EMplify by EB Medicine

Sam Ashoo, MD

EMplify summarizes evidence-based reviews in a monthly podcast. It highlights the latest research published in EB Medicine’s peer-reviewed journals to educate and arm you for life in the ED.

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5d ago
15 mins
A brief summary of what you need to know if you work in the emergency department or urgent care. Epidemiology Caused by double stranded DNA virus, genus orthopoxvirus, closely related to smallpox and cowpox.Discovered in 1958 in monkeys with first human case recorded in 1970 in the Democratic Republic of Congo. (CDC) It is a zoonotic disease , meaning it is transmitted from animal to humans, with primary reservoir in squirrels, Gambian poached rats, dormice, different species of monkeys and others.  First reported in the U.S. in 2003. Cases were related to pet prairie dogs that had been housed with monkeypox virus infected African rodents, imported from Ghana (WHO)There are 2 clades (having evolved from same ancestral line) of the disease. The current outbreak is from the West African lineage. (WHO)West African - milder disease, 1-3% fatalityCongo Basin - severe disease, 10% fatality Due to the similarity in the viruses, immunization against smallpox has been found to prevent infection with monkeypox. The WHO believes that increasing frequency of worldwide infection may be related to waning immunity against smallpox, since that disease was eradicated in 1980 and the vaccine is no longer popularly used.  Transmission Animal to human - contact with sick or dead animals, ingesting poorly cooked meat of infected animals.Human to human -" Human-to-human transmission is thought to occur primarily through large respiratory droplets. Respiratory droplets generally cannot travel more than a few feet, so prolonged face-to-face contact is required. Other human-to-human methods of transmission include direct contact with body fluids or lesion material, and indirect contact with lesion material, such as through contaminated clothing or linens." (CDC) Symptoms Initial 1-3 days - fever, lymphadenopathy, back pain, headache, myalgias, fatigue2-4 weeks of rash progression: macules -> papules -> vesicles -> pustules -> scabsThe pox rash starts on the face and spreads to the rest of the body. Source: CDC Testing Detection is by PCR testing, ideally of body fluid contained in the pox blisters.Test kits are available through local U.S. Health Departments and the CDC. All suspected cases should be reported to local authorities. Treatment Treatment includes vaccinating anyone who has been exposed with the smallpox vaccine (ring vaccination). The general population is no longer routinely vaccinated due to side-effects of the smallpox vaccine. No current recommendation exists for antiviral therapy or smallpox immunoglobulin therapy.  See CDC recommendations  Prevention The JYNNEOS vaccine was FDA approved in 2019 for adults > 18 against both smallpox and monkeypox. It is a 2 dose non-replicating attenuated virus that does not produce a lesion, and therefore can not cause transmission to others. The CDC Advisory Committee on Immunization Practices is currently evaluating vaccine data with a formal recommendation pending. Media reports note the U.S. government has ordered millions of doses. The original smallpox vaccine (DRYVAX) is no longer in production. However, a second generation clone, ACAM2000, is produced by Synofi and approved by the FDA. The WHO notes that smallpox vaccine is 85% effective in preventing monkeypox.Vaccination is recommended for lab workers and anyone exposed to monkeypox. The CDC recommends vaccination within 4 days of exposure to prevent disease, with ACAM2000. However, vaccination between days 4-14 is also recommended to reduce disease severity. Vaccination does carry risks. The CDC estimates "Based on past experience, it is estimated that between 1 and 2 people out of every 1 million people vaccinated will die as a result of life-threatening complications from the vaccine"  (ACAM2000) but notes that disease fatally is 1-10% outweighing the risk of vaccination.  Further Reading Current WHO Outbreak TrackerCDC Monkeypox ReferenceJohns Hopkins Monkeypox Reference
5d ago
15 mins
Conversation- Ep. 2- Airway ManagementEpisode 69 – Cellulitis and Other Skin and Soft Tissue Infections
May 9 2022
48 mins
Conversation – Dr. Lorna Breen LegislationEpisode 68 — Meningitis and Encephalitis – An Interview with Dr. Andrew Hogan
Episode 68 -- Emergency Department Management of Adults With Infectious Meningitis and Encephalitis – An Interview with Dr. Andrew Hogan EMplify -- April 2022 Interview with the Author: Andrew N. Hogan, MD 1.Meningitis vs encephalitis Why this topic? What do the words mean? What's the difference? 2.Bacterial meningitis How common is it in the US? Is it more common in third world countries? Mortality rate in the US Causes – if Neisseria and H influenzae improved post vaccination, why not S pneumoniae disease ? (Table 1) 3.Viral meningitis How common is it in the US? What are the common causes? (Table 2) 4.Viral encephalitis Same prognosis as viral meningitis? Same organisms as viral meningitis? (Table 2) Does COVID-19 cause this illness? 5.Fungal infections Who gets these? 60% die? 1 million cases a year, 600K deaths? 6.Prehospital care: What does EMS need to know? How do they protect themselves from being exposed? How can they help us make the diagnosis? EMS is giving antibiotics in some areas? PEP 7.ED evaluation: History 8.ED evaluation: Physical exam 9.Diagnostics: CSF What's large volume? Is it safe? Cell counts on tubes 1+4, all the time or only if traumatic and obviously bloody? Is opening pressure helpful? CSF lactate level – can this be run in a normal lactic acid analyzer? PCR/NAAT testing 10.Serum labs What is helpful? Serum PCR Serum cryptococcal antigen 11.Imaging  Is CT imaging before LP still necessary? Can we be selective? Is MRI helpful in the ED, or is there a role in encephalitis? 12.Treatment Antibiotics Steroids: Who gets them? When? Are there downsides of giving them? 13.Special populations Autoimmune disease Lacking childhood vaccines Healthcare associated infections 14.Cutting edge 15.Disposition
Apr 1 2022
56 mins
Episode 67 – Managing Postpartum Complications in the Emergency Department – An Interview with Dr. Nicole Yuzuk, Dr. Joseph Bove, and Dr. Riddhi DesaiEpisode 66 – Acute AsthmaEpisode 65 – Acute Joint PainEpisode 64 – Thoracic Aortic Syndromes- An Interview with Dr. Anthony HackettEpisode 63 – Rib Fracture- An Interview with Dr. Patrick MaherEpisode 62 – Cervical Spine Injuries- An Interview with Dr. Jara-AlamonteEpisode 61 – Abnormal Uterine BleedingEpisode 60 – Less Lethal Law Enforcement WeaponsEpisode 59 – HIV – An Interview With Dr. Daniel Egan
EMplify - July 2021 Announcements: Be on the lookout for an announcement regarding the new EB Medicine app, coming to an App Store near you this month !! HIV- An Interview With Dr. Daniel Egan See the EB Medicine Article @ https://www.ebmedicine.net/topics/infectious-disease/HIV Why HIV?  2018 , 1,2 million people living with HIV, almost 40k new infections People living with HIV visit the ED 3 x per year on average HIV infected patients accounted for 6 in 1000 ED visits in 2017 New Transmission of HIV, Figure 1 What does acute infection look like ? What about chronic infection ?The chronic phase can last 10 years or more and be asymptomatic. Are people with HIV more likely to develop: CAD, COPD, DVT and why? What if they are on medication for HIV? Screening in the ED, everyone? Do they have to have symptoms or risks? What does universal screening mean? What does risk based screening mean? What are the risk factors? What if I see someone on PrEP who is in the ED for an unrelated complaint? History Ask about cd4 and viral load and last test Ask about he of opportunistic infections Ask about medication side effects What else? Exam Labs - rapid testing, 4th gen, viral load and cd4, etc Imaging Treatment Table 1 Highly effective and reduces transmission Medication side effects (we don’t have to dwell on each Med and side effect and just reference the charts) hep B virus deactivation System Based Disease Heart Failure and CAD PCP (role of LDH) TB COPD Renal Disease - stones , radiolucent Neurologic- CVA, cryptococcal meningitis, toxo, progressive multi focal leukoencephalopathy, HAND GI - diarrhea causes, c diff, hep C Heme- cytopenia Endocrine - metabolic syndrome Musculoskeletal Psychiatric table 3 Derm Special Circumstances PEP PrEP
Jul 2 2021
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Episode 58 – Syncope – An Interview With Dr. James Morris
Jun 2 2021
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Episode 57 – Atrial Fibrillation : An Approach To Diagnosis And Management In The Emergency DepartmentEpisode 56 – Management of Suspected Rabies Exposure in the Emergency Department
EMplify - April 2021 Announcements Traumatic Hemorrhage in the ED- with Dr Scott Weingart - April 13th, 8pm EST Free ! Register now: https://www.crowdcast.io/e/traumatic-hemorrhagic/register Pandemic Preparedness publication is coming soon. Mt Sinai COVID-19 Treatment Protocols have been updated and are available for free here: https://www.ebmedicine.net/topics/COVID-19/Protocols The Clinical Decision Making in the Emergency Department conference is June 23-27 live and virtual. More information here: https://clinicaldecisionmaking.com   Management of Suspected Rabies Exposure in the Emergency Department - An Interview with Dr. Bess Storch Epidemiology: Fatality rate of over 99% Half of cases occur in children 95% of cases are in resource limited countries, 35% in India 99% caused by infected dogs (worldwide) In the US, cases are predominantly bat variant Why this topic? "In a recent survey of licensed physicians, less than half could identify rabies transmission routes, the correct PEP schedule, and the correct anatomic administration sites." Pathophysiology: What causes it? The RNA virus Lyssavirus How is it transmitted? How does it reach the brain? ED Evaluation: What does it look like clinically? 5 stages- incubation, prodrome, acute neurologic phase, coma death Why doesn’t everyone just get vaccinated? What patient medical history is important ? Steroids, chloroquine What animals are high risk? What about pets and quarantine? What about rodents ? Is there any role for labs or imaging ? What is the treatment regimen for those who are unvaccinated? And vaccinated? What about people who are immunosuppressed? Children? Pregnant? Recently traveled?
Apr 6 2021
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Episode 55 -Management of Acute Urinary Retention in the Emergency DepartmentEpisode 54 – Community-Acquired Pneumonia in the Emergency Department – Interview with  Matthew DeLaney, MDEpisode 53- Evaluation and Management of ST-Segment Elevation Myocardial Infarction in the Emergency Department