Stephen Alerhand

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in the Pediatric Population: A Review

Abstract Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe dermatologic reactions with mucocutaneous involvement that carry elevated mortality rates. They differ along a spectrum of severity based upon body surface area affected. These conditions, usually caused by a drug or infection, are believed to result from cell-mediated and often drug-specific cytotoxic reactions against keratinocytes, leading to widespread dermal-epidermal detachment. Studies attempting to identify potential curative therapies such as intravenous immune globulin (IVIG) and corticosteroids remain inconclusive. However, improved outcomes have been demonstrated by early withdrawal of offending medications, early transfer to an intensive care unit or burn unit, and aggressive supportive care. Due to the rare incidence of SJS and TEN, its recurrence among survivors hints at future vulnerability for these patients, and notorious offending medications should thus be avoided. This clinical review will highlight the diagnostic and therapeutic challenges posed by SJS and TEN, while emphasizing the need to maintain them high on the emergency medicine physicians differential. The review will also detail the supportive measures to take for preventing the rapid progression of mucocutaneous complications and subsequent sepsis-related mortality.

The time-sensitive challenge of diagnosing spinal epidural abscess in the emergency department

Spinal epidural abscess (SEA) is a rare but devastating condition. Entry of infectious contents into the epidural space occurs via contiguous infected tissue, hematogenous spread, or iatrogenic inoculation. Traditionally, emergency providers are taught to assess for the “classic triad” of spinal pain, fever, and neurological deficits, but this constellation of findings is seen in only 10–15% of cases. Delays in diagnosis and treatment of this condition directly correspond to worse, and often debilitating, outcomes for these patients. This review will demonstrate the challenges of diagnosing SEA, describe key diagnostic pitfalls, and present a model and framework for its evaluation. The authors conducted a systematic review in PubMed and Google Scholar for articles describing the emergency medicine evaluation and management of spinal epidural abscess dating from 1996 to 2016. Of the initial 219 articles found, 18 articles were selected based on their relevancy to emergency medicine. Lower back pain is a common chief complaint, whereas SEA is a rare condition and may not be anticipated. The “classic triad” of SEA symptoms presents infrequently. Moreover, the early symptoms of back pain and fever are non-specific, and patients seek medical attention at varying stages of disease progression. Once the more conspicuous and wide-ranging neurological symptoms develop, they are often irreversible. In fact, final outcomes correlate with the severity and duration of symptoms before surgery. Furthermore, discovering these late neurological symptoms can be particularly difficult in bed-bound and chronically ill patients. MRI is the best diagnostic imaging tool for SEA. Early diagnosis is the major prognostic factor for favorable outcome of SEA, and yet, making this diagnosis in the emergency department (ED) has proved challenging. Shifting from a “classic triad” screening to a risk factor-based model of evaluation represents the current optimal strategy for diagnosing SEA. An algorithm incorporating the most recent data is provided.

Spontaneous Intracerebral Hemorrhage

Although commonly arising from poorly controlled hypertension, spontaneous intracerebral hemorrhage may occur secondary to several other etiologies. Clinical presentation to the emergency department ranges from headache with vomiting to coma. In addition to managing the ABCs, the crux of emergency management lies in stopping hematoma expansion and other complications to prevent clinical deterioration. This may be achieved primarily through anticoagulation reversal, blood pressure, empiric management of intracranial pressure, and early neurosurgical consultation for posterior fossa hemorrhage. Patients must be admitted to intensive care. The effects of intracerebral hemorrhage are potentially devastating with very poor prognoses for functional outcome and mortality.

Association of Delay in Appendectomy With Perforation in Children With Appendicitis.

Objective The aim of this study was to assess whether increased time from emergency department (ED) triage to appendectomy is associated with a greater risk of children developing appendiceal perforation. Methods We performed a multicenter retrospective cohort study of children younger than 18 years hospitalized with appendicitis. To avoid enrolling patients who had perforated prior to ED arrival, we included only children who had a computed tomography (CT) scan demonstrating nonperforated appendicitis. Time to appendectomy was measured as time from ED triage to incision. The main outcome was appendiceal perforation as documented in the surgical report. Variables associated with perforation in bivariate analysis (P < 0.05) were adjusted for using logistic regression. Results Overall, 857 patients had a CT scan that demonstrated nonperforated appendicitis. The median age was 12 years (interquartile range, 9–15 years), and 500 (58%) were male. The median time to appendectomy was 11 hours (interquartile range, 8–15 hours). In total, 111 patients (13%) had perforated appendicitis at operation. Children who developed perforation were more likely to require additional CT scans and return to the ED and had a significantly longer length of stay. After adjusting for potential confounders, every hour increase in the time from ED triage to incision was independently associated with a 2% increase in the odds of perforation (P = 0.03; adjusted odds ratio, 1.02; 95% confidence interval, 1.00–1.04). Conclusions Delays in appendectomy were associated with an increase in the odds of perforation. These results suggest that prolonged delays to appendectomy might be harmful for children with appendicitis and should be minimized to prevent associated morbidity.

Echocardiography in cardiac arrest: An emergency medicine review

Introduction: Cardiac arrest management primarily focuses on optimal chest compressions and early defibrillation for shockable cardiac rhythms. Non‐shockable rhythms such as pulseless electrical activity (PEA) and asystole present challenges in management. Point‐of‐care ultrasound (POCUS) in cardiac arrest is promising. Objectives: This review provides a focused assessment of POCUS in cardiac arrest, with an overview of transthoracic (TTE) and transesophageal echocardiogram (TEE), uses in arrest, and literature support. Discussion: Cardiac arrest can be distinguished between shockable and non‐shockable rhythms, with management varying based on the rhythm. POCUS provides a diagnostic and prognostic tool in the emergency department (ED), which may improve accuracy in clinical decision‐making. Several protocols incorporate POCUS based on different cardiac views. TTE includes parasternal long axis, parasternal short axis, apical 4‐chamber, and subxiphoid views, which may be used in cardiac arrest for diagnosis of underlying cause and potential prognostication. TEE is conducted by inserting the probe into the esophagus of intubated patients, with several studies evaluating its use in cardiac arrest. It is associated with few adverse effects, while allowing continued compressions (and evaluation of those compressions) and not interrupting resuscitation efforts. Conclusions: POCUS is a valuable diagnostic and prognostic tool in cardiac arrest, with recent literature supporting its diagnostic ability. TTE can guide resuscitation efforts dependent on the rhythm, though TTE should not interrupt other resuscitation measures. TEE can be useful during arrest, but further studies based in the ED are needed.

Evaluating the risk of appendiceal perforation when using ultrasound as the initial diagnostic imaging modality in children with suspected appendicitis

Background Ultrasound scan has gained attention for diagnosing appendicitis due to its avoidance of ionizing radiation. However, studies show that ultrasound scan carries inferior sensitivity to computed tomography scan. A non-diagnostic ultrasound scan could increase the time to diagnosis and appendicectomy, particularly if follow-up computed tomography scan is needed. Some studies suggest that delaying appendicectomy increases the risk of perforation. Objective To investigate the risk of appendiceal perforation when using ultrasound scan as the initial diagnostic imaging modality in children with suspected appendicitis. Methods We retrospectively reviewed 1411 charts of children ≤17 years old diagnosed with appendicitis at two urban academic medical centers. Patients who underwent ultrasound scan first were compared to those who underwent computed tomography scan first. In the sub-group analysis, patients who only received ultrasound scan were compared to those who received initial ultrasound scan followed by computed tomography scan. Main outcome measures were appendiceal perforation rate and time from triage to appendicectomy. Results In 720 children eligible for analysis, there was no significant difference in perforation rate between those who had initial ultrasound scan and those who had initial computed tomography scan (7.3% vs. 8.9%, p = 0.44), nor in those who had ultrasound scan only and those who had initial ultrasound scan followed by computed tomography scan (8.0% vs. 5.6%, p = 0.42). Those patients who had ultrasound scan first had a shorter triage-to-incision time than those who had computed tomography scan first (9.2 (IQR: 5.9, 14.0) vs. 10.2 (IQR: 7.3, 14.3) hours, p = 0.03), whereas those who had ultrasound scan followed by computed tomography scan took longer than those who had ultrasound scan only (7.8 (IQR: 5.3, 11.6) vs. 15.1 (IQR: 10.6, 20.6), p < 0.001). Children < 12 years old receiving ultrasound scan first had lower perforation rate (p = 0.01) and shorter triage-to-incision time (p = 0.003). Conclusion Children with suspected appendicitis receiving ultrasound scan as the initial diagnostic imaging modality do not have increased risk of perforation compared to those receiving computed tomography scan first. We recommend that children <12 years of age receive ultrasound scan first.

Isoniazid Poisoning: A Pediatric Simulation Case for Emergency Medicine Residents

Introduction Seizures in the setting of isoniazid (abbreviated INH, from isonocotinylhydrazide) toxicity can be intractable and persistent despite treatment with the usual status epilepticus (SE) medications. If not recognized in a timely fashion, SE can lead to significant morbidity and mortality. This simulation scenario instructs emergency medicine and pediatric residents and fellows in any year of training on the principles and management strategies of approaching a pediatric patient with SE due to INH toxicity. Methods This scenario presents a 5-year-old pediatric patient brought into the emergency department after a witnessed seizure at home, another en route to the emergency department, and a third event in front of the medical provider. This scenario was designed to include one 15- to 20-minute group simulation session, followed by a 10- to 15-minute debriefing of the case. The simulation can be run with a minimum of two participants—one to play the role of physician and the other to play the case director or simulation operator. Also included are visual stimuli consisting of relevant lab results, imaging, and other diagnostic studies. Finally, an educational handout created for all simulation participants reviews important teaching points related to the case. Results To date, 30 residents have participated in this simulation during one of the weekly conference days. In the postactivity survey reviews, residents have reaffirmed their appreciation for their simulation time and have requested more exposure. Discussion Simulation scenarios are an ideal teaching tool for rare and life-threatening diseases, as medical trainees will have little to no prior applied experience with such conditions.

Inner Conflicts From a Resident Medico-legal Consulting Case.

Barely had I received my PGY2 in-service exam score when an attorney wrote me offering to pay for my supposed “medical expertise.” Having come across one of my FOAM blog write-ups, he asked if I would consult with him on that topic for his clients medico-legal case against the defendant emergency physician. My natural response was to inform the attorney that I was only a resident. However, it seems that is precisely why he sought my insight. This article is protected by copyright. All rights reserved.

Does the choice of antibiotic affect outcome in strep throat

There is insufficient evidence to show clinically meaningful differences between antibiotics for group A beta hemolytic streptococci tonsillopharyngitis. Penicillin or amoxicillin is recommended as first choice, given the absence of resistance and low cost.

WHAT IS THE LONG-TERM EMOTIONAL AND BEHAVIORAL IMPACT OF GENETIC RISK ASSESSMENT FOR ALZHEIMER'S DISEASE? FINDINGS FROM THE REVEAL STUDY

information linked to routine hospital and mortality data, and to be contacted again by the researchers. A second wave of data collection is ongoing (20142017) with additional questions onmemory, carers and diet. The cohort is also being replenished and coverage widened to include the entire Yorkshire and Humber region (pop 5.25mn). The new recruitment target for the cohort is 50,000. In the first wave of recruitment 28,000 adults (1,700 aged 75 or over) returned completed Health Questionnaires. The response rate was 17%. As expected, respondents were more likely to be female, over 55 years, and living in areas of low deprivation. However, the population is broadly representative of the reference population. To date 12 health studies have identified and recruited over 1100 participants to their studies (including randomised controlled trials, qualitative interviews, matched case control studies) and local authorities are using the data to inform their Joint Strategic Needs Assessments. With over 3000 participants likely to receive a diagnosis of dementia in the next five years, the Yorkshire Health Study provides an opportunity to test a range of individual and public health level interventions to treat, manage and/or prevent dementia and to understand more about the health related behaviours that affect the onset and trajectory of dementia.