UMEM Educational Pearls - International EM

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

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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

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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:

• H5N1 (aka. Highly Pathogenic Avian Influenza A): Case Fatality Rate (CFR) 60%, no sustained person to person transmission, primarily in Asia and Middle East--first death in the Americas occurred in Canada last week (returned traveller from China)
• H7N9: new strain of avian influenza identified this year, 135 cases so far, CFR 33%, no sustained person to person transmission, found in China

Swine flu:

• H1N1: pandemic flu of 2009 making a comeback. causes more severe disease in young and middle-aged adults, predominant this season in the US (of subtyped virus tests ~98% were H1N1)

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

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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:

• Rabbits (often used as an analog for human S. aureus disease) were inoculated with the vaccine.
• Each rabbit then had a high dose of various strains of MSSA or MRSA introduced via the respiratory tract and were monitored for pneumonia.
• 86/88 vaccinated rabbits survived while only 1/88 non-vaccinated rabbits survived.

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

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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.

• Acute Care: all promotional, preventive, curative, rehabilitative, and palliative actions, whether oriented toward individuals or populations, whose primary purpose is to improve health and whose effectiveness depends largely on time-sensitive and frequently rapid intervention.
• Emergency Medicine: a named field of specialty practice for which formal training prepares a candidate whose competence is officially standardized and regulated (thus EM is a subset of acute care)
• Emergency services: the sum of all efforts to deliver effective health action in response to extreme risk under intense time pressure
• Emergency care: the subset of emergency services focused on delivery of curative interventions targeting severe clinical cases

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

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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:

• Infiltrate the wound and surrounding tissue RIG 20 IU/kg (if human RIG) or 40 IU/kg (if equine RIG). 
• Can be administered up to 7 days after the first vaccine. 

Vaccine:

• Several vaccine regimens are approved by the WHO. Based on the CDC guidelines, vaccination should be administered at day 0, 3, 7 and 14. 
• Had the patient received rabies immunization prior to travel, he would only need 2 vaccines should be given on days 0 and 3. 
• Thus our patient needs RIG today and 3 more vaccinations (one today and then  one at days 7 and 14)

Bottom Line:

• Travelers at highest risk are individuals visiting families in endemic areas.
• Often times, rabies IG is not available but can be administered up to 7 days after initial vaccination. 

University of Maryland Section of Global Emergency Health

Author: Jenny Reifel Saltzberg

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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:

• 95% of Polio cases are asymptomatic. (Not important clinically, but important for transmission)
  • 4-8% present with non-specific flu-like symptoms +/- nuchal rigidity
  • Only 1% have the classic syndrome of flaccid limb paralysis with decreased limb reflexes
  • Paralysis may affect respiratory muscles leading to respiratory failure and death
• Treatment is supportive, but immunization of contacts is important

Relevance to the EM Physician:

The diagnosis can be made by detecting:

• Virus in stool sample or a nasopharyngeal swap is sensitive and specific in all patients.
• Polio antibodies in the patient’s serum is sensitive and specific in symptomatic patients.

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

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• Chikungunya Virus (CHIKV): transmitted by day-biting mosquito.
• Primarily seen in Asia, sub-Saharan Africa, France, Italy, but the first cases in the Western Hemisphere (the Caribbean) were reported this week.

Clinical Presentation:

• Similar to dengue: fever, headache, muscle pain, rash, joint pain, mild bleeding dyscrasia
• Prolonged, incapacitating joint pain often seen

Diagnosis

• Based off of clinical features, travel to affected area
• ELISA available through CDC

Treatment

• Supportive: fever reducers, fluids, avoid aspirin

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:

• Pain is more intense and localized to joints and tendons in CHIKV
• Onset of fever is more acute and duration is shorter in CHIKV
• Shock or severe hemorrhage is rare in CHIKV

University of Maryland Section for Global Emergency Health

Author: Andi Tenner, MD, MPH, FACEP

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General Information:

• Separate outbreaks of meningococcal disease at two college campuses have the CDC warning clinicians to be alerted to possible disease outbreaks among contacts as college students start traveling home for the holidays.
• At Princeton University, eight cases of serogroup B meningococcal disease have been reported in the past 8 months. In addition, three undergraduate students at the University of California in Santa Barbara became ill with the disease in November. The outbreaks are caused by two distinct strains.
• CDC officials advise that meningococcal disease should be suspected when a fever and headache or rash develops in a person affiliated with one of those universities or in a person with close contact with someone from the universities.
• A serogroup B vaccine -- licensed for use abroad -- is being offered at Princeton. The currently approved U.S. meningococcal vaccine does not cover serogroup B.

Fever and headache or rash in those with close contacts from the affected universities should be considered for rapid, empiric meningococcal treatment.

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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.

• A: most common cause of meningitis in the Meningitis Belt in Sub-Saharan Africa, caused pandemics in the 1960s-1980s in Asia as well
• B, C, Y: Cause the large majority of cases in Europe and the Americas
• A, W-135: most common culprits in outbreaks of meningitis associated with the Hajj
• X: causes disease in some countries in Sub-Saharan Africa

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

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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

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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:

• Travel to the Arabian Peninsula within 14 days of symptom onset
• Close contact with a person with fever and respiratory illness within 14 days of travel to the Arabian Peninsula
• Member of a cluster of patients with severe ARI being evaluated for MERS-CoV

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

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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

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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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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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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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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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General Information:

• Injuries are responsible for 10% of all deaths worldwide.

• About 5.8 million people die from injuries worldwide every year.

• Injuries kill 32% more people around the world than malaria, tuberculosis, and HIV/AIDS combined.

• Injuries have an immeasurable impact on the families and communities affected.

• They are responsible for about 16% of all disabilities.

• Road traffic injuries are the leading cause of injury related deaths among young people, aged 15–29 years.  Available global cost estimates show that the cost of road injuries annually is about US$518 billion.

• More than 90% of deaths that result from road traffic injuries occur in low- and middle-income countries.

• Road traffic crashes cost most countries 1-2% of their Gross National Product (GNP).

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

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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

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