Catching Necrotizing Fasciitis Early in the ED

A well-known adage is that necrotizing fasciitis, which is colloquially abbreviated to “nec-fasc,” is a rapidly progressive and often fatal disease that proves difficult to diagnose.

Image Courtesy of DermNet NZ

Nomenclature and Background Information

Necrotizing fasciitis is a subset of a larger group of diseases known as necrotizing soft tissue infections or NSTIs. In this blog post, the term NSTI will be used in an effort to be inclusive of infection that may be affecting the muscles (myositis), deeper dermis and subcutaneous tissue (cellulitis) or fascia (fasciitis).

The first known reference to the disease process can be traced back to the 5th century; Hippocrates, who is often referred to as the father of medicine, wrote, “[m]any were attacked by the erysipelas all over the body when the exciting cause was a trivial accident…flesh, sinews, and bones fell away in large quantities…there were many deaths.” The description from over two thousand years ago still holds true today, and although NSTIs are rare, the average mortality reported has been around 20% in the past 20 years (ranging from 15% to 45%, depending on the study examined).


The types of NSTIs can be classified either by anatomical location (i.e. most commonly affects the extremities, or, if there is perineal, genital and perianal involvement, it is known as Fournier gangrene) or bacterial involvement (divided into the following types).

  • Type 1: polymicrobial (aerobic and anaerobic) – more common than type 2
    • elderly patients, comorbidities (DM, ulcers), previous surgical intervention
  • Type 2: monomicrobial (Group A streptococcus, MRSA)
    • in any age group and even patients without underlying disorders
    • 50% of cases have no clear portal entry
  • Type 3: gas gangrene (Clostridium sp.)

Risk Factors

Although NSTIs can occur in patients without significant medical disease, there are definite risk factors that increase one’s chance of developing an NSTI:

  • patient-related factors: diabetes mellitus, obesity, peripheral arterial disease, chronic alcohol abuse, immunosuppression, malignancy, end-stage renal disease
  • barrier integrity-related factors: cutaneous lesions like insect bites or penetrating trauma, injection drug use, surgical incisions (for example, neonatal circumcision), mucosal breach (such as hemorrhoids, episiotomy)

Sign and Symptoms

  • hard signs (note that only 1/3rd of patients may present with these “textbook” signs): bullae, crepitus, violaceous hue, “dishwater” discharge
  • systemic signs: low-grade fever with tachycardia (out of proportion to the fever)
    • other non-specific signs: malaise, myalgias, diarrhea, anorexia
  • edema, brownish skin discoloration, decreased sensation in affected limb, a sense of heaviness
    • PEARL: make sure to mark the borders of the erythema to track progression
  • mental status changes (delirium, irritability)

In an article titled, “Pitfalls in Diagnosing Necrotizing Fasciitis,” Table 2 outlines the evolution of physical signs from early to late disease.


The gold standard for diagnosis is via surgical exploration; however, in order to get a patient to surgery in a timely fashion, there are important tests that can raise suspicion that there is an underlying NSTI.

In laboratory tests, the following findings may be suggestive of NSTI, but there is no one specific sign that would be pathognomonic. A patient may have metabolic acidosis, coagulopathy, leukocytosis with left shift, anemia, thrombocytopenia, elevated CRP/ESR, myoglobinuria, signs of renal or hepatic dysfunction, and interestingly, hyponatremia and well as hyperlactatemia.

One notable finding is that elevated serum CK or AST concentrations suggest deep infection involving muscle or fascia rather than more superficial cellulitis. Furthermore, another source considered the utility of trending procalcitonin levels as a representation of adequate infection source control.

In terms of imaging tests, radiography can be useful but is not a necessity. If suspicion for NSTI is high, patient should immediately be sent to surgery. The best imaging modality is CT, and the presence of gas is nearly pathognomonic. Other signs suggestive of NSTI may be:

  • presence of fluid collections or abscess
  • heterogeneity or absence of tissue enhancement
  • edema at or below level of fascia

LRINEC (Laboratory Risk Index) Score

While there is a score for screening NSTIs, known as the Laboratory Risk Index, it has not been externally validated as of 2017. Nevertheless, looking at the components of the score on MDCalc gives a clinician an idea of what type of parameters might be of interest in diagnosing necrotizing soft tissue infections. 

The LRINEC score determined that the laboratory findings of interest are: CRP, WBC, hemoglobin, sodium, creatinine and glucose. The score has “high specificity but low sensitivity” – what does this mean? This means that if your LRINEC score is low or normal, this does not rule out an NSTI; however, if it is 6 or higher, that raises the suspicion and further workup is recommended.

Differential diagnosis

  • cellulitis
  • dermatological rash (contact dermatitis)
  • pyoderma gangrenosum
  • pyomyositis
  • deep vein thrombosis
  • calciphylaxis (cutaneous manifestations)


The two pillars of treatment are surgery and antibiotics.

Broad spectrum antibiotics should be given intravenously as soon as necrotizing infection is suspected, but only aftertwo sets of blood cultures have been taken. The antibiotic of choice, according to Tintinalli’s Emergency Medicine Manual (8th) edition are the following:

  • vancomycin 1 gram IV every 12 hours PLUS meropenem 500 to 1000 mg IV every 8 hours
  • alternatively: vancomycin (same regimen) PLUS piperacillin/tazobactam 4.5 gram IV every six hours
  • clindamycin can be added to the regimen (mechanism of action: inhibits toxin synthesis)

Surgical debridement is key. In severe cases, surgery will need to be radical and aggressive to ensure optimal outcomes and include fasciotomy or even amputation.

Other considerations:

  • aggressive intravenous fluid resuscitation (IV crystalloids)
  • may consider: blood transfusion (if hemolysis results in severe anemia)
  • may consider: tetanus prophylaxis (based on mechanism of injury)


Certain clinical characteristics have been associated with higher mortality; these vary by study; the list below compiles the features that are frequently mentioned across the board:

  • advanced age
  • female sex
  • multiple comorbidities
  • sepsis upon presentation

Potential Treatment Delays

Treatment of NSTIs is unequivocally surgical debridement, but unfortunately surgery doesn’t always happen within 24 hours. There are a few factors that inhibit prompt treatment, which can be broken into three larger categories: patient delay (not seeking care early enough), physician delay (not recognizing the signs) and system delay (logistical issues within a hospital system). Issues in one or all of these categories can result in catastrophic outcomes.

Two out of these three categories are outside a physician’s control; however, with thorough training and continuing medical education, we can work to minimize the cases in which the delay is due to a “missed diagnosis” on the part of the clinician.

Tips for Recognizing NSTIs Early

Always maintain a high index of suspicion. What does that mean? It means that the threshold for considering (and ruling out) necrotizing soft tissue infections needs to be low.

Host of the Trauma ICU Rounds podcast Dr. Dennis Kim stated that for him, a patient who presents with soft tissue infection with swelling, erythema, pain out of proportion (POOP) to physical exam with systemic symptoms is enough to consider a surgical consultation.

Although knowing the classic signs and symptoms of necrotizing soft tissue infections is paramount to a timely diagnosis, it is prudent to keep in mind that not all cases will present “classically.” 

Here are some important considerations:

  • patient need not have comorbidities to develop an NSTI
  • fever may be absent; this could be due in part to use of over-the-counter NSAIDs
  • although classically associated with a break in the skin, bacteria can travel hematogenously from other sites (like Streptococcal pharyngitis)
    • in fact, patient may not have cutaneous manifestations superficially
  • infection can be acute (developing over hours) but can also be indolent (like in DM foot ulcers)
  • pain out of proportion in what appears to be a simple cellulitis should raise warning bells

References and Further Reading

  • Goh T, Goh LG. Pitfalls in diagnosing necrotizing fasciitis. Patient Safety Network. Published August 21, 2014. Accessed September 1, 2021.
  • Ho, Wong Chin. MDCalc: LRINEC Score for Necrotizing Soft Tissue Infection. LINK
  • Kim, D. (Host). (2021, June 07). Necrotizing Soft Tissue Infections (No. 39) [Audio podcast episode]. In Trauma ICU Rounds. Surgery Academix Corps. LINK
  • Nawijn, F., Smeeing, D.P.J., Houwert, R.M. et al. Time is of the essence when treating necrotizing soft tissue infections: a systematic review and meta-analysis. World J Emerg Surg 15, 4 (2020).
  • Stevens D. Necrotizing soft tissue infections. UpToDate. Published August 25, 2021. Accessed September 2, 2021.
  • Tintinalli, Judith E, and David Cline. Tintinalli’s Emergency Medicine Manual (8th ed.). New York: McGraw-Hill Medical, 2017.
Cite this article as: Helena Halasz, Hungary, "Catching Necrotizing Fasciitis Early in the ED," in International Emergency Medicine Education Project, December 6, 2021,, date accessed: September 21, 2023

Question Of The Day #60

question of the day
Which of the following is the most likely cause for this patient’s condition? 

This first-trimester pregnant patient presents with generalized weakness, nausea, and vomiting.  She is hypotensive and tachycardic with no sign of urinary infection on the urinalysis.  The many ketones in the urine indicate the patient has inadequate oral nutrition and is breaking down muscle and adipose tissue for energy.  This is likely related to the persistent vomiting the patient is experiencing.  This patient has hyperemesis, a common condition in the first trimester of pregnancy that is caused by rising levels of beta-human chorionic gonadotropin (BHCG).  Treatment for this patient should include IV hydration and antiemetics.  Admission criteria for these patients includes intractable vomiting despite antiemetic administration, over 10% maternal weight loss, persistent ketone or electrolyte abnormalities despite rehydration, or uncertainty in the diagnosis. 

The fluid losses caused by vomiting in this condition result in hypovolemic shock (Choice B).  Distributive shock (Choice C) is caused by other conditions, like sepsis, anaphylaxis, and neurogenic shock.  A ureteral stone (Choice D) is unlikely as the patient does not report any abdominal, back, or flank pain.  The urinalysis also does not show any hematuria, which is a common sign of a ureteral stone.  Pyelonephritis (Choice A) can cause vomiting and septic shock which can result in hypotension and tachycardia.  However, there is no sign of infection in the urinalysis provided, no fever, and no back or flank pain.  The best answer is choice B.  


Cite this article as: Joseph Ciano, USA, "Question Of The Day #60," in International Emergency Medicine Education Project, October 22, 2021,, date accessed: September 21, 2023

Infectious mononucleosis

Infectious mononucleosis

Case Presentation

A 16-year-old boy presents to A&E with a fever, an extremely sore throat, and a recent blotchy rash on his back that has been concerning him. He complains of feeling extremely tired and lethargic for the past two weeks. He denies having recently been in contact with anyone ill and confirms that he is up-to-date with his vaccinations. He mentions a visit with his local GP last week, where his doctor prescribed a dose of amoxicillin for a suspected throat infection. He has no other significant medical history. Upon further examination, his pharynx and tonsils appear inflamed with whitewash exudate and he has swollen neck lymph nodes in both the anterior and posterior triangles of the neck.

What is/are the most appropriate next step(s) in the patient’s management?

The answer is c) Arrange a full blood count and a monospot test

What is Glandular Fever?

Infectious mononucleosis, also known as glandular fever, is an infection resulting most commonly (80-90%) from an Epstein-Barr virus (EBV). About 95% of adults in the world have been infected with EBV; however, it is rare for it to progress into glandular fever. Glandular fever is most commonly seen in individuals aged 15-24, but can present in all age groups. The prevalence of glandular fever is estimated to be between 5-48 cases per 1000 persons. Glandular fever is rather rate in those under 10 or older than 30 (1/1000 persons), so it may not need to be in your top differentials in those age groups! In young adults, the likelihood of developing glandular fever from a primary EBV infection is about 50%; in older adults the chances of EBV infection progressing to glandular fever is slim.

For the most part, glandular fever is not contagious. It’s mostly spread through contact with saliva; such as by kissing, sharing food, or children putting things in their mouths. It can also be spread through sexual contact. Luckily, in most occurrences, glandular fever is self-limiting and lasts two to four weeks. The most common lasting effect is fatigue, which can continue from weeks to months.

When Should You Suspect Glandular Fever?

The classic ‘triad’ of symptoms for glandular fever are: 

  • Fever
  • Lymphadenopathy
  • Pharyngitis (‘sore throat’)

Bilateral posterior cervical lymphadenopathy is typical for glandular fever. Tonsils may also be enlarged, and exudate on the tonsils is described as ‘whitewash’. 

Additional signs and symptoms that could include:

  • Prodromal symptoms: 
    • Fatigue, chills, myalgia, headache
  • Palatal petechiae
    • 1-2mm in diameter and lasting 3-4 days
  • Abdominal pains 
  • Nausea and vomiting 
  • Non-specific rash
    • In this case, the patient had a maculopapular rash which is associated with EBV infection. It can be caused by the infection directly but more commonly presents after being treat with amoxicillin; patients should not take penicillin antibiotics when they have infectious mononucleosis. 
  • Splenomegaly 

If you see, or the patient tells you, of any of the following symptoms during their visit to the emergency department, it requires hospitalization! 

  • Difficulty swallowing 
  • Difficulty breathing 
  • Severe stomach/abdominal pain

These may suggest malignancy. Difficulty swallowing and breathing are most often due to inflamed tonsils and may require steroids. Severe stomach/abdominal pain might suggest a ruptured spleen. Refer to your local guidelines for investigation and treatment if these symptoms present. 

Differential Diagnoses

Viral pharyngitis

  • This is the most common alternative diagnoses
  • Viral pharyngitis tends to be more erythematous 
  • Exudate is not common with viral pharyngitis

Bacterial tonsillitis

  • Bacterial tonsillitis is more commonly described as having ‘speckled’ exudate on tonsils, compared to the ‘whitewash’ exudate on tonsils in glandular fever
  • Lymphadenopathy is usually limited to the upper anterior cervical chain, where in glandular fever, lymphadenopathy can be commonly seen in both anterior and posterior triangles

Other differentials could include other causes of lymphadenopathy, such as inflammation/infection, lymphoma, or leukemia. Alternative viral infections should also be considered (e.g. cytomegalovirus, acute toxoplasmosis, acute viral hepatitis, inter alia). 

Investigations If Glandular Fever Is Suspected

In children younger than 12, or a person who is immunocompromised, a blood test for EBV viral serology should be arranged (if the patient has been ill for seven days). 

In individuals older than 12, a full blood count with differential white cell count and a monospot test should be arranged in their second week of illness. Glandular fever is likely if:

  • The monospot test is positive
  • The full blood count has more than 20% atypical lymphocytes 


More than 10% atypical lymphocytes and the lymphocyte count is more than 50% of the total white cell count.


The patient only needs to be hospitalized if they have stridor, difficulty swallowing, are dehydrated, or there is a chance of potentially serious complications (such as a splenic rupture). Steroids should only be used if the patient shows to have difficulty breathing, otherwise, management should be conservative. If the patient doesn’t have any of these concerning signs, it is appropriate to advise the patient of their illness and discharge them for follow-up with their GP.

Some Recommendations To Patients

Some things you can advise the patient on for self-management of glandular fever include:

  • Symptoms usually only last 2-4 weeks 
  • Fatigue may be the last symptom to resolve
  • Relieve symptoms of pain and fever with paracetamol or ibuprofen
  • Encouraging normal daily routines and that exclusion from work or school is not necessary
  • Spreading of disease can be limited by avoiding kissing and not sharing eating utensils
  • They should return to the hospital if they suspect any serious complications (such increased difficulty to breath/swallow, or severe abdominal pain)

References and Further Reading

Cite this article as: Nadine Schottler, Great Britain, "Infectious mononucleosis," in International Emergency Medicine Education Project, August 16, 2021,, date accessed: September 21, 2023

Sepsis – An Overview and Update

An Overview and Update

What is Sepsis?

Sepsis is a composite of symptoms and clinical signs that correspond to infection within a patient. This clinically heterogeneous syndrome may be fatal due to the extensive inflammatory processes and organ dysfunction it can provoke.

The New Definition of Sepsis

In 2016, after a revision by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine, sepsis was redefined as “a life-threatening organ dysfunction caused by a dysregulated host response to infection.”

This new definition of sepsis means that the patient’s body, in response to infection, reacts by causing damage to its own organ structures, and this process can progress to the point where death can be an unfortunate end result.

Along with this up-to-date definition of sepsis, up-to-date criteria for evaluating sepsis were also provided; however, let’s first consider the causes of sepsis.

What is the Aetiology of Sepsis?

Sepsis can be caused by various organisms ranging from viruses to fungi to protozoans; however, bacterial infections are the main offenders. Vincent et al. (2009) concluded in the international EPIC II study that gram-negative bacteria were the principal perpetrators, accounting for 62%, while the gram-positives followed with a frequency of 47%. Of these groups, the principle organisms include:

  • Staphylococcus aureus and Pseudomonas at 20%
  • Escherichia coli at 16%

Different risk factors may predispose persons to become infected by these organisms.

Risk Factors

  • Non-Communicable diseases (Diabetes Mellitus, Chronic Kidney Disease)
  • Hemodialysis
  • Liver disease
  • Immunodeficient conditions
  • Trauma
  • The elderly, children, infants
  • Burns
  • Corticosteroid Use
  • Cancer
  • Prolonged Hospital Stay
  • Indwelling catheters

What is the Clinical Presentation of Sepsis?

The presentation of sepsis ranges from acute to insidious. There are cases where the patient may indicate a site of infection to cases where there is none apparent. Symptoms and signs of this syndrome generally include the following:

Another early sign of sepsis includes the presence of leukopenia or leukocytosis.
Along with these parameters, there are also specific signs within each organ system that must also be taken into account when investigating the source of primary infection or exploring the secondary effects of the same.

For example, when examining the respiratory system, listen for adventitious sounds or decreased breath sounds that may point to pneumonia and other chest infections. Respiratory causes of sepsis account for 42% of cases, according to the EPIC II study.

Patients who present with abdominal pain should be evaluated to rule out infection sources in abdominal structures such as the appendix, colon, pancreas, gallbladder. Other sources of infection may include the urinary tract and the prostate gland.

Patients with a history of trauma, wounds, and recent surgeries should be evaluated for any signs of wound infection (e.g., pain, erythema, purulent discharge, weeping wound, abscess formation)

In patients who are already admitted to the hospital and have been given invasive adjuncts, such as a central line, urinary catheters, and hemodialysis access sites, evaluate for inflammatory signs around the insertion site.

Warning Signs of Severe Sepsis

Sepsis progresses through a continuum that begins with a systemic inflammatory response syndrome (SIRS) and ends with multi-organ dysfunction syndrome (MODS), where mortality is almost inevitable. Its severest form is known as Septic Shock, a subcategory of sepsis where there is a great probability of mortality due to severe metabolic and circulatory irregularities.

The New Criteria for Evaluating Sepsis

The Sequential Organ Failure Assessment score, otherwise known as the SOFA score, is the new criteria used to evaluate sepsis. It replaces the SIRS Criteria.

SOFA takes into consideration six parameters that relate to specific organ systems. These systems are aligned with clinical signs and laboratory values, which fit into a numerical score ranging from 0 to 4, where 0 corresponds to normal values, and 4 corresponds to a high level of organ failure. See the image below, adapted from Vincent et al. (1996).

Since this criteria at its base enable physicians to assess the level of dysfunction occurring in the patient’s organ systems, the higher the score given, the more probable there will be an increase in mortality.

Using the SOFA criteria,  a score equal to and greater than 2 in the presence of confirmed or suspected infection corresponds to organ dysfunction. It indicates a mortality risk of around 10%.

The abbreviated version of the SOFA score, known as quick SOFA or qSOFA, is helpful for screening patients suspected to have sepsis by quickly evaluating three parameters, mental status, systolic blood pressure, and the respiratory rate.

REBELEM Blog (2016) qSOFA Score

Laboratory and Imaging

The general laboratory, imaging, and special studies for sepsis can include various tests depending on the suspected source of the infection, for example:

  • A Chest X-ray may show signs of pneumonia or any other lung infection.
  • CT imaging may reveal abdominal abscesses, perforation of the bowels.
  • An ultrasound can rule out pelvic sources of infection, as well as in organs such as the gall bladder.
  • Cardiac tests (electrocardiogram and troponins) may reveal suspected causes such as Myocardial Infarction.
  • Routine tests such as Complete Blood Count and Chemistry studies provide a baseline analysis for infection screening and organ dysfunction (kidney and liver).
  • Procalcitonin is a sepsis biomarker and increases in the presence of systemic bacterial infection.
  • Blood, urine, and source cultures should be taken for organism identification and antibiotic sensitivities.
  • Certain clinical presentations may necessitate abscess aspiration, lumbar puncture, or paracentesis.
  • Arterial blood gas is also a beneficial test for analyzing how septic a patient may be.

It is also important to note that serum lactate has become an important test in diagnosing sepsis, especially in relation to septic shock. (Lee and An, 2016)

The image below provides a summary of test results related to sepsis, as adapted from Mahapatra and Heffner (2020):

Treatment of Sepsis

The foundational aspects of treating sepsis rest upon rapid recognition and rapid remedy.

Schmidt and Mandel (2021) explain that resuscitation must be aggressively instituted in order to reperfuse the organs; just like antibiotic therapy, fluid resuscitation should be implemented within the first hour. It is given at 30 mL/kg and should be finalized by the third hour.

Initial antibiotic therapy should aim to cover both gram-positive and gram-negative organisms, any other considerations must be fully in line with the information found in the patient’s history, and physical examination. Where the source of infection necessitates surgical intervention, this must be pursued additionally.

The patient’s response to the treatments should be continuously monitored for improvements or worsening condition, and appropriate transfers should be pre-empted, for example, if the patient needs to be transferred to the Intensive Care Unit.

Key Points

  1. Sepsis is a clinically heterogeneous syndrome, which has a progression that can lead to severe cellular, metabolic, and overall hemodynamic dysfunction.
  2. If left un-recognized or, if it is not treated aggressively, the patient outcomes may be dim.
  3. The SOFA score is a criteria that is used in-depth and in a quick overview to assess the level of organ dysfunction in suspected or confirmed sepsis.
  4. Patients should be consistently monitored while exploring for the possible primary source.
  5. Sepsis is treated with rapid infusion of intravenous fluids and by using broad-spectrum antibiotics.
Cite this article as: Kohylah Piper, Antigua & Barbuda, "Sepsis – An Overview and Update," in International Emergency Medicine Education Project, June 28, 2021,, date accessed: September 21, 2023

References and Further Reading

Question Of The Day #43

question of the day

Which of the following is the most likely cause for this patient’s altered mental status?

This patient presents to the Emergency Department with altered mental status and fever.  Altered mental status can be due to a large variety of etiologies, including hypoglycemia, sepsis, toxic ingestions, electrolyte abnormalities, stroke, and more.  The management and evaluation of a patient with altered mental status depends on the primary assessment of the patient (“ABCs”, or Airway, Breathing, Circulation) to identify any acute life-threatening conditions that need to be managed emergently, the history, and the physical examination.  One mnemonic that may help in remembering the many causes of altered mental status is “AEIOUTIPS”.  The table below outlines this mnemonic.


This patient has confusion, fever, lower abdominal pain, dysuria, and no focal neurological deficits on exam.  Diabetic ketoacidosis (Choice A) is unlikely as the patient does not have marked hyperglycemia (>250mg/dL (13.8mmol/L)), polyuria, or polydipsia.  Intracranial hemorrhage (Choice C) is unlikely as the patient has no headache, history of trauma, focal neurologic deficits, or coma.  Severe hypothyroidism (Choice D), known as myxedema coma, can cause altered mental status.  This condition is marked by somnolence or coma, hypothermia, nonpitting edema on the hands and feet, dry skin, macroglossia (enlarged tongue), and hair loss.  This patient does not have symptoms consistent with severe hypothyroidism. 

Sepsis (Choice B), especially in elderly individuals, can cause altered mental status.  The patient’s fever, confusion, lower abdominal pain, and dysuria all point to a likely diagnosis of urosepsis.  Sepsis is the most likely cause of this patient’s disoriented state.  Treatment with early IV hydration and antibiotics will help remedy the patient’s altered mental status.  Correct Answer: B


Cite this article as: Joseph Ciano, USA, "Question Of The Day #43," in International Emergency Medicine Education Project, June 25, 2021,, date accessed: September 21, 2023

Empiric Antibiotics for Sepsis in the ED Infographics

Empiric Antibiotics for Sepsis in the ED Infographics
Empiric Antibiotics for Sepsis in the ED Infographics
Cite this article as: Sarah Bridge, USA, "Empiric Antibiotics for Sepsis in the ED Infographics," in International Emergency Medicine Education Project, June 7, 2021,, date accessed: September 21, 2023

Recent Blog Posts By Sarah Bridge

Approach to Jaundice in the Emergency Department

A 50-year-old male presents to the emergency department (ED) with nausea and vomiting, diminished appetite, and recent changes in his skin color, which he describes as turning “yellow.” This seemed to have worsened over the past few weeks, after which he began to worry and presented to the ED.

The patient’s vital signs are normal. His physical exam is positive for icteric sclerae, jaundice in the face and chest, and hepatomegaly. He is not tender to palpation on the abdomen. The rest of his exam is otherwise normal.


Jaundice is not a diagnosis, but a clinical manifestation of an underlying problem, specifically elevated serum bilirubin. Patients with Jaundice present with yellow discoloration of the skin, mucous membranes, and sclera. They can present to the ED with Jaundice in isolation or along with other symptoms. It is the Emergency Physician’s task to evaluate the patient, find the underlying cause, order the appropriate investigation and decide whether the patient requires admission to the hospital and consultation with other physicians.

Normal physiology of bilirubin metabolism

Bilirubin is the end product of heme metabolism. This occurs in three phases: pre-hepatic, hepatic, and post-hepatic phases. Approximately 75-80% of bilirubin comes from the catabolism of red blood cells. Initially, this bilirubin is unconjugated, which is insoluble in water and soluble in fat. Therefore, unconjugated bilirubin can easily cross the blood-brain barrier and the placenta [1].

Unconjugated bilirubin is actively transported to the liver by albumin and is conjugated by the enzyme glucuronosyltransferase. Subsequently, conjugated bilirubin is either stored in bile in the gallbladder or excreted through the biliary tract, where it eventually reaches the intestines and is excreted from the body [1,2].

Pathophysiology and differential diagnosis

The classic definition of jaundice is a serum bilirubin level greater than 2.5 to 3 mg per dL (42.8 to 51.3 µmol per L), with a clinical presentation of yellow skin and sclera [1]. As described in the above section, bilirubin metabolism occurs in three phases, and dysfunction of any of these steps can lead to jaundice.

Pre-hepatic causes

Unconjugated hyperbilirubinemia or elevated levels of unconjugated bilirubin before it reaches the liver can lead to jaundice. This can occur due to excessive heme metabolism from increased red blood cell breakdown (hemolysis) and the saturation of enzymes that conjugate it. A few underlying etiology for this include hemolytic anemia, sickle cell anemia, spherocytosis, glucose-6-PD deficiency, hemolytic uraemic syndrome, and transfusion reaction [1,3].

Hepatic causes

Any process that impacts liver functioning can lead to jaundice. Some of the hepatic causes of jaundice in adults include viral hepatitis, chronic alcohol consumption, autoimmune diseases such as primary biliary cirrhosis, genetic disorders such as Gilbert syndrome, hereditary metabolic defects such as Dubin-Johnson syndrome, and some drugs that can lead to drug-induced liver disease such as acetaminophen, oral contraceptives, estrogenic and anabolic steroids [4-6].

Post-hepatic causes

Any process that instigates post-hepatic obstruction can lead to jaundice due to elevated levels of conjugated bilirubin. Some of these include cholelithiasis leading to obstruction of the biliary duct system, biliary tract tumors, biliary duct strictures, and jaundice secondary to pancreatitis [1, 7].

History and physical examination

A good history and physical examination of patients presenting with jaundice to the ED is key in their diagnosis.

On history, the patient should be asked about alcohol and drug use, recent travel, sexual contact with a person with known or suspected hepatitis, recent tattoos or body piercings, and previous biliary surgery. A focused review of systems should also be conducted. For example, a history of fever and viral symptoms can point towards viral hepatitis, while the presence of constitutional symptoms such as weight loss and night sweat may point towards a malignancy [8].

The physical examination should comprise vital signs and a complete abdominal examination, assessing for right upper quadrant tenderness, ascites, hepatomegaly, splenomegaly, and ascites [9]. Additionally, the physical examination should focus on evaluating encephalopathy by looking for asterixis and changes in mental status and underlying liver disease by assessing for bruising, spider angiomas, gynecomastia, and palmar erythema [1, 8-9]. Lastly, it is important to remember that the presence of painless jaundice and an abdominal mass may point towards obstruction from a malignancy.


Laboratory assessment

First line serum testing should include a complete blood count (CBC) to check for hemolysis, bilirubin level with fractionation, aminotransferases (AST and ALT) to assess for hepatocellular injury (although these may be normal in chronic liver disease), alkaline phosphatase, prothrombin time and/or international normalized ratio, albumin, and protein to assess for liver synthetic function. If these tests come back normal, further tests may be needed to identify the underlying cause of the patient’s jaundice, such as hepatitis serology, autoimmune markers, and investigation for acetaminophen levels [1,8].


The majority of diagnostic imaging will be done outside of the ED. However, emergency physicians can conduct initial ultrasound screening to assess for bile duct dilation, biliary obstruction, and the presence of cholelithiasis. A CT scan can also be ordered to assess for intraparenchymal liver and pancreas disease [1,8]. Outside of the ED, investigation with Endoscopic Retrograde Cholangio-Pancreatography (ERCP), Magnetic Resonance Cholangio-Pancreatography (MRCP), and a liver biopsy may be warranted.


In the ED, emergency physicians are often involved in the initial investigation of a patient with jaundice in ruling out life-threatening conditions and to decide whether a patient should be discharged or admitted for further management. For example, physicians should first assess medical emergencies that can present with jaundice, such as ascending cholangitis, acute hepatic failure, and massive hemolysis. Timely diagnosis, resuscitation, treatment initiation, and emergent consultation of these conditions are critical in the ED. Additionally, patients with elevated AST/ALT levels should be admitted if there are any signs of sepsis, coagulopathy, altered mental status, and intractable pain and vomiting. The presence of hepatocellular injury, coagulopathy, and altered mental status may point towards fulminant liver failure and may require acute fluid resuscitation and hemodynamic monitoring in an acute care setting [10]. Otherwise, depending on the underlying cause of a patient’s jaundice, surgical, gastroenterological or interventional radiological consultation may be required in an outpatient setting.

References and Further Reading

  1. Roche, S. P., & Kobos, R. (2004). Jaundice in the adult patient. American family physician69(2), 299-304.
  2. Wolfson, A. B., Hendey, G. W., Ling, L. J., Rosen, C. L., Schaider, J. J., & Sharieff, G. Q. (2012). Harwood-Nuss’ clinical practice of emergency medicine. Lippincott Williams & Wilkins.
  3. Sackey K. (1999). Hemolytic anemia: part 1. Pediatr Rev, 20,152-8.
  4. Pasha, T. M., & Lindor, K. D. (1996). Diagnosis and therapy of cholestatic liver disease. Medical Clinics of North America80(5), 995-1019.
  5. Schramm, C., Kanzler, S., Zum Büschenfelde, K. H. M., Galle, P. R., & Lohse, A. W. (2001). Autoimmune hepatitis in the elderly. The American journal of gastroenterology96(5), 1587-1591.
  6. Lewis, J. H. (2000). Drug-induced liver disease. Medical Clinics84(5), 1275-1311.
  7. Custis, K., Brown, C., & El Younis, C. M. (2000). Common biliary tract disorders. Clinics in Family Practice2(1), 141-154.
  8. Fargo, M. V., Grogan, S. P., & Saguil, A. (2017). Evaluation of jaundice in adults. American family physician95(3), 164-168.
  9. Winger, J., & Michelfelder, A. (2011). Diagnostic approach to the patient with jaundice. Primary Care: Clinics in Office Practice38(3), 469-482.
  10. Vaquero, J., & Blei, A. T. (2003). Etiology and management of fulminant hepatic failure. Current gastroenterology reports5(1), 39-47.
Cite this article as: Maryam Bagherzadeh, Canada, "Approach to Jaundice in the Emergency Department," in International Emergency Medicine Education Project, May 17, 2021,, date accessed: September 21, 2023

Recent Blog Posts By Maryam Bagherzadeh

Illness Narratives In Global Health

Storytelling is a powerful tool that allows us to relate to one another across borders, cultures, and experiences. It is a significant aspect of global health. Images associated with international health are those of pediatric patients in low and middle-income countries (LMICs) with descriptions of ailment or news stories on television of an outbreak in a faraway country. These stories capture our attention and allow us to process situations far removed from ours. While stories allow us to communicate the urgency and extent of international health topics, there are challenges associated with illness narratives. It is important to examine how stories are told in medicine, and specifically in global health. It is critical to question who tells stories, how they’re told, and what their impact is. These can be stories of individual patients in a country, medical aid organizations, or even stories of a country’s health infrastructure.

A recent Lancet essay titled “Global Health 2021: Who tells the Story” examines the role of journals when it comes to research in academic global health. The essay cites data showing a lower number of publications authored by those affiliated with or came from LMIC in The Lancet Global Health(1). Here, the authors reflect on how, as a London-based global health journal, they need to examine the narration disparities. They note that an imbalance in authorship is a symptom of an imbalance in power when it comes to academic global health.

This essay was in part motivated by a crucial article by Seye Abimola and Madhukar Pai. In their article examining the decolonization of global health, Abimola and Par state “even today, global health is neither global nor diverse. More leaders of global health organisations are alumni of Harvard than are women from low-income and middle-income countries. Global health remains much too centred on individuals and agencies in high-income countries (HICs).”(2) This important point highlights the distance between the subject of stories and those who tell them. This can limit diversity in perspective while taking away ownership of stories from those who experience it.

An article looking at illness narratives in an outbreak reported that when it comes to Ebola, Zika, and SARS, marginalized communities often bear the burden of disease while their account of illness is often neglected. The authors state, “regardless of income setting, there is a need to give voice to the most marginalized communities during an epidemic.”(3) This point on narration should extend beyond authorship in research to include news coverage of global health events. The way the Ebola outbreak and even early days of COVID pandemic were portrayed are examples of the dangers associated with lack of nuance in the way global health topics are discussed in the media.

Inclusivity of illness narratives around global health can allow us to avoid pitfalls that lead to widespread misinformation and discrimination. In addition to examining who tells the story, it is also important to explore how stories are told. An essay highlighting the challenges of storytelling in medicine notes that at times the trauma of subjects has been exploited by international charities. The article states the importance of communicating stories in a way that does not “feast on the trauma of others”(4). 

At the core of his argument is the need to examine how we communicate the stories of others. As described above, allowing locals to tell stories regarding their experience of illness, outbreaks, and research can help us deal more carefully with the associated trauma. Stories told without careful consideration can lead to widespread misinformation and potentially harmful generalizations. As we move towards examining how we improve global health delivery, it is critical to explore how we can improve the stories we share. In order to create a better system to communicate important global health topics, it is imperative to challenge the ways we receive information constantly.

This will broaden our understanding of complex issues and allow us to consider alternative solutions.

To this end, the following five questions should help us navigate the challenges of global storytelling. These questions are suggested to help guide our approach towards a more

  1. Has the subject given informed consent to tell their story?
  2. How is the story presented?
  3. Is there a way to allow the story subject to be
  4. Do the stories told reinforce harmful stereotypes?
  5. Are there negative consequences to the subject if the story is told?

References and Further Reading

  1. Health TLG. Global health 2021: who tells the story? The Lancet Global Health. 2021;9(2):e99.
  2. Abimbola S, Pai M. Will global health survive its decolonisation? The Lancet. 2020;396(10263):1627-1628.
  3. Kapiriri L, Ross A. The politics of disease epidemics: a comparative analysis of the sars, zika, and ebola outbreaks. Glob Soc Welf. 2020;7(1):33-45.The
  4. Harman S. The danger of stories in global health. The Lancet. 2020;395(10226):776-777
Cite this article as: Nardos Makonnen, USA, "Illness Narratives In Global Health," in International Emergency Medicine Education Project, April 5, 2021,, date accessed: September 21, 2023

iEM Image Feed: Camel Bite

iem image feed camel bite
camel bite injury

EMS brought a 24-year-old man due to camel bite happened while feeding the camel in the early morning. The injury was basically on the right arm and forearm. No other injuries, vitally stable.

Students should know the following while taking care of these patients.

  1. Systematic evaluation of the patient – remember ATLS, primary and secondary survey.
  2. Focused neurologic and vascular examination.
  3. Exposing the wound and ordering an x-ray
  4. Wound cleaning and management
  5. Be aware of fracture – Open Fracture!
  6. Antibiotic coverage and tetanus toxoid/IG
  7. For open fractures – Look for Gustilo-Anderson Classification and choose appropriate antibiotics.  
  8. Do not forget – pain medication.
Cite this article as: iEM Education Project Team, "iEM Image Feed: Camel Bite," in International Emergency Medicine Education Project, February 10, 2021,, date accessed: September 21, 2023

The Unspoken Damage of COVID-19 on Spanish-Speaking Patients

The Unspoken Damage of COVID-19 on Spanish-Speaking Patients

The COVID-19 pandemic has uncovered some ugly truths about the American healthcare system. One of the ugliest is discrimination against non-English-speaking patients. This form of discrimination particularly affects native Spanish-speaking only patients (defined in this article as “Spanish-speaking patients), who comprise not only a large proportion of America’s hospital patronage but also a majority of those suffering from COVID-19.

In May 2020, as part of my Emergency Medicine residency training, I worked at a small community hospital in northern Virginia, located in an agricultural area with a large number of Central American and Mexican migrant workers. The first few days of the rotation were relatively unremarkable until the COVID-19 cases began to pour in. Most of those suffering from severe COVID-19 were Spanish-speaking patients employed at a local plant nursery where an outbreak was occurring.

I intubated a COVID-19 patient almost every day I worked there. I speak Spanish fluently, and since I was able to communicate with Spanish-speaking patients and their families, I was able to obtain consent for the procedure. I will never forget one patient who had tears rolling down his face shortly after intubation as we titrated his post-intubation sedation medications. I spoke with his son over the phone, in Spanish, who thanked me profusely and cried, worried he would never see his father alive again. He asked if he could visit his father in the hospital. He cried more when I explained the no visitor policy for hospitalized COVID-19 patients. He still thanked me.

The ER staff also thanked me, because until I arrived, few in-person Spanish interpreters or fluent Spanish-speaking providers worked there. Therefore Spanish-speaking patients consented to intubations using a phone-based interpretation service. Though The Joint Commission states that telephone or video interpretation is sufficient to obtain informed consent (especially during the COVID-19 pandemic), in-person interpretation has proved superior. Unfortunately, at this small hospital, out of necessity and due to inundation by COVID-19 victims, Spanish-speaking patients had occasionally been intubated without true informed consent. For example, I remember a case when the overwhelmed nursing staff struggled to connect to and understand the phone-based interpreter while donning PPE and equipping a Spanish-speaking patient’s room for emergent intubation, only to be followed shortly thereafter by another critical COVID-19 patient.

Despite the large number of Spanish-speaking patients receiving care in the United States, a 2016 survey of 4,586 American hospitals showed that only 56 percent offered some sort of linguistic and translation services. As a former volunteer Spanish interpreter for a university hospital, the cost is cited as the primary reason, among many. Discrimination against undocumented people and xenophobia are unstated reasons. I remember distinctly a Grand Rounds presentation about native Spanish-speaking patients in hospitals and how a Latinx pediatrician emotionally expressed how often she witnessed Spanish-speaking families receive worse care than their English-speaking counterparts. Indeed, inadequate or inaccurate interpretation has resulted in serious legal, financial, and patient safety repercussions for hospitals.

In June, I worked in the COVID-19 ICU at my residency program’s hospital. Most of the COVID-19 ICU patients had been transferred from the same small hospital where I worked the previous May. After rounds, most of my afternoon was spent contacting Spanish-speaking family members and updating them on their loved one’s condition. It was heartbreaking to tell these families that they could not visit their loved ones in the hospital. Undoubtedly, the family is incredibly important to all cultures, and particularly to central and Mexican-Americans. Sadly, these strong family ties underscore an important reason Latinx people have been disproportionately affected by COVID-19: many live in large, multigenerational family homes, accelerating virus exposure and transmission. Furthermore, many are undocumented and work under substandard conditions, with few or no COVID-19 precautions. They may also be underinsured or have no insurance or benefits like sick leave, further fueling the virus’ devastation.

When you pull the bandage off a gangrenous wound to expose the decaying flesh below, you have two options: put the bandage back on and let someone else deal with it, or clean the wound and treat it so it can heal. The COVID-19 pandemic has pulled the bandage off and exposed certain disgusting realities of our health care system – how can we as Emergency Physicians heal this wound?

We must recognize that hospital under-investment in adequate Spanish interpreters is a form of racism. Medical Spanish should be required curriculum for medical students and residents. The knowledge of basic conversational Spanish goes a long way when communicating with patients and their families. Medical Spanish is not difficult, and there are enough cognates and Latin derivatives that most people, with minimal practice, can get through history and physical in Spanish. Most importantly, hospitals should invest in full-time in-person Spanish interpreters, at the very least for the Emergency Department.

The COVID-19 pandemic has ravaged our healthcare system in myriad ways. With destruction comes the opportunity to rebuild and improve. This is one area that needs it.

Cite this article as: Sarah Bridge, USA, "The Unspoken Damage of COVID-19 on Spanish-Speaking Patients," in International Emergency Medicine Education Project, January 11, 2021,, date accessed: September 21, 2023

Question Of The Day #7

question of the day
qod7 - sepsis

Which of the following is the most appropriate next step in management for this patient’s condition?

This patient has a diagnosis of septic shock due to pneumonia. In all patients presenting to the Emergency Department, the initial assessment should involve the “ABCs” (assessment of Airway, Breathing, and Circulation). The patient is given supplemental oxygen for her hypoxemia with an improved oxygen saturation from 89% to 95%. Performing endotracheal intubation (Choice A) is too aggressive at this time as the patient is improving with non-invasive oxygenation techniques. The Centers for Medicare and Medicaid sepsis guidelines recommend a 30 mL/kg of isotonic crystalloid fluid bolus in patients with sepsis. However, there is limited data to support this recommendation, as some patients may benefit from less or more fluids than 30 mL/kg. The question stem indicates that an appropriate bolus of fluids has been given, so providing more IV fluids (Choice B) is not the best course of action. The use of passive leg raising or bedside ultrasonography to assess for Inferior Vena Cava (IVC) size may help a clinician discern if more or less fluids are required. For example, visualizing a flat, collapsible IVC on ultrasound indicates additional fluids may be helpful. An increase in blood pressure after a patient’s legs are raised above the level of the heart (“passive leg raise”) also supports the use of additional IV fluids. Giving acetaminophen (Choice D) will help reduce the patient’s fever and improve patient comfort. However, initiating vasopressor therapy (Choice C) is the more appropriate next course of action. Vasopressors (i.e. norepinephrine, epinephrine) are generally recommended after IV fluid boluses if a patient is persistently hypotensive with a MAP less than 65mmHg. Vasopressors help to maintain cerebral and organ perfusion in states of shock. They should be titrated to a dose that maintains a MAP of 65mmHg or above.  Correct Answer: 


Nicks BA, Gaillard JP. Approach to Nontraumatic Shock. “Chapter 12: Approach to Nontraumatic Shock”. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th ed. McGraw-Hill.

Cite this article as: Joseph Ciano, USA, "Question Of The Day #7," in International Emergency Medicine Education Project, August 7, 2020,, date accessed: September 21, 2023

COVID-19; Reflecting on a Globalized Response

COVID-19; Reflecting on a Globalized Response

As I write this is, it has been 200 days since the first reports in China came out regarding an unspecified viral illness in Wuhan, China. What is now the pandemic of COVID-19 has spread around the world, and in history books and our collective memory, the year 2020 will forever be closely associated with this virus. There have been nearly 14 million confirmed cases around the world and nearly 600,000 known deaths from COVID-19. Some countries have done incredibly well with containment measures, while others continue to see case counts grow every day.

It has been fascinating to see how the outbreak has had different impacts in communities around the world, including how local and global responses have efficiently controlled or been unable to contain this novel public health problem. Prevention and mitigation strategies continue to form the foundation of public health management of this outbreak. The capacity for any country or locality to provide the most invasive supportive care is widely variable, and even when it is available mechanical ventilation is certainly not a panacea as COVID-19 case-survival rates in those being mechanically ventilated have been low (from 14% to 25%).

At the core of the variable outcomes seems to be a mix of sociological issues: a mix of personal beliefs, geography, politics, socio-economics and health infrastructure which lead to vastly different outcomes around the globe.

The accumulation of more epidemiological data over the past 200 days has improved our collective understanding of the COVID-19 virus, as today we have improved models and a better understanding of the rates of asymptomatic carriers (estimated at 40%) and mortality rates (1.4%-15.4%). Yet still, uncertainties and local variability (even within countries) have made an accurate calculation of the COVID-19 basic reproductive number (R0; the number of people who are infected by a single disease carrier) difficult. In the early stage of the outbreak in Wuhan, R0 calculation ranged from 1.4-5.7, and some have suggested that instead of single R0 value, modellers should consider using ongoing contact tracing to gain a better range of transmissibility values.

We have seen how prevention strategies such as hand-washing, face-masking, and physical distancing can impact local and disseminated disease spread. While many communities have come together through a collective approach to lock-downs and universal masking measures, other localities have struggled to get adequate levels of citizen compliance. Others have struggled with obtaining testing supplies. Certain political systems allow for streamlined and unified directives while others have made it difficult to provide adequate centralized coordination.

As the COVID-19 pandemic has spread to almost every country in the world, outbreaks are smoldering in much of the global south. While the United States continues to see rising numbers of cases with numerous states confronting ongoing daily record high incident cases, other countries such as Brazil are seeing similar upward trends. At the global level, the curve of daily incident cases seemed to have “flattened” and held steady through much of April and into May with aggressive seemingly worldwide measures. However, since the last days of May, global incident cases have been again steadily increasing. This is likely due to a variety of reasons but is linked, at least in part, to efforts to reopen economies and return to pre-pandemic routines and lifestyles.

covid-19 daily cases
Source: Johns Hopkins University Coronavirus Resource Center, accessed July 17, 2020

As an American citizen and a physician with training in public health, it has been both interesting and frustrating to see the how some countries (including my own) have had deficiencies in dealing with testing and basic prevention (such as mandatory universal masking). While I don’t want to engage in political rhetoric or cast blame in any one place, I do think it is instructive to point out that in the United States (or anywhere else for that matter) the sociological factors of personal preferences and autonomy, geography, and local politics have had an overwhelming influence in determining the progress of the pandemic.

Quarantining has always been a unique problem that sits at the intersection of personal autonomy and communal wellbeing, and is implemented and respected by citizens in different ways around the world. It would seem, at least anecdotally, that cultures with an emphasis on personal independence and autonomous choice have had greater difficulty with containment or in obtaining high levels of compliance with masking and distancing measures, even when compared to other localities with similar socio-economic situations.

These sociological factors are key to responding to and managing any epidemic health concern. We have come to see that in our globalized world, our ability and desire to work together towards a common goal, even at the cost of personal sacrifice, will determine our ability to control both the COVID-19 pandemic and the next health crisis of the future.

Public health education and communication, it would seem, is at the crux to getting collective buy-in and global participation.

Unfortunately, as with so many things these days, such issues can be easily politicized and cause fractured and disparate approaches to response. In our globalized world, this coronavirus outbreak is unlikely to be the last public health crisis we must face as a worldwide community.

As thoughts turn towards what is to come, from vaccine development and distribution to numerous long-term economic impacts, we are not nearing the end of this outbreak yet.

The incidence curve is growing, and there is much work left to be done. My hope is that as we move into the second half of 2020, our global community can continue to find ways to improve communication and coordination in order to come together to approach and control this pandemic collectively. The fate of this outbreak, and likely the next, hangs in the balance.

Cite this article as: J. Austin Lee, USA, "COVID-19; Reflecting on a Globalized Response," in International Emergency Medicine Education Project, August 3, 2020,, date accessed: September 21, 2023