EMS World

AUG 2011

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CE ARTICLE proliferate, secondary to vascular insuf- fi ciency and poor peripheral circulation and perfusion common with the disease. The lack of adequate perfusion inhibits the immune system’s ability to access the infection site and fi ght the pathogen. In addition, the sensory neuropathy charac- teristic of diabetes may delay the identifi - cation of a worsening infection, and the patient may not feel pain. For these reasons, the physical exam of a diabetic patient with vague or nonspecifi c complaints should include examination of all surfaces of the feet and legs. Any signs of infection, ulcers or wounds should be evaluated in the ED. ALCOHOLISM AND CIRRHOSIS Both acute and chronic alcohol consumption increase the risk of infection through direct suppression of the immune system, depression of mental status and delay in seeking medical care.15 Acute There are two ways to take the CE test that accompanies this article and receive 1.5 hours of CE credit accredited by CECBEMS: 1. Go online to EMSWorld.com/ cetest to download a PDF of the test. The PDF has instructions for completing the test. 2. Or go online to www. rapidce.com to take the test and immediately receive your CE credit. Questions? E-mail editor@ EMSWorld.com. alcohol intoxication is associated with a decrease in circulating immune cells, as well as decreased ability for them to mobilize when a pathogen is identifi ed. This occurs in part secondary to a decrease in the circulating plasma proteins responsible for the complement cascade (part of the innate immune system) that is produced in the liver. These changes are reversible with cessation of drinking and abstaining from alcohol. In chronic alcoholics with alcoholic cirrhosis, impaired liver func- tion weakens the immune system, and chronic malnutrition exacerbates the situation. Alcoholics also tend to have an increased incidence of bacterial coloniza- tion of the oropharynx. This, combined with a suppressed cough refl ex and high risk of aspiration, increases the risk of pulmonary infections. Alcoholics are also more likely to aspirate because of withdrawal seizures, intoxication and encephalopathy. RENAL FAILURE Patients with renal failure are at risk of infection for a number of reasons, and infections are the second most common cause of death in this patient population (up to 20% of all deaths).16 The immune system is weakened by the reduced renal clearance of toxins and nutritional defi cien- cies. Disruption of the skin as a protective 50 AUGUST 2011 | EMSWORLD.com barrier by dialysis access sites, especially peritoneal access, also increases the risk of infection. As many as two-thirds of patients receiving chronic ambulatory peritoneal dialysis will develop peritonitis in the fi rst year of dialysis. The mortality rate from sepsis in dialysis patients is increased 100 to 300 times compared to persons not receiving dialysis.17 SPLENECTOMY, HYPOSPLENIA, ASPLENIA The spleen is an important part of the immune system, producing phagocytotic cells (monocytes, macrophages) that are located in connective tissue and engulf and destroy pathogens. In addition, it is a major site of antibody synthesis. As such, any derangement to the spleen will poten- tially result in immune system dysfunction. Common splenic disorders are asplenia, the absence of normal spleen function in which the spleen may or may not be present, and hyposplenia, the presence of a small spleen. In addition, a patient may have undergone a splenectomy, during which the spleen was removed secondary to complications resulting from disease or trauma. Functional asplenia occurs when a spleen is present but its function is impaired by disease such as sickle cell anemia, celiac disease, SLE, rheumatoid arthritis or ulcerative colitis. CORTICOSTEROIDS AND OTHER MEDICATIONS Corticosteroid medications (pred- nisone, cortisone, hydrocortisone) are frequently prescribed for the treatment of a variety of conditions ranging from rash to arthritis to asthma. Prescribed corticosteroids mimic the effects of the naturally produced steroid hormones from the adrenal gland, and, when prescribed in doses that exceed the body’s normal levels, act to suppress infl ammation. Unfortunately, corticosteroids also suppress the immune system, affecting the function of immune cells like lympho- cytes, monocytes and neutrophils, and impairing the function of cell-mediated immunity. In addition, corticosteroid administration has a hyperglycemic effect, which also increases the risk of infection. Patients particularly at risk for infec- tion are those with gastrointestinal issues such as appendicitis, peptic ulcers and diverticulitis. The use of corticosteroids may mask the usual signs and symptoms associated with infection, making iden- tifi cation of a potentially life-threatening infection from, for instance, a perforated diverticula diffi cult to recognize. The use of corticosteroids can also result in increased infections caused by bacteria, varicella zoster and herpes simplex viruses, tuberculosis, and a wide variety of other bacteria, fungi and parasites.12 Other immunosuppressive medica- tions are used to treat a wide variety of conditions including SLE, infl ammatory bowel disease, rheumatoid arthritis and psoriasis. These include sirolimus, tacro- limus, cyclosporine, methotrexate and cyclo- phosphamide. Summary Marie considers the exam and history fi ndings and constructs her reply to the patient’s statement that he does not want to go to the hospital. “Sir”, she says, “I appreciate that you think this is just a stomach bug, but here’s what I’m concerned about: Your lupus and the Imuran and prednisone you take to treat it weaken your immune system. And, with your history of diverticular disease, I’m worried that you may have devel- oped diverticulitis, which your weakened immune system might struggle to fi ght effectively. Worst case scenario, you could be developing an infection that you cannot effectively fi ght. This infection could get worse, spread to other places in your abdomen or even your blood, and make you very sick. For that reason, I recommend that you go to the hospital for an evaluation.” Presented with this information, the patient agrees to transport with the EMS crew to the local ED. He is placed on the cardiac monitor and IV access is initiated. He is monitored during an uncomplicated trip to the receiving ED. Later, the attending physician informs Marie and Don that the patient had diverticulitis with a perfo- rated diverticula, was likely developing peritonitis, and had been admitted to the hospital for treatment and observation. Correction: In the July issue, Jake Kleinman should have been listed as the primary author of the CE article on abdominal pain. azathioprine, mycophenolate,

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