General Information:

14 cases of lower respiratory infection caused by a new coronavirus (not the original SARS virus, but with a similar picture) occurred in the past year.  Mortality rate of this virus is >50%.

Area of the world affected:

• Arabian Peninsula
• United Kingdom

Relevance to the US physician:

• Suspect this with a lower respiratory tract infection not responding to therapy and a travel history
• Person to person transmission possible
• Can have coinfection with influenza
• PCR testing can be done at the CDC in suspected cases

Bottom Line:

Consider this infection in patients with a lower respiratory tract infection who have traveled to or had contact with someone who traveled to the above regions in the past 10 days.

ASK ABOUT RECENT TRAVELS IN PATIENTS PRESENTING WITH SYMPTOMS OF SEVERE LOWER RESPIRATORY TRACT INFECTION!

University of Maryland Section of Global Emergency Health

Author:  Veronica Pei MD, MPH

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Extubating in the ED

• With the increasing LOS for many of our intubated critically ill ED patients, it is possible that select patients may be ready for extubation while still in the ED.
• Patients who remain intubated unnecessarily are at increased risk for pneumonia, increased hospital LOS, and increased mortality.
• To be considered for extubation, patients should meet the following criteria:
  • The condition that resulted in intubation is improved or resolved
  • Hemodynamically stable (off pressors)
  • P_aO₂/F_iO₂ > 200 with PEEP < 5 cm H₂O
• If these criteria are met, perform a spontaenous breathing trial (SBT).
  • Discontinue sedation
  • Adjust the ventilator to minimal settings: pressure support or CPAP (5 cm H₂O) or use a T-piece.
  • Perform the trial for at least 30 minutes.
  • If the patient develops a RR > 35 bpm, S_pO₂ < 90%, HR > 140 bpm, SBP > 180 mm Hg or < 90 mm Hg, or increased anxiety, the SBT ends and the patient should remain intubated.
• Before removing the endotracheal tube, be sure to assess mentation, the quantity of secretions, and strength of cough.

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Question

A 56-year-old woman with a history of psoriasis presents with fever, nausea, and painful pin-point pustules on an erythematous base. Her dermatologist recently reduced her prednisone dose. What's the diagnosis?

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Scapular fractures

• Usually the result of a significant force, because of this associated injuries are frequent and sometimes life- or limb-threatening.
• Some of the associated injuries are:
• Rib fractures
• Ipsilateral lung injuries
• Pneumothorax
• Hemothorax
• Pulmonary contusion
• Injuries to the shoulder girdle complex
• Clavicle fractures
• Shoulder dislocations with associated rotator cuff tears
• Neurovascular injuries (rare)
• Brachial plexus injuries
• Axillary artery or nerve injuries
• Subclavian artery injury
• Suprascapular nerve injury
• Vertebral compression fractures

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In 2013, the American Academy of Clinical Toxicology and European Association of Poisons Centres and Clinical Toxicologists published a second update to their position statement on gastric lavage for GI decontamination (original 1997, 1st update 2004).

• Gastric lavage should not be performed routinely, if at all, for the treatment of poisoned patients.
• Further, the evidence supporting gastric lavage as a beneficial treatment even in special situations is weak.
• In the rare instances in which gastric lavage is indicated, it should only be performed by individuals with proper training and expertise.

Bottom line: Gastric lavage generally causes more harm than good. It should not be thought of as a viable GI decontamination method.

Bonus: Dr. Leon Gussow (@poisonreview) reviews the position paper on his blog, The Poison Review, here: http://www.thepoisonreview.com/2013/02/23/gastric-lavage-fuggedaboutit/

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Case Presentation: A 31 yo Hispanic male presents to your emergency department with extensive facial abrasions and contusions from an assault 7-8 days ago, c/o difficulty swallowing for 1-2 days.   He was seen at that time in a nearby emergency department for his abrasions and contusions.

Upon examination, you find him to be irritable and restless, diaphoretic, tachycardic, and with mild neck stiffness.   Over the course of his stay in the ED, he develops generalized muscle rigidity, severe neck stiffness and opisthotonic posturing.

Clinical Question: What is the diagnosis? And what went wrong?

Answer:  This is an early presentation of generalized tetanus.

Unfortunately, little evidence exists to support any particular therapeutic intervention in tetanus. There are only nine randomized trials reported in the literature over the past 30 years. The goals of treatment include:

              .      At risk populations:

o   Elderly patients are substantially less likely than young individuals to  have adequate immunity against tetanus.

o   Immigrants from Mexico had a 67% non-protective anti-tetanus antibody (ATA) level.

o   In a pilot study 86% of Korean immigrants did not have protective ATA levels

o   Emergency physicians were less likely to adhere to the tetanus guidelines when admitting patients to the hospital.

·      Halting the toxin production: wound management and antimicrobial therapy

o   Metronidazole 500mg IV q 6-8 hrs or Penicillin-G 2-4M units IV q4-6 hrs for 7-10 days

·      Neutralization of the unbound toxin

o   Human Tetanus Immunoglobulin (HTIG): A dose of 3000 to 6000 units intramuscularly should be given ASAP

o   Since tetanus is one of the few bacterial diseases that does NOT confer immunity following recovery from acute illness, all patients with tetanus should receive FULL active immunization immediately upon diagnosis

              ·      Treatment of generalized tetanus:  this is best performed in the ICU and includes:

o   Early and aggressive airway management

o   Control of muscle spasms

o   Management of dysautonomia

o   General supportive management

Bottom Line:

o   EP’s consistently under-immunize for tetanus, especially in elderly and immigrant populations, who have a much higher risk of under-immunization.

o   Better awareness of tetanus prophylaxis recommendations is necessary, and future tetanus prophylaxis recommendations may be more effective if they are also based on demographic risk factors.

o   Emergency physicians must comply with immunization guidelines for injured patients to assure adequate protection from both tetanus and diphtheria.

University of Maryland Section of Global Emergency Health

Author: Terry Mulligan DO, MPH

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Mechanically ventilated patients can develop a condition in which air becomes trapped within the alveoli at end-expiration; this is called auto-PEEP.

Auto-peep has several adverse effects:

• Barotrauma from positive pressure trapped within the alveoli 
• Increased work of breathing
• Worsening pulmonary gas exchange
• Hemodynamic compromise secondary to increased intra-thoraic pressure

Auto-PEEP classically occurs in intubated patients with asthma or emphysema, but it may also occur in the absence of such disease. The risk of auto-PEEP is increased in patients with:

• Short expiration times (i.e., inadequate time for the evacuation of alveolar air at end-expiration)
• Bronchoconstriction
• Plugging of the bronchi (e.g., mucus or foreign body) creating a one-way valve and air-trapping

Auto-PEEP may be treated by:

• Reducing tidal volume
• Reducing the respiratory rate
• Decreasing inspiratory time
• Increasing PEEP

Patients may need to be heavily sedated to accomplish the above ventilator maneuvers.

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Question

40 year-old female requiring intubation for altered mental status. CXR is below with something under the left diaphragm. What’s the diagnosis? 

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• HIV infected patients are at higher calculated risk for CHD compared w/the general population of the same age
• HIV is known to promote atherosclerosis through mechanisms related to immune activation, chronic inflammation, coagulation disorders, and lipid disturbances
• Additionally combination anti-retroviral therapy (cART) has an affect on lipid and glucose metabolism demonstrated both in vitro and in vivo 
• The presence of an accelerated process of coronary atherosclerosis in this population is a major concern 
• Practitioners should have a high index of suspicion when confronted by young HIV patients and further data/strategies to prevent early CHD in HIV-infected patients is warranted

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Key components in the determination of return to play following concussion include assessment of 1) brain function, 2) reaction time and 3) balance testing

Balance testing has become increasingly utilized in the diagnosis and management of sports related concussion. Studies have identified temporary or permanent deficits in static and/or dynamic balance in individuals with mild-to-moderate traumatic brain injury and sports related concussion.  An example of this is the Balance Error Scoring System (BESS). Three stances are testing (narrow double-leg stance, single leg stance and a tandem stance) with the hands on the hips and eyes closed for 20 seconds. The FNL Sideline Concussion Assessment Tool utilizes a modified BESS. Example video below:

http://www.youtube.com/watch?v=xtJgv-D7IdU

• Tinea capitis (ringworm of the scalp) is caused by dermatophytic fungi
• Trichophyton tonsurans is the most common species in the US, and does NOT flouresce under Wood's lamp
• Griseofulvin (20-25mg/kg/ day orally) is the standard first-line therapy in children older than 2 years, and has a good safety profile
• Both tablet and suspension formulations are available, and it should be taken with food that are high in fat to increase drug concentrations
• NO laboratory assessment of hepatic enzymes is required during the 8-week therapy course in children who have no history or clinical examination findings concerning for liver disease.
• Topical antifungal agents are ineffective because they do not penetrate sufficiently into the hair shaft.

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--The diagnosis and treatment of pediatric urinary tract infections (UTIs) can be broken down into different age groups. The AAP has recently updated its recommendations for children age 2 - 24 months.

--In ill-appearing febrile infants age 2 – 24 months, who require early initiation of antibiotics, clinicians should obtain urinalysis and urine culture by catheterization or suprapubic aspiration prior to administration of the first dose of antibiotics.

--Key components of diagnosing a UTI include: urinalysis with the presence of pyuria (>10 WBCs per µL) and bacteriuria. The ultimate diagnosis relies on identification of >50,000 CFUs per mL of a single urinary pathogen in culture.

--Treatment of most UTIs in well appearing infants 2-24 months can be done with oral antibiotics for a course of 7-14 days. Common antibiotics used include: amoxicillin-clavulanate, trimethoprim-sulfamethoxazole, or cephalosporins (cefpodoxime, cefixime) based on local patterns of susceptibility.

--Febrile infants with UTIs should undergo renal and bladder ultrasound (RBUS) to evaluate the renal parenchyma and identify complications of UTI in children who are not responding to treatment within 48 hours.

--Voiding cystourethrography (VCUG) to diagnose vesicoureteral reflux (VUR) as a cause of UTI should not be obtained routinely, but only in children with abnormal RBUS or with recurrent febrile UTIs.

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• A recent Cochrane review examined the use of early statin therapy in patients with ACS.

• They evaluated 18 studies (14,303 patients), which compared early statin therapy (within 14 days) to placebo or usual care.

• The conclusion was that initiation of early statin therapy does not reduce death, myocardial infarction of stroke up to four months, but reduces the occurrence of unstable angina by 24% at 4 months following ACS.

• Many smaller studies previously noted benefits with early statin initiation prior to this meta-analysis.

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-A genetic autosomal recessive blood disorders that result from a defect in either the alpha (α) or Beta (β) globin chain in the hemoglobin molecule.

-Most common in people from a Mediterranean origin.

-Three types depending on the affected globin chain, α, β, or Delta (δ)

-Presents as hemolytic anemia with hepato-splenomegaly.

-Can present as mild anemia and may be misdiagnosed as iron deficiency anemia.

-Diagnosis is made through studies such as bone marrow examination, hemoglobin electrophoresis, and iron studies.

-The disease can cause hemochromatosis, which may be worsened by repeated blood transfusions.

-Hemochromatosis damages multiple organs including the Liver, spleen, endocrine glands and the heart causing cardiomyopathy and consequently heart failure.

-Severe thalassemia usually requires blood transfusion on regular basis (first measure effective in prolonging life)

-Treatment of trait cases is symptomatic with analgesics, anti-inflammatory  (steroids or NSAIDs)

-The introduction of chelating agents capable of removing excessive iron from the body has dramatically increased life expectancy.

-Deferasirox (Exjade) was approved by the FDA in January 2013 for treatment of chronic iron overload caused by nontransfusion-dependent thalassemia.

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Ventilator-associated Pneumonia

• Ventilator-associated pneumonia (VAP) is a well known complication of mechanical ventilation (MV) and is associated with increased duration of MV, hospital length of stay, and cost.
• VAP is commonly associated with multi-drug resistant organisms, including Pseudomonas, Acinetobacter, Klebsiella, and Enterobacteriaceae.
• Given the significant impact upon morbidity, a number of organizations have recommended "bundles" of care for the prevention of VAP.
• Important measures for the prevention of VAP include:
  • Strict hand hygiene
  • Head of bed elevation to 30-45 degrees
  • Closed endotracheal suctioning
  • Maintaining endotracheal tube cuff pressure > 20 cm H2O
  • Oral chlorhexidine rinses
  • Orogastric tube placement

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Question

65 year-old male with acute pulmonary edema. Ultrasound at the bedside shows this. What's the diagnosis?

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• International guidelines recommend early invasive strategy (<24hrs) for patients with NSTEMI w/high risk factors defined by a GRACE score >140
• A recent meta-analysis based on 7 RCTs & 4 observational studies demonstrated an inconclusive survival benefit with an early invasive strategy 
• Heterogeneity across multiple studies including timing of intervention, definition of MI, patients' risk profiles, major bleeding, and sample size make the interpretation of survival results difficult
• Based on the most recent data the optimal timing of intervention remains unclear and a more definite RCT is warranted to guide clinical practice

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The newest iteration of 'Guidelines for the Early Management of Patients with Acute Ischemic Stroke' was recently published. Here are the key revisions specific to blood pressure management:

• In patients with markedly elevated blood pressure who do not receive fibrinolysis, a reasonable goal is to lower blood pressure by 15% during the first 24 hours after onset of stroke. The level of blood pressure that would mandate such treatment is not known, but consensus exists that medications should be withheld unless the systolic blood pressure is >220 mmHg or the diastolic blood pressure is >120 mmHg (Class I; Level of Evidence C).
• No data are available to guide selection of medications for the lowering of blood pressure in the setting of acute ischemic stroke. Labetalol and/or nicardipine are listed as preferred, but other options can be used (Class IIa; Level of Evidence C).
• Restarting antihypertensive medications is reasonable after the first 24 hours for patients who have preexisting hypertension and are neurologically stable (Class IIa; Level of Evidence B).

If administering rtPA, blood pressure needs to be <185/110 mm Hg. That recommendation didn't change.

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Question

A foley is inserted in a fire victim patient. Urine return is in picture. Describe the reason for this colored urine.

Special Thanks to Dr. Doug Sward for the urine picture 

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