jump to navigation
Free Trial Subscription

A 12-year-old boy presents to the ED with a flulike illness — Brain Teaser. Do you know the answer? December 26, 2018

Posted by Andy Jagoda, MD in : Brain Tease , 1 comment so far

Test your knowledge and see how much you know about treating and managing suspected bioterrorism in pediatric patients.


Did you get it right? Click here to find out!

The correct answer: A.

Earn CME for this topic by purchasing this issue. 

 

Using chemoprophylaxis in a child aged 1 year — Brain Teaser. Do you know the answer? December 24, 2018

Posted by Andy Jagoda, MD in : Brain Tease , add a comment

Test your knowledge and see how much you know about treating and managing influenza in the ED.


Did you get it right? Click here to find out!

The correct answer: A.

Earn CME for this topic by purchasing this issue. 

 

10 Risk Management Pitfalls in the Management of Suspected Bioterrorism in the Pediatric Patient December 19, 2018

Posted by Andy Jagoda, MD in : Feature Update , add a comment

10 Risk Management Pitfalls in the Management of Suspected Bioterrorism in the Pediatric Patient

1. “This isn’t New York City or Washington, DC; we don’t live in a target area. Bioterrorism preparedness is not a high priority for my practice.” Bioterrorism events often occur without warning—at any time, in any place. Many bioterrorism agents are highly contagious and can spread to remote areas of the country, due to travel of infected persons or wide dispersal of aerosolized agents. It is every emergency clinician’s obligation to become familiar with bioterrorism agents.

2. “If a bioterrorism patient shows up, I will be able to rely on the infectious disease and infection control teams for recommendations.” Recognizing suspicious illness patterns is an important responsibility of front-line emergency clinicians. While infectious disease and infection control specialists provide specific expertise, the protection of patients and staff depends on adherence to recommended protocols as early as possible.

3. “There are so many different agents that could be biological weapons. Trying to prepare for all the possibilities is overwhelming.” Many resources in print and online can support the emergency clinician. The CDC publishes clinical guidelines and manages electronic applications to support clinical decision making. The AAP also provides online resources for bioterrorism issues pertaining to children. (See Table 2.)

4. “Yes, he triggered the screening tool, but we have no rooms to isolate this patient. Besides, it is very unlikely that this is bioterrorism.” Failure to properly isolate patients can put other patients and staff at risk for any contagious illness. It is important to put safety first.

5. “Where would a child get anthrax? I haven’t heard anything in the news.” Children have particular physiologic and developmental vulnerabilities that put them at higher risk of being victims of bioterrorism agents. Therefore, children may show symptoms before public officials are aware that there has been an outbreak.

6. “Managing a surge from a bioterrorism event is similar to managing a mass casualty. We should be able to use similar protocols” Bioterrorism agents are often highly contagious and require public health support beyond the scope of any single healthcare facility. Specific protocols are important to best recognize and respond to the threat of bioterrorism.

7. “All children should receive postexposure pro-phylaxis after exposure to a bioterrorism agent. It’s the right thing to do.” Apply the recommended guidelines for PEP as recommended by the CDC. Not all medications or vaccines are safe for children and they should be considered in the context of the potential risks to the child.

8. “Yes, there has been a spike in pneumonic tularemia in the ED, but it’s endemic to this area, so that shouldn’t be cause for concern.” Any unusual cluster of presentations of Category A bioterrorism agents should be cause for concern. The inhalational form of any Category A illness should also be a red flag, as the aerosolized form of these agents is the most likely mechanism used for a bioterrorism attack.

9. “I don’t know how I would be able to tell if a cluster of patients had these unusual symptoms. There are at least 8 other hospitals in this city. I don’t have time to call them all to find out if they are seeing similar presentations.” Coordination with your local public health resources is essential in rare disease outbreaks. Since 2001, biosurveillance systems have been used to track unusual outbreaks and serve as a resource for health systems.

10. “Even though I have suspicions that this case could be due to a bioterrorism agent, I don’t want to cause the laboratory staff to panic. I’ll just send the culture and wait for the results.” Laboratory personnel are at high risk for exposure from the highly contagious bioterrorism agents. Most Category A agents require special reagents and tests only available in secured public health laboratories. Communicating concerns early and using appropriate personal protective gear consistently are essential to prevent further outbreak of a highly contagious illness.

 

Treatment Pathway for Managing a Patient Who Presents to the ED With an Influenza-Like Illness December 17, 2018

Posted by Andy Jagoda, MD in : Feature Update , add a comment

Patients presenting to the ED with “influenza-like illness” (cough, sore throat, fever) are typical in the fall and winter. How can you tell whether a patient might have influenza and infect others with a potentially dangerous strain?  Influenza can present with a wide range of nonspecific clinical signs and symptoms, making ED management challenging.

This clinical pathway will help you improve care in the management of patients who preset with an influenza-like illness. Download now.

Clinical Pathway for Managing a Patient Who Presents to the ED With an Influenza-Like Illness

 

Are you prepared? — Bioterrorism Attacks Involving Pediatric Patients Conclusion December 14, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 1 comment so far

Case Recap:

Your next patient is a 2-year-old girl with a 3-day history of high fevers, body aches, fatigue, and a rash. Her vital signs are; temperature, 40.5°C (104.9°F); heart rate, 105 beats/min; and blood pressure, 100/60 mm Hg. The physical examination reveals pustular vesicles with central umbilication in the same stage of development on her face, torso, and extremities. The mother says the lesions started in the girl’s mouth 3 to 4 days ago. The patient’s past medical history is notable only for severe eczema.

What features of this suggests a potential bioterrorism threat? Does the patient require isolation? What public health notifications are needed?

Case Conclusion:

The 2-year-old girl with a history of high fevers, body aches, fatigue, and rash concerned you because you remembered a rash like this from textbooks, though you had never seen a rash like this before in person. An older nurse called you from triage and said, “I’ve placed her in a negative pressure room. I think this is smallpox—I remember the pictures from when I was little.” You recalled the CDC diagnostic guidelines for smallpox and noted that the patient had (1) febrile prodrome > 38.3°C (101°F), (2) classic appearing smallpox lesions, and (3) lesions in the same stage of development. Thus, the patient met the high-risk criteria. You initiated airborne and contact precautions and alerted the infection control team and dermatology. They agreed with your risk analysis and the local health department was called. The smallpox response team was dispatched to your facility to collect lab specimens. You were fortunate that 2 of the clinicians on staff received the smallpox vaccine when they were younger because of prior military deployments. They volunteered to care for the patient using appropriate PPE in coordination with the infection control team. You later found out that the patient was the daughter of a military parent who was recently deployed for a high-risk mission requiring vaccination for smallpox. The child likely had a case of contact vaccinia.

What influenza testing do you choose? — Influenza in the ED Conclusion December 12, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , add a comment

Case Recap:

Your patient is a 32-year-old man with the following chief complaints: cough and fever. His maximum temperature over the past 5 days was 40˚C (103.9°F). He has been taking over-the-counter cold remedies without relief, and today he is markedly short of breath. The patient has no regular primary care provider and has no significant past medical history. His initial vital signs are: temperature 39.2˚C (102.5°F); heart rate, 118 beats/min; respiratory rate, 28 breaths/min; blood pressure, 134/78 mm Hg; and oxygen saturation, 88% on room air. On examination, he appears uncomfortable, with notable tachypnea. The oropharynx is clear and the neck supple. Crackles are noted in the right lower lung field, without any wheezing. The abdomen is soft and nontender. The patient is given oxygen via face mask, with an improvement in saturation to 100%. Chest x-ray reveals a right lower lobar pneumonia with a small pleural effusion. You start IV antibiotics and request an inpatient bed, as he is hypoxic with his pneumonia. 

You wonder whether influenza testing is indicated, and if so, what type of test to do?

Case Conclusion:

Delving further into the CDC website, you find that the false-negative rate with rapid antigen testing for influenza can be significant, especially when disease prevalence is high, as it is in your region. Based on this information, you decide to start your more seriously ill 32-year-old patient on oseltamivir 75 mg twice a day for 5 days despite the initially negative result reported by the hospital laboratory.

Are you prepared? — Bioterrorism Attacks Involving Pediatric Patients December 7, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 7comments

Your next patient is a 2-year-old girl with a 3-day history of high fevers, body aches, fatigue, and a rash. Her vital signs are; temperature, 40.5°C (104.9°F); heart rate, 105 beats/min; and blood pressure, 100/60 mm Hg. The physical examination reveals pustular vesicles with central umbilication in the same stage of development on her face, torso, and extremities. The mother says the lesions started in the girl’s mouth 3 to 4 days ago. The patient’s past medical history is notable only for severe eczema.

What features of this suggests a potential bioterrorism threat? Does the patient require isolation? What public health notifications are needed?

What influenza testing do you choose? — Influenza in the ED December 5, 2018

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 15comments

Your patient is a 32-year-old man with the following chief complaints: cough and fever. His maximum temperature over the past 5 days was 40˚C (103.9°F). He has been taking over-the-counter cold remedies without relief, and today he is markedly short of breath. The patient has no regular primary care provider and has no significant past medical history. His initial vital signs are: temperature 39.2˚C (102.5°F); heart rate, 118 beats/min; respiratory rate, 28 breaths/min; blood pressure, 134/78 mm Hg; and oxygen saturation, 88% on room air. On examination, he appears uncomfortable, with notable tachypnea. The oropharynx is clear and the neck supple. Crackles are noted in the right lower lung field, without any wheezing. The abdomen is soft and nontender. The patient is given oxygen via face mask, with an improvement in saturation to 100%. Chest x-ray reveals a right lower lobar pneumonia with a small pleural effusion. You start IV antibiotics and request an inpatient bed, as he is hypoxic with his pneumonia. 

You wonder whether influenza testing is indicated, and if so, what type of test to do?

About EB Medicine:

Products:

Accredited By:

ACCME ACCME
AMA AMA
ACEP ACEP
AAFP AAFP
AOA AOA
AAP AAP

Endorsed By:

AEMAA AEMAA
HONcode HONcode
STM STM

 

Last Modified: 10-23-2019
© EB Medicine