A panicked mother rushes into the emergency department, screaming that her baby is not breathing. Taking the apneic infant from her, you hurry to the resuscitation bay. Within seconds, the infant begins to breathe spontaneously. You provide supplemental oxygen by face mask as the team attaches leads and obtains vital signs. The monitor shows a respiratory rate of 30 breaths/min, heart rate of 140 beats/min, and oxygen saturation of 98% on room air. As you note a rather unremarkable physical examination, apart from occasional gagging, his school-age sibling begins coughing. Does this sibling’s apparent upper respiratory illness have anything to do with your patient’s condition? You consider the infectious processes that could present with apnea and the key historical questions you should ask the mother, and you begin to plan your next step in the assessment and management of this baby.
Leaving a resident to begin appropriate investigations on the baby, you enter an examination room to find a 5-year-old boy holding a bandage to his foot. His parents report that he stepped on a nail while playing at a farm earlier that day. On examination, you note a small puncture wound that does not appear grossly soiled and is not actively bleeding. He is otherwise both engaging and well-appearing. As you review the triage notes, your eye falls to a red circle around the words, “No Imm!” You quickly realize this child is unimmunized and at risk for tetanus. You sigh, hesitant to broach the topic. It seems unlikely you alone can change the parents’ minds about vaccines. Should you bother discussing the topic? Should you call the primary care doctor and see if he can convince them? Could an antibiotic prevent tetanus infection?
As you consider your options, the ambulance bay doors open and a local EMS crew comes rushing in with a toxic-appearing young girl on the gurney in obvious respiratory distress. The child has a fever of 38ºC, respiratory rate of 35 breaths/min, heart rate of 150 beats/min, and a blood pressure of 75/45 mm Hg. On examination, there is inspiratory stridor, significant cervical lymphadenopathy, and a thick, grayish membrane that seems to be coating the posterior pharynx. Chest examination reveals bilateral rales and tachycardia with frequent ectopic beats. Having now decided that this patient is your top priority, you ask the charge nurse to notify the PICU and cardiology, and you begin to form a differential diagnosis in your mind. Could this child have a viral myocarditis associated with a simple pharyngitis? Or is there is a more sinister etiology at play? You turn to your senior resident and ask him to page the on-call pediatric infectious disease specialist. You ask the nurse to institute strict isolation precautions. As the phone rings, you grow increasingly confident of your patient’s diagnosis.
A PubMed search for the terms diphtheria, pertussis, and tetanus was performed, along with terms such as diagnosis, treatment, and case report. A search of the Cochrane Database of Systematic Reviews was also performed for each of the 3 diseases. The United States Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), the World Health Organization (WHO), and the National Guideline Clearinghouse websites were searched for related articles or web pages. The vast majority of recent literature on these illnesses focuses on the vaccines themselves rather than the management of the diseases. Pediatric-specific literature is extremely limited. Most of the relevant literature for this issue is in the form of expert consensus, review articles, and case reports.
At the beginning of the 20th century, 10% of all babies born in the United States died before their first birth day, often from infectious diseases.1 Current estimates are that childhood vaccination will save over 700,000 American lives for those born in the United States in the last 20 years.2 The Advisory Committee on Immunization Practice (ACIP) annually reviews the recommended routine childhood (age 0-18 years) vaccination schedule.3 Despite this carefully considered schedule that is designed to be both maximally safe and effective, there has been an increase in certain vaccine-preventable diseases in the United States. This is due, in part, to geographical pockets of low vaccination coverage despite overall high vaccination coverage nationally.4 Because of this, emergency clinicians should not only advocate for vaccination, but also be able to recognize and manage these illnesses when they do occur. This issue of Pediatric Emergency Medicine Practice reviews 3 vaccine-preventable illnesses—diphtheria, pertussis, and tetanus—and describes the role of the emergency clinician in managing these illnesses, identifying and managing close contacts, and involving local health officials.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
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Lara Zibners, MD, FAAP, FACEP
February 2, 2017
March 1, 2020
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Infectious Disease CME and 1 Pharmacology CME credits
Date of Original Release: February 1, 2017. Date of most recent review: January 15, 2017. Termination date: February 1, 2020.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Included as part of the 4 hours, this CME activity is eligible for 3.5 hours Infectious Disease credit, subject to your state and institutional requirements. Included as part of the 4 hours, this CME activity is eligible for 0.5 hours Infection Control credit, subject to your state and institutional requirements.
ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
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AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2A or 2B credit hours per year.
Other Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Infectious Disease CME and 1 Pharmacology CME credits, subject to your state and institutional requirements.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical ED presentations; and (3) describe the most common medicolegal pitfalls for each topic covered.
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