UMEM Educational Pearls - International EM

Whether in the U.S. or overseas, there are four main phases of emergency management:

1. Mitigation
   1. Identifying risks and hazards to reduce or eliminate the risks, such as:
      1. Building codes (for earthquakes, hurricanes, fires, etc.)
      2. Zoning rules (floodplain restrictions)
      3. Dams and levees (prevent flooding)

2. Preparedness
   1. To enhance response capacity, such as
      1. Training, including exercises to assure adequacy of planning efforts
      2. Planning
      3. Resource procurement

3. Response
   1. Immediate post disaster activities to save lives and property, such as
      1. Evacuating victims
      2. Response teams deployment
      3. Incident command operations

4. Recovery
   1. Efforts to restore essential services and repair damage, such as
      1. Reconstruction of government operations and services
      2. Housing and services for displaced families/ individuals
      3. Replenish stockpiles

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Background: While much of international health focuses on communicable diseases, it is clear that noncommunicable diseases (NCDs), such as cardiovascular diseases, cancer and diabetes, causes substantial morbidity and mortality.

Epidemiology:

• NCDs kill 38 million people each year
  • Approximately 28 million of these deaths occur in low- and middle-income countries.
• Of the 38 million deaths, 16 million of these deaths occur in patients <70 years of age
  • 82% of these “premature” deaths occur in low- and middle-income countries
• Causes of NCD deaths
  • Cardiovascular diseases (heart attacks and strokes): 17.5 million
  • Cancers: 8.2 million
  • Chronic respiratory diseases (COPD and asthma): 4 million
  • Diabetes: 1.5 million

Bottom line: As in developed countries, risk factors for NCDs deaths include physical in activity, tobacco use, unhealthy diabetes, harmful use of alcohol.

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The Centers for Disease Control continues to report increased numbers of measles patients in the US. From January 1 to February 13, 2015 there have been 141 cases.  It has spread to 17 states and the District of Columbia, with 80% linked to the multistate outbreak from Disneyland.

Measles is not a benign disease!

Per the World Health Organization, there were 146,700 measles deaths globally in 2013.  Most of these deaths occur in lower- and middle-income countries,

Even in the US, measles can cause serious complications and death. Complications from measles can be seen in any age group, but particularly in children <5 years of age and in adults >20 years of age.

Measles Complications:

Common:

• Ear infections (about 1 in 10 children)
  • Can result in permanent hearing loss
• Diarrhea (about 1 in 10 people with measles)

Severe:

• Pneumonia (as many as 1 in 20 children)
  • Most common cause of death
• Encephalitis (about 1 in 1,000 children)
  • Can lead to seizures, hearing loss, intellectual disability
• Death (1 to 2 per 1,000 children)
• Measles in pregnancy can cause premature birth and low-birth-weight babies

Long-term:

• Subacute sclerosing panencephalitis (SSPE)
  • Aside from the long-term complications above, an estimate 4 to 11 out of every 100,000 will develop this fatal disease of the central nervous system 7 to 10 years after infection.

Bottom Line:

Per Dr. Anne Schuchat of the CDC: “This is not a problem with the measles vaccine not working. This is a problem of the measles vaccine not being used.”

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From January 1^st to January 30^th, 2015, 102 people from 14 states were reported to have measles. This one month total is greater than the annual number of U.S. cases from 2002 to 2012.  Most of these cases are related to a large outbreak from a Californian amusement park. Measles can spread in communities without adequate vaccination (low herd immunity). The majority of the people in the US who get measles are unvaccinated. However, measles remains common in many parts of the world.

Bottom Line:

As noted in the recent ACEP Fact Sheet, “A very high index of suspicion for Rubeola is necessary especially among patients with an exposure history, travel to foreign or domestic areas where disease is present, and those without adequate immunization. Immediate isolation of these patients should be considered in the ED or other outpatient healthcare setting.”

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As noted previously (UMEM Pearl of 1/7/2015), tuberculosis (TB) is a major infectious disease that occurs worldwide. Strains of tuberculosis can be resistant to one or more anti-tuberculosis medications. TB strains resistant to at least one medication have been found in all surveyed countries.

What is multidrug-resistant tuberculosis (MDR TB)?

• A TB organism resistant to at least isoniazid and rifampin
  • Two of the most common, potent and standard TB medications
• Primary cause of MDR TB is inappropriate or incorrect usage of TB medications
• In 2013, there were approximately 480,000 cases of MDR TB globally
  • Most cases were in India, China and the Russian Federation
• A concerning form of resistant TB is extensively drug resistant TB (XDR TB), which is resistant to multiple anti-tuberculosis medications (see UMEM Pearl from 8/14/2013).

Treatment of MDR TB

• MDR TB can usually be treated and cured with second-line treatments
• Use of second-line treatments tend to be more:
  • Difficult to access the medications
  • Expensive
  • Likely to produce severe adverse reactions

Bottom line:

As noted previously, in your emergency department have a high index of suspicion for TB and MDR TB in patients with an appropriate risk profile.

• Recent travel from appropriate countries
  • Most TB cases/deaths are in developing countries
• Individuals infected with HIV.
• Individuals using tobacco
  • Increases the risk of infection and death from TB.
• Any age group, including children
  • Mostly affects young adults in their productive years

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Tuberculosis (TB) is a major infectious disease that occurs worldwide.

• TB is second only to HIV/AIDS for the number of individuals killed worldwide from a single agent.
• In 2013, 1.5 million died from TB and 9 million became ill
• The vast majority (>95%) of TB deaths occur in low- and middle-income countries

Fortunately, public health and clinical measures have had some success.

• The estimated number of individuals annually become ill with TB is declining
• The TB death rate dropped 45% between 1990 and 2014
• An estimated 37 million lives were saved between 2000 and 2013 through diagnosis and treatment

Bottom line:

• Tuberculosis (TB) is a major killer worldwide.
• Treatments are available to treat both latent and active disease
  • See: http://www.cdc.gov/tb/topic/treatment/
• Good clinical awareness is key to disease identification

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As you get ready to celebrate the coming of a new year, it is important to be safe while you are having a good time.

Injuries seen during holidays, such as new years, include:

• Firework related injuries
  • particular hand and ocular
• Celebratory gunfire related injuries
  • including occasional deaths
• Motor vehicle crash related injuries
  • particularly due to increased drinking and driving

If you are working, be ready to see increased alcohol and injury related visits.

If you are off and plan to celebrate, be sure to identify a designated driver or an alternate means of getting home.

Have a Happy and Safe 2015!

Background:  As discussed previously, influenza (flu) is a common respiratory disease that causes significant morbidity and mortality worldwide (see pearl from October 1. 2014).  We are now in the midst of the current flu season.

Current Update: This year’s vaccine was only a partial match (<50%) for the current influenza A (H3N2) circulating virus, so there is a significant potential for a “bad” flu season with widespread disease and severe illness.  Currently, influenza is now widespread throughout the US, with some states reporting more activity than others.  The CDC has a weekly surveillance map that highlights current disease spread.

Bottom Line:

• Remember that influenza annually causes between 250,000 and 500,000 deaths worldwide.
• Your emergency department will likely see many individuals with influenza this year, even if the patient received the vaccination.
• Know your emergency department protocols and policies for cohorting influenza patients  and addressing droplet isolation precautions.

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In December 2013, Academic Emergency Medicine published the results of the 2013 consensus conference that focused on advancing global health and emergency care research.

As noted in the issue’s executive summary, “Emergency physicians are uniquely poised to address challenges in health services, health care systems development and management, and emerging global disease burdens (both communicable and noncommunicable). “

The consensus conference covered developing research in eight focus areas, including understanding of cardiac and injury resuscitation, ethics of research, health systems development, and the education of future global health leaders.

For anyone interested in global health and emergency care, this issue of Academic Emergency Medicine is an outstanding resource and roadmap to developing research. It can be found at: http://onlinelibrary.wiley.com/doi/10.1111/acem.2013.20.issue-12/issuetoc

Background: As noted in a previous pearl (November 5, 2014), the Centers for Disease Control and Prevention (CDC) classifies potential bioterrorism agents into three categories. Category B & C agents are of less priority than the previously discussed Category A agents.

Category B: Second highest priority agents. These agents:

1. are moderately easy to disseminate;
2. result in moderate morbidity rates and low mortality rates; and
3. require specific enhancements of CDC's diagnostic capacity and enhanced disease surveillance.

These Agents/Diseases include:

•Brucellosis (Brucella species)

•Epsilon toxin of Clostridium perfringens

•Food safety threats (e.g., Salmonella species, Escherichia coli O157:H7, Shigella)

•Glanders (Burkholderia mallei)

•Melioidosis (Burkholderia pseudomallei)

•Psittacosis (Chlamydia psittaci)

•Q fever (Coxiella burnetii)

•Ricin toxin from Ricinus communis (castor beans)

•Staphylococcal enterotoxin B

•Typhus fever (Rickettsia prowazekii)

•Viral encephalitis (alphaviruses [e.g., Venezuelan equine encephalitis, eastern equine encephalitis, western equine encephalitis])

•Water safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum)

Category C agents: Third highest priority agents. These include emerging pathogens, such as hantavirus and Nipah virus, which could be potentially engineered for mass dissemination in the future.

Bottom Line: While in general of less concern, bioterrorism agents in Category B & C remain of significant risk.  Many of these diseases still occur in various parts of the globe including the United States.

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Background: The Centers for Disease Control and Prevention (CDC) classifies potential bioterrorism agents into three categories, with Category A the most deadly.

Category A: These are the highest priority agents/diseases because they:

• can be easily disseminated or transmitted from person to person;
• result in high mortality rates and have the potential for major public health impact;
• might cause public panic and social disruption; and
• require special action for public health preparedness.

Specific Category A Agents/Diseases:

• Anthrax (Bacillus anthracis)
• Botulism (Clostridium botulinum toxin)
• Plague (Yersinia pestis)
• Smallpox (variola major)
• Tularemia (Francisella tularensis)
• Viral hemorrhagic fevers (including filoviruses such as Ebola and Marburg, as well as arenaviruses such as Lassa)

Bottom Line: With the exception of smallpox, these disease still occur in various parts of the globe including the United States. As can be seen by the current Ebola epidemic in West Africa, the U.S. public health system and healthcare providers must be prepared to recognize and treat these agents.

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Background:

• There is a great deal of fear, media attention, and misinformation concerning Ebola.  
• As an emergency physician, you must be able to identify and appropriately manage individuals with possible Ebola presenting to your hospital. 
• ACEP's Ebola Expert Panel worked with the Centers for Disease Control and Prevention to help create a clear and concise algorithm in case someone presents with possible Ebola.

ED Algorithm For Patients with Possible Ebola

• Identify:
  • Do they have the right travel history (step 1)?
  • Do they have the right signs and symptoms (step 2)?

If yes to both identification questions, then:

• Isolate (step 3):
  • Place patient in private room or separate enclosed area
    • Private bathroom or covered, bedside commode
  • Only essential personnel should evaluate patient and provide care
  • Level of personal protective equipment should be determined
    • Based upon patient’s clinical status (signs and symptoms)
• Inform (step 4)
  • Immediately notify the hospital infection control program and other appropriate staff
  • Immediately notify the health department

• Further evaluation and management will depend on the patient’s clinical status and other potential diagnoses (step 5).

Bottom line:

Whether the patient has Ebola or not, a well-developed response is necessary for patient management and public health preparedness. The fear of the disease is much more widespread and impactful than the disease itself.

See the full algorithm, with more details at: http://www.cdc.gov/vhf/ebola/pdf/ed-algorithm-management-patients-possible-ebola.pdf

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With all the current concern about Ebola, it is important to understand what are quarantine and isolation and who can order these.

Per the Centers for Disease Control:

• Quarantine: separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick.
• Isolation: separates sick people with a contagious disease from people who are not sick

Federal Law allows for quarantine and isolation:

• From the Commerce Clause of the U.S. Constitution
• Delegated to the Centers for Disease Control (CDC) by the U.S. Secretary of Health and Human Services
  • The CDC is "authorized to detain, medically examine, and release persons arriving into the United States and traveling between states who are suspected of carrying these communicable diseases."
• The CDC may issue a federal isolation or quarantine order
  • Last large scale use was during the influenza pandemic of 1918-1919
• Breaking of a federal quarantine order is punishable by fines and imprisonment

State laws allows for the enforcement of isolation and quarantine within their borders.

Bottom Line:

• There have been no large-scale quarantine or isolation orders for 100 years. However, the CDC can issue an order that has the authority of the Constitution and federal law for enforcement.

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INFLUENZA

What is it?

• Common disease that causes significant morbidity and mortality worldwide
  • Both seasonal and pandemic influenza occurs
  • Vaccination can decrease disease incidence and spread
  • Treatment can decrease disease severity
• Orthomyxoviruses (RNA virus)
  • 6 genera

Why do we care about influenza?

• Pandemic Influenza
  • Can infect and kill young, healthy people
  • 1918 H1N1 Influenza pandemic infected an estimated 500 million globally
    • Approximately 20% of the world’s population
  • Killed an estimated 50 million (may be as high as 100 million)
    • 2%-3% of the world’s population died

• Seasonal Influenza
  • Most often causes severe disease in the very young, very old, and those with chronic illnesses
  • Estimated between 3-5 million cases of severe illness around the world annually
  • Between 250,000 and 500,000 deaths

Bottom line

• Influenza is a potentially life threatening disease.
• Both seasonal and pandemic influenza are global concerns.
• Morbidity and mortality can be decreased through appropriate vaccination and treatment

While sitting on an international flight, ever wonder what your risks are for a blood clot?

General Background:

It is estimated that the risk for a deep venous thrombosis (DVT) is 3-12% on a long-haul flight. However, the real incidence is difficult to evaluate, due in part to the lack of consensus about 1) diagnostic tests, and 2) the appropriate time frame to relate a venous thromboembolic event (VTE) to travel.

Risks Factors for VTEs on long-haul flights:

• General:
  • stasis: prolonged sitting & crowded conditions
  • relative hypoxia
  • dehydration

• Patient specific:
  • Age >40
  • Female gender
  • Use of estrogen-containing contraceptives/hormone replacement therapy
  • Obesity
  • Varicose veins in the legs
  • Family/personal history of prior VTEs
  • Active cancer/recent cancer treatment

Bottom Line:

• Even healthy individuals are at risk on long-haul (>8 hour) flights.
• The risk increases the longer the flight
• Current data does not appear to show a risk difference between economy and business class.
• Avoid dehydration and immobility
  • Exercise your legs/calf muscles
  • Drink plenty of fluid

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Hyperthermia can be defined as a core body temperature > 38.5ºC. In contrast to fever, the body’s temperature rises uncontrollably and the body is not able to dissipate the heat. There can be many causes of hyperthermia, including from environmental exposure. 

There are two main environmental heat illnesses, heat exhaustion and heat stroke.

Heat exhaustion:

• Vague malaise, fatigue, headache
• Core temperature may be normal or elevated (below 40ºC)  
• May have tachycardia, orthostatic hypotension, clinical dehydration
• Liver function tests (transaminases) may be normal or elevated
• IMPORTANT- there is no altered mental status (i.e.: no coma or seizures)

Heat stroke

• Usually tachycardia, orthostatic hypotension, clinical dehydration
• May have hot, dry skin, but not always
• Liver function tests (transaminases) are markedly elevated
• May have rhabdomyolysis and renal failure
• IMPORTANT- Signs of altered mental status (i.e.: coma, seizure, delirium)
• Mortality may be up to 33%

Bottom line:

• Heat stroke is a life threatening emergency.
  • Early recognition and rapid appropriate therapy can save a life
• The most effective cooling is evaporative cooling along with ice packs

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General Background:

Heat transfer is important to understand, especially when evaluating and treating someone who is hyperthermic or hypothermic. Are they really hot (or cold) from exposure, or is there an underlying metabolic or toxicological cause?

Mechanisms of Heat Transfer:

There are 4 main methods of heat transfer:

• Radiation
  • Transfer of thermal energy through space by electromagnetic waves
  • Dependent on exposed surface area
  • Normally about 60% of heat loss
• Conduction
  • Transfer of thermal energy through direct physical contact
  • Depends on conductivity of the surface (stone floors > water > air)
  • Can cause significant hypothermia for someone who is down for an extended period on a stone floor
• Evaporation
  • Transfer of thermal energy through converting liquid to a gas
  • Occurs through perspiration and respiration
  • Can lead to dehydration
• Convection
  • Transfer of thermal energy through movement of air or liquid across an object
  • Rate of heat loss depends on temperature gradient, density and velocity of moving substance
  • Can lead to extreme heat loss, especially when combined with evaporation (wet clothes on a cold, windy day)

Bottom line:

When evaluation someone for hyper- or hypothermia from a potential environmental exposure, be sure to obtain the history about where they were found and the circumstances in which they were found. This can help you develop your diagnostic differential.

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General Information:

Hypothermia is when the body’s core temperature is less than 35º C. Often thought as a winter disease, it can occur in nearly any climate or weather condition. However, a number of cold related conditions can occur without a drop in core body temperature.

Specific Cold Related Conditions:

• Frostnip
  • Condition: Ice crystal deposited in the dermis
  • Exposure: Freezing, damp exposure over hours to days
  • Treatment: Warm water (37º-41ºC) immersion with movement of affected area for 15-30 minutes

• Frostbite
  • Condition: Frozen skin surface with damage to dermis and deeper structures
  • Exposure: Freezing, damp exposure over hours to days
  • Treatment: Warm water (37º-41ºC) immersion with movement of affected area for 15-30 minutes

• Trench foot
  • Condition: Tissue necrosis without freezing
  • Exposure: Cold water exposure for hours to days
  • Treatment: Warm water (37º-41ºC) immersion with movement of affected area for 15-30 minutes

• Chillblains
  • Condition: Epidermis repeatedly partially frozen and thawed
  • Exposure: Chronic cold, dry wind exposure over weeks
  • Treatment: Calcium-channel blockers can provide pain relief and decrease necrosis

Bottom line:

Remember that cold related injuries can occur without core hypothermia. Don’t forget the tetanus and antibiotics, as indicated.

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General Information:

Ebola is a deadly hemorrhagic fever of the virus family Filoviridae. 

• The largest outbreak known is currently affecting multiple countries in West Africa (especially Guinea, Liberia and Sierra Leone).
• As of July 23^rd, the WHO has recorded a total of 1,201 cases and 672 deaths (case fatality rate of 56%).

Clinical Information:

• Spread by close contact (direct contact with body fluids)
  • Primarily seen in family members of those infected and health care workers
• Incubation is usually from 8-10 days (can be from 2-21 days)
• Typical signs and symptoms include: fever, headaches, muscle/joint aches, abdominal pain, vomiting, diarrhea
• Additionally, some patients may experience: rash, red eyes, chest pain, difficulty breathing, difficulty swallowing, bleeding from multiple areas

Treatment and Public Health

• Supportive care and treatment of complications
• Contact isolation
• Immediately report to the local health authorities

Bottom Line:

            While the likelihood of general dissemination to the general U.S. population is very low, U.S. healthcare workers need to be aware and alert for the signs and symptoms of Ebola for patients recently returned from West Africa.

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·      Smallpox (Variola):

o   Only eradicated human infectious disease. 

o   Prior to the advent of vaccination, it killed an estimated 400,000 Europeans annually and was a major cause of blindness.

·      Major potential as a bioterrorism agent:  

o   Now only supposed to exist in two laboratories in the world (at the CDC in Atlanta, Georgia and in the Vector Institute in Koltsovo, Russia).

·      Recently, previously unknown vials of active virus from the 1950s were found in a NIH laboratory in Maryland.

·      Clinical Presentation:

o   Incubation is usually 10-12 days (range 7-17 days)

o   Signs and symptoms include:

§  Febrile (38.8-40.0C) prodome lasting 1-4 days, headache, myalgia (esp. back/spinal pain), pharyngitis, chills, abdominal pain

§  Rash: classically round and well circumscribed.  May be confluent or umbilicated. The rash evolves slowly: macules to papules to pustules to scabs.

·      It is important to differentiate smallpox from chicken pox (Varicella): 

o   Smallpox: Significant prodrome. Centrifugal rash (trunk to extremities). Can involve soles and palms. Lesions are in the same stage of development on any one part of the body.

o   Chickenpox: Minimal prodrome. Centripetal rash (extremities to trunk). Seldom on soles and palms. Asynchronus evolution of rash.

Bottom Line:

Smallpox is a global public health emergency and requires immediate reporting.  If the clinical presentation is unclear, discuss with local infectious disease experts or public health officials.

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