General Information:

• Middle East Respiratory Syndrome (MERS) is a viral illness caused by the coronavirus MERS-CoV.
• First reported as a novel species in Saudi Arabia in September 2012, it has an estimated fatality rate of 40%.
• MERS can present like a URI or can be as severe as pneumonia and ARDS.
• More than half of the laboratory-confirmed secondary cases have been associated with health care settings.

Area of the world affected:

• A second spike of cases occurred over the past few weeks in the Arabian Peninsula and has spread to Northern Africa and Europe.
• All cases outside of the Middle East involve patients that have either been to the Middle East or have been in contact with someone returning from the region.

Relevance to the US physician:

• Inbound travel to the US from the Middle East increases significantly between April and September. The WHO’s Global Alert Response recommends that countries with travelers from the Arabian Peninsula maintain a high level of vigilance.

Bottom Line:

Evaluate patients for MERS-CoV infection if they develop fever and pneumonia within 14 days after traveling to countries in or near the Middle East or if they had close contact with someone from this area.

University of Maryland Section of Global Emergency Health

Author: Walid Hammad, MB ChB

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Direct vs. video laryngoscopy in the patient with an acute TBI

Hypoxia and hypotension are considered the "lethal duo" in patients with traumatic brain injury.  In a recent randomized control trial (by our own Dr. Dale Yeatts at the Shock Trauma Center) mortality outcomes were compared between 623 consecutive patients who were intubated with either direct laryngoscopy (DL) or video laryngoscopy (VL).  Here is what they found:

1. No significant difference in mortality for all comers (Primary Outcome)
2. In the subset of patients with severe head injuries, there was:

• A significantly higher mortality in patients with TBI if VL was used
• A significantly longer intubation duration for VL (74 sec) than DL (65 sec)
• A greater incidence of low oxygen saturations of 80% or less in the VL group (27 patients) than DL (15 patients) - objectively recorded data, not self reported.

There is a reasonable amount of literature that shows hypoxia and hypotension significantly contribute to morbidity & mortality in the TBI patient, and a growing body of literature that suggests intubation with VL takes longer than DL.

Bottom Line: When choosing a method of intubation for the TBI patient, remember the "Lethal Duo" and consider direct laryngoscopy with manual inline stabilization first.

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Subcutaneous Defibrillator

- The implantable cardioverter-defibrillator (ICD) has evolved from devices through epicardial patch electrodes introduced by thoracotomy to transvenous leads advanced to the right ventricle

- Transvenous ICD (T-ICD) reduced the morbidity associated w/thoracotomy implants, however involves potential complications including: hemopericardium, hemothorax, pneumothorax, lead dislodgement, lead malfunction, device-related infection, and venous occlusion

- Subcutaneous ICD (S-ICD) offers the advantage of eliminating the need for intravenous & intracardiac leads. Clinical trials have proven its effectiveness in detecting and treating ventricular fibrillation/tachycardia; however its major disadvantage is its inability to provide bradycardia rate support and anti-tachycardia pacing to terminate ventricular tachycardia

- No study has directly compared the T-ICD & the S-ICD, however clinical data suggests that its use be considered in relatively younger patients (i.e., age <40 years), those at increased risk for bacteremia, patients with indwelling intravascular hardware at risk for endovascular infection, or in patients with compromised venous access

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Scabies is considered by the WHO to be one of the main neglected diseases with approximately 300 million cases worldwide each year. One third of cases of scabies seen by dermatologists are in kids less than 16 years old. The belief had been that presentation varies by age.  One French study reported a first time miss rate of more than 41% and an overall diagnostic delay of 62 days.
 

A prospective, multi center observational study of patients with confirmed scabies sought to determine common phenotypes in children. All patients were seen by dermatologists in France and administered standard questionnaires.  They were divided into 3 age groups, <2 years, 2-15 years and > 15 years.  323 patients were included.

The study found that: 
-infants were more likely to have facial involvement and nodules, especially on the back and axilla
-relapse was more common in < 15 year olds - this was hypothesized to be due to poor compliance with treatment to the head
-family members with itch, or planter or scalp involvement were independently associated with diagnosis of scabies in kids < 2 years
-burrows were seen in 78%, nodules in 67% and vesicles of 43% of patients (see photo)
-itching was absent in up to 10% of patients

Bottom line:  Have a high suspicion for scabies in any rash.

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Attachments

• 1404180657_scabies_figures.docx (1,793 Kb)

Caustic ingestion can potentially cause significant esophageal and/or gastric injury that can lead to significant morbidity, including death.

Endoscopy is often performed:

·      To determine the presence of caustic injury.

·      To determine the severity of caustic injury (grade: I to III).

·      Placement of orogastric or nasograstic tube for nutritional support if needed (grade IIb and III)

Evidence for predictor of esophageal injury (frequently cited) comes from mostly studies involving pediatric population and unintentional ingestion:

1.     Gaudreault et al. Pediatrics 1983;71:767-770.

o   Studied signs/symptoms: nausea, vomiting, dysphagia, refusal to drink, abdominal pain, drooling or oropharyngeal burn

o   Presence of symptoms: Grade 0/I lesion: 82%; Grade II: 18%

o   Absence of symptoms: Grade 0/I: 88%; Grade II: 12%

2.     Crain et al. Am J Dis Child. 1984;138(9):863-865

o   Presence of 2 or more (vomiting, drooling and stridor) identified all (n=7) grade II and III lesion.

o   Presence of 1 or no symptoms: no grade II/III lesions

o   Stridor alone associated with grade II/III lesions (n=2)

o   10% of patients without oropharyngeal burns had grade II/III lesions.

3.     Gorman et al. Am J Emerge Med 1990;10(3):189-194.

o   Two or more symptoms: vomiting, dysphagia, abdominal pain or oral burns

o   Sensitivity: 94%; specificity 49%

o   Positive predictive value 43% ; negative predictive value: 96%

o   Stridor alone (n=3): grade II or greater lesion

4.     Previtera et al. Pediatric Emerg Care 1990;6(3):176-178.

o   Esopheal injury in 37.5% of patients without oropharyngeal burn

o   Grade II/III injury: 8 patients

Available data suggests that there are no “good” or reliable predictors for esophageal injury.

However, high suspicion for gastrointestinal injury should be considered with GI consultation for endoscopy in the presence of

·      Stridor alone

·      Two or more sx: vomiting, drooling or stridor (Crain et al)

·      Intentional suicide attempt

General Information: 

• Mental disorders account for 7.4% of the world’s burden of disease in terms of disability-adjusted life years and nearly 25% of all years lived with disability — more than cardiovascular disease or cancer (Source: 2010 Global Burden of Disease Study)
• Suicide is a leading cause of death among young people globally
• Evidence suggests that people with mental disorders are often subject to severe human rights violations

Relevance to the US physician:

• The majority of the world’s population has no access to the pharmacologic, psychological, and social interventions that can transform lives.
• In May 2013, 194 ministers of health adopted the WHO Comprehensive Mental Health Action Plan, recognizing mental health as a global health priority.

Bottom Line:

Mental illness is an often-forgotten cause of significant morbidity worldwide. Front-line care delivered by appropriately trained and supervised community-based health workers operating in partnership with emergency physicians, primary care physicians, and mental health specialists is key to address this health crisis.

University of Maryland Section of Global Emergency Health

Author: Terrence Mulligan DO, MPH

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• Only 50% of hemodynamically unstable patients will improve their hemodynamics in response to a fluid bolus. However, because excessive fluid administration can lead to organ edema and dysfunction, it is important to give hemodynamically unstable patients only the necessary amount of fluids to improve their hemodynamics.

• There are two general categories of assessing a patient's response to volume administration; static and dynamic assessments (see referenced article below):

  • Static assessment (generally unreliable, but traditionally used):

    • Physical exam (dry mucus membranes, cool extremities, etc.)

    • Urine output

    • Blood pressure

    • Central venous pressure via central-line

  • Dynamic assessment (more reliable but more labor intensive)

    • Pulse Pressure Variation

    • IVC Distensibility Index

    • End-expiratory occlusion test

    • Passive Leg-Raise

• There is no simple way to accurately determine the need for a fluid bolus however the integration of the techniques above can help the clinician make better decisions.

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Question

25 year-old female (G1P1) presents with 3 weeks of vaginal bleeding. Her serum beta-HCG is 65,000. Her bedside ultrasound is below; what's the diagnosis? 

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Optimal out of hospital cardiac arrest (OHCA) airway management strategies remain unclear. In the US, 80% of OHCA patients receive prehospital airway management, most commonly endotracheal intubation (ETI). There is growing enthusiasm for use of supra-glottic airways (SGA) by EMS because of ease of insertion, and the thought that use of SGA reduces interruptions in chest compressions. More recently, studies have suggested improved survival without the insertion of any advanced airway device at all. 

A recent secondary analysis of OHCA outcomes in the Cardiac Arrest Registry to Enhance Survival (CARES) compared patients receiving endotracheal intubation (ETI) versus supra-glottic airway (SGA), and also patients receiving [ETI or SGA] with those receiving no advanced airway. 

Of 10,691 OHCA, 5591 received ETI, 3110 SGA, and 1929 had no advanced airway. Unadjusted neurologically-intact survival was: ETI 5.4%, SGA 5.2%, no advanced airway 18.6%. Compared with SGA, ETI achieved higher sustained ROSC, survival to hospital admission, hospital survival, and hospital discharge with good neurologic outcome. Moreover, compared with [ETI or SGA], patients who received no advanced airway attained higher survival to hospital admission, hospital survival, and hospital discharge with good neurologic outcome. 

Conclusion: In CARES, patients receiving no advanced airway exhibited superior outcomes than those receiving ETI or SGA. When an advanced airway was used, ETI was associated with improved outcomes compared to SGA.

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• Male infants are routinely given a sweet solution prior to circumcision for analgesia.
• Michelis and Hoyle recently published a great review of the possible use of sweet solutions in the ED for pediatric patients.
• Pediatric patients often undergo painful, but rather routine procedures in the ED such as IV and urinary catheter placement, venipuncture, and lumbar punctures.
• More often than not, however, they are not provided analgesia prior to these procedures.
• It is believed that repetitive early pain events lead to anxiety and other behavioral disorders while also decreasing pain tolerance.
• In children less than 12 months, consider giving a sweet solution (2mL of 24% sucrose) 2 minutes before any painful procedure.
• Multiple studies indicate decreased pain as measured by significantly reduced crying times.
• It's cheap, safe, and works!

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In a 12-week treatment course,150 alcohol-dependent patients were randomized to receive placebo, gabapentin 900 mg/day, or gabapentin 1,800 mg/day.

• The abstinence rate was 4.1% (95%CI, 1.1%-13.7%) in the placebo group, 11.1% (95%CI, 5.2%-22.2%) in the 900-mg group, and 17.0% (95%CI, 8.9%-30.1%) in the 1,800-mg group (P = .04 for linear dose effect; number needed to treat [NNT] = 8 for 1,800 mg).

• The no heavy drinking rate was 22.5% (95%CI, 13.6%-37.2%) in the placebo group, 29.6% (95%CI, 19.1%-42.8%) in the 900-mg group, and 44.7% (95%CI, 31.4%-58.8%) in the 1,800-mg group (P = .02 for linear dose effect; NNT = 5 for 1,800 mg).

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General Information:

• 5 families of RNA viruses

1. Arenaviradae – Lassa fever
2. Bunyaviradae – Crimean – Congo hemorrhagic fever (CCHF)
3. Hantavirus - Hemorrhagic Fever with Renal Syndrome (HFRS)
4. Flaviviruses – Yellow fever, Dengue
5. Filoviridae – Ebola, Marburg

• Vector transmission – humans, rodents, livestock, bush meat, mosquito, tick, contaminated feces
• Incubation of 2-14 days

Clinical Presentation:

• Mild – Mod: fever, fatigues, malaise, myalgia followed by coagulopathy (petechial rash)
• Severe: shock, coma, delirium, seizure, liver/renal failure

Diagnosis:

• Whole blood or serum can be sent to the CDC for testing (PCR, IgM/IgG, viral culture)
• Leukopenia/leukocytosis, proteinuria, thrombocytopenia, ­LFTs/PT/PTT, may see DIC

Treatment:

• Supportive
• Contact and airborne precautions
• Ribavirin – effective in patients with Lassa fever or HFRS (not approved by the FDA)
• Convalescent-phase plasma has been used with success in some patients with Argentine hemorrhagic fever
• FFP, high dose steroids has been reported to be successful in Crimean-Congo (CCHF)

Bottom Line:

• Immediate isolate patents with fever and signs of coagulopathy
• Supportive care primarily

University of Maryland Section of Global Emergency Health

Author: Veronica Pei

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How low should you go? MAP Goals in Septic Shock

Background:

• Since Rivers’ Early-Goal Directed Therapy, a MAP of 65 mm Hg was been the standard goal for blood pressure in septic shock
• Some studies have suggested a higher target may be better for patients with hypertension
• Potentially less renal failure with a higher target

The Trial:

• 776 adult patients in France; Multi-center; randomized; non-blinded
• All patients had septic shock and on vasopressors
• MAP was maintained for 5 days or when the patient was weaned off pressors
• Primary outcome: Mortality at Day 28
• High target 65-70 mm Hg vs Low target 80-85 mm Hg

Outcome:

• No significant difference in mortality at 28 days: 36.6%  (high target) vs 34% (low target) (95 %CI; 0.84 to 1.38; P=0.57)
• No significant difference at 90 days: 43.8% (high target) vs 42.3% (low target) (95% CI; 0.83 to 1.30; P=0.74)
• Incidence of newly diagnosed atrial fibrillation was higher in the high-target group
• Patients with chronic hypertension: those in the higher target group required less renal-replacement therapy
• Significant percentage of patients in the high target group did not meet goal MAP BUT the trial mirrored actual clinical practice and allowed clinicians the ability to limit blood pressure and differences in actual MAP attained in both groups was significantly different

Bottom Line:

• A MAP goal of 65 is just fine in most patients
• Patients with chronic hypertension and atherosclerosis seem to benefit (less need for renal-replacement therapies) with a higher MAP: so aim higher in these patients or monitor renal function and increase MAP goals accordingly

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Question

23 year-old female presents complaining of progressive right lower quadrant pain after doing "vigorous" pushups. CT abdomen/pelvis below. What’s the diagnosis? (Hint: it’s not appendicitis)

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Perinatally Infected HIV & Cardiovascular Disease

*Perinatally HIV-infected adolescents are susceptible to aggregate atherosclerotic cardiovascular disease risk, but few studies have quantified risk or developed a scoring system

*A recent study of perinatally HIV-infected adolescents calculated coronary artery and abdominal aorta PDAY (Pathobiological Determinants of Atherosclerosis in Youth) scores using modifiable risk factors: HTN, HLD, smoking, obesity and hyperglycemia

*Significant predictors of a high coronary arteries and abdominal aorta scores include: male sex, Hx AIDS-defining condition, long duration of ritonavir-boosted protease inhibitor, and no prior use of tenofovir

*PDAY scores may be useful in identifying high-risk youth who may benefit from early lifestyle or clinical interventions given their trend of increased aggregate atherosclerotic cardiovascular disease risk factor burden

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A new study of almost 2 million prescriptions in VA patients compared the risk of cardiovascular death or dysrhythmia in patients receiving azithromcyin, levofloxacin, and amoxicillin.

What they found

Compared with amoxicillin, azithromycin was associated with a significant increase in mortality (HR = 1.48; 95% CI, 1.05-2.09) and dysrhythmia risk (HR = 1.77; 95% CI, 1.20-2.62) on days 1 to 5, but not 6 to 10.

Levofloxacin was associated with an increased risk throughout the 10-day period. Days 1-5 mortality (HR = 2.49, 95% CI, 1.7-3.64) and serious cardiac dysrhythmia (HR = 2.43, 95% CI, 1.56-3.79). Days 6-10 mortality (HR = 1.95, 95% CI, 1.32-2.88) and dysrhythmia (HR = 1.75; 95% CI, 1.09-2.82).

Important limitations

This study did not have a comparator group of patients getting no antibiotics. Previous data suggest patients on any antibiotic (eg, penicillin) have a higher risk of death or dysrhythmia.

The supplemental index shows that patients receiving azithromycin and levofloxacin had more serious infections (eg, PNA, COPD, etc.) which may have put them at higher risk for worse outcome irrespective of antibiotic choice.

What it means

It seems azithromycin and levofloxacin may contribute to a small increase in cardiovascular mortality and dysrhythmia during their use. A previous study found this is more likely in those with existing cardiovascular disease.

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• Naloxone has technically always been able to be prescribed by physicians to individual patients.
   
• New laws however, make it acceptable for prescribers in many states to prescribe naloxone to “third parties,” e.g parents, friends, etc. of patients, with the assumption that the overdosed patient will not be capable of administering the antidote to themselves.

• Many states are offering short 10-20 minute training sessions on how bystanders can administer the reversal agent to the patient who has overdosed.

• If prescribed, it should be prescribed to the individual who completed the training, not the intended patient, and may be written for intranasal or intramuscular administration.

• Intranasal (IN) is “off label” and an approved intranasal preparation is not commercially available, but the intramuscular preparation can be prescribed along with an atomizer device. The usual IN dose is 1 mg per nostril which may be repeated in 3-5 minutes.

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Question

You are working in a clinic in Tanzania (or Baltimore, for that matter) when a 24 year old presents with this itchy rash on his feet.  What's the diagnosis and what underlying systemic condition does it indicate?

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Attachments

• 1404012249_HIV-Associated_Puritic_Papular_Eruptions.JPG (2,920 Kb)

Coagulopathies in Critical Illness - DIC

• Disseminated intravascular coagulation (DIC) is an acquired syndrome of intravascular coagulation and is commonly encountered in critically ill patients.
• Think about DIC in the critically ill patient with oozing at vascular sites (or wounds) and the following lab abnormalities:
  • Thrombocytopenia
  • Prolonged PT and aPTT
  • Decreased fibrinogen
  • Elevated fibrin split products and D-dimer
• Guidelines for the management of DIC are primarily based on expert opinion and include:
  • Treat the underlying condition (i.e., sepsis)
  • Transfuse platelets if < 50,000 per mm³
  • Transfuse FFP to maintain PT and aPTT < 1.5 times normal control
  • Transfuse cryoprecipitate to maintain fibrinogen levels > 1.5 g/L
• The use of heparin remains controversial and cannot be routinely recommended.

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Question

25 year-old female presents with the following. It seems to have occurred spontaneously and spontaneously resolves during her ED evaluation.

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