UMEM Educational Pearls

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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The morbidity and mortality from pseudomonas aeruginosa infections is high and empiric double-antibiotic coverage (DAC) is sometimes given; quality evidence for this practice is lacking.

Although there is little supporting data, the following reasons have been given for DAC:

• DAC provides better empiric coverage through differing mechanisms of antibiotic action
• DAC prevents the emergence of antibiotic resistance during therapy

The potential harm of antibiotic overuse cannot be ignored, however, and include adverse reaction, microbial resistance, risk of super-infection with other organisms (e.g., Clostridium difficile), and cost.

There may be a signal in the literature demonstrating a survival benefit when using DAC for patients with shock, hospital-associated pneumonia, or neutropenia. The IDSA guidelines, however, do not support DAC for neutropenia alone; only with neutropenia plus pneumonia or gram-negative bacteremia.

Bottom line: Little data supports the routine use of DAC in presumed pseudomonal infection. It may be considered in patients with shock, hospital-associated pneumonia, or neutropenia (+/- pneumonia), but consult your hospital’s antibiogram or ID consultant for local practices.

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Question

Patient with a history of osteogenesis imperfecta presents with right lateral chest pain following a sneeze. The ultrasound of his chest is shown (hint: arrow points to a rib). What's the diagnosis? 

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Metoprolol Usage Cardioprotective

• Intravenous (IV) metoprolol is sparingly used in STEMI given concern about precipitation of cardiogenic shock (COMMIT/CCS-2 Trial)
• A recent study (n=220) looked at usage of IV metoprolol versus controls in patients with STEMI and a killip class II or less prior to primary PCI
• MRI was preformed 5-7 days after STEMI revealing reduced infarct size and increased left ventricular ejection fraction in the IV metoprolol group
• IV beta-blockade appears cardioprotective in those with a low killip score and should be considered prior to primary PCI in certain subgroups  

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JNC8 (the Eigth Joint National Commission) released their recommendations for blood pressure management this week. The full article as published in JAMA can be found at http://jama.jamanetwork.com/article.aspx?articleid=1791497

Highlights from this report are

• Older adults do not need to be placed on antihypertensive medications unless their SBP > 150 or DBP > 90. 
• Younger patients should still be started if their SBP > 140 or DBP > 90.
• Firstline drug treatment recommendations are:
  • Non-black patients: start with thiazide diuretics, calcium channel blockers, angiotension converting enzyme (ACE) inhibitors, or angiotension-receptor blockers (ARBs).
  • For black patients start with thiazide diuretics or calcium channel blockers.
  • Patients with chronic kidney disease should be on an ACE or ARB.

General Pearl:  Remember to be cautious in acutely lowering the blood pressure in asymptomatic patients.  Acute lowerings can cause watershed ischemia leading to strokes.
 

A new drug is coming onto the drug scene with some case reports beginning to build. The internet appears to have been a major driver or mode of distribution for this particular drug.

One study of users showed that this ketamine analog has more vivid hallucinations that would liken it to LSD. It has been theorized that this drug has the dissociative effects of ketamine but also has prominent serotninergic effects making additions more likely and hallucinations possible.

If you see a case in your ED, you can say you heard it here first!

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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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Hepatic Encephalopathy (HE)

Pathogenesis: Several theories exist that include accumulation of ammonia from the gut because of impaired hepatic clearance that can lead to accumulation of glutamine in brain astrocytes leading to swelling in patients with hepatic insufficiency from acute liver failure or cirrhosis.

Clinical Features:

• Impaired mental status
• impaired neuromotor function (hyperreflexia, hypertonicity, asterixis)
• Subtle signs include personality changes, decreased energy level, and impaired sleep-wake cycle

Diagnostic tests: Ammonia levels are routinely drawn but must be drawn correctly without the use of a tourniquet, transported on ice, and analyzed within 20 minutes to get an accurate result. Severity of HE does not correlate with increasing levels.

Management:

1.     Airway protection as needed

2.     Correct precipitating factors (GI bleed, infection-SBP, hypovolemia, renal failure)

3.     Consider neuro-imaging if new focal neurologic findings are found on exam

4.     Correct electrolyte imbalances

5.     Lactulose by mouth (PO/Naso-gastric tube or Rectally)

a.     10-30 g every 1-2 hours until bowel movement or lactulose enema (300 mL in 1 L water)

b.     Facilitates conversion of NH3 to NH4+, decreases survival of urease-producing bacteria in the gut

6.     Rifaximin 550 mg by mouth BID (minimally absorbed antibiotic with broad-spectrum activity)

7.     Do not limit protein intake acutely

8.     TIPS reduction in certain patients with recurrent HE

9.     Transplant referral as needed

10.  Consider other causes if patient does not improve within 24-48hrs. 

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Question

46 year-old female found unresponsive at a party. EMS transports the patient in cardiac arrest. A parasternal-long axis view of the heart is obtained during the pulse check. What's the diagnosis?

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Treating knee osteoarthritis - from the American College of Rheumatology 

Exercise whether it be aquatic, aerobic (land -based) or resistance can decrease pain and improve functional capacity. Exercise should be performed 3 to 5 times a week. Effects are usually noted after 3 to 6 months.

Weight loss of 5% or greater body weight is associated with a small improvement in pain and physical function. The main benefit of weight loss has more to do to effects on co-morbid conditions.

Walking aids: A single crutch or cane should be held on the side contralateral to the affected knee and should be advanced with the affected limb when walking to reduce the load on the affected joint. 

Cane sizing: The distance from the floor to the patient's greater trochanter (brings the elbow to 15º to 20º of flexion.

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• Significant morbidity and mortality has been consistently documented in pediatric sickle cell patients due to overwhelming sepsis from encapsulated organisms, especially S. pneumoniae
• All pediatric sickle cell patients presenting with fevers greater than 101.5F (38.6C) should receive antibiotics within 60 minutes of triage.
• Historically, and still in many pediatric sickle cell centers, ceftriaxone (75mg/kg/dose) is administered
• However, reported cases of deadly intravascular hemolysis in pediatric sickle cell patients whom had recieved multiple doses of ceftriaxone has led to new recommendations for antibiotic coverage to include cefuroxime (200mg/kg/day) or ampicillin/sulbactam (200mg/kg/day)

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Can acetaminophen concentrations < 100 mcg/mL obtained between 1-4 hours after acute ingestion accurately predict a nontoxic 4-hour concentration? NO!

Despite a high negative predictive value, a new study found there are still cases with toxic concentrations after 4 hours despite earlier levels < 100 mcg/mL. 

The Rumack-Matthew nomogram is to be utilized starting at 4 hours after an acute acetaminophen ingestion. Unless the concentration is zero, a second level must be drawn at 4 hours if an earlier one is positive.

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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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The Concentrated Overview of Resuscitative Efforts (CORE) Scan

• Ultrasound has become an essential tool in the evaluation and management of the crashing patient.
• The CORE scan utilizes emergency bedside ultrasonography to systematically evaluate and resuscitate the rapidly deteriorating patient.
• Essentially steps in the CORE scan include:
  • Endotracheal tube assessment
  • Lung assessment
    • Pneumothorax?
    • Pleural effusion?
    • Hemothorax?
  • Cardiac assessment
    • Pericardial effusion?
    • Massive PE?
    • Estimated ejection fraction?
  • Aorta assessment
    • Abdominal aortic aneurysm?
    • Aortic dissection?
  • IVC assessment
  • Abdominal assessment
    • Intraperitoneal fluid?

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Question

37 year-old male presents with cough and a fever. What's the diagnosis and name three risk factors assiciated with disease?

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Attachments

• 1312081410_International_Journal_of_Cardiology_2013_Backus.pdf (371 Kb)
• 1312081419_Neth_Heart_J_2008_Six.pdf (144 Kb)

In a potentially ground breaking study of healthcare-associated pneumonia (HCAP) patients, atypical pathogens were identified in 10% of cases!

Application to clinical practice: Add atypical coverage with a macrolide or respiratory fluoroquinolone for HCAP patients who have been in the community for any length of time.

The study also identified HCAP patients who may not require 3 'big gun' broad-spectrum antibiotics. This is a practice changing article for ED providers. For more analysis of the study, please note the bonus reading links below.

Bonus reading:

Dr. Emily Heil (@emilylheil) analyzes the full study in more depth at Academic Life in Emergency Medicine: http://academiclifeinem.com/new-treatment-strategy-not-so-sick-health-care-associated-pneumonia/

Dr. Ryan Radecki (@emlitofnote) critiques the study at Emergency Medicine Literature of Note: http://www.emlitofnote.com/2013/10/down-titrating-antibiotics-for-hcap.html

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It has linear, predictable pharmacokinetics, achieves maximal concentration within 1-2 hours, is 50% renally excreted, and has a half life is 9-11 hours.

Edoxaban was evaluated in a recent trial comparing warfarin in patients with atrial fibrillation.

The primary end point or first stroke or systemic pulmonary embolic event occurred in 1.5% with warfarin, compared with 1.18% in the high dose edoxaban (HR 0.79; 97.5% CI 0.63-0.99, P<0.001). In the intention to treat there were trends favoring high dose edoxaban and unfavorable trends with the lower dose.

The principal safety end point of major bleeding occurred in 3.43% with warfarin versus 2.75% with high dose edoxaban (HR 0.86; 95% CI 0.71-0.91, P<0.001). 

Bottom line: Both high dose (60 mg) and low dose (30 mg) edoxaban were non-inferior to warfarin with prevention of stroke or systemic emboli, and were associated with significantly lower rates of bleeding and death from cardiovascular causes.

Currently it is approved for use in Japan.

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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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