The two available Tetanus/reduced diphtheria toxoid/acellular pertussis (Tdap) vaccine products in the U.S. are Boostrix and Adacel. Neither were originally approved in older adults age 65 and older. Boostrix received FDA-approval for use in this age group in July 2011, but Adacel never has.
However, in June 2012 ACIP issued new guidance recommending Tdap for all adults age 65 years and older.
"When feasible, Boostrix should be used for adults aged 65 years and older; however, ACIP concluded that either vaccine administered to a person 65 years or older is immunogenic and would provide protection. A dose of either vaccine may be considered valid."
Bottom line: Regardless of which Tdap product is stocked at your institution, both are considered safe to use in adults 65 years and older.
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Rotavirus is the leading cause of gastroenteritis worldwide and a leading cause of infant death in the developing world.
95% of U.S. children have had a rotavirus infection by the age of 5 years.
Most cases occur in late winter and early spring.
Route of transmission is mostly fecal-oral but may be airborne in cooler months.
Most common presenting signs and symptoms include fever (1/3 of cases), vomiting (in the first 1-2 days), and diarrhea (copious, watery, lasting 5-21 days).
Diagnosis is largely based on clinical manifestations, but antigen assays are available and may be useful in patients with extraintestinal complications, such as hepatitis, pneumonitis, or encephalopathy.
Treatment is largely supportive with efforts to maintain hydration.
Prevention is key to disease control and accomplished with good hand hygiene and widespread vaccination.
Newly implemented vaccine programs worldwide have proven to be effective in decreasing hospitalizations and deaths in developing countries.
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Creatine
- is the most popular nutritional supplement, accounting for $400 million in sales annually
- a nonessential amino acid
- has been shown to improve performance in short, high intensity exercises, including weight lifting
Adverse effects: weight gain, edema, GI cramping, fatigue and diarrhea
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General Information:
-Leptospirosis is a tropical infectious disease that is also endemic in the US. (Estimated 16% seroprevalence in inner city Baltimore!)
-The spirochete is spread through animal urine and can survive in water or soil for weeks.
-Risk factors: rural exposure to animal urine (farming, adventure sports) or urban exposure to rat urine.
-Infection is acquired through breaks in the skin or mucus membranes
-Outbreaks are often seen following rain or floods.
Clinical Presentation:
-Non-specific febrile illness (usually not diagnosed in these cases)
-If untreated, 5-10% progress to jaundice, renal failure, thrombocytopenia, hemorrhage, and respiratory failure.
Diagnosis:
- Primarily based on clinical presentation and history
- Paired serum sent to CDC (the acute serum sample should be drawn in the ED)
Treatment:
- Doxycycline, Ceftriaxone and Penicillin are all effective
Bottom Line:
Consider and treat for Leptospirosis in patients with possible exposure animal urine (especially after a flood) who present in extremis with renal failure, jaundice, and thrombocytopenia.
University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH
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DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms) or DIHS (Drug-Induced Hypersensitivity Syndrome) is a potentially life-threatening adverse drug-reaction.
Incidence is 1/1,000 to 1/10,00 drug exposures. It occurs 2-6 weeks after the drug is first introduced, distinguishing it from other adverse drug-reactions which typically occur sooner.
The syndrome classically includes:
- Severe skin eruptions (typically morbilliform or erythrodermic eruptions)
- Hematologic abnormalities (eosinophilia or atypical lymphocytosis)
- Organ involvement; e.g., hepatic (most common), pneumonitis, renal failure, etc.
- Fevers
- Arthralgia
- Lymphadenopathy
The most commonly implicated drugs are anticonvulsants (e.g., carbamazepine, phenobarbital, and phenytoin), sulfonamides, and allopurinol.
Recovery is typically complete after discontinuing the offending drug; systemic steroids may promote resolution of the illness.
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Question
31 year-old male with recently diagnosed hypertension presents with rapid lip swelling. He started taking an unknown medication for his hypertension last week. Further history reveals that he has had prior, although milder, episodes previously. Name two medications that may help treat him.
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- Type 1: Ischemic myocardial necrosis secondary to plaque rupture (ACS)
- Type 2: Ischemic myocardial necrosis not secondary to ACS, but rather supply/demand mismatch, vasospasm, emboli, anemia, hypoperfusion, and/or arrhythmia
- Type 3: Sudden cardiac death
- Type 4a: PCI related
- Type 4b: Stent thrombosis
- Type 5: CABG related
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Metacarpal Neck Fractures (i.e.: Boxer’s Fracture if 5th Metacarpal)
Depending on the MCP joint involved a certain amount of angulation is permissible before it adversely affects normal function.
- 2nd and 3rd Metacarpal fractures < 10۫ angulation ideally these should be perfectly aligned.
- 4th Metacarpal fracture <20۫ angulation allowed
- 5th Metacarpal fracture <30۫ angulation.
- Studies have shown that even 30۫ angulation will decrease normal function by 20%.
- Normal excursion of the 5th MCP is 15۫ to 25۫.
- No amount of rotation deformity should be allowed.
Wishing everybody a Happy and Healthy New Year.
- Nebulized epinephrine: 0.9mg/kg for racemic epi or 0.03 mL/kg of the 2.25% solution (diluted in 3mL) - improves oxygen saturation and respiratory rate, but does not affect admission rates
- Hypertonic saline (3%): decreases hospital length of stay and improves clinical scores, possibly by decreasing airway edema and mucus plugging
- Nasal CPAP: improves ventilation in children with bronchiolitis and hypercapnia
- Heliox: decreases respiratory distress, by reducing gaseous flow resistance and improving alveolar ventilation
Interventions that have shown no benefit and are not recommended:
- Anticholinergics
- oral and/or inhaled corticosteroids
Reference:
Joesph, M. Evidence-Based Assessment and Management of Acute Bronchiolitis in the Emergency Department. Pediatric Emergency Medicine Practice 2011; 8(3)
Despite a paucity of data, pain management clinics are administering topical gel mixtures that have included ketamine, tricyclics, calcium channel blockers and baclofen. Internet blogs have already identified this gel mixture as a way to "get high". This is one of those google searches you have to do on your own.
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- Case Presentation from our ED
- 20 y/o presents 3 weeks after emigrating from Senegal with headache and malaise. CT/LP and work up was otherwise negative. Thin smear shows 1 plasmodium falciparum parasite in 7000 RBC.
- Appropriate therapy is initiated with malarone (atovoquone and progranuil). 24 hours later the patient represents with worsening headache and fever.
- Repeat smear shows 10% parasitemia and massive numbers of parasites
- Clinical Question: Can parasitemia rise after initiation of treatment?
- Answer: Yes
- Increase in blood parasite count in falciparum malaria after initiation of treatment (artemisinin derivatives or quinine) is not uncommon.
- Increased blood parasite count does not indicated treatment failure if it the parasitemia is LESS THAN 2.5 x the baseline count.
- Clinical Question: Did this patient have treatment failure with malarone?
- Answer: Yes
- The patient’s parasitemia rose to 10% after initiation of therapy.
- There are increasing case reports of treatment failure in West Africa with Malarone.
Bottom Line: A mild increase in blood parasite count after initiation of treatment is not uncommon. Marked increases should indicated treatment failure and the treatment drug should be changed to another class.
University of Maryland Section for Global Emergency Health
Author: Emilie J.B. Calvello, MD, MPH
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Attachments
VV-ECMO for Refractory Hypoxemia
- In the absence of significant cardiac disease, patients with refractory hypoxic respiratory failure should be considered for venovenous extracorporeal membrane oxygenation (VV-ECMO).
- Though indications vary slightly among organizations, the Extracorporeal Life Support Organization states that ECMO is indicated when the PaO2/FiO2 is < 80 mm Hg on FiO2 > 90% or safe plateau pressures (< 30 cm H2O) cannot be maintained.
- A few pearls when initiating VV-ECMO:
- Fluids are often needed in the first few hours after initiation of ECMO
- Reduce tidal volumes to maintain plateau pressures < 25 cm H2O
- Decrease FiO2 to maintain oxygen saturations > 88%
- Use a hemoglobin threshold of 7-8 g/dL for blood transfusion
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Question
52 year-old male with diabetes complains of severe left foot pain for one month and now inability to ambulate. Vital signs are normal and X-rays are shown below. What's the diagnosis and why should you get a biopsy early?
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- ST-elevation may represent STEMI or other alternative diagnoses (e.g., aortic dissection)
- Computed tomographic (CT) scanning may help in identifying these alternative diagnoses
- ACTIVATE-SF Registry consists of patients w/a Dx of STEMI admitted to the ED
- 410 patients w/a suspected diagnosis of STEMI, 45 (11%) underwent CT scanning before primary PCI; 2 (4%) of these CT scans changed clinical management by identifying a stroke
- Those who underwent CT scanning had far longer door-to-balloon times (median 166 vs 75 minutes, p <0.001) and higher in-hospital mortality (20% vs 7.8%, p=0.006)
- CT scanning before PCI rarely changed management and was associated w/significant delays in door-to-balloon times
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NSAIDs are commonly used by professional and recreational athletes to both reduce existing and/or prevent anticipated exercise induced musculoskeletal pain
NSAIDs have potential hazardous effects on the gastrointestinal (GI) mucosa during strenuous physical exercise
Potential effects include mucosal ulceration, bleeding, perforation. and short-term loss of gut barrier function in otherwise healthy individuals
Intense exercise by itself has previously been shown to induce small intestine injury
Human intestinal fatty acid binding protein (1-FABP) is a protein found in mature small bowel enterocytes which diffuses into the circulation upon injury
Ibuprofen and endurance exercise (cycling) independently result in increased 1-FABP levels
When occurring together, ibuprofen ingestion with subsequent exercise causes significantly increased small bowel injury and intestinal permeability
Small bowel injury was found to be reversible in 2 hours
Taking empiric NSAIDs before endurance exercise may be an unhealthy practice and should be discouraged in the absence of a clear medical indication
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Parents bring in their child who placed a bead, seed, or other object up her nose. What do you do? Who should you call?
Research suggests that a decades-old home remedy (of sorts) known as the “mother’s kiss” may do the trick for children 1-8 years of age. It’s also much less invasive or frightening than some of the tools and techniques used in emergency departments with a success rate approaching 60%
What Is the “Mother’s Kiss”?
First described in 1965, here’s how the mother’s kiss technique works:
- The parent or caretaker places their mouth over their child’s mouth while holding the unaffected nostril closed with one finger.
- The parent or caretaker blows into the child’s mouth.
- The forceful breath may force the object out (warning: may want to wear protective covering as other things have been known to fly out as well!)
Myth: The ornamental red plant - poinsettia - gained a reputation as a poisonous plant from a case report. In 1919, a 2-year-old child reportedly died from an ingestion and later an 8-month-old developed mucosal burns. These anectdotal case reports perpetuated the myth that poinsettia plants are poisonous. In the modern literature there is one single case of anaphylaxis(1) due to poinsettia ingestion/exposure, an allergic dermatitis(2) and one case of dermatitis(4).
Krenzelok et al.(3) showed there were 22,793 cases of poinsettia exposure and there were no fatalities reported to poison centers. 96.1% were kept at home without sequelae.
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· A parasitic disease transmitted by the bite of the 'Glossina' insect (tsetse fly.)
· The disease is most prevalent in rural areas of Africa. Untreated, it is usually fatal. Infection with the genus Trypanosoma brucei gambiense may lead to chronic asymptomatic illness.
· Travelers to endemic areas in Africa are risk becoming infected.
· Symptoms resemble a viral illness; headaches, fever, weakness, pain in the joints, and stiffness. The parasite is able to crosses the blood-brain barrier and causes neurological symptoms, mainly psychiatric disorders, seizures, coma and ultimately death.
· Diagnosis is by serological tests (Card Agglutination Trypanosomiasis Test or CATT). Confirmation of infection requires the performance of parasitological tests to demonstrate the presence of trypanosomes in the patient.
· Treatment: four drugs are registered for the treatment of HAT: pentamidine, suramin, melarsoprol and eflornithine.
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Management of patients with severe traumatic brain injury (TBI) typically involves the use of invasive intra-parenchymal pressure monitors. Although use of these monitors is recommended by TBI management guidelines, good quality evidence of benefit is lacking.
A recently published study evaluated the outcomes of TBI patients using a management protocol incorporating either an intracranial pressure (ICP) monitor compared to use of the clinical exam PLUS serial neuroimaging; a total of 324 patients were prospectively randomized into either group.
The primary study outcome was a composite of survival, impaired consciousness, and functional status at both three and six months.
The results of the study did not show a significant difference in the:
- Primary outcome
- Median length of ICU stay
- Distribution of serious adverse events
Bottom line: This study suggests that clinical exam PLUS serial neuroimaging may perform as well as invasive intra-parenchymal monitors for guiding therapy in TBI patients.
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Question
50 year-old man with presents with acute-onset sharp left-sided chest pain and dyspnea. What's the diagnosis and the name of the abnormality on chest x-ray?
