  • Meningitis
  • Osteomyelitis
  • Cotton fever
  • HIV related
  • TB (a lot of these guys are homeless and in Dublin anyhow there are reasonably high rates of TB amongst the homeless)
  • Haematological malignancy
  • And yes I suppose it could just be a flu or the dreaded ‘viral illness’

Shortness of breath

  • PE
  • Talcosis or trash lung
  • Chronic pulmonary hypertension
  • Pneumothorax from trying to inject a neck vein
  • Aspiration from their recent OD, GCS 3 episode
  • And yes I suppose it could be a good old fashioned chest infection too

Cellulitis in IDU

  • necrotising fasciitis
  • Pyomyositis
  • Subcutaneous abscess
  • And yes I suppose it could be a simple staph or strep cellulitis

 

References/FOAMed Resources:

  •  Nice EM News Post on the febrile IDU
  • Hardwood-Nuss 5th edition p1398
  • A paper from our place characterising our population

Recent controversies in sepsis

Below is a recent talk I prepared for a teaching meeting for the ICU and ED staff. Unfortunately I was still on my train when I was due to give it so here it is online instead.


References:

  • Annane D. Effects of Fluid Resuscitation With Colloids vs Crystalloids on Mortality in Critically Ill Patients Presenting With Hypovolemic Shock. JAMA. 2013 Nov 6;310(17):1809.
  • Brown SGA. Fluid resuscitation for people with sepsis. BMJ (Clinical research ed). BMJ Publishing Group Ltd; 2014 Jul 22;349(jul22 16):g4611–1.
  • SMACC Podcast: Myburgh: Fluid Resuscitation: Which, When and How Much?
  • EMCrit Podcast: Marik: Fluids in Sepsis
  • EMCrit Podcast: Angus on Process
  • Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008 Jul;134(1):172-8. doi: 10.1378/chest.07-2331. Review. PubMedPMID: 18628220.
  • Marik PE. Iatrogenic salt water drowning and the hazards of a high central venous pressure. 2014 Jun 24;:1–9. [free pdf]
  • Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001 Nov 8;345(19):1368–77.
  • Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA. Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy: A Randomized Clinical Trial. JAMA. 2010 Feb 24;303(8):739–46.
  • Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R; Surviving Sepsis Campaign Guidelines Committee2012. Crit Care Med.2013 Feb;41(2):580-637. doi: 10.1097/CCM.0b013e31827e83af. PubMed PMID: 23353941.
  • The ProCESS Investigators. A Randomized Trial of Protocol-Based Care for Early Septic Shock. N Engl J Med. 2014 Mar 18;:140325070040003.
  • Kaukonen K-M, Bailey M, Suzuki S, Pilcher D, Bellomo R. Mortality Related to Severe Sepsis and Septic Shock Among Critically Ill Patients in Australia and New Zealand, 2000-2012. JAMA. American Medical Association; 2014 Apr 2;311(13):1308–16.
  • Marik PE. Early Management of Severe Sepsis. Chest. American College of Chest Physicians; 2014 Jun 1;145(6):1407–18.

EMS Gathering Review

It’s been a month since the Irish EMS Gathering conference that I had the pleasure of speaking at. This was the second year and it’s a pretty unique event. It’s main focus is naturally pre hospital care and it’s great to see a medical conference that isn’t just doctors talking about how awesome doctors are… Plus, Carley was there so it was nice to catch up.

Here’s just 3 (of many) highlights.

Gareth Davies [London HEMS]

Gareth Davies

Absolutely lovely bloke with brain the size of the a planet and clearly very, very good at what he does. My take home message was his talk on impact brain apnoea. This is a new phenomenon to me and to be fair I think the London HEMS guys have coined the term. It is based on some wonderful rat models from a long time ago though. The basic idea is that the massive trauma of high speed motor vehicle accidents leads to some form of brainstem event that results in transient apnoea and blown pupils. This is associated with a massive surge of catecholamines and resultant cardiovascular instability and collapse. You only see this if you do prehospital care, and even more so if you’re a doc on the scene of something like the Isle of Man TT or the North West 2oo, both designed to allow young crazy, northern irish men try to kill themselves in as dramatic a way as possible. The key, Davies says, is early intervention not nihilism. The reason these guys do so badly is not because of the their structural brain injury but from prolonged prehospital apnoea. Davies, like the wonderful Mark Wilson advocates that if these guys are oxygenated early then they need aggressive neurosurgical intervention and never mind the blown pupils. The poor outcomes that people quote are self-fulfilling prophecies – if you do not intervene then it’s no surprise they do poorly.

He always goes down in history for his nuanced critique of the PK format of talks as Pokemon talks.

[Impact Brain Apnoea also here on Resus.ME]

The ATACC guys

ATACC

I made the mistake of not going to their simulation workshop but chatting to Mark Forrest and Jason you get an idea of how much these guys are passionate about improving prehospital trauma care. They have made the ATACC manual available as a FOAMed resource and I’m about half way through and loving it so far. Alan Watts, one of my fellow trainees and FOAMed connoisseur told me it was the best course he’s ever been on so it’s on my wish list.

Conor Deasy and the Trauma audit

Conor Deasy

To me Conor Deasy was always the lead singer in this band but turns out he’s a researcher, EM consultant and now the trauma audit lead for Ireland

I’ve bemoaned our lack of a functional trauma system in Ireland on twitter before but I suppose it’s worth mentioning again. We only have one hospital in the country with all the requisite specialties but as Karim Brohi has noted, a hospital of specialties is not a specialist hospital. Ireland has a population of less than 5 million. It’s not clear how many trauma centres we might need, but it’s going to be a lot less than the current 28 EDs we have that have the potential to receive major trauma. Trauma remains an inconvenience to hospitals in Ireland. No one is really planned and prepared for it and there is no systems wide approach to making it efficient, effective and seamless. At present we have no data to show that we’re not very good at trauma. Hopefully trauma audit (no matter what issues there may be with TARN) will give us a basis for something like the NCEPOD report that seemed (to me as a very junior doc at the time) a big deal in improving UK trauma care.

(Yet more) reflections on SMACC Gold

Lots of other folk have put their reflections on SMACC Gold online and I’m here to join the crowd.

I missed the first SMACC as purse strings were a little tight. They’re a little tight this year too but I really wasn’t going to miss two SMACCs…

It was great to have an opportunity to come and speak though I’ll confess I was much more comfortable teaching neuroanatomy than being on the airway panel with Levitan, Weingart, John Hinds and Brent May. But it was all good really.

levitan 1

I was very impressed that they chose to devote a 2 hr main area session on end of life issues that incorporated a live integrated twitter discussion.

SonoWars in particular caught my eye as one of the most creative and slickly ran sessions on education I’ve ever seen. Those guys (ultrasoundpod and the sonocave guys) are the best in the business.

The highlight though, without doubt, was the people. This is why you come to SMACC, to meet and be inspired by people. You can throw this off as soft and fluffy and no relevance to medicine but this was the key thing.

smacc gold audience

Ireland has a small EM community and it’s a tough place to do EM. We have a very small number of trained EPs and our departments are crowded, understaffed and morale is frankly pretty low at times. It’s hardly surprising that so many of our trainees or EPs have moved to Oz or New Zealand.

As a result #FOAMed has been an inspiration and an revelation to me. To know the imaginative possibilities of EM out there is what gets me excited about the job. I get to discuss online with some fascinating, interesting and passionate clinicians from whom I can learn. SMACC gold gave me the chance to meet these people in person. And meeting people in person beats twitter hands down.

People who engage in #FOAMed tend to be a little bit off the spectrum in terms of our enthusiasm. We love the medicine, we love to talk about  medicine and we just can’t get enough of talking about medicine so much so that our spouses, our friends and even our medical colleagues get bored of us. SMACC is a conference for all these enthusiastic, excitable little puppies to get together and bond with all the other freaks and geeks.

All these people, the passion, the enthusiasm and the relationships are an inspiration to be a better doctor and a better team member.

So my thanks for SMACC gold are to the people. In particular the committee for being mad enough to invite me and Rob Rogers for being a great roomie – that man rocks!

Here’s some more reflections on SMACC gold so you can check out the love.

I Teach EM

Manu Et Corde

REBEL EM

Injectable Orange

LITFL

Jess

KI Docs

Doug Lynch (with a fascinating set of interview)

Damian Roland

AmboFOAM

Nomadic GP

Bishan

[Let me know if I missed any]

And here’s the opening ceremony

We’ll be in Chicago next year in May 2015 and I for one plan on being there. Be sure and check out the SMACC podcast to catch up on all the talks.

[Images via Oli Flower]

PK Talk for SMACC 2014

Here’s my PK talk for SMACC for 2014. The PK talks for those who can’t remember are short, snappy focused presentations on anything – the SMACC ones are of course focused on critical care.

I presented the same material at our  joint ICU/ED meeting a few days ago so I figured I may as well share it as a PK.


Genuinely intersted as to whether people are aiming for the higher MAPs in SCI. Was news to me and no one in our department was that impressed by it. The studies aren’t wonderful after all.

For those interested here’s last years PK too.

See you at SMACC Gold people!