Infection Control Management of Suspected and Confirmed Ebola Cases (Ebola Management Training)

Good day …

On behalf of Dr. Sami Yousef, A/Chairman, Disaster Preparedness Committee / Consultant, Emergency Medicine, we are glad to announce the rest of the schedule for the above mentioned training. For those who were not able to attend the last training schedule, kindly choose to attend the Ebola Management training as follow :

November 2014 : ( 23, 24 & 30) & December 2014 ; (4,7,11,14 & 18) from 8am-1pm

P.S. The Max number per session is 10 Physician.

Regards

EBM Workshops for the Academic Year 2014-2015

Greeting all,

We are going to have 2 EBM Workshops (duplicated) focusing mainly on critical appraisal of therapeutic and diagnostic articles, as follow:-

1st workshop: 9 September 2014 , 8 – 12 am

2nd workshop: 23 September 2014, 8 – 12 am

They will take place in KAMC-ED Conference Room.

They will be provided by Dr. Majed Alsalamah and Dr. Abdulmehsen Alsaawi.

Each resident is allowed to register in one workshop, and maximum of 16 resident in each.

Any resident welling to join, he can contact me through email (dr.aas3@gmail.com), first come first served.

Priority is for potential R2, however, all are more than welcome to join.

 

Thank you and good luck

Abdussalam Alshehri

Ex-Journal Club Moderator

ST-elevation in aVR due to RCA occlusion

1 - Edited

Fig. 1

2 - Edited

Fig. 2

This is the case of a 56 year old male admitted 2 days prior for headache which turned out to be ICH patient was treated on a medical ward for this. His vital signs were stable and sustained no neurological deficits. The next evening, the medical on call was contacted for this patient for unilateral leg pain and swelling, which was appropriately investigated with doppler ultrasound. Results showed a DVT. The decision was made NOT to heparinize the patient due to his ICH. This decision was multidisciplinary involving the patient and family (including his son who is a HCP) with neurology and internal medicine. Next morning, the patient developed chest pain and the above EKG was taken see fig. 1.

A few minutes later the patient arrested and CPR was done as per ACLS protocol. This EKG was compared to the EKG done on admission, two days prior, see fig 2. So what was the reason for the arrest? The only investigation done prior to the arrest and subsequent death was the EKG in Fig. 1 This EKG has many telltale findings that could explain what made this patient arrest. There are ST-segment elevations in both the inferior leads and anterior leads. There is also ST-segment elevation in aVR of greater that 0.5 mV. There is pooled data demonstrating that this finding has approximately 78% sensitivity and 83% specificity for left main coronary artery disease.

Alternatively, this finding can also be the result of multi-vessel disease of acute proximal LAD or less commonly left circumflex or RCA.(1) To favor left main coronary artery occlusion ST-Elevation of AvR would be greater than that of V1, which is not the case in the above fig 1 EKG (2) In keeping with which territory the occlusion has occurred or what has caused the arrest, an ST-segment elevation inferiorly that is greater in lead III than in lead II, accompanied by ST-segment depression in lead aVL, I, or both, is 90% sensitive and 71% specific for right coronary artery occlusion. (3) With this evidence at hand, I believe this is more likely to be a very unlikely EKG presentation of RCA occlusion rather than a left main coronary occlusion. Furthermore, this extensive RCA occlusion was likely to be accompanied by RV infarction.

ST segment elevation is usually greater in lead III than in lead II when right ventricular infarction coexists with inferior AMI.(4) A coexistent reciprocal change with inferior STEMI is associated with larger infarct size and increased mortality.(5) A completely different theory was challenged. The patient had a DVT diagnosed and was not treated for it, then developed chest pain. Could the arrest and EKG finding be due to a PE? We know that PE can well cause ST-elevation in aVR. The fact that there is ST-depressions in lead I and aVL increases the sensitivity that this is AMI up to 84%.(6) Reciprocal findings are not present in PE. Also, PE does not cause ST-elevation in the inferior leads. And in keeping with AMI, the inferior leads have pathological Q waves. With all that said, my opinion is that this is a case of RCA occlusion with RV infarct, that caused the arrest of this patient.

Note! Consent has been taken from the patient’s son to publish the EKG.

References

1. Rostoff P, et al: Electrocardiographic prediction of acute left main coronary artery occlusion. Am J Emerg Med  2007 Sep;25(7):852-5.

2. Yamaji H, et al: Prediction of acute left main coronary artery obstruction by 12-lead electrocardiography. ST segment elevation in lead aVR with less ST segment elevation in lead V1. J Am Coll Cardiol 2001 Nov 1;38(5):1348-54. 

3. Zimetbaum PJ, Josephson ME: Use of the electrocardiogram in acute myocardial infarction. N Engl J Med 2003 Mar 6;348(10):933-40.

4. Zehmer U, et al: Effects of fibrinolytic therapy in acute myocardial infarction with or without right ventricular involvement. J Am Coll Cardiol 1998; 2:876

5. Martin TN, Groenning BA, Murray HM et al. ST segment deviation analysis of the admission of 12 lead ECG as an early diagnosis of AMI with cardiac Magnetic Resonance Imaging as gold standard. J Am coll cardiol. 2007;50(11):1021-1028. doi:10.1016/j.jacc.2007.04.090

6. Saw J, Davies C, Fung A, Spinelli JJ, Jue J: Value of ST elevation in lead III greater than lead II in inferior wall acute myocardial infarction for predicting in-hospital mortality and diagnosing right ventricular infarction. Am J Cardiol Feb 15;87(4):448-50, A6.

Educational Pearls (last week)

Good afternoon all, here are some points from our last academic activity entitled (The Immunocompromised Patient):

  • There are 2 types of immunity: innate which does not need previous exposure and acquired (adaptive) immunity which needs pervious antigen exposure .

 

  • The stem cell of bone marrow contains 3 times the number of WBC found in the circulation .

 

  • Pregnancy causes immunosuppression .

 

  • Cyclosporine is metabolized by cytochrome P-450, so try to avoid prescribing any medication that shares the same enzyme for metabolism, for example, a concomitant macrolide can cause hepatotoxicity or even rejection .

 

  • Corticosteroids:
    1. May cause change in WBC count as early as 6 hours from administration.
    2. Any abdominal pain in a patient who is on corticosteroid should be taken seriously and needs to be investigated for serious complications  such as perforated viscous and intra-abdominal abscess.
    3. Sutured wounds in patients on corticosteroids need double the time to heal (it affects healing).

 

  • Febrile Neutropenia:     ANC = WBC count * ((PMNs/100) + (Bands/100)).

Initiation of monotherapy with an anti-pseudomonal beta-lactam agent, such as cefepime, meropenem, imipenem/cilastatin or piperacillin-tazobactamCeftazidime monotherapy has also been shown to be as effective as other regimens .

  • HIV-positive patients: if CD4 is below 200 then this patient needs a prophylactic antibiotic for PCP.

 

  • 30% of elderly patients with infection will present without fever. Thus, absence of fever does not rule out infection.

 

  • 89% of elderly patients coming with fever will have an infection. (so deal with fever seriously in this group of patients).

MERS-Cov In Your ED!

To date, there are 133 deaths and nearly 500 confirmed cases of MERS-cov in Saudi Arabia alone. This means that there is not a major ED in KSA that has not seen at least one case. The risk is real. Presentations range. Talking to residents in our program, most have seen a case some have seen a few, this exceeds any other area in the world with a country as big as USA for example only having two.

The emergency department numbers over the past few months are quieter in the capital, Riyadh. With the worry of the same patient, one may ask is this corona or not?! Even the frequent flyer elderly who has had the same presentation of her pulmonary edema for the past 5 years due to her non-compliance to medication wants to know if this time it is corona or not! In April, as shown in the graph below from WHOthe majority of cases has been diagnosed. Could it be because we are screening more people?

Alqattan - Edited

 

 

 

 

 

 

 

 

 

Epidemic curve of 536 patients worldwide lab-confirmed cases of MERS-cov by outcome as of 8 may 2014

The biggest danger seems to be us, health care professionals. Sadly, we have lost consultants, residents and nurses to this disease. Precaution is vital. Person-to-person transmission has been documented. WHO as does the Saudi Authority M.OH, recommend droplet precautions as the disease. So wearing of a mask is important. All our triages give surgical masks to patients with a respiratory complaint. Anyone who may get in contact with secretions as for example those nurses and RTs doing suctioning or residents intubating should be more careful. This may include gowns in addition to gloves. Instruct family members who have accompanied the patient to do the same. The incubation period of the virus is 14 days.

Patients with MERS-cov may present with a mixture of upper and lower respiratory tract infection. This includes fever, cough, sputum, coryza. There are cases that presented with diarrhea in addition to above. Patients then go to acute renal failure. The mean age was 48.5 years but the youngest case in KSA was 9 months. Health care workers are more likely to be younger, female and milder disease. However, 15% of health care workers have been affected by a severe course of the disease, resulting in ICU admission or death. One confirmed case was a middle aged diabetic who came with altered mental status and a fever. The altered mental status turned to be due to a third degree heart block from a potassium of 7.5 from her acute renal failure from her MERS-cov! So presentations vary!

As for management and treatment, hospitals are requesting all admitted patients with suspicision to be swabbed. Some hospitals such as KFSH have opened itsPCR for twice daily due to the influx. Treatment is supportive care and symptom relieve.