A 30 year old mechanic presents for a right lower leg injury. He was working on his car when it fell on his right leg. Urinanalysis reveals dark urine with a dipstick positive for large mount of blood. Serum CK is 28,000 units/L. The primary treatment modality is: 

A. Sodium Bicarbonate

B. Furosemide

C. Mannitol

D. Normal Saline

E. Calcium Gluconate

Answer is D - Normal Saline

Recommend against reversal of LMWH in patients receiving prophylactic dosing of LMWH. 

Low quality of evidence for the use of FFP or PCC to reverse LMWH. 

Protamine:

• Dosed within 8 hours - 1 mg IV per 1 mg Lovenox (up to 50 mg in a single dose).
• Dosed within 8-12 hours - 0.5 mg IV per 1 mg Lovenox (up to 50 mg in a single dose). 
• Minimal utility in reversal of >12h from dosing. 

rFVIIa: 90 ug/kg iV if Protamine is contraindicated. 

A 52 year old male with history of asplenia after a car accident presents with a fever for 8 days. Tmax is 101.8. Denies any other symptoms. Denies rash. Reports he walks every morning through a path in the woods behind his house. Denies recent travel, animal exposure, sexual history. Blood pressure is 120/80, heart rate is 110, Temperature is 101.0 F, respiratory rate is 18, SpO2 is 100% on room air. Physical exam is otherwise unremarkable. Blood work is significant for evidence of hemolytic anemia and peripheral smear shows maltese cross. What is the next step in management? 

Consider tick borne illness when:

• Influenza-like illness presentations, especially during the summer months. 
• Fever of unknown origin
• When viral meningitis is on your differential diagnosis. 

Babesiosis:

• PO: Atovaquone + Azithromycin
• IV: Clindamycin + Quinine
• Exchange transfusion indications (would need Hematology/Oncology consult): 1. Asplenia       2. Parasite Load > 10%

Lyme's Disease:

A man with a bullae. 

Pearls from today's talk on cutaneous abscess. 

Pathology: Chronic autoimmune mucocutaneous disease against desmosomes in epidermis

Clinical:

• painful; rarely pruritic; afebrile
• flaccid bullae but may start tense, +Nikolsky's sign
• mucosal involvement common 
• Bullous pemphigus: Have tense bullae (may start with urticarial lesions), negative Nikolsky's sign, mucosal involvement less likely

Diagnosis: clinical; biopsy is gold standard. 

Management:

A 32 year old male history of IV drug use presents for redness to his right arm extending the antecubital fossa. He has pain out of proportion to the area and pain outside of the erythematous margins. He is febrile to 103.2 F, heart rate is 125, blood pressure is 80/40. Patient is given normal saline. Vancomycin and Cefepime are started. What is the next step in management? 

A. Immediate Surgical Consult and Clindamycin. 

B. Draw labs to risk stratify via the LRINEC score and a CT scan

C. Immediate Surgical Consult and a CT scan. 

A 58 yo patient with a hx of CLL presents with a chief complaint of dyspnea, wheezing, and cough for 3 days. He is noted to be tachypneic with o2 sats of 91% on RA. There is diffuse expiratory wheezing. Peripheral WBC count is 199,000, increased from a baseline of ~80,000. A CT scan shows scattered interstital infiltrates. What is going on with this patient and what is the indicated therapy?