While most cases of measles are mild and will self-resolve, the high infectivity of the virus is a public health hazard due to rare complications of the disease that can cause long-term morbidity and mortality. Particularly high risk populations include unvaccinated individuals, children < 5 years, adults > 20, pregnant women, and immunocompromised patients.  

Look forward to part 2 for more details on measles management, treatment, and complications! 

References: 

https://www.nj.gov/health/cd/topics/measles.shtml

https://www.cdc.gov/measles/hcp/index.html

Takhar SS, Moran GJ. Serious Viral Infections. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020. 

Nguyen M, Dunn AL. Rashes in Infants and Children. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020. 

Use these medications for aggressive blood pressure control

Load patients with magnesium early

Ultimate treatment is delivery – involve OB/NICU teams early, transfer patients if these teams are not available

Referneces:

• Episode 113.0 – Preeclampsia + Eclampsia – Core EM
• Preeclampsia and Eclampsia – Core EM
• Pre-eclampsia and Eclampsia • LITFL • CCC Obstetrics 
• Eclampsia • LITFL • CCC Obstetrics 
• ED Management of Severe Preeclampsia — EM Curious
• ACOG PRACTICE BULLETIN
• Pre-eclampsia – The Lancet
• Preeclampsia pathophysiology and adverse outcomes during pregnancy and postpartum – PMC
• Maternal Hemorrhage and Severe Hypertension/Pre-eclampsia: Identification and Management in the Emergency Department 

References:

1. Shakur H, Elbourne D, Gülmezoglu M, et al. The WOMAN Trial (World Maternal Antifibrinolytic Trial): tranexamic acid for the treatment of postpartum haemorrhage: an international randomised, double blind placebo controlled trial. Trials. 2010;11:40. doi:10.1186/1745-6215-11-40.

2. American College of Obstetricians and Gynecologists (ACOG). Postpartum hemorrhage: ACOG practice bulletin no. 183. Obstet Gynecol. 2017;130:168-186.

Peptic Ulcer Disease

Chronic illness, recurrent ulcers in stomach and duodenum most commonly due to H. Pylori and NSAIDs. 10% people in the western world will have this in their lifetime.

Symptoms:

• Burning, gnawing, achy, “empty, hungry” epigastric pain
• Relieved by ingestion of food (usually), milk, antacids (buffers/dilutes gastric acid)
• Worsens after gastric emptying, classically the pain awakens patients at night
• Chronic ulcers can be asymptomatic or cause painless GI bleeding
• NOT (usually) related to PUD: pain after eating, nausea, belching
• “Alarm features” for suspicion of cancer –> need more emergent endoscopy: >50 yo, weight loss, persistent vomiting, dysphagia/odynophagia, GIB, abdominal mass, lymphadenopathy, Family hx

Physical Exam: For uncomplicated PUD, expect benign physical exam +/- epigastric tenderness (not sensitive or specific). VS should be normal. 

Workup: Generally includes CBC to rule out anemia from chronic GIB. Consider LFT, lipase, EKG, trop, upright CXR, RUQ US to rule out other etiologist that may present similarly with epigastric pain if indicated. Gold standard for diagnosis is endoscopy.

Treatment: 

• Stop NSAIDs 
• Proton pump inhibitors: decrease acid secretion from gastric parietal cells, irreversibly bind with H+K+ATPase (proton pump).
  • Example: omeprazole, pantoprazole.
  • Heal ulcers faster than any other tx. 
• H2 receptor antagonists: Inhibit action of histamine on H2 receptor on gastric parietal cells
  • Example: famotidine, ranitidine.
  • Dose should be adjusted for patients in renal failure. 
• Sucralfate: covers ulcer crater, protects it and allows healing, but doesn’t relieve pain as well 
• Antacids: buffer gastric acid. Use for breakthrough pain. (Ex: Mylanta, Rolaids, Tums, etc) 

Dispo: As long as uncomplicated (no bleed, obstruction, perforation, etc), can be discharged from ED with Rx for meds above and referral to PCP or GI.

Gastritis

• Not the same as PUD
• Acute or chronic inflammation of gastric mucosa (not discrete ulcers) 

Causes: ischemia, toxic effects of NSAIDs, steroids, bile, alcohol, H. Pylori, autoimmune processes that destroy gastric parietal cells 

Exam: epigastric pain, N/V. Often presents with GIB: hematemesis vs chronic anemia vs melena 

References:

Fashner J, Gitu AC. Diagnosis and Treatment of Peptic Ulcer Disease and H. pylori Infection. Am Fam Physician. 2015 Feb 15;91(4):236-42. PMID: 25955624.

Malfertheiner P, Chan FK, McColl KE. Peptic ulcer disease. Lancet. 2009 Oct 24;374(9699):1449-61. doi: 10.1016/S0140-6736(09)60938-7. Epub 2009 Aug 13. PMID: 19683340.

The Basics

• On average, approximately 1300 Americans die of hypothermia each year 
• These don’t all occur in cold mountain regions. Homelessness, mental illness and substance abuse are important risk factors, particularly in urban areas. 
• Not all hypothermia cases are related to exposure! Other causes include hypoglycemia, hypothyroidism, hypoadrenalism, hypopituitarism, CNS dysfunction, drug intoxication, sepsis and dermal disease 
• Hypothermia = core body temperature < 35 degrees C (95 degrees F) 
• Mild hypothermia (32-35 degrees C): present with shivering, tachycardia, tachypnea and hypertension 
• < 32 degrees C: shivering stops and HR and BP decrease; patients become confused, lethargic and then comatose; Reflexes are lost, RR increases; bronchorrea occurs; aspiration is common; cold diuresis and hemoconcentration occur 
• As temp lowers, sinus bradycardia develops into atrial fibrillation with slow ventricular response to ventricular fibrillation to asystole. At temps < 30 degrees C, the risk for dysrhythmias increases

Rewarming and Management

• Type of rewarming is based on cardiovascular status, NOT temperature 
• Passive rewarming: removal from cold environment and wet clothes, insulation 
• Active external rewarming: warm water immersion, heating blankets set at 40 degrees C, radiant heat, forced air 
• Active core rewarming at 40 degrees C: Inhalation rewarming (warm air via the vent), heated IV fluids, GI tract lavage, bladder lavage, peritoneal lavage, pleural lavage, extracorporeal rewarming, mediastinal lavage by thoracotomy 
• Remember to handle these patients gently to avoid precipitation of ventricular fibrillation!

ECMO in Hypothermic Arrest

• The use of ECMO has been recommended as the rescue therapy of choice for hypothermic cardiac arrest for its ability to rapidly rewarm patients (8-12 degrees/hour) and provide complete cardiopulmonary support 
• Studies have shown that patients with cardiac arrest have a rate of survival of 50% with the use of ECMO, whereas, at centers without ECMO, these same types of patients have a survival rate of only 10% 
• Cases of survival with a good clinical outcome have been reported with core temperatures as low as 13 degrees Celsius and in cases requiring long transport with more than 5 hours of CPR!

Risk Factors for Poor Prognosis Despite Aggressive Therapy (ECMO, etc):

• Clear history of cardiac arrest before cooling 
• Obvious signs of irreversible death 
• Core body temperature higher than 32 degrees Celsius with asystole 
• Potassium greater than 12 mEq/L

References:

Dialysis Related Emergencies | CorePendium (emrap.org)

ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment – Philip Kam-Tao Li, Kai Ming Chow, Yeoungjee Cho, Stanley Fan, Ana E Figueiredo, Tess Harris, Talerngsak Kanjanabuch, Yong-Lim Kim, Magdalena Madero, Jolanta Malyszko, Rajnish Mehrotra, Ikechi G Okpechi, Jeff Perl, Beth Piraino, Naomi Runnegar, Isaac Teitelbaum, Jennifer Ka-Wah Wong, Xueqing Yu, David W Johnson, 2022 (sagepub.com)

Levine, Brian J. EMRA Antibiotic Guide. Emergency Medicine Residents’ Association, 2022.

Peritoneal Dialysis–Related Peritonitis: Towards Improving Evidence, Practices, and Outcomes – ClinicalKey

https://www.kidney.org/content/what-peritoneal-dialysis

Many facilities may have multiple services – often, the same facility will offer subacute rehab and long-term care and memory care services

Level of care dependent on the need of assistance as per PT/OT/Speech evaluation

Instrumental Activities of Daily Living (IADLs) = managing house, finances, transport, medications, shopping

Activities of Daily Living (ADLs) = walking, toileting, bathing, feeding, transferring

Starting to talk about rehab in the ED:

• Is this a rehab-able condition?
  • Rehab-able condition examples: stroke, hip fracture, deconditioning after serious illness
  • Potentially not rehab-able examples: any progressive, gradual degenerative disease in which the patient is expected to continue to decline
• Why does this matter?
  • Insurance will stop paying for rehab if patient is not improving or making progress based on their PT/OT/ST notes
  • There is a daily copay for patients after 21 days in rehab and the full cost is on the patient after 100 days
    • PT is amazing but cannot fully reverse a months-long decline in 21 days!

• Will the patient be able to physically and cognitively participate in rehab?
  • Acute inpatient rehab = 3 hours therapy/day
  • Subacute rehab = 3 hours/week
• Patients are not rehabbed until they can go home safely – patients are rehabbed until they can safely live in a one-story home.
  • So what is the goal after rehab? What is the backup plan if they still can’t go home after 21 days? Will they still need help?

References:

https://www.genworth.com/aging-and-you/finances/cost-of-care.html

https://www.medicare.gov/care-compare/

https://www.aarp.org/caregiving/

Flint LA, David DJ, Smith AK. Rehabbed to Death. N Engl J Med. 2019;380(5):408-409. doi:10.1056/NEJMp1809354

Flint LA, David D, Lynn J, Smith AK. Rehabbed to Death: Breaking the Cycle. J Am Geriatr Soc. 2019;67(11):2398-2401. doi:10.1111/jgs.16128

Burke RE, Jones J, Lawrence E, et al. Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care. J Gen Intern Med. 2018;33(5):678-684. doi:10.1007/s11606-017-4298-1

Halifax E, Bui NM, Hunt LJ, Stephens CE. Transitioning to Life in a Nursing Home: The Potential Role of Palliative Care. J Palliat Care. 2021 Jan;36(1):61-65. doi: 10.1177/0825859720904802. Epub 2020 Feb 27. PMID: 32106767; PMCID: PMC8127871.