General Information:

• 50% of victims in man-made and natural disasters are children.

• In low and middle income countries (where 95% of disasters occur), children are particularly vulnerable.

• Early responders must be well versed in caring for pediatric diarrheal disease, acute respiratory tract infections, measles, malaria, severe bacterial infections, malnutrition, micronutrient deficiencies, injuries, burns and poisonings with few resources.

• Pediatric specific triage systems have been developed to aid in resource allocation during mass casualty responses.

• Pediatric patients are singularly vulnerably to exploitation, abuse and trafficking during disaster, particularly when they are separated from their families.

Area of the world affected:

• All

Bottom Line:

• Many US based emergency medicine physicians are keen to respond to international disasters.  A clear understanding about the particular risks to children during disaster response are critical in order to care for the most vulnerable of disaster victims.

University of Maryland Section of Global Emergency Health

Author: Emilie J.B. Calvello, MD, MPH

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Background

• Acute lung injury that develops within 6 hours after transfusion of 1 or more units of blood or blood components.
• Increased risk with greater number of transfusions
• Incidence is 1 in 4000

Definition

• Acute onset
• Hypoxemia (PaO2/FiO2 < 300 mm Hg)
• Bilateral pulmonary opacities on chest x-ray
• Absence of left atrial hypertension

Pathogenesis

Two-hit hypothesis: first hit is underlying patient factors causing adherence of neutrophils to the pulmonary endothelium; second hit is caused by mediators in the blood transfusion that activate the neutrophils and endothelial cells.

Differential

Can be confused or overlap with TACO or transfusion-associated volume/circulatory overload, which presents similarly but has evidence of increased BNP, CVP, pulmonary wedge pressure, and left sided heart pressures. Patients with TACO tend to improve with diuretic treatment

Supportive tests

• Echocardiogram 
• BNP (tends to be low)
• Transient leukopenia

Treatment

• Supportive care
• Lung protective ventilation strategies
• Fluid restrictive strategy
• Aspirin (shown to be helpful in animal studies)
• Pre-washing of stored RBCs prior to transfusion
• Decrease the amount of transfusions!

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Question

55 year-old male presents with chest pain. You take a look at his cardiac function with ultrasound and here's the patient's apical four-chamber view. What's in his right ventricle and why would it be there?

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Ebstein's Anomaly

• Congenital defect of the tricuspid valve (TV) and the right ventricle (RV)
• TV septal and posterior leaflets are apically displaced resulting in "atrialization" of a portion of the right ventricle (ultimately a large right atrium and small right ventricle)
• ~40-50% of individuals with Ebstein anomaly have evidence of Wolf-Parkinson-White, secondary to the atrialized right ventricle
• ECG abnormalities include:
  • Right atrial enlargement or tall and broad P waves (Himalayan P waves) 
  • Prolonged PR interval
  • Right bundle branch block 
  • Low amplitude QRS complexes in the right precordial leads
  • T wave inversions V1-V4 and/or Q waves V1-V4

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Pediatric patients with an isolated skull fracture and normal neurological exam have a low risk of neurosurgical intervention and outpatient follow up may be appropriate (assuming no suspicion of abuse and a reliable family).  In a study published in 2011, a retrospective review over a 5 year period at a level 1 trauma center showed that 1 out of 171 admitted patients with isolated skull fractures developed vomiting.  This patient had a follow up CT showing a small extra-axial hematoma that did not require intervention.  58 patients were discharged from the ED within 4 hours.

You can also check out another recent article published in Annals of Emergency Medicine on the same topic this month!

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Drugs that cause hearing loss:

Reversible - Chloroquine, erythromycin, quinine, CO, loop diuretics, NSAIDS, ASA

Irreversible - aminoglycosides, bleomycin, vincristine, vinblastine, cisplatin, lead, mercury, arsenic

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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

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There have been so many great talks at ACEP 2013, but Dr. Michael Winters' talk "The ICU is NOT Ready for Your Patient" was chock full of great critical care pearls. Here are just a few:

• Increased mortality for ICU patients boarding in the Emergency Department; the increase is 1.5% per each hour of delayed transfer.
• Intubated patients should receive analgesia BEFORE sedation; fentanyl is recommended because hemodynamically stable, but you can use anything. Good analgesia will also reduce total sedative dosing
• Use continuous capnography for the intubated patient; can detect equipment malfunction and allow titration of ventilation
• Keep an eye out for abdominal compartment syndrome. Physical exam is not always conclusive, should obtain bladder pressures
• Reduce the risk of ventilator-associated pneumonia by keeping endotracheal cuff pressures adequate and keeping the head of bed elevated 30-45 degrees

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Question

A 23 year-old male presents with the rash below. He originally presented to his primary care doctor for a sore throat and was given a prescription for a medication; this rash subsequently broke out. What's the diagnosis and which medication did he receive?

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Question

A 48 year-old female presents to the ED with progressive dyspnea and chest discomfort over the past 3 months. HR = 105, BP = 100/60 mmHg, with mild JVD on exam. Her ECG is shown below. What ECG abnormalites are present? What does your differential diagnosis include? What is the best initial diagnostic test?

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Attachments

• 1310132023_ECGs_with_small_QRS_voltages.pdf (578 Kb)
• 1310132023_Low_QRS_voltage_and_its_causes.pdf (108 Kb)

Toxicologists should be aware of non-toxicological mimics of delirium, including anti-NMDA receptor encephalitis. It is an under-recognized progressive neurological disorder caused by antibodies against NMDA receptors.

Cases often present with altered mental status, autonomic instability, increased muscle tone, and movement disorders. It can easily be mistaken for neuroleptic malignant syndrome (NMS). A new case series describes two such patients for which toxicologists were consulted.

Must read links:

Dr. Leon Gussow provides a great review of the case series on his Poison Review blog.

Dr. Chris Nickson reviews the basics of the disease on the Life in the Fast Lane blog.

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General Information:

• Salmonella: gram-negative rod-shaped bacilli

• S/S: diarrhea (often bloody), fever and abdominal cramping; Incubation: 12-24hrs, duration: 4-7d

• Generally resolves without treatment. Antibiotics prolong bacterial shedding and thus only recommended in severely ill patients (high fever, severe diarrhea/dehydration, sepsis), the very young, and the very old.

Area of the world affected:

• Worldwide, especially in developing countries

Relevance to the US physician:

• As of Oct. 7^th, 278 people infected in the most recent US outbreak, thought to be related to chicken from Foster Farms

• Many of these strains of Samonella were drug-resistant

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

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Want to improve your chances of success in the resus room?  Download a metronome app on your smartphone and set it to a rate of 100-120 beats per minute.  There are a number of cheap (usually free) metronome applications for both iOS and Android devices.

A recent review looked at the evidence behind CPR feedback devices and found:

• Compared to baseline, chest compression rates and end-tidal CO₂ improved after activation of the metronomes.

So instead of going to iTunes and downloading the Bee Gees, go over to the App store and download a free metronome.  Your resus team will be able to stay on track with their compressions and even better - they won't have to hear you sing!

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Question

25 year-old female struck in the left hand by a football. Presents with pain, visible deformity, and the Xray below. What are the next step(s) in management?

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Acute Aortic Syndromes

Classically, aortic dissection is considered the primary culprit in patients with chest pain that radiates to the back (aortic pain) or chest pain combined with ischemia (cerebral, cardiac, peripheral), syncope, or cardiac arrest. However, it should not be your only concern: the rate of aortic rupture is much higher in penetrating atheromatous ulcer (42%) and intramural hematoma (35%) than in aortic dissection (types A 7.5% and type B 4.1%).

Chest pain with concomitant ischemic symptoms and acute decompensation should prompt consideration of several etiologies under the umbrella of aortic syndromes and not limited to dissection :

1. Penetrating atheromatous ulcer - rupture of an atheromatous plaque through the internal elastic lamina, with subsequent localized medial disruption and potential dissection, pseudoaneurysm formation, or free rupture
2. Intramural hematoma - rupture of the vasa vasorum or hemorrhage within an atherosclerotic plaque followed by aortic wall infarct
3. Aortic dissection- an intimal tear with resultant propagation within the middle third of the medial layer of the aorta
4. Aneurysm leak or rupture - progressive vessel dilation and increased wall tension
5. Traumatic transection - rapid deceleration forces or direct trauma, commonly shearing distal to left subclavian artery at aortic isthmus where the aorta is fixed by ligamentum arteriosum

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Treatment of patients with HIV/AIDS can frequently mean consideration for, and need to treat cryptoccocal meningitis.

Since 1997, studies have demonstrated that high-dose Amphotericin B combined with flucytosine has improved outcomes compared to low dose treatment or monotherapy.

A recent 2013 study reiterated this approach, showing significant decrease in deaths at 70 days post-treatment and increased rates of yeast clearance with combination therapy of Amphotericin B plus flucytosine. 

Recommendation:

Antifungal treatment of cryptococcal meningitis should start with Amphotericin B at 0.7-1 mg/kg IV daily plus concurrent flucytosine 25 mg/kg orally q6 hours. Fluconazole can be substituted in place of flucytosine if it is not available or not tolerated.

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Should you be concerned about erythema around the umbilical stump?!

Yes!

Often parents will bring their neonate to the ED with concerns about the umbilical cord and it is just a simple granuloma or normal detachment. But is it omphalitis???

Omphalitis incidence is low in developed countries, but that means it’s easier, and no less catastrophic, to miss!

Omphalitis is a superficial cellulitis of the umbilical cord, but 10-16% progress to necrotizing fasciitis of the abdominal wall!!!

Always ADMIT and consider consulting surgery early in case of rapid progression…

Most often polymicrobial and should be treated with:

• Anti-staphylococcal PCN,  Vanc, & an Aminoglycoside
• Also consider adding Metronidazole or Clindamycin for anaerobic coverage
• Anti-pseudomonal coverage if toxic

Should notice improvement within 12-24 hours, so if don’t or begin to observe

• Fever
• Induration
• Peau d’orange tisse
• Tenderness
• Violaceous discoloration
• Crepitace
• Increased erythema
• Systemic signs of toxicity/shock

CONSULT SURERY for concern of necrotizing fasciitis which has a mortality rate of close to 60%!!!

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ACLS recommendation for procainamide in tachycardic rhythms is:

Loading dose 20 mg/minute (up to 50 mg/minute for more urgent situations) until:

• Arrhythmia is controlled
• Hypotension occurs
• QRS complex widens by 50% of its original width
• or total of 17 mg/kg is given

Maintenance infusion is 1 to 4 mg/min.

An easier method for dosing acute onset atrial fibrillation in stable patients was used in the Ottawa Aggressive Protocol, in which they administered 1 gm over 60 min, which was interrupted if BP < 100 mmHg; if corrected by a 250 ml IV bolus, the infusion was resumed. This was not used, however if the patient was to be admitted.

A strategy for treating stable monomorphic VT with procainamide used:

100 mg IV over 1-2 minutes, repeat as necessary until an endpoint of

• Termination of tachycardia
• Drug induced hemodynamic deterioration
• Completion of 800 mg maximal dose

If no slowing of the tachycardia occurred with a dose of 400 mg, the administration was ceased.

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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

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• The efficacy of epinephrine during out-of hospital cardiac arrest has been questioned in recent years, especially with respect to neurologic outcomes (ref#1).

• A recent study demonstrated both a survival and neurologic benefit to using epinephrine during in-hospital cardiac arrest when used in combination with vasopressin and methylprednisolone.

• Researchers in Greece randomized 268 consecutive patients with in-hospital cardiac arrest to receive either epinephrine + placebo (control group; n=138) or vasopressin, epinephrine, and methylprednisolone (intervention arm; n=130)

  • Vasopressin (20 IU) was given with epinephrine each CPR cycle for the first 5 cycles; Epinephrine was given alone thereafter (if necessary)

  • Methylprednisolone (40 mg) was only given during the first CPR cycle.

  • If there was return of spontaneous circulation (ROSC) but the patient was in shock, 300 mg of methylprednisolone was given daily for up to 7 days.

• Primary study end-points were ROSC for 20 minutes or more and survival to hospital discharge while monitoring for neurological outcome

• The results were that patients in the intervention group had a statistically significant:

  • probability of ROSC for > 20 minutes (84% vs. 66%)

  • survival with good neurological outcomes (14% vs. 5%)

  • survival if shock was present post-ROSC (21% vs. 8%)

  • better hemodynamic parameters, less organ dysfunction, and better central venous saturation levels

• Bottom-line: This study may present a promising new therapy for in-hospital cardiac arrest and should be strongly considered.

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