pem network sep '12 newsletter
DESCRIPTION
TRANSCRIPT
[1]
ENVIRONMENTAL EMERGENCIESFrom the Editors:
Do you remember the difference between a crotaline and an elapid snake? Neither do we. That’s why the focus of the fall edition of the PEMNetwork newsletter is environmental emergencies. Hot and cold, bites and stings, disasters and preparedness, you’ll find it all here.
September 2012
From the Site Administrator:
"Welcome to the exciting new face of the PEMNetwork. With new topic search-ability, active group forums, and more collaborative members than ever before, we continue to innovate and educate. We are looking forward to seeing you at the 2012 NCE where the PEMNetwork will hold an open meeting and present at the SOEM conferences.”
- Angela Lumba, MD, FAAPWashington University School of Medicine
PEMNetwork.org, Head Site Administrator
Contents:
Bath Salts..........................2Lyme Disease........................3BASE Camp...........................4Hurricane Preparedness............5-6 EKG Feature: Hypothermia............7Heat Illness........................8Board Review: Bites and Stings...9-10Altitude Illness...................11Image Feature: Worms!.............12Notes from the Sub-site Editors....13
[2]
“Bath salts” were first reported as drug of abuse to the North Texas Poison Center in 2010. Since then, Poison Centers across the United States have reported increasing numbers of calls involving “bath salts”. These “bath salts” usually contain mephedrone and methylenedioxypyrovalerone (MDPV) and are insufflated or “snorted” much like cocaine. Mephedrone is a synthetic stimulant of the amphetamine and cathionine class. Methylenedioxypyrovalerone is also a synthetic stimulant with effects similar to amphetamines. Both drugs have been reported to cause agitation, euphoria, hypertension and tachycardia. These effects resemble methamphetamine and cocaine toxicity. Patients can also develop hyperthermia and ultimately rhabdomyolysis, end organ failure and possibly death from the use of “bath salts.” So far, one death in Florida in 2011 has been attributed to the use of bath salts.
Bath salts are easily purchased on the Internet and at “head shops.” It is considered a designer drug because although mephedrone and MDPV have never been used for bath salts, they are labeled as such with the phrase “Not for Human Consumption” in order to bypass the Federal Analog Act. The Federal Analog Act of the United States Controlled
Substance Act states that any chemical "substantially similar" to a controlled substance listed in Schedule I or II is to be treated as if it were also listed in those schedules, but only if intended for human consumption. Many states such as Florida have now made the substances contained in bath salts illegal to own and sell. Also, as of September 7, 2011, The United States Drug Enforcement Administration (DEA) used its emergency scheduling authority to temporarily control mephedrone. This was deemed necessary to protect the public from the supposed hazard posed by the drug. Except as authorized by law, this action will make possessing and selling mephedrone or the products that contain it illegal in the U.S. for at least one year while the DEA and the United States Department of Health and Human Services conduct further study.
BATH SALTSSing-Yi Feng, MD FAAPAssistant Professor of Pediatrics/Medical Toxicologist
UT Southwestern Medical Center at Dallas
[3]
LYME DISEASEMatthew Thornton, MDYale University School of Medicine
Lyme Disease is the most common
vector-borne illness in the U.S. “Lyme
arthritis” was first described in 1976, with
the discovery of the causative spirochete,
Borrelia burgdorferi in 1981. Borrelia is
transmitted by the Ixodid tick and occurs
primarily in New England, New York, the
mid-Atlantic Coast, Wisconsin, and
Minnesota.
Animal studies have shown that
infected ticks must feed for 36-72 hours in
order for transmission to occur, such that
the risk of transmission from a known tick
bite is only 1-2%.
Lyme Disease is divided into 3
chronological stages, all with different
presentations and distinct pathology,
though there may be some degree of
overlap. These stages are 1) Early
localized, 2) Early disseminated, and 3)
Late disseminated.
Early localized disease occurs 1-55
days after a bite, involving the classic
erythema chronicum migrans (EM) rash at
the site of the bite, and may also include
flu-like symptoms. A characteristic rash
and possible tick exposure are all that is
required for diagnosis and treatment.
Early disseminated disease occurs
3-10 weeks after a bite when the
spirochetes spread via blood or
lymphatics to bone, synovial tissue, CNS,
heart, or skin. 25% of patients will have
multiple EM. Fever and myalgia are also
common. Meningitis, cranial
neuropathies, and carditis are more
serious complications. Heart block
responsive to antibiotics is the most
common manifestation of carditis.
Late disseminated disease causes
“Lyme arthritis”, typically in the knee.
Arthritis resolves in 1-2 weeks, but even
untreated cases will eventually resolve.
Recurrences are not uncommon.
Serologic testing is an adjunct to
clinical diagnosis in disseminated disease.
ELISA for IgM and IgG may be sent, and if
positive, followed by confirmatory Western
Blot. False-positive ELISA is extremely
common.
Treatment of Lyme disease is a bit
tricky, with regimens differing based on
disease stage and manifestations. Tick
bite prophylaxis is not recommended,
even in Lyme endemic regions, unless the
tick has been attached for >36 hours and
the patient is able to take doxycycline.
Early localized disease is treated with oral
doxycycline, amoxicillin, or cefuroxime for
14-21 days. Doxycycline has the
advantage of being active against possible
coexisting ehrlichiosis. Disseminated
disease causing multiple EM or an isolated
nerve palsy requires a longer treatment of
21-28 days. Meningitis/encephalitis and
symptomatic carditis with heart block
require IV therapy with ceftriaxone, as
does persistent or recurrent arthritis.
1. Steere AC. Lyme disease. N Engl J Med 2001; 345:115.2. Shapiro ED, Gerber MA. Lyme disease. Clin Infect Dis
2000; 31:533.3. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease,
human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of
America. Clin Infect Dis 2006; 43:1089.4. Centers for Disease Control and Prevention: Lyme Disease. Accessed 7/3/12. http://www.cdc.gov/lyme/
Manifestations
Erythema migrans rash (top)is caused by local spread of spirochetes. It is nonpruritic and nonpainful and lasts 1-2 weeks. Bells palsy (middle) in early disseminated disease. Lyme arthritis (above) is a late manifestation.
LYME DISEASE
Incidence of Lyme (per
100,000 pop.)
[4]
Kevin Ching, MDWeill-Cornell Medical Center
In the fast-paced practice of emergency medicine, fellows must develop critical skills and behaviors swiftly. From day one, PEM fellows are expected to develop an ability to lead a team under crisis conditions, while possessing the technical proficiency to perform a staggering number of complex procedural skills. Yet, with only a 4-month pediatric residency requirement for acute care, there is no guarantee that graduating residents have been adequately prepared for this challenge. The probability is high that a new fellow has never had the opportunity to insert a chest tube or manage an infant in cardiopulmonary arrest. In addition to technical competency, fellows must develop team leadership and crisis management skills, neither of which are likely to fully develop in residency. The ACGME requires that fellows “learn the skills necessary to prioritize and simultaneously manage the emergency care of multiple patients,” and that “they must have supervised experiences using their technical/procedural and resuscitation competency skills.” Such skills have traditionally been acquired through “trial by fire” in the emergency department—with all the risks related to such practice.
BASE Camp: Basic Training for Pediatric Emergency Medicine Fellows was developed to offer a high-impact, immersive, and standardized learning solution that would level the playing field for incoming fellows and prepare them for the challenges of an EM fellowship. BASE camp brings together new first-year PEM fellows to collectively introduce, review, and provide opportunities to practice teamwork behaviors and critical emergency procedural skills. The first PEM “boot camp” of its kind in the Northeast, the inspiration for BASE Camp grew out of a pediatric critical care program inspired by Nishizaki at the Childrenʼs Hospital of Philadelphia.
In order to provide similar experiences for PEM fellows, BASE Camp assembled a collaborative group of expert PEM faculty from 10 universities to develop an intensive two-day multidisciplinary training program. Using state-of-the-art simulation technology, BASE Camp provides new fellows with an opportunity to begin developing hands-on experience and proficiency in crucial teamwork and procedural domains. Before arriving at BASE Camp, fellows are provided online an interactive pre-conference introduction and overview of teamwork concepts, emergency trauma procedural skills, the approach to a difficult pediatric airway, and advanced airway techniques to establish a cognitive framework for the 2-day course. In the course, fellows are challenged to collaborate in teams, often as leaders, in varied resuscitations. Fellows are given ample opportunities to learn, practice, and apply advanced airway maneuvers, like the use of an intubating-LMA in a child with a retropharyngeal abscess, or the video laryngoscope in an adolescent with laryngeal edema in anaphylaxis. Emergency trauma procedural skills like cricothyroidotomy, chest tube thoracostomy, and pericardiocentesis are practiced first on advanced trauma simulators, then human cadavers and animal tracheas, before applying these skills together as teams during a large-scale multi-casualty trauma simulation. Last year, BASE Camp hosted its 2nd annual conference, training 24 first-year PEM fellows from 13 fellowships across 8 Northeastern states. Preliminary data has shown that even among this population of highly motivated learners, the opportunities to acquire experience as team leaders in a resuscitation or inserting a chest tube are limited. As BASE Camp looks forward to introducing new educational strategies for its 3rd year this Fall, the hope is not only to provide experiences that foster complex thought and decision making within a teamwork domain, but to provide practice in rare but critical emergency procedural skills.
BASE CAMP
For more information, see: PEMBasecamp.com
BASE Camp: A Multi-Institutional Teamwork and Procedural Skills Simulation Training Conference for Pediatric Emergency Medicine Fellows
[5]
The 2012 hurricane season runs
from June 1 through November 30. This
year’s season is marked by the 20th
anniversary of Hurricane Andrew, the
catastrophic category 5 hurricane that
barreled through South Florida on
August 24, 1992. Andrew caused an
estimated 20-40 million dollars in
damage and killed at least 60 people.
For those living in hurricane prone areas,
knowledge of hurricane readiness and
evacuation procedures is not only
prudent but essential. The Centers for
Disease Control and the American
Academy of Pediatrics have outlined
specific steps for hurricane readiness
that will arm the prescient citizen with
the knowledge to protect one’s family
and vulnerable members of the
community.
Emergency care places the ABCs
paramount during an initial evaluation of
any patient. Similarly, hurricane
preparedness carries its own critical
reflexive moves: 1) Taking the first steps,
2) Preparing to evacuate, and 3)
Completing your family disaster plan.
Taking the first stepsIf you are under a hurricane watch or
warning, the CDC advises the following:
• Learn about your community’s
emergency plans, warning signals,
evacuation routes, and locations of
emergency shelters
• Inform local authorities about any
special needs. For children with
special health care needs it is
important to complete a health care
summary, including names/contact
information for the child’s medical care
providers. A two-week supply of
medications, equipment, supplies, and
foods for special diets is also
recommended.
• Locate and secure important
documents
• Stock your home with emergency
supplies. At minimum, this should
include a 3-5 day supply of water (5
gallons/person) and non-perishable
food, first aid kit, battery-powered
radio, flashlights, batteries, sleeping
bags/blankets, water-purifying
supplies (chlorine, iodine tablets, etc.),
baby food/supplies, toiletries, and an
emergency kit for the car with food,
flares, booster cables, maps, tools, a
first aid kit, fire extinguisher, etc.
Preparing to evacuateIf the forecast calls for a hurricane,
expect the need to evacuate and
Mass flooding prompts helicopter rescues after Hurricane Katrina (top, center); Hurricane Victim holds a meal package administered by U.S. Army (above).
Specific steps to ensure food and water safety during hurricanes, power outages, and floods can be found at www.fda.gov.
HURRICANE PREPAREDNESSDaniel Park, MDMedical University of South Carolina
[6]
prepare for it. When a hurricane watch is issued you
should:
• Never ignore an evacuation order
• Fill up your car’s gas tank/arrange for transport
• Fill up clean water containers
• Prepare an emergency kit for your car
• Cover windows and doors with plywood or boards
to reduce risk of flying glass
• Place pets and livestock in safe areas. Often,
animals are prohibited from emergency shelters.
• Fill sinks and bathtubs with water for washing
If ordered to evacuate:
• Take only essential items with you
• Make sure the car’s emergency kit is ready
• Follow designated evacuation routes
• Stay indoors until authorities declare the storm over;
if possible take shelter in a windowless, interior room or
closet. Stay away from all windows and exterior doors.
After the storm has passed, the American Academy of
Pediatrics recommends the following before children are
returned to areas impacted by flooding and/or hurricanes:
• Basic utilities and public services should be reliably
re-established
• Living and learning spaces (including homes,
schools, and day-care facilities) are free from physical
and environmental hazards to children
• Spaces where children play should be clear of
debris and free from environmental hazards to children
Completing your family disaster plan It is important to meet with your family before a
disaster occurs to discuss the importance of preparation.
If developmentally appropriate, discuss with children what
to do if the family is separated. Practicing the disaster
plan is both a practical and essential exercise not only for
hurricanes, but for any emergency.
Sources:
1. AAP Children and Disasters: Disaster preparedness to meet
children’s needs. Retrieved June 30, 2012, from http://www2.aap.org/
disasters/hurricanes-storms.cfm
2. AAP: Clinician Recommendations Regarding Return of Children
to Areas Impacted by Flooding and/or Hurricanes. Retrieved June 30,
2012, from http://www2.aap.org/disasters/pdf/Hurricanes-
ReturnofChildren.pdf
3. CDC Emergency Preparedness and Response. Retrieved June
30, 2012, from http://www.bt.cdc.gov/
4. Food Facts from the U.S. Food and Drug Administration: What
Consumers Need to Know About Food and Water Safety During
Hurricanes, Power Outages, and Floods. Retrieved June 30, 2012, from
http://www.fda.gov/Food/ResourcesForYou/Consumers/ucm076881.htm
[7]
EKG FEATURE:Rahul Kaila, MDUniversity of Minnesota Amplatz Children's Hospital
This is a case of 14 y/o male who had altered mental status and was found to be hypothermic with a temperature of 91 F on the street. His EKG showed Osborne or J wave ( marked in the EKG ) which is the upward deflection at the junction of QRS and ST representing distortion in the earliest phase of repolarization. J waves are usually observed in people suffering from hypothermia with a temperature of less than 32 C though they may also occur in people with high blood levels of calcium, brain injury, vasoplastic angina.
J-waves
J-waves were noted on the EKG (above), with resolution on the repeat EKG (right) after rewarming.
BABY, IT’S COLD OUTSIDE!
[8]
Heat illness is defined as “the
inability to maintain normal body
temperature because of excess heat
production or decreased heat transfer
to the environment.” Heat stroke
occurs when the excess body
temperature results in cellular injury,
and is a common cause of morbidity
and mortality among athletes, with
mortality rates of nearly 10%.
Acclimatization, or lack thereof,
can play a significant role in the risk for
heat illness. With prolonged exposure,
sweating rates increase, promoting
effective cooling as well as triggering
increased aldosterone secretion (and
thus decreased sodium losses). Un-
acclimatized people are prone to
significantly greater salt losses and
less effective sweating.
Heat illness can progress from
mild to severe depending on a variety
of factors, including acclimatization
and conditioning. Heat cramps are a
relatively minor condition occurring in
well-acclimatized and conditioned
patients. Severe muscle cramps
occur upon relaxation, contact with
cold, or passive extension of a flexed
limb. This occurs after inadequate salt
replacement causes electrolyte
depletion.
Heat exhaustion occurs primarily
in un-acclimatized patients who have
either inadequate fluid or salt
replacement. It is characterized by
profuse sweating, fatigue, weakness,
thirst, headache, vomiting, mild
hyperthermia (38-40*C),
and incoordination.
Heat stroke is a life-
threatening emergency, defined
as severe hyperthermia (>40*C),
with severe CNS dysfunction.
Patients with heat stroke present
with hot, dry, ashen skin and can have
significant end-organ involvement.
Profound peripheral vasodilation and
thermal damage to the myocardium
leads to decreased cardiac output and
shock. Acute tubular necrosis leading
to renal failure, rhabdomyolysis,
hepatic failure, and DIC are common
manifestations. The major outcome
determinant in heat stroke victims is
the duration of hyperpyrexia.
Management of heat cramps and
heat exhaustion involve simple,
practical measures of removal from
heat, rest, and oral or IV fluid and salt
replacement. Management of heat
stroke involves immediate, active
cooling to a temperature of 38.5*C.
This may be achieved by ice packs to
the neck, groin, and axilla, submersion
in ice water, cooling blankets,
convection cooling with fans and mist,
cooled IV fluids, and lavage (gastric,
bladder, peritoneal, thoracic) if
necessary. Ice water submersion is
most effective, but may be impractical,
with evaporative cooling the most
effective next choice. Sedation and
paralysis may be used to decrease
metabolic heat production. Heat
stroke patients often have insufficient
cardiac output due to massive
peripheral vasodilation and a stressed,
dysfunctional myocardium (resulting
from thermal damage). Patients do
not often require aggressive volume
resuscitation as they are not typically
severely dehydrated. Inotropic
support (specifically dobutamine,
which increases contractility while
maintaining peripheral vasodilation
and thus cooling) should be
considered early, with a goal to
maintain UOP>1mL/kg/hr.
Chemistries, creatine kinase, coags,
and urine should be used to assess for
end-organ involvement.
References:Council on Sports Medicine and Fitness
and Council on School Health. Climatic Heat
Stress and Exercising Children and Adolescents.
Pediatrics. 2011;128(3):e741-7.
Ewald MB, Baum CR. Environmental
Emergencies. In Fleisher GR and Ludwig S 6th
Edition Textbook of Pediatric Emergency
Medicine (783-6, 791-4). 2010. Philadelphia:
Lippincott Williams and Wilkins.
McLaren C, Null J, Quinn J. Heat Stress
From Enclosed Vehicles: Moderate Ambient
Temperatures Cause Significant Temperature
Rise in Enclosed Vehicles. Pediatrics. 2005;
116:e109-112.
Smith JE. Cooling Methods Used in the
Treatment of Exertional Heat Illness. British J. of
Sports Med. 2005;39:503-7.
HEAT-RELATED ILLNESSAmanda Greuter, MDChildrens Medical Center of Dallas
The major outcome determinant in heat stroke is duration of
hyperpyrexia.
[9]
1. Which of the following crotaline snakes causes
significant neurological toxicity with or with- out local
tissue damage and hemotoxicity?
a.Cottonmouth snake
b.Eastern Diamondback Rattlesnake
c.Mojave Rattlesnake
d.Copperhead snake
2. Which of the following is a common finding following
black widow spider envenomation?
a. Severe local tissue damage at the site of the bite
b.Muscle pain and cramping
c.Respiratory failure
d.Thrombocytopenia
3. What is one of the most common toxicities following
brown recluse spider envenomation?
a.Dermatonecrosis
b.Neuromuscular weakness
c.Respiratory failure
4. What is the most appropriate treatment for rapidly
progressing local tissue swelling and hemotoxicity
following crotaline envenomation?
a. Fasciotomy
b.Corticosteroids
c.Constrictive tourniquet of affected extremity
d.CroFab® antivenom administration
5. Which toxic species and matching distinguishing
physical characteristic is correct?
a. Eastern coral snake: red on black on yellow bands
b. Crotaline snake: triangular head, elliptical pupils
c. Brown recluse spider: red hourglass -shaped mark
on ventral abdomen
d.Black widow spider: violin-shaped mark on dorsal
thorax
6. Which of the following statements regarding
Centruroides exilicauda scorpion stings is correct?
a. Local pain and paresthesias are decreased by
percussion over the affected area
b.Young children are least severely affected
c. Severe cases include fasciculations, uncontrolled
muscle movements, and cranial nerve dysfunction
7. Which of the following is the best treatment modality
for dermatonecrosis caused by brown recluse spider
envenomations?
a. Good local wound care, analgesia, and tetanus
prophylaxis
b.Hyperbaric oxygen therapy
c.Electric shock therapy
d. Dapsone or colchicine
8. Which of the following are important aspects for
treatment for coral snake envenomation?
a. Careful monitoring and support of respiratory
function
b. Repeated monitoring of coagulation profiles
c. Careful monitoring of the site of envenomation for
severe tissue damage
Snakes, Spiders, and ScorpionsQuestions used with permission by Jennifer Pai, MD, editor of Pediatric Emergency Medicine Practice.
For full text and more review topics, visit EBMedicine.net.
see p. 9 for answers and discussion
BOARD REVIEW: BITES AND STINGS
[10]
Bites and Stings Answers
1. c. While local tissue damage is
the most common complication of
most crotaline bites, the venom of
the Mojave Rattlesnake contains a
potent neurotoxin, with clinical
presentation similar to coral snake
(elapid) envenomation.
2. b. Black widow spider venom
lacks cytotoxic agents, so there is
little to no local tissue injury.
Instead, the venom decreases
acetylcholine reuptake, resulting in
severe muscle cramps, abdominal
pain and muscle spasm. Symptoms
can be managed with opioids and
benzodiazepines.
3. a. Brown recluse venom
contains many cytotoxic digestive
enzymes, thus the hallmark of bites
is local tissue necrosis ranging from
mild to extensive.
4. d. Antivenom, while not able to
reverse pathology at the site of
envenomation, does halt progression
of local toxicity, systemic
dysfunction, and coagulopathy.
Repeat dosing may be needed in
severe cases. CroFab® is a
fragmented antibody which is less
antigenic than previous formulations,
with lower risk of serum sickness.
Fasciotomy, steroids, and
tourniquettes are not recommended,
as these treatments may worsen
outcomes.
5. b. Crotaline snakes, or pit
vipers, account for 99% of
venomous snake bites in the U.S.
They are identified by their triangular
head, elliptical pupils, and fangs.
Eastern Coral Snake has red on
yellow on black bands but is easily
confused with the nonvenomous
King Snake, leading to the saying,
“red on yellow, kill a fellow; red on
black, venom lack”. The black
widow spider is characterized by a
red hourglass-shaped mark on its
abdomen, while the brown recluse
has a violin-shaped mark on its
thorax.
6. c. The neurotoxins of C.
exilicauda scorpions cause
sympathetic and parasympathetic
overstimulation, which may be
mistaken for seizure activity.
Catacholamine release may result in
myocardial damage and
dysrhythmias as well.
7. a. Tetanus status should be
addressed in all bites and stings.
Rest and elevation to decrease
venom spread, analgesics, and
antihistimines for pruritis are typically
the only necessary care. Steroids,
antibiotics, dapsone, and hyperbaric
oxygen have been reported but not
shown to be effective.
8. b. Coral snake venom
produces systemic neurotoxicity,
which may be delayed up to 18
hours after envenomation.
Envenomation can lead to loss of
muscle strength and paralysis, thus,
patients with a history of an elapid
bite should be observed in the
hospital for neurologic abnormalities.
Stay Away from these Bad Boys!
Pictured above are a watermoccasin (top), scorpion, and diamondback rattlesnake. Both snakes are of the crotaline class.
BITES & STINGS
EBMedicine.net CME Reviews >3
years old are downloadable
for free.
[11]
Lilia Reyes, MDNYU Medical Center
Altitude illness is defined as the cerebral and
pulmonary syndromes resulting from an ascent to high
altitude, and represents a broad spectrum of pathology,
ranging from mild to life threatening. Hypobaric hypoxia
results in a broad range of physiologic responses, including
increased sympathetic activity (with increased cardiac
output), pulmonary vasoconstriction, and diuresis,
with eventual increase in hematocrit to increase
oxygen-carrying capacity. Three major
factors influence the incidence and severity
of altitude sickness; rate of ascent, altitude
achieved, and length of stay.
Acute Mountain Sickness (AMS) is the
most common form of altitude sickness,
occurring in approximately half of lowland-
living individuals who ascend to >14,000 ft. It
presents (in order of prevalence) with headache, fatigue,
shortness of breath, dizziness, anorexia, and nausea/
vomiting. AMS typically occurs 8-36 hours after arrival at
altitudes above 8200 ft (2500m). Of note, children are at
greater risk of AMS due to increased susceptibility to
hypoxia and V/Q mismatch. Age less than 1 year,
prematurity, systemic disease, and respiratory infections
are all risk factors.
Treatment of AMS consists of halting further ascent
until symptoms resolve, or descent to lower altitude if
symptoms are not improving. Acetazolamide can also be
used as treatment or as a preventative medication, acting
by causing a mild metabolic acidosis, increasing ventilatory
rate and thus the PaO2.
More serious altitude related illnesses include high
altitude cerebral edema (HACE) and high
altitude pulmonary edema (HAPE). HACE is
the most severe form of altitude sickness in
which hypoxia increases cerebral blood
flow, resulting in edema and decreased
integrity of the blood-brain barrier. It occurs
in 1-2% of individuals who ascend without
acclimatization and progresses from confusion
and truncal ataxia to coma, with a 60% mortality
rate among patients with coma. HAPE also occurs after
excessive hypoxia, with edema resulting from alveolar
capillary membrane leak, increased ADH and resultant
overload, and inflammatory cytokine release. Treatment of
both consists of descent from altitude, oxygen, bed rest,
and dexamethasone. Dexamethasone’s mechanism of
action is unknown, but has been proven somewhat
effective in management of altitude illness.
Bogota, Colombia (above) 8,661 ft (2640m) above sea level. As a point of reference, the elevation of Denver, CO is 5280 ft (1609m).
Children are at greater risk of AMS than adults due to
increased susceptibility to
hypoxia.
HIGH ALTITUDE ILLNESS
[12]
Ascariasis is a nematode (roundworm) and one of the most common human parasitic infections worldwide.
Transmssion occurs via ingestion of contaminated water or food, or less commonly, contaminated soil. Its prevalence
is greatest in tropical climates, with the majority of infections in Asia, Africa, and South America. Often, there are no
symptoms with an A. lumbricoides infection. However, in the case of a particularly bad infection, symptoms may
include bloody sputum, cough, fever, abdominal discomfort, or passing worms. Most diagnoses are made by
identifying the appearance of the worm or eggs in feces. Due to the large quantity of eggs laid, physicians can
diagnose using only one or two fecal smears.
Infections can be treated with drugs called ascaricides. The treatment of choice is mebendazole. The drug
functions by binding to tubulin in the worms' intestinal cells and body-wall muscles.
FEATURE PHOTO: NAME THAT PARASITESanti MintegiPediatric Emergency Department. Cruces University Hospital. BilbaoProfessor of Pediatrics. University of the Basque Country
Ascaris lumbricoides
“A fellow came one night
some months ago to my
office showing me what I send to you. She told me
that boy's parents found it in
the stools. Grandpa is a
hunter.”
[13]
From the Fellowship Corner:
Hello everyone,
Over these past few weeks, we
have been hard at work updating the
fellowship subsection of
PEMNetwork.org so that it contains
even more helpful information for the
upcoming PEM fellowship application
season.
The Applicant's Corner has been
updated to include the application
timeline for the 2012 season. We have
also included a variety of topics to
help you through this application
season. We have included general
application tips, advice on how and
when to ask for letters of
recommendation, and suggestions on
what to include in your personal
statement. We have also included a
list of suggested questions to ask on
your interview days along with some
helpful tips on how to schedule
interviews and even arrange your
travel plans.
We look forward to hearing your
suggestions on how we can continue
to improve the Applicant's Corner.
- Saranya Srinivasan, MD
Boston Combined Residency
Program in Pediatrics
NOTES FROM OUR SUB-SITE EDITORS
Send Us Your Cases!
We are currently accepting case reports, interesting photos, radiographic images, and EKGs for our winter newsletter.
Editors:
Purva Grover Michelle Alletag Angela Lumba
From the Ultrasound Subsite:
The PEM Fellows ultrasound
subsite includes a list of ultrasound
fellowships, cases and teaching
points. We welcome submissions
for interesting cases and hope to
see the subsite continue to grow.
- Catherine Chung, MD
Inova Fairfax Hospital for Children