Category: International EM
Keywords: Virus, Fever, West Nile, Dengue (PubMed Search)
Posted: 1/29/2014 by Andrea Tenner, MD
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Case Presentation: A 63 year old woman from Texas with no recent international travel presents to the ED with persistent fatigue which onset a month ago and is associated with anorexia and occasional fevers and chills. She has been to her family doctor who tested her for a number of viral illnesses and was told she had West Nile virus.
Clinical Question:
What other febrile illness could this be?
Answer:
This patient had dengue. Dengue is now endemic in the US, and locally-acquired cases have been reported in Florida, Texas and Hawaii. The fatigue and anorexia are typical and can last for weeks after other symptoms have resolved.
West Nile virus testing may be falsely positive when another flavivirus is present such dengue, yellow fever or Japanese encephalitis.
Bottom Line:
Other possible illnesses like dengue should be considered in patients who have tested positive for West Nile virus.
University of Maryland Section of Global Emergency Health
Author: Jenny Reifel Saltzberg, MD, MPH
Sharp TM, et al. Fatal hemophagocytic lymphohistiocytosis associated with locally acquired dengue virus infection - New Mexico and Texas, 2012. MMWR Morb Mortal Wkly Rep. 2014 Jan 24;63(3):49-54. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6303a1.htm?s_cid=mm6303a1_w
Centers for Disease Control and Prevention. Dengue and Dengue Hemorrhagic Fever: Information for Health Care Practitioners. http://www.cdc.gov/dengue/resources/Dengue&DHF%20Information%20for%20Health%20Care%20Practitioners_2009.pdf
Category: International EM
Keywords: International, snake, venom, (PubMed Search)
Posted: 1/22/2014 by Andrea Tenner, MD
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98% of venomous snake bites in the US are due to pit vipers. Occasionally a snake bite is from an exotic venomous snake being kept as a pet. In 2005, 142 exotic poisonous snakes were reported to poison control. It can be very challenging to find antivenom for these exotic animals.
Antivenom is usually specific to a family or subfamily, so the snake must be identified. Most exotic snake owners will know the common name and possibly the scientific name of the animal.
The WHO database of venomous snakes can help with identification of the species and will list antivenom available globally.
Poison centers are essential to help locate the antivenom and assist with treatment.
Relevance to the EM Physician:
When a patient presents with an exotic snake envenomation, the WHO website below can be helpful to identify the species and possible antivenom.
http://apps.who.int/bloodproducts/snakeantivenoms/database/
University of Maryland Section of Global Emergency Health
Author: Jenny Reifel Saltzberg
C Lubich and EP Krenzelok. Exotic snakes are not always found in exotic places: how poison centres can assist emergency departments.” Emerg Med J. 2007 November; 24(11): 796–797.
Melisa W. Lai, et al. 2005 Annual Report of the American Association of Poison Control Centers’ National Poisoning and Exposure Database. Clinical Toxicology, 44:803–932, 2006
http://www.who.int/neglected_diseases/diseases/snakebites/en/index.html
Category: International EM
Keywords: influenza, China, Asia, Avian, Swine, Global (PubMed Search)
Posted: 1/12/2014 by Andrea Tenner, MD
(Emailed: 1/15/2014)
(Updated: 1/15/2014)
Click here to contact Andrea Tenner, MD
General Information:
The H’s and N’s refer to hemagglutinin and neuraminidase—two proteins on the surface of the Influenza A virus that help it attach. Here’s a quick breakdown of important emerging strains of influenza:
Avian flu:
Swine flu:
Relevance to the EM Physician:
As the frontline against the flu virus, we should know what to expect. H1N1 has predominated this flu season—so far 60% of hospitalizations occurred in patients aged 18-64, which is unusual. H7N9 is new on the scene but might be imported, and H5N1 has arrived.
Bottom Line:
Expect to see more severe illness in the 18-64 y/o age group due to H1N1. Watch for more deadly flu imports--obtain a travel history and notify the CDC of severe influenza-like illness in returned travellers.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH, FACEP
http://www.cdc.gov/flu/avianflu/h5n1-people.htm
http://www.cdc.gov/flu/weekly/summary.htm
http://www.cdc.gov/flu/avianflu/h7n9-virus.htm
Category: International EM
Keywords: MRSA, Vaccine, Staphylococcus (PubMed Search)
Posted: 1/8/2014 by Andrea Tenner, MD
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Background Information:
Infections by Staphylococcus aureus cause significant morbidity and mortality around the world, but up until now no effective vaccines have been developed. Some prior attempts at vaccination actually led to higher mortality in the vaccinated group. However, a group at University of Iowa developed a vaccine targeting S. aureus virulence factors that has shown promise in animal models.
Pertinent Study Design and Conclusions:
Bottom Line:
While not available for human use yet, this is the first promising vaccine against S. aureus infections (including MRSA). Stay tuned…
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH, FACEP
Spaulding AR, Salgado-Pabon W, Merriman JA, et al. Vaccination against Staphylococcus aureus pneumonia. J Infect Dis. First published online Dec. 19, 2013 doi:10.1093/infdis/jit823.
Category: International EM
Keywords: International, health systems, acute care, services (PubMed Search)
Posted: 12/31/2013 by Andrea Tenner, MD
(Emailed: 1/1/2014)
(Updated: 1/1/2014)
Click here to contact Andrea Tenner, MD
Background Information: While the concept of Emergency Medicine is fairly well understood in the United States, it is less clear in countries where the concept is not as well established. This has caused quite a bit of confusion and hindered progress and collaboration.
Pertinent Study Design and Conclusions: In a recent consensus conference held at SAEM several definitions were standardized.
Bottom Line:
It is imperative that the same terminology be used when discussing the delivery of care on a time-sensitive basis.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH, FACEP
Calvello EJB, Broccoli M, Risko N et al. Emergency care and health systems: consensus-based recommendations and future research priorities. Academic Emergency Medicine. 2013. 20(12): 1278-1288.
Hirshon JM, Risko N, Calvello EJ, et al. Health systems and services: the role of acute care. Bull World Health Organ. 2013. 91:386-388.
Category: International EM
Keywords: rabies, vaccine, immunoglobulin, infectious disease, international (PubMed Search)
Posted: 12/25/2013 by Andrea Tenner, MD
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Case Presentation:
A 10 year old boy presents with a dog bite sustained 3 days ago, during a family trip to India. He has no prior history of vaccination and, at the time, he was taken to a local clinic where the wound was irrigated and he received a rabies vaccine.
Clinical Question:
Now that his has come to your ED 3 days later, is there anything further to be done?
Answer:
This patient should also receive rabies immunoglobulin (RIG) and complete his post-exposure prophylaxis. Post-exposure prophylaxis is a combination of rabies vaccine and rabies immunoglobulin (RIG).
RIG:
Vaccine:
Bottom Line:
University of Maryland Section of Global Emergency Health
Author: Jenny Reifel Saltzberg
http://www.cdc.gov/rabies/index.html
Gautret P, Shaw M, Gazin P, et al. Rabies postexposure prophylaxis in returned injured travelers from France, Australia, and New Zealand: a retrospective study. J Travel Med. 2008 Jan-Feb;15(1):25-30.
Hatz CF, Kuenzli E, Funk M. Rabies: relevance, prevention, and management in travel medicine. Infect Dis Clin North Am. 2012 Sep;26(3):739-53.
Category: International EM
Keywords: Polio, Viral, Infectious, Outbreak (PubMed Search)
Posted: 12/18/2013 by Andrea Tenner, MD
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In November 2013, the CDC issued multiple Alerts on various polio outbreaks in Asia and Africa. Countries currently with the heaviest burden are Syria, Pakistan, Somalia, Kenya, and Cameroon. Nigeria and Afghanistan have also had persistent epidemics.
General Information:
Relevance to the EM Physician:
The diagnosis can be made by detecting:
The CSF analysis results will resemble that of aseptic meningitis.
Bottom Line:
Have a high suspicion for travellers to affected regions and recognize the high prevalence of asymptomatic infection (and thus importable epidemic potential). Pre-travel vaccination is essential.
University of Maryland Section of Global Emergency Health
Author: Walid Hammad, MB ChB
McFee RB. Polio. Dis Mon. 2013 Dec;59(12):445-7. doi:10.1016/j.disamonth
Center for disease control and prevention, Travellers health http://wwwnc.cdc.gov/travel/
Category: International EM
Keywords: Chikungunya, Virus, International, (PubMed Search)
Posted: 12/11/2013 by Andrea Tenner, MD
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Clinical Presentation:
Diagnosis
Treatment
Bottom line:
Chikungunya virus can cause symptoms similar to dengue fever but is not as deadly. This week the first cases of CHIKV were reported in the Caribbean. Consider this in travelers returning from endemic areas.
Distinguishing features:
University of Maryland Section for Global Emergency Health
Author: Andi Tenner, MD, MPH, FACEP
http://www.cdc.gov/chikungunya/pdfs/CHIKV_Clinicians.pdf
http://www.thedailyherald.com/index.php?option=com_content&view=article&id=44572
Category: International EM
Keywords: Vaccine, Meningitis, Neisseria meningitidis, Outbreak (PubMed Search)
Posted: 12/4/2013 by Andrea Tenner, MD
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General Information:
Fever and headache or rash in those with close contacts from the affected universities should be considered for rapid, empiric meningococcal treatment.
CDC Health Alert Network, Nov. 27, 2013 http://emergency.cdc.gov/HAN/han00357.asp
Category: International EM
Keywords: Pediatric, Trauma, Ultrasound, Abdomen, International (PubMed Search)
Posted: 11/27/2013 by Andrea Tenner, MD
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Bottom Line: In a stable pediatric abdominal trauma victim, combined FAST and LFT results are an effective screening tool to evaluate for intra-abdominal injury.
Kenefake et al, Pediatric Emergency Medicine Nuances in Pediatric Truama. Emergency Medicine Clinics of North America, August 2013, 31;3:627-652
Krug E. Injury: a leading cause of the global burden of disease. Geneva: World Health Organization; 1999 (WHO/HSC/PVI/99.11).
Retzlaff et al, Is sonography reliable for the diagnosis of pediatric blunt abdominal trauma. J of Ped Surg 2010; 45: 912-915
Sola et al, Pediatric FAST and Elevated Liver Transaminases: An Effective Screening Tool in Blunt Abdominal Truama. J of Surgical Research 2009; 157;1: 103-107
Category: International EM
Keywords: meningoccocus, Neisseria meningitidis, global, infectious disease (PubMed Search)
Posted: 11/20/2013 by Andrea Tenner, MD
(Updated: 8/14/2024)
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General Information:
Nisseria meningitidis is the common culprit in epidemic meningitis. Serogroup B is currently causing an outbreak on the Princeton campus. So what are the serogroups and why are they important?
Six main serogroups cause disease: A, B, C, Y, X, W-135.
Two quadrivalent vaccines are currently licensed in the US that cover Serogroups A, C, Y, and W-135.
Relevance to the EM Physician: The currently available vaccines in the US cover the majority of serogroups of meningococcus, however, Serogroup B (currently causing an outbreak at Princeton) is not covered, nor is Serogroup X (for travelers to Sub-Saharan Africa).
Bottom Line: Serogroups B and X are not covered by the currently available vaccines in the US and at risk populations (and physicians treating those patients) should be made aware of the gap in coverage. Investigations for a vaccine for Serogroup B (licensed in Europe and Australia, but not in the US) are currently underway.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH, FACEP
Cohn A, MacNeil JR. Chapter 3: Infectious Diseases Related to Travel: Meningitis. Centers for Disease Control Yellow Book. 2014. Accessed at: http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-3-infectious-diseases-related-to-travel/meningococcal-disease on 20 Nov 2013.
Harrison LH. The Epidemiology of Meningococcal Disease in the United States. Clin Infect Dis. 2010 March 1; 50(S2):S37.
Meningococcal Disease in Other Countries. Center for Disease Control. Accessed at: http://www.cdc.gov/meningococcal/global.html on 20 Nov 2013.
National Travel Health Network and Centre. Meningitis Fact Sheet. Accessed at: http://www.nathnac.org/pro/factsheets/meningococcal.htm on 20 Nov 2013.
Category: International EM
Keywords: Air transport, trauma, EMS (PubMed Search)
Posted: 11/13/2013 by Andrea Tenner, MD
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Helicopter EMS (HEMS) has rapidly grown over the past 30 years. HEMS is frequently used to transport trauma patients from the scene of a crash. The question is: for which trauma patients is HEMS most useful?
A recent article published in the Journal of the American Medical Association, based upon data from the National Trauma Data Bank (NTDB), looked at injured patients transported to a trauma center by helicopter versus ground ambulance. It showed that, after controlling for multiple known confounders, more severely injured patients had better outcomes when transported by helicopter than when transported by ground ambulances. Another recent article in the Journal of Trauma and Acute Care Surgery, again based upon the NTDB further showed that HEMS survival benefit seems to limited to individuals with physiologic instability.
Bottom Line:
Transport of severely injured trauma patients by helicopter versus ground from the scene of injury to a trauma center improved patient outcomes and decreased mortality. Transportation of stable, less injured patients by helicopter may actually worsen outcomes.
University of Maryland Section of Global Emergency Health
Author: Jon Mark Hirshon
Galvagno SM,Jr, Haut ER, Zafar SN, et al. Association between helicopter vs ground emergency medical services and survival for adults with major trauma. JAMA 2012;307:1602-10.
Ryb GE, Dischinger P, Cooper C, Kufera JA. Does helicopter transport improve outcomes independently of emergency medical system time? J Trauma Acute Care Surg. 2013 Jan;74(1):149-54.
Category: International EM
Keywords: MERS-CoV, Viral Illness, Respiratory (PubMed Search)
Posted: 11/6/2013 by Andrea Tenner, MD
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Case Presentation:
A 56y/o man with diabetes presents with fever, cough, and diarrhea x 2 days.
V/S: T:38.7 BP:165/88 P: 105 R:24 O2 sat:91% on room air
CXR: left lower lobe infiltrate.
On further history you learn he has just returned from visiting family in Saudi Arabia 7 days ago. While there, he visited a cousin that was ill.
Clinical Question:
Should this patient be isolated for Middle Eastern Respiratory Syndrome – Corona Virus (MERS-CoV)?
Answer:
Yes, there are 150 cases to date and 64 have died. None confirmed in the US yet but 6 confirmed in Europe.
Patients who should be isolated in an airborne iso room with N95 mask use (similar to TB) are:
Patients with fever + pneumonia/ARDS AND one of the following:
Bottom Line:
In patients with febrile respiratory illness requiring hospitalization and recent travel to the Arabian Peninsula: isolate for MERS-CoV and contact the health department.
University of Maryland Section of Global Emergency Health
Author: Jenny Reifel Saltzberg
Assiri A, et al. Epidemiological, demographic, and clinical characteristics of 47 cases of Middle East respiratory syndrome coronavirus disease from Saudi Arabia: a descriptive study. Lancet Infect Dis. 2013 Sep;13(9):752-61.
Category: International EM
Keywords: international, EPTB, extrapulmonary, tuberculosis, ultrasound (PubMed Search)
Posted: 10/30/2013 by Andrea Tenner, MD
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Case Presentation: 28 year old woman from South Africa presents with 5 days of body weakness, nausea, vomiting and cough. BP 86/38, HR 142, RR 36, Temp 101.4 (oral) Sats 96% on RA. PMH: HIV+ last CD4=33, on HAART, history of pulmonary TB which was treated 2 years ago.
Clinical Question: The CT scanner, Xray and labs are down. What work-up can you do to best manage this patient?
Answer: The FASH Exam (Focused Assessment with Sonography for TB-HIV)
Technique: 6 probe positions--Similar to the FAST exam but with additional evaluation of the liver, the aorta, the spleen, as well as evaluation for pleural effusions over the diaphragm.
Evaluate for extrapulmonary TB (EPTB):
-Pericardial/Pleural effusion and ascites
-Periportal/para-aortic lymph nodes
-Focal liver and spleen lesions
(Go to http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3554543/ to view images of probe position.)
Bottom Line: The FASH exam can be taught to physicians with limited to no ultrasound experience. If there is concern for EPTB in an undifferentiated hypotensive patient, the FASH exam can performed in the emergency setting and treatment can be started.
University of Maryland Section of Global Emergency Health
Author: Laura Diegelmann, MD RDMS
Category: International EM
Keywords: Pediatrics, Disaster (PubMed Search)
Posted: 10/23/2013 by Andrea Tenner, MD
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General Information:
Area of the world affected:
Bottom Line:
University of Maryland Section of Global Emergency Health
Author: Emilie J.B. Calvello, MD, MPH
Rothstein, D. Pediatric Care in Disasters. Pediatrics. 2013, 132;25.
Category: International EM
Keywords: trachoma, international, blindness, infection (PubMed Search)
Posted: 10/16/2013 by Andrea Tenner, MD
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General Information:
Trachoma is the leading cause of preventable blindness caused by an infectious disease. It is spread by direct contact with people, objects, or flies carrying Chlamydia trachomatis. Blindness occurs due to corneal scarring with repeated infections (severe scaring of the eyelid-->eyelid inversion-->repeated corneal abrasions).
Clinical Presentation:
-Mild: Hypopigmented follicles on the inner eyelid; Moderate: inner eyelid scarring/eyelash inversion; Severe: corneal scarring/blindness (irreversible)
Diagnosis:
- Clinical: eyelid eversion and careful examination looking for the above
Treatment:
- Azithromycin 20mg/kg ONE TIME DOSE (preferred)
- 1% Tetracycline ointment bid x6 weeks
- If scarring or eyelid inversion is present, surgery is needed.
Bottom Line:
Trachoma is a clinical diagnosis and easy to treat early with a single dose of antibiotics. Patients with late findings should be referred for surgery.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH, FACEP
Trachoma control: a guide for programme managers. World Health Organization. 2006. Accessed on 16 Oct 2013 at: http://www.who.int/blindness/publications/tcm%20who_pbd_get_06_1.pdf
Category: International EM
Keywords: Salmonellosis, Infectious disease, diarrhea (PubMed Search)
Posted: 10/9/2013 by Andrea Tenner, MD
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General Information:
Area of the world affected:
Relevance to the US physician:
Bottom Line:
Suspect Salmonellosis in patients with appropriate exposure and symptoms, give supportive care for most, only give antibiotics to severely ill patients after sending blood and stool culture and sensitivities.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH
http://www.cdc.gov/salmonella/heidelberg-10-13/index.html
Category: International EM
Keywords: Malaria, Pediatrics, Quinine, Drug Reaction (PubMed Search)
Posted: 10/2/2013 by Andrea Tenner, MD
Click here to contact Andrea Tenner, MD
Case Presentation:
You are working in an ED in Houston when a 2 year old girl presents with fever for one day and decreased po intake. On arrival her temp=103, HR=180, and RR=50 SaO2=100%. She was born in the US and is up to date on all of her vaccinations, but has just returned from a trip to Liberia where she was visiting her extended family and received multiple mosquito bites. Physical exam, CXR and urinalysis are otherwise unremarkable and you suspect malaria, based on her history. You start quinine IV while you are waiting for the smear when suddenly the child becomes unresponsive.
Clinical Question:
What is the next investigation you should perform?
Answer:
Rapid blood glucose!
This patient has at least 4 reasons to be hypoglycemic:
1. fasting (Kids can become hypoglycemic from fasting alone in ~24hrs)
2. infection (any infectious disease can cause it, esp in kids <3 yrs old)
3. malaria (thought to be due in part to increased consumption by parasite)
4. quinine (stimulates insulin release)
Bottom Line:
Kids can become hypoglycemic fast—check a blood glucose in all pre-pubertal sick children.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH
Zijlmans WCWR et al. Glucose metabolism in children: influence of age, fasting, and infectious diseases. Metabolism Clinical and Experimental. 2009. 58:1356-1365.
Category: International EM
Keywords: Trauma, Global, MVA (PubMed Search)
Posted: 9/25/2013 by Andrea Tenner, MD
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General Information:
Relevance to the EM Physician:
Although road traffic injury deaths have decreased in some high-income countries, by 2030 it is predicted that they will be the fifth leading cause of death worldwide, and the seventh leading cause of Disability Adjusted Life Years (DALY) lost.
Bottom Line:
Developing trauma and acute care capacities in low and middle-income countries is of utmost importance to mitigate the global burden of injuries.
University of Maryland Section of Global Emergency Health
Author: Walid Hammad, MB ChB
World Health Organization, Global status report on road safety, 2013
World Health Organization, Injuries Violence The Facts, 2010
Category: International EM
Posted: 9/18/2013 by Walid Hammad, MD, MBChB
Click here to contact Walid Hammad, MD, MBChB
General Information:
· The coming of the Affordable Care Act (ACA) is designed to shift patient care from episodic encounters to continuous community based partnerships.
· Elsewhere in the world, community health workers (CHWs) have been used effectively to improve health outcomes, reduce heath care costs and create jobs in infectious disease (TB, HIV), maternal child health and chronic disease management.
· CHWs are paid, full time lay provider members of community health systems.
o Sub-Saharan Africa is training, deploying and integrating one million CHWs into the health system via a targeted campaign.
o Brazil’s CHWs are part of family health teams that care for 110 million people.
o India employs 600,000 CHWs paid through a fee-for-service system for primary care functions.
· CHWs cost less, reduce readmissions and help address root causes of preventable chronic disease while remaining embedded in the community helping to strengthen long-term community relationships.
Relevance to the EM Physician:
As frustration with non-compliant patients mounts and the impact of the ACA looms, CHWs integrated into American communities may be just the answer we haven’t yet considered to help reduce ED overcrowding and improve our patients’ outcomes.
University of Maryland Section of Global Emergency Health
Author: Emilie J.B. Calvello, MD, MPH
Singh,P. Chokshi, D. Community Health Workers – A Local Solution to a Global Problem. NEJM. 2013, 369: 894 – 896.