Rosen & Barkin's 5-Minute Emergency Medicine Consult (736 page)

• Universal precautions
  
• Management of ABCs
  
• Treat dehydration/hypotension with boluses of normal saline.
  

• ABCs
  
• Supplemental oxygen for hypoxia
  
• Fluid resuscitation with normal saline for intravascular volume depletion or septic shock
  
• Central line access for unstable patients
  
• Vasopressors for persistent hypotension
  

• Fever control with acetaminophen
  
• Early administration of antibiotic therapy after obtaining cultures
  
• Antibiotic options:
  
  • 1st-line agents: Streptomycin or gentamicin continued for 10 days
    
  • Ciprofloxacin if community-acquired pneumonia is in the differential diagnosis of patients ≥18 yr of age
    
  • Tetracycline or doxycycline in those >8 yr of age; or chloramphenicol:
    
    • Continue for 14 days, since these drugs are only bacteriostatic.
      
    • Associated with a higher rate of treatment failures than the previously mentioned antibiotics
      
    • 3rd tier of treatment, since they are static
      
• F. tularensis
  is resistant to β-lactam drugs and carbapenems
  

Streptomycin and gentamicin are recommended as 1st-line agents.

• Gentamicin: 5 mg/kg IV or IM q24h (peds: 2.5 mg/kg IV or IM q8h) × 10 days
  
• Streptomycin: 1 g IM (peds: 15 mg/kg, not to exceed 2 g/d) q12h × 10 days
  

• Ciprofloxacin: 400 mg IV q12h × 10 days
  
• Doxycycline: 100 mg (peds: If weight ≥45 kg and child >8 yr, 100 mg; if weight ≤45 kg and child >8 yr, 2.2 mg/kg) IV q12h for at least 14 days (longer treatment needed since doxycycline is bacteriostatic); max. 200 mg/d
  
• Chloramphenicol is usually avoided due to the possibility of adverse reactions. However, chloramphenicol may be considered in cases of tularemic meningitis due to its ability to cross the blood–brain barrier and reach higher concentrations in the CSF.
  

FOLLOW-UP

• ICU admission for advanced age, neutropenia, severe hypoxemia, hemodynamic instability, or patients presenting with typhoidal tularemia
  
• Inpatient floor bed admission for mild to moderate illness:
  
  • Isolation bed required only for the purpose of ruling out other etiology (e.g., tuberculosis)
    

Outpatient therapy: Oral or IM therapy for mild illness with close follow-up

Critical care and infectious disease consultation to assist in assessment of differential considerations and manage life-threatening complications

Infectious disease consultation to manage ongoing treatment and reduce subsequent exposures

• Patients presenting with high fever and regional lymphadenopathy, especially if there is an ulcer or conjunctivitis, should have tularemia in the differential.
  
• Epidemiology may be useful in pointing to this diagnosis.
  
• Definitive diagnosis ultimately based upon serology, which usually isn’t positive until >10 days of infection.
  
• Vaccine currently under review by FDA; not currently available in US
  
• Currently listed as category A (critical agent of concern) bioterrorism agent because of pathogenicity. It can be disseminated via dispersal in food, water, or air.
  

• American Academy of Pediatrics.
  Red Book 2012 Report of the Committee on Infectious Diseases
  . Elk Grove, IL: AAP; 2012.
  
• Centers for Disease Control and Prevention. Available at
  www.cdc.gov/tularemia
  . Accessed on January 2011.
  
• Hofinger DM, Cardona L, Mertz GJ, et al. Tularemic meningitis in the United States.
  Arch Neurol
  . 2009;66(4):523–527.
  
• Snowden J, Stovall S. Tularemia: Retrospective review of 10 years’ experience in Arkansas.
  Clinical Pediatrics
  . 2011;50(1):64–68.
  
• Treat JR, Hess SD, McGowan KL, et al. Ulceroglandular tularemia.
  Pediatr Dermatol.
  2011;28(3):318–320.
  
• World Health Organization Guidelines on Tularemia, 2007.
  

CODES

• 021.0 Ulceroglandular tularemia
  
• 021.3 Oculoglandular tularemia
  
• 021.9 Unspecified tularemia
  

BASICS

• Complications arising from the compression of neural or vascular structures by solid tumors or their direct infiltration of such structures
  
• Spinal cord compression:
  
  • Affects over 20,000 patients each year
    
  • Occurs in 5–14% of cancer patients
    
  • More than 50% of cases are metastases from lung, breast, or prostate cancer.
    
  • Vertebral metastases are far more common than epidural spinal cord compression (ESCC).
    
  • Approximately 20% of cases of ESCC represent the initial manifestation of malignancy.
    
• Other neurologic tumor compression:
  
  • Brachial plexus
    
  • Recurrent laryngeal nerve compression by mediastinal lymph nodes
    
• Superior vena cava (SVC) syndrome:
  
  • Obstruction of returning blood flow in the SVC by compression, infiltration, or thrombosis
    
  • Venous hypertension within the area ordinarily drained by the SVC
    
  • In severe cases, gradual elevation of the intracranial pressure (ICP), with altered mental status and coma
    
  • 60–85% caused by malignancy
    

• Spinal cord compression:
  
  • Prostate cancer
    
  • Breast cancer
    
  • Lung cancer
    
  • Renal cell carcinoma
    
  • Multiple myeloma
    
  • Melanoma
    
  • Thyroid cancer
    
  • Lymphoma
    
  • Sarcoma
    
• Brachial plexus compression:
  
  • 0.4% of cancers
    
  • 2–5% of those who receive radiation treatment
    
  • Lung cancer
    
  • Breast cancer
    
• SVC syndrome from tumor compression:
  
  • Lung cancer (most common):
    
    • Small cell lung cancer primarily
      
• Postirradiation fibrosis
  
• Lymphoma
  
• Breast cancer
  
• Testicular cancer
  
• See “Differential Diagnosis” for non malignant etiologies of the SVC syndrome.
  

In children with spinal cord compression, common causes are sarcoma, neuroblastoma, germ cell tumors, and lymphoma.

DIAGNOSIS

• Spinal cord compression:
  
  • History of malignancy
    
  • Back or neck pain:
    
    • Prolonged
      
    • Worse with rest
      
    • Most commonly affects the thoracic spine
      
  • Paresthesias
    
  • Difficulty ambulating
    
  • Constipation
    
  • Urinary retention
    
  • Urinary or fecal incontinence
    
  • Weight loss
    
• Brachial plexus compression:
  
  • Neuropathic pain involving the medial aspect of the upper extremity
    
• Intrathoracic vagal nerve compression:
  
  • Ipsilateral aching facial pain around the ear
    
• SVC syndrome:
  
  • Orthopnea
    
  • Dyspnea
    
  • Tightness of the shirt collar
    
  • Cough
    
  • Chest pain
    
  • Headache
    
  • Facial swelling
    
  • Head fullness
    
  • Blurred vision
    
  • Dizziness
    
  • Syncope
    

• Spinal cord compression:
  
  • Loss of rectal tone
    
  • Loss of anal wink
    
  • Weakness in 60–85% of patients
    
  • Sensory findings less common
    
• Laryngeal nerve compression:
  
  • Hoarseness
    
  • Vocal cord paralysis
    
• Brachial plexus:
  
  • Ulnar paresthesias
    
  • Weakness and wasting of intrinsic hand muscles
    
  • Pan-plexopathy
    
  • Horner's syndrome
    
• SVC syndrome:
  
  • Periorbital edema
    
  • Conjunctival suffusion
    
  • Facial swelling
    
  • Facial plethora
    
  • Upper extremity edema
    
  • Findings exacerbated by recumbent or stooped-over position
    
  • Usually worse in the early morning hours
    
  • ICP may be elevated in severe cases:
    
    • Altered mental status
      
    • Coma
      
    • Papilledema