Tag: emergency medicine

Management of Pain in the Emergency Department (2024)

~ iEM Education Project Team ~ Leave a comment

by Kayla Peña, Kelsey Thompson, & Munawar Farooq

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You have a new patient!

A 57-year-old woman with a PMH of peptic ulcer disease presents to the emergency department 20 minutes after slipping and falling while out for a jog. She twisted her left ankle awkwardly while stepping off the pavement and fell to the side. She did not hit her head. She got up after the fall but has not tried to put weight on the ankle. Her vital signs are stable. She has a temperature of 37°C, a heart rate of 110 beats per minute, respirations at 18 breaths per minute, a blood pressure of 128/60, and an oxygen saturation of 96% on room air. 

a-photo-of-a-57-year-old-female-patient-(the image was produced by using ideogram 2.0)

She is currently seated in a chair and appears uncomfortable. On exam, the left ankle appears more swollen than the right, with no bruising. She has tenderness to palpation at the posterior edge of the left lateral malleolus but no left midfoot tenderness. The right foot is non-tender. Pulses are intact throughout with a 2-sec capillary refill distally. She states, “Please help me; I can’t take the pain!”

Introduction

Pain is one of the most common reasons patients seek care in the ED. Pain is a signal from the body to alert the patients of actual or potential tissue damage. Addressing pain is a key part of the emergency department practice. However, doing so appropriately requires understanding our options to treat pain and a clear process to assess the factors causing the patient’s pain [1]. Pain treatment offers numerous advantages, such as alleviating pain-induced tachycardia in specific cases like acute MI and aortic dissection. Additionally, improved pain relief contributes to higher patient satisfaction.

Pain Assessment

When administering analgesics to patients in pain, there are no definitive contraindications. However, several factors should be considered when selecting the appropriate analgesic agent, including its route and dose. These factors encompass the pain’s intensity, probable cause, and the patient’s age, weight, medical history (including comorbidities and drug allergies), and vital signs. Pain is a complex and subjective experience that is unique to each patient. Appropriately assessing pain requires a thorough history and physical exam that include:

  • Location: Where is the pain? Does it travel or go anywhere else? 
  • Onset: When did the pain begin? Is this an acute, chronic, or exacerbation of a chronic issue?
  • Provocation: What makes the pain worse?
  • Palliation: Does anything make this pain feel better? What has the patient tried to make it feel better, even if it didn’t work? Has the patient taken any medication at home to help with this, and what was the impact? If this patient has had this pain before, what made it better last time?
  • Quality: How does the pain feel?
  • Radiation: Does the pain go to any other location?
  • Severity: How severe is the pain? Can they compare it to other experiences they’ve had? How does it limit their activities, such as movement, eating, and sleeping?
  • Timing: Is the pain constant, or does it come and go? Does it change severity or quality over time?

Pain intensity scale

  • Numerical ranking: Ask your patient to rank the severity from 0 to 10, with 0 being no pain at all and 10 being the worst pain possible.
  • Verbal descriptors: Use descriptions from the patient of the pain and its impact on their functionality to rank their pain.
  • Visual descriptors: Use visual cues from your patient to rank their pain. The most common of these scales is the Wong-Baker scale, which is commonly used in children or nonverbal patients.

It is also important to remember that patients in pain may become agitated or mentally altered due to their pain. Severe pain in one area of the body may mask other symptoms or signs the patient is experiencing; hence, it is crucial to re-examine these patients after analgesia.

Analgesics

In the emergency department, treatment plans are often tailored to moderate/severe and acute and/or chronic pain.

Severe Acute Pain

In the management of moderate to severe acute pain, parenteral opioids are the primary treatment choice. These opioids target specific receptors in the central and peripheral nervous systems, altering how painful stimuli are perceived and responded to. Initially, they are administered as a bolus dose based on the patient’s weight, followed by titration every 5-15 minutes after reassessment. Opioids provide excellent analgesia, but they come with a long list of side effects that can be detrimental to the patient, even in the acute pain setting. Nausea and respiratory depression are the most significant side effects of all opioids, albeit with varying degrees. Parenteral opioids can also trigger pruritus and/or urticaria due to mast cell destabilization. Medications such as antiemetics, antihistamines, and naloxone can help reverse these potential side effects. Morphine is often the preferred parenteral opioid, with fentanyl and hydromorphone serving as alternatives. A safe initial dose of morphine is 0.1 mg/kg administered intravenously, while subcutaneous administration can be used if IV access is not available (although it is more painful and slower in onset). Please refer to the complete list of opioids and their recommended initial dosing regimens provided below.

  • Fentanyl: 0.25-1 µg/kg IV push [2], Short-acting opioid q. 15-60 minutes for severe pain.
  • Hydromorphone: 0.015 mg/kg IV/SC [3], q. 2-4 hours, avoid large doses in naive patients.
  • Oxycodone: 0.05-0.15 mg/kg PO [4], q. 3-4 hours.
  • Morphine: 0.1 mg/kg IV/SC [5], q. 3-4 hours, may cause release of histamine.
  • Oxycodone/Acetaminophen: 5-10 mg oxycodone/325-650 mg acetaminophen PO [6], q. 4-8 hours, moderate or severe pain (max dose of acetaminophen 4,000 mg/day).
  • Hydrocodone/Acetaminophen: 5 mg hydrocodone/325 mg acetaminophen, 1 to 2 tablets PO [7], q. 4-8 hours, moderate or severe pain (max dose of acetaminophen 4,000 mg/day).

Moderate Acute Pain

In cases of mild to moderate pain, oral opioids provide a suitable choice after initial non-opioid analgesia. Among these options are oxycodone combined with acetaminophen or hydromorphone combined with acetaminophen to impose a maximum daily dosage. The recommended dose for the opioid component is 0.05-0.15 mg/kg, and it can be repeated every 4-6 hours.  Refer to the full list of opioids and their initial dosing regimens above.

However, the primary recommendation for moderate acute pain is non-opioid analgesics like NSAIDs and acetaminophen. They can synergistically complement opioids, potentially reducing the overall required dose of medications and minimizing the likelihood of side effects.
Acetaminophen is the safest option among these analgesics, accessible in oral and intravenous forms. While its exact mechanism remains uncertain, it exerts its effects centrally. NSAIDs, such as ibuprofen and ketorolac, inhibit cyclooxygenase (COX), thereby blocking prostaglandin-mediated inflammation. However, inhibiting prostaglandin synthesis leads to renal vasoconstriction and thus should be avoided in those with kidney disease. Please refer to the complete list of non-opioids and their recommended initial dosing regimens provided below.

  • Acetaminophen: 10-15 mg/kg PO/IV [8], Avoid if taking other acetaminophen-containing drugs or in patients with liver failure.
  • Ibuprofen: 5-10 mg/kg PO [9], Avoid in elderly patients and those with renal disease and peptic ulcer disease.
  • Ketorolac: 0.5 mg/kg IV/IM [10], Should only be given q6 hours, No more than 5 days.

Chronic Pain

It is important to recognize that patients with conditions that cause chronic pain or recurrent episodes of severe pain, such as sickle cell, have frequent or even chronic usage of opioid medications that require an individualized pain management plan. While chronic pain is challenging to address in the ED setting, these patients frequently get undertreated for their acute exacerbations [11]. Chronic pain is treated similarly to acute pain, using opioids for severe pain and non-opioids for more moderate pain. Treatment depends on the severity and previous history of analgesic success [12]. A step ladder approach, including non-opioid and opioid therapy, will be appropriate as part of departmental guidelines.

In addition, patients with a past or current history of a substance use disorder, including opioid use disorder, can still present with real, severe pain that may require the use of opioids for management. It is essential to assess these patients carefully and treat their pain like any other patient. If there are concerns that the patient’s condition may be related to a substance use disorder, it may be appropriate to refer them to a multidisciplinary specialist for support. This should be done after conducting a thorough history and physical examination and addressing immediate medical needs [13]. It is also vital that the ED team sticks to an individualized pain management plan once made by a multidisciplinary team on every recurrent presentation.

When making decisions for your patient, it is crucial to prioritize awareness of the addictive nature of opiates. To aid in this challenging choice, assess the patient’s opioid tolerance, history of substance abuse, and the risk associated with prescribing short-term PRN opioids upon discharge. The NIH Opioid Risk Tool (ORT) is helpful for screening for opioid abuse risk [14].

Local Anesthesia

Local anesthetics obstruct pain signal transmission by temporarily obstructing sodium channels in sensory nerve membranes. In the emergency department, lidocaine is commonly used, with or without epinephrine, to enhance hemostasis and prolong anesthetic efficacy. Bupivacaine, a longer-acting agent, is typically employed for regional anesthesia. While local anesthetics are generally safe, systemic CNS and cardiovascular toxicity can occur at large doses. Traditional teaching states that local anesthetic administration should be avoided in end organs such as the ears, nose, and penis to prevent ischemia. However, strong evidence is lacking to support this concern [15]. Local departmental or hospital guidelines should be followed in this case.

  • Lidocaine:
    • Dose: Nerve Block 5-300 mg (maximum 4 mg/kg or 300 mg),
      • Acute Pain (Patch) 4%-5% patch q24 hours.
    • Rapid onset. The maximum dose of lidocaine is 4 mg/kg (without epinephrine) and 7 mg/kg with epinephrine [16,17].
    • Lidocaine is safe in pregnancy and breastfeeding.
  • Bupivacaine:
    • Dose: Max dose 2.5 mg/kg, 3 mg/kg with epinephrine [18].
    • Slower onset and higher risk of cardiovascular toxicity.
  • Chloroprocaine:
    • Dose: Max dose 10 mg/kg, 15 mg/kg with epinephrine [19].
    • Used in the case of allergy to lidocaine and other amide local anesthetics.

Procedural Sedation

Procedural sedation refers to the administration of medications aimed at reducing anxiety and pain while enhancing tolerance to a particular medical procedure. This technique is reserved for hemodynamically stable patients who are expected to be able to maintain their airways throughout the procedure. Common indications of this technique include cardioversion, orthopedic reductions, and other painful procedures [20]

A common approach to procedural sedation:

  1. Risk stratification to prepare for potentially difficult airway management
    1. Use the Mallampati Score to assess the difficulty of the airway should the patient lose their airway during the procedure. Refer to UpToDate Mallampati Airway Classification.
    2. Determine the ASA Score category. Refer to the ASA Physical Status Classification System.
  2. Informed Consent
    1. Typically, it is required before the procedure to discuss the complications and alternative options.
  3. Gathering Supplies
    1. IV, O2, Monitoring including capnography.
    2. BVM and airway trolley
  4. Assemble Team
    • Depending on the complexity of the procedures, decide about the team members and their roles. A separate person should typically be responsible for sedation and airway monitoring while one or two other members perform the procedure. For details about team dynamics, refer to this book’s chapter on Teamwork.
  5. Perform the procedural sedation
    1. Administer procedural sedation medications (See below)
    2. Perform the procedure while constantly assessing hemodynamic stability and respiratory status.
  6. Post Sedation Care
    • Provide post-sedation monitoring and reassessment, and then discharge instructions according to the individual case and departmental guidelines.

Most Common Procedural Sedation Medications

  • Midazolam:
    • Dose: 0.1 to 0.5 mg/kg IV [21].
    • Comments: No analgesic effect, administered before the procedure to reduce anxiety and provide amnesia.
  • Fentanyl:
    • Dose: 1 mcg/kg IV [22].
    • Comments: Reduces pain, commonly used in reductions and I&D as an adjunct to other medications or local anesthesia.
  • Propofol:
    • Dose: 0.5-1 mg/kg IV [23].
    • Comments: Used as a general short-acting anesthetic and causes respiratory depression and hypotension.
  • Etomidate:
    • Dose: 0.15 mg/kg IV [24].
    • Comments: Used as a general anesthetic; can cause myoclonus.
  • Ketamine:
    • Dose: 1-2 mg/kg IV [25], 2-4 mg/kg IM (especially in pediatrics).
    • Comments: The dissociative anesthetic that provides both amnesia and analgesia. Known to cause aggressive emergence reaction and rarely laryngospasm.

Hints and Pitfalls

Like all treatments, it is crucial to reassess the patient after giving them medication and understand how medication can change your ability to evaluate the patient. A patient in severe pain may be unable to provide a full history or participate in a complete physical exam until their pain has been controlled. For example, a patient with an extremely painful angulated fracture of the humerus may not be able to participate in an exam to evaluate their distal neurovascular status, or the same patient may have such severe pain in their arm that they do not notice that they are also having abdominal pain. Treating pain earlier in such encounters can help facilitate high-quality patient care.

Factors that can lead to undertreatment include atypical presentation, communication barriers, and implicit bias. Pediatric patients, patients with neurocognitive disorders, and patients from different cultural or linguistic backgrounds are frequently undertreated for their pain.

Special Patient Groups

It is essential to carefully evaluate pain in patients who cannot directly communicate with the physician [26].

Those patients may be:

  • Nonverbal at baseline
  • Speak a different language than the physician
  • Have a cognitive impairment
  • Geriatric patients
  • Underreporting of pain
  • Higher frequency of illness-causing cognitive impairment and communication barriers such as Alzheimer’s
  • Concerns for side-effects

Geriatric patients generally have poor physiological reserve and polypharmacy. While these factors need to be considered in the choice of analgesics, their dosage, and required monitoring, these concerns should not lead to undertreatment of pain in this population.

Revisiting Your Patient

How should we manage our 57-year-old female with peptic ulcer disease, who presented with a twisted ankle? Given that her left ankle is swollen and that she has bony 9/10 tenderness at the posterior edge of the left lateral malleolus but no left mid-foot pain, it is likely that she has an uncomplicated closed ankle fracture.

The initial step in management would be to start treating her pain soon after her presentation. An important KPI (Key Performance Indicator) in this regard is that the degree of pain is assessed on arrival in every patient who presents to ED with pain, and individually planned titrated analgesia is started as early as possible.
Given that she is in acute, moderately severe pain with a history of peptic ulcer disease (PUD), she would most likely benefit from a drug like Oral Hydromorphone and Oral/IV Paracetamol. In this patient’s case, NSAIDs, such as Ibuprofen, should specifically be avoided due to her history of PUD. Initial pain management in the emergency department can also be managed with “RICE,” which includes rest, ice, compression, and elevation of the injured body part. The RICE technique is an effective way to alleviate pain in patients who deny pain medication or who are still waiting to see a provider. It is important to reassess pain and vital signs after administering analgesics.

If this patient had an evident ankle deformity with weak pulses, she would have required procedural sedation and urgent reduction.

Authors

Picture of Kayla Peña

Kayla Peña

Rutgers Robert Wood Johnson Medical School

Picture of Kelsey Thompson

Kelsey Thompson

UCLA Harbor

Picture of Munawar Farooq

Munawar Farooq

College of Medicine and Health Sciences, UAEU Al Ain, UAE

Listen to the chapter

References

  1. Hachimi-Idrissi S, Coffey F, Hautz WE, et al. Approaching acute pain in emergency settings: European Society for Emergency Medicine (EUSEM) guidelines-part 1: assessment. Intern Emerg Med. 2020;15(7):1125-1139. doi:10.1007/s11739-020-02477-
  2. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
  3. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
  4. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
  5. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
  6. Oxycodone/Acetaminophen: Drug Information. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
  7. Hydrocodone/Acetaminophen: Drug Information. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
  8. Paracetamol: In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
  9. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
  10. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
  11. Dora-Laskey, A. (2022). Acute Pain Control. Society for Academic Emergency Medicine (SAEM M3 Curriculum). Retrieved from https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m3-curriculum/group-acute-pain-control/acute-pain-control.
  12. Busse JW, Wang L, Kamaleldin M, et al. Opioids for chronic noncancer pain: A Systematic Review and Meta-analysis. JAMA. 2018;320(23):2448-2460. doi:10.1001/jama.2018.18472
  13. Nordt SP, Ray L. Lidocaine. In: Mattu A and Swadron S, ed. ComPendium. Burbank, CA: CorePendium, LLC. Updated May 12, 2023. Accessed May 13, 2023.https://www.emrap.org/corependium/drug/recUEl2x9lfeYKbws/Lidocaine#h.tuo0od96 muij.
  14. Perry JS, Stoll KE, Allen AD, Hahn JC, Ostrum RF. The opioid risk tool correlates with increased postsurgical opioid use among patients with orthopedic trauma. Orthopedics. 2023;46(4):e219-e222. doi:10.3928/01477447-20230207-04
  15. Schnabl SM, Herrmann N, Wilder D, Breuninger H, Häfner HM. Clinical results for use of local anesthesia with epinephrine in the penile nerve block. J Dtsch Dermatol Ges. 2014; Apr;12(4):332-339. doi: 10.1111/ddg.12287. Epub 2014 Mar 3. PMID: 24581175.
  16. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
  17. Lidocaine with epinephrine. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
  18. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
  19. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
  20. Miner James R., Paetow Glenn. Procedural Sedation. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: ComPendium, LLC. https://www.emrap.org/corependium/chapter/recCvtWt5In5h4fLJ/Procedural-Sedation#h.9du7441ga4gn. Updated September 15, 2021. Accessed May 13, 2023.
  21. Midazolam. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
  22. Fentanyl. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
  23. Propofol. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
  24. Etomidate. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
  25. Ketamine. In: Lexicomp. UpToDate Inc; 2023. Accessed May 10, 2023. http://online.lexi.com
  26. Tagliafico L, Maizza G, Ottaviani S, et al. Pain in non-communicative older adults beyond dementia: a narrative review. Front Med (Lausanne). 2024;11:1393367. PublishedAugust 15, 2024. doi:10.3389/fmed.2024.1393367

FOAM and Further Reading

Pediatric pain: Pediatric Pain Management

Chronic pain: I CAN’T GET NO SATISFACTION FOR MY CHRONIC NON-CANCER PAIN

Reviewed and Edited By

Picture of Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Fever in Children (2024)

~ iEM Education Project Team ~ Leave a comment

by Camilo E. Gutierrez

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Disclaimer: The guidelines for evaluating febrile infants in this publication are based on current U.S. practices and epidemiology. These may not apply to other regions, particularly low- and middle-income countries, where vaccination rates, healthcare access, and local factors may differ. Local guidelines should be consulted in those settings.

You have new patients!

You are working in an emergency department, and during your shift, you see a number of different patients.

Bed 1

In bed 1, a parent brings a full-term 2-month-old male infant who has been complaining of fever at home for 1 day. The child has been drinking well, has normal urine output, and has no associated symptoms.

Prenatal care was normal, infant was born by normal vaginal delivery with no complications and went home with mom after a couple of days. Of note, the mother had a fever during delivery and received antibiotics—no sick contacts at home.

The male infant is vigorous and appears well during your examination. Currently afebrile with normal vital signs.

Bed 2

In bed 2, you find a well-appearing 2-month-old female infant with complaint of fever at home. This child has had fever for 1 day. She also has a runny nose and a couple of episodes of vomiting after feeding. The family is visiting from out of town and has no way to contact their pediatrician.

Prenatal care was normal, infant was born by normal vaginal delivery with no complications and went home with mom after a couple of days—no sick contacts at home.

The female infant is vigorous and well-appearing during your examination. Currently afebrile with normal vital signs.

Bed 3

In bed 3, you have a 3-year-old fully vaccinated boy who has had fever of up to 38.5°C every day for the last week. Aside from the fever, there were no significant respiratory symptoms, vomiting, or diarrhea. He has been able to drink well, although not eating his usual amount.

Vital signs are remarkable for fever of 39°C, mild tachycardia to 120 bpm, and respiratory rate of 32 rpm. On exam, he has mildly injected conjunctiva, cervical adenopathy, and some peeling of his fingers.

How will you approach each of these patients?

Introduction

Fever is a common childhood complaint frequently encountered in emergency medicine [1]. It is a symptom of an underlying illness or infection and occurs when the body’s temperature rises above its normal range [2]. In children, a fever is generally defined as a temperature of 38°C (100.4°F) or higher in infants under 3 months and 38.5°C (101°F) in older toddlers and children [3].

Many causes of fever in children include viral or bacterial infections, autoimmune disorders, allergies, and reactions to medication. In some cases, the cause of the fever may be difficult to determine [2].

In emergency medicine, the primary concern with fever in children is identifying the underlying cause and treating it appropriately. This may involve a thorough physical examination, blood tests, imaging studies, or other diagnostic tests to help identify the cause of the fever.

In addition to treating the underlying cause of the fever, several measures can be taken to help manage the symptoms of fever in children. These may include administering acetaminophen or ibuprofen to help lower the child’s temperature, ensure adequate hydration, and closely monitor the child’s temperature and other vital signs  [4].

It is important to seek medical attention promptly if your child has a fever accompanied by other symptoms such as difficulty breathing, severe headache, rash, or lethargy. With prompt diagnosis and treatment, most cases of fever in children can be successfully evaluated and managed in the emergency department.

Temperature should ideally be measured rectally in infants [5]. In older toddlers and children, oral or axillary measurements are acceptable, understanding there is an approximate 0.5°C difference between the latter and rectal temperatures [6]. Also, rectal or oral measurements might be contraindicated in patients with immunodeficiency or neutropenia.

The pathophysiology of fever is associated with the liberation of cellular mediators such as interleukins, tumor necrosis factor, and interferon and their impact on prostaglandins at the hypothalamic level, raising the endogenous thermostat [7]. Fever is thought to be a benign and useful mechanism to stimulate the immune system, although it does increase metabolic demands, which can affect homeostasis at various levels [8].

This chapter will review the evaluation of febrile children in the emergency department.

What do you need to know?

Fever in infants

The American Academy of Pediatrics (AAP) recently updated its guidelines [9] for evaluating and managing fever in infants, providing evidence-based recommendations for healthcare providers.

According to the new guidelines, any infant younger than 60 days of age with a fever (rectal temperature of 38°C or higher) should be evaluated promptly. Fever in this age group can be a sign of a serious bacterial infection or invasive infection that requires urgent medical attention. The evaluation should include a complete physical examination, blood tests, urine tests, and possibly a lumbar puncture.

The guidelines also emphasize the importance of assessing the infant’s overall clinical appearance, including their hydration status, activity level, and interaction with caregivers. Any infant who appears ill, dehydrated, or has other concerning symptoms should be evaluated and managed as an inpatient.

Overall, the AAP guidelines aim to provide a systematic approach to evaluating and managing fever in infants, focusing on early recognition and treatment of serious bacterial infections while minimizing unnecessary diagnostic testing and hospitalization. It is important for healthcare providers and parents to be aware of these guidelines and to seek prompt medical attention if an infant develops a fever.

Prenatal risk factors should be assessed and include prematurity, prenatal care, maternal infections such as Group B Streptococcus and herpes, prolonged rupture of membranes, birth by C-section of normal vaginal delivery, maternal fever, and need for peripartum antimicrobial administration. Postnatal factors may include admission to the neonatal intensive care unit, the presence of respiratory support, central or peripheral lines, exposure to sick contacts, or the use of antibiotics as a newborn. Social determinants of health, such as access to healthcare, education, adequate environment, economic stability, and social and community support, play a key role in the decision-making process considering the disposition of the febrile infant once assessed in the emergency department.

Clinical prediction rules have been developed and validated, and guidelines have been adapted to include their use. Currently, the Step-by-step and the PECARN prediction rules offer a high sensitivity (96.7% and 92%, respectively) for the detection of SBI/IBI in infants and, more importantly, a very high negative predictive value (>99%) by which if all the high-risk lab criteria, including inflammatory markers, are negative, the presence of IBI/SBI is extremely unlikely [10] [11].

Infants < 21 days of age

The risk of serious bacterial infection (SBI), which includes bacteremia, urinary tract infection, and meningitis in infants younger than 21 days of age, is very high, and clinical examination parameters are not sensitive or specific enough to determine which infants are not at risk of sepsis. Patients at this age with a fever > 38°C, hypothermia, bradycardia, or apnea have a high risk of sepsis and septic shock. Infants under 21 days of age require thorough evaluation, including complete blood cell counts (CBC), blood culture, catheterized urine sample for microscopic urinalysis and urine culture, and a spinal puncture (LP) for evaluation and culture of cerebrospinal fluid. In addition, these patients should receive parenteral antibiotics such as Ampicillin, Gentamycin, and/or Cefotaxime as per local guidelines. For patients of this age, it is important always to consider the possibility of herpes simplex virus (HSV) infection, and parenteral acyclovir should be considered pending results of HSV nucleic amplification tests (HSV DNA PCR) or viral culture studies [12]. These patients should be admitted to an inpatient level of care for close monitoring and pending results of blood, urine, and CSF cultures.

Infants 22-28 days

It is important to understand that any current guidelines for evaluating febrile infants apply to well-appearing children. Suppose there is any concern or clinical finding regarding an ill-appearing infant. In that case, a thorough examination and laboratory testing, including blood, urine, CSF cultures, broad-spectrum antibiotics, and admission to a hospital service, are indicated [13].

Infants in this age range are still considered at high risk for serious invasive infections, especially if there are any risk factors, as described above. Current guidelines still strongly recommend considering full evaluation of the patients 22 to 28 days old, strongly consider antibiotic management pending culture results, and possible admission to a hospital.

However, in select infants of this age range, a more conservative approach has been suggested: obtaining catheterized urine samples, a complete blood count, urine and blood cultures, and introducing inflammatory markers. Currently studied and available inflammatory markers include c-reactive protein (CRP), Procalcitonin, and absolute neutrophil count (ANC). These tests’ recommended cut-offs are CRP > 20 mg/L, Procalcitonin > 0.5 ng/ml, and ANC > 4000/µL or <1000/µL, respectively.

If a well-appearing infant has normal urinalysis, normal WBC, and negative inflammatory markers, one possibility would be admission to a hospital service with or without obtaining a lumbar puncture. However, this opens the opportunity to admit without giving antimicrobial agents and observing pending culture results [14]. However, if any of the screening labs or inflammatory markers are elevated, antibiotics and admission are necessary. Still, the possibility of HSV infection should be considered at this age.

Infants 29-60 days

For this age group, for well-appearing infants with a temperature >38°C, the recommendation is to obtain urine and blood, including cultures and inflammatory markers [15]. At this age, obtaining a lumbar puncture is no longer mandatory for a well-appearing child with otherwise normal laboratory evaluation and negative inflammatory markers. If inflammatory markers are elevated in the absence of a positive urinalysis, a lumbar puncture is indicated to rule out meningitis. If the urinalysis is positive and inflammatory markers are below the threshold, there is no clear indication to perform a spinal tap, and the infant can be treated for a urinary tract infection potentially with oral antimicrobials and can be considered a candidate to be discharged home with close follow up within 24 hours. Suppose all the screening labs and inflammatory markers are within normal limits. In that case, there is no indication for antibiotic treatment, and the patient can be observed at home with close follow-up in 24 hours [16]. Recent literature suggests that well-appearing infants with an uncomplicated urinary tract infection (UTI) have a very low risk of bacteremia and an even lower risk of meningitis.

In order to discharge an infant home, the clinician must ensure that the parents understand the degree of risk, the importance of prompt follow-up within 24 hours, the capacity and ability to return to medical care, and the understanding to return immediately if there is any deterioration in the infant’s status. If not all of these criteria can be fulfilled, and there are social, language, or intellectual barriers to healthcare, the patient should be admitted to the hospital for observation.

In infants older than 30 days of age, antimicrobial regimens can include ceftriaxone for the treatment of bacteremia and/or urinary tract infections, with the consideration of ceftazidime or vancomycin for the treatment of bacterial meningitis. Oral regimens of first or second-generation cephalosporins can be considered for uncomplicated urinary tract infections. Always consider the local flora, antibiograms, and susceptibility to antibiotics before prescribing antimicrobial courses.

Also, it’s important to remember that if there is any concern, a full septic workup should be obtained, and broad-spectrum antibiotics should be used pending the culture results.

Infants older than 2 months of age

Vaccination has significantly reduced the incidence of bacterial infections in children, including serial bacterial infections. For example, the Haemophilus influenzae type b (Hib) vaccine has been highly effective in reducing the incidence of invasive Hib disease, which can cause meningitis, pneumonia, and other serious infections in young children. The introduction of the pneumococcal conjugate vaccine (PCV) has also led to a significant reduction in the incidence of invasive pneumococcal disease, including pneumonia and meningitis. E. coli has become the most common pathogen responsible for IBI in infants, bacteremia, and meningitis.

Furthermore, vaccination can indirectly reduce the incidence of serial bacterial infections by reducing the overall burden of bacterial infections in the community. When fewer people are infected with a particular bacterium, there is less opportunity for that bacteria to be transmitted from person to person, known as herd immunity, reducing the risk of serial infections for the general population.

Vaccination has significantly reduced the incidence of bacterial infections in children, including serial infections. Vaccination is a safe and effective way to protect children from serious bacterial infections and is an important part of routine healthcare for children.

For the evaluation of well-appearing, febrile infants older than 2 months of age, the main recommendation is always to consider the possibility of a urinary tract infection (UTI). The incidence of bacteremia and meningitis in areas with adequate vaccination coverage has decreased to approximately 1% risk of bacteremia and <0.5% risk of bacterial meningitis. However, the risk of UTI remains at 10-20% risk.

In general, the risk of UTI is similar in females and males up to 6 months of age. However, it drops for circumcised males after 6 months. The prevalence of UTI remains high in females up to 24 months of age.

As discussed above, if there is any concern about a high fever or a child who is not well-appearing, a more aggressive evaluation should be undertaken, and appropriate antimicrobial therapy should be considered.

The need to obtain a lumbar puncture (LP) in a well-appearing infant in this age group is of less debate currently as the incidence of bacterial meningitis is so rare, especially with a reassuring examination and low-risk screening labs.

After 2 months of age, it is important to consider the prevalence of viral infections. Common viral infections such as Respiratory Syncytial Virus (RSV), Influenza Virus, Rhinovirus, Enterovirus, Metapneumovirus, and Coronavirus, including SARS-COVID-2 virus, are prevalent in infants, and studies reveal that the presence of these viral infections is related to less possibility of serious invasive bacterial etiology perhaps with the exception of UTI’s. The incidence of UTIs in children with associated RSV infection is still high and warrants evaluation. However, it is important always to be vigilant of the possibility of HSV disease, a thorough maternal history, exposure, and physical examination is important, as well as considering obtaining blood, skin, mucosal, and CSF samples to send for culture or nucleic acid amplification and consider starting antiviral therapy presumptively due to the severity of these infections in infants, specially central nervous system or disseminated disease, which carry high morbidity and mortality.

Recent antimicrobial use also needs to be considered in infants within this age group. If any oral antimicrobials have been administered within 72 hours, the clinician should consider the possibility of partially treated infection or masking of signs and symptoms of bacterial infection. In this scenario, obtaining urine and blood cultures should be strongly considered.

There is poor evidence regarding the extent of evaluation in recently immunized infants. Recent immunizations are generally considered vaccinations administered in the previous 24 to 48 hours. In general, for a well-appearing infant older than 2 months, with a normal physical examination after a recent immunization less than 24 hours prior to the evaluation, the general consensus is not necessarily to obtain any testing but to direct the patient for a follow-up evaluation in the next 24 hours to ensure fever is not further present within 48 hours after vaccinations. However, the clinician should consider the possibility of catheterized urine evaluation within 48 hours of immunization due to the prevalence of UTI.

Invasive Bacterial Infections (IBI)

IBI is used to discuss the evidence of localized bacterial infections in infants and toddlers. A thorough physical examination should provide a clue of the presence of any of these disease processes. The term usually includes acute otitis media, cutaneous cellulitis or omphalitis around the umbilicus in infants, bacterial arthritis, skin abscess, and mastitis. Occult causes of IBI are less evident by physical examination and require a high index of suspicion, and the likely need for laboratory or imaging evaluation includes bacterial pneumonia, osteomyelitis, epidural abscess, brain abscess, or meningitis. Ill-appearing infants with focal infections do require a thorough evaluation, including cultures of abscess drainage, fluid aspirates, and skin or mucosal discharge [17].

Hyperpyrexia

The literature describes a linear correlation between high fever and serious bacterial infection. Hyperpyrexia is defined as rectal temperature ≥40°C (104°F) and is uncommon among febrile infants but is highly associated with invasive bacterial infection. If an infant presents with hyperpyrexia, blood cultures should be obtained and treated with broad-spectrum antimicrobials pending the blood culture results.

Fever of unknown origin / Fever without a source

Fever of unknown origin (FUO) is generally defined as a temperature >38.3°C (101°F), at least once daily, that lasts for at least 8 days and for which the cause cannot be identified after an initial workup. FUO can be challenging to diagnose, especially in children, as it can be caused by a variety of infectious, inflammatory, and neoplastic diseases, usually in this order of prevalence. Fever without a source (FWS) is generally defined as fever for less than 1 week without adequate explanation after a thorough history and physical examination.

The evaluation of FUO in children typically involves a comprehensive history and physical examination, as well as laboratory tests, imaging studies, and sometimes more invasive procedures [18]. It is important to understand the local distribution of infectious agents and the regional or ethnic presentation of specific inflammatory or rheumatologic conditions. Still, there is a small minority of patients in whom, after thorough evaluations, no cause is identified.

The following is a general approach to the evaluation of FUO in children:

History and physical examination: A thorough history and physical examination are critical in identifying any clues that may help narrow down the potential causes of the fever. Important details to gather include the child’s age, travel history, recent infections, medication use, and exposure to animals or sick contacts. Concerning fever, it is important to verify its height, duration, pattern, if it is documented or subjective, and any other associated symptoms surrounding febrile spikes. Associated complaints or symptoms can be useful in helping establish a correlation. Respiratory symptoms, gastrointestinal complaints, bone and muscle aches, and skin rashes may suggest specific etiologies that may present with prolonged fevers. Travel and exposure are key questions that can help narrow the possibility of etiologic agents. Contact with sick individuals, pets, farms, and other animals can point to specific infectious etiologies. It is easy to find lists of common infectious diseases by geographic location.

Vital signs should be documented, and discrepancies should be analyzed. For example, fever and bradycardia might suggest a few specific conditions (tick-borne or mosquito-related illnesses, legionella, Leptospira). Weight loss might suggest systemic diseases or malignancy.

The physical examination should include a detailed examination of all organ systems. Detailed skin evaluation might suggest dermatologic manifestations, as skin rashes can be associated with specific infectious or rheumatologic diseases. Examination of mucosal surfaces, including conjunctiva, mouth, and genitalia, might provide clues to systemic, rheumatologic, infectious, or inflammatory diseases. Lung and cardiovascular exam might reveal evidence of effusions or endocarditis. Attention to typical and atypical lymphadenopathy, organomegaly, or bone or muscle tenderness that might suggest infiltrative disease, inflammatory or infectious process. The genitourinary examination should be considered to exclude sexually transmitted diseases, pelvic masses, and inflammatory or malignant etiologies. Finally, a detailed neurological assessment might suggest subtle neuro deficits that might point to neuropathies, spinal pathology, medication, or toxic overdoses.

The physical exam should be repeated frequently in children, as it often evolves and changes according to disease progression.

Often, the initial assessment will be performed by a primary care clinician in an outpatient setting unless the child has become ill, has rapidly progressing symptoms or deterioration, or initial common studies have been performed and need for more complex testing needs to be performed.

Laboratory tests: A complete blood count with differential cell count, blood cultures, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), liver and renal function tests, and urinalysis should be obtained as part of the initial workup. Depending on the clinical presentation and suspected etiology, additional tests such as serologic studies, viral cultures, and molecular diagnostic tests may be indicated. Leukocytosis, cytopenia, anemia, thrombocytosis or thrombocytopenia, and atypical cell lines such as atypical leukocytes, bandemia, eosinophilia, can all point to various infectious etiologies, and might suggest viral, fungal, parasitic, rickettsial, and chronic disease or malignancy. Inflammatory markers are non-specific but can help the clinician trend the progression of a disease process.

Secondary-tier testing may involve ANAs, cryoglobulins, immunoglobulins, ferritin, and targeted rheumatologic and immunologic tests to help identify a more specific etiology. Additionally, tumor markers and specialized viral and infectious testing—such as DNA and RNA viral profiles, serologies for viral, bacterial, or rickettsial infections, and RPR or VDRL for presumed syphilis—can be utilized. Stool studies can reveal infectious etiologies, and calprotectin or occult blood can suggest inflammatory pathology.

Imaging studies: Chest X-ray, abdominal ultrasound, and/or computed tomography (CT) scans may be necessary to evaluate for pulmonary, abdominal, or pelvic pathology. Plain films can help evaluate bony malignancy or infections, soft tissue calcifications, and bone density. Magnetic resonance imaging (MRI) or positron emission tomography (PET) scans may be helpful in identifying occult infections or tumors. A conscious balance between radiation, costs, risks and benefits should guide imaging studies. A discussion with radiology experts might help direct the imaging study of choice and the need for contrast material.

Invasive procedures: Depending on the clinical presentation and initial workup, invasive procedures such as bone marrow biopsy, lymph node biopsy, or liver biopsy may be necessary to establish a diagnosis.

It is important to note that the evaluation of FUO in children should be individualized based on the patient’s clinical presentation and suspected etiology. A multidisciplinary approach involving infectious disease specialists, hematologists/oncologists, and rheumatologists may be necessary to establish a diagnosis and guide management.

Revisiting Your Patient

In bed 1, the 2-month male infant with fever at home for 1 day with history of maternal fever during delivery underwent a full septic workup due to the risk factors, received a dose of ceftriaxone and was admitted to the hospital for observation for 24 hours, until urine, blood, and CSF cultures were negative.

In bed 2, your 2-month-old female infant with fever at home only underwent a catheterized urine sample that was unremarkable. Because the mom had no good follow-up with a primary care provider, the infant was admitted to the hospital for 24 hours with no antibiotics until the urine culture was negative for 24 hours.

In bed 3, you have a 3-year-old fully vaccinated child who has had fever of up to 38.5◦C every day for the last week—examination with fever, conjunctivitis, and skin peeling.

This child underwent laboratory workups, including inflammatory markers, blood counts, chemistry, and liver function tests. He was admitted to the hospital for consultation with Cardiology and infectious Diseases to consider further evaluation for Kawasaki disease.

Author

Picture of Camilo E. Gutierrez

Camilo E. Gutierrez

Dr. Gutiérrez is an Associate Professor of Pediatrics and Emergency Medicine at George Washington University School of Medicine and Health Sciences, practicing Pediatric Emergency Medicine at Children’s National Hospital in Washington, DC. He is a renowned Pediatric Emergency Physician with extensive experience in clinical care, education, and global health. He leads international initiatives to improve pediatric emergency systems, having served in leadership roles for various global organizations. With over 90 international lectures, 30 publications, and a focus on pediatric trauma, critical care, and ultrasound, he is a key advisor in developing acute care systems worldwide.

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References

  1. Courtney, L., Franklin., Bernie, Carter., David, Taylor-Robinson., E., Carrol. “P09 Understanding the reasons behind paediatric attendances to emergency departments for febrile illness in the UK: A qualitative study.” JECH (2023). doi: 10.1136/jech-2023-.
  2. Jayashree M, Parameswaran N, Nallasamy K, et al. Approach to fever in children. Indian J Med Microbiol. 2024;50:100650. doi:10.1016/j.ijmmb.2024.100650
  3. Rajesh, Kasbekar., Aftab, Naz., Lorenzo, Marcos., Yingjie, Liu., Kristine, Hendrickson., James, C, Gorsich., Matt, Baun. “Threshold for defining fever varies with age, especially in children: A multi-site diagnostic accuracy study..” (2021).:2705-2721.
  4. “The management of fever in children.” Minerva pediatrics, 74 (2022). doi: 10.23736/s2724-5276.22.06680-0.
  5. Luis, Ángel, Bolio, Molina., Gabriela, Toledo, Verónico. “1. New Technique to Verify Permeability and Anorectal Malformations, and Take Rectal Temperature in Neonates And Infants.” (2023). doi: 10.33425/2689-1085.1057.
  6. Mohammed, Baba, Abdulkadir., W, B, Johnson. “6. A comparative study of rectal tympanic and axillary thermometry in febrile children under 5 years of age in Nigeria.” Paediatrics and International Child Health (2013). doi: 10.1179/2046905513Y.00.
  7. Soszyński D. Mechanizmy powstania i znaczenie goraczki [The pathogenesis and the adaptive value of fever]. Postepy Hig Med Dosw. 2003;57(5):531-554.
  8. Norbert, J., Roberts., Juan, C., Sarria. “4. Recognizing the Roles of Fever in Host Survival and in Medical Intervention in Infectious Diseases..” The American Journal of the Medical Sciences, (2024). doi: 10.1016/j.amjms.2024.05.013.
  9. https://www.aap.org/
  10. Tahir, Hameed., Sereen, AlMadani., Walaa, Shahin., Husam, Ardah., Walaa, A, Almaghrabi., Mohammed, Alhabdan., Ahmed, Mohammed, Alfaidi., Asma, Abuthamerah., Mamdouh, Al‐Ahmadi., Majed, Almalki., Mona, Al-Dabbagh. “1. Application of the Pecarn Prediction Rule for Febrile Infants up to 90 Days of Age: A Multi- Center Study. doi: 10.21203/rs.3.rs-4761730/v1.
  11. Natalia, Sutiman., Zi, Xean, Khoo., Gene, Yong-Kwang, Ong., Rupini, Piragasam., Shu-Ling, Chong. “2. Validation and comparison of the PECARN rule, Step-by-Step approach and Lab-score for predicting serious and invasive bacterial infections in young febril. e infants..” Annals Academy of Medicine Singapore (2022). doi: 10.47102/annals-acadmedsg.2022193.
  12. Stacy, Lund., Tine, Brink, Henriksen., Anja, Poulsen., Kia, Hee, Schultz, Dungu., Emma, Louise, Malchau, Carlsen., Bo, Mølholm, Hansen., Lise, Aunsholt., Ulrikka, Nygaard. “1. [Herpes simplex virus infection in newborns]..” Ugeskrift for Læger, 2022.
  13. Pantell RH, Roberts KB, Adams WG, et al. Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old [published correction appears in Pediatrics. 2021 Nov;148(5):e2021054063. doi: 10.1542/peds.2021-054063]. Pediatrics. 2021;148(2):e2021052228. doi:10.1542/peds.2021-052228
  14. Rajendra, Prasad, Anne., Sourabh, Dutta., Haribalakrishna, Balasubramanian., Ashutosh, N., Aggarwal., Neelima, Chadha., Praveen, Kumar. “2. Meta-analysis of Cerebrospinal Fluid Cell Count and Biochemistry to Diagnose Meningitis in Infants Aged < 90 Days.”. American Journal of Perinatology. (2024), doi: 10.1055/a-2095-6729.
  15. Jamie, M., Pinto., Vaidehi, Patel., Anna, Petrova. “Role of viral pathogen(s) detection in hospital-based management of 29-90-day-old infants with unexplained fever..” MINERVA Pediatrica. (2023). doi: 10.23736/S2724-5276.23.07207-5.
  16. Rachel, G., Greenberg., Tamara, I., Herrera. “4. When to Perform Lumbar Puncture in Infants at Risk for Meningitis in the Neonatal Intensive Care Unit.” (2019). doi: 10.1016/B978-0-323-54391-0.00008-4.
  17. Dana, M., Foradori., Michelle, A., Lopez., Matthew, Hall., Andrea, T., Cruz., Jessica, L., Markham., Jeffrey, D., Colvin., Jennifer, A., Nead., Mary, Ann, Queen., Jean, L., Raphael., Sowdhamini, S., Wallace. “2. Invasive Bacterial Infections in Infants Yo. unger Than 60 Days With Skin and Soft Tissue Infections. Pediatric Emergency Care, doi: 10.1097/PEC.0000000000001584.
  18. Sandra, Trapani., Adele, Fiordelisi., Mariangela, Stinco., Massimo, Resti. “1. Update on Fever of Unknown Origin in Children: Focus on Etiologies and Clinical Approach.” Children (Basel), (2023). doi: 10.3390/children11010020.

Reviewed and Edited By

Picture of Jonathan Liow

Jonathan Liow

Jonathan conducts healthcare research in the Emergency Department at Tan Tock Seng Hospital. A graduate of the University at Buffalo with a BA in Psychology and Communication, he initially worked on breast cancer research studies at GIS A*STAR. His research interests focus on integrating AI into healthcare and adopting a multifaceted approach to patient care. In his free time, Jonathan enjoys photography, astronomy, and exploring nature as he seeks to understand our place in the universe. He is also passionate about sports, particularly badminton and football.

Picture of James Kwan

James Kwan

James Kwan is the Vice Chair of the Finance Committee for IFEM and a Senior Consultant in the Department of Emergency Medicine at Tan Tock Seng Hospital in Singapore. He holds academic appointments at the Lee Kong Chian School of Medicine, Nanyang Technological University, and the Yong Loo Lin School of Medicine, National University of Singapore. Before relocating to Singapore in 2016, James served as the Academic Head of Emergency Medicine and Lead in Assessment at Western Sydney University's School of Medicine in Australia. Passionate about medical education, he has spearheaded curriculum development for undergraduate and postgraduate programs at both national and international levels. His educational interests focus on assessment and entrustable professional activities, while his clinical expertise includes disaster medicine and trauma management.

Picture of Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Heat Illnesses (2024)

~ iEM Education Project Team ~ Leave a comment

by Patrick Joseph G. Tiglao, Rhodney P. Canada, & Emmanuel Luis S. Mangahas

Authors
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You have a new patient!

A 24-year-old man was brought to your Emergency Department by his football coach. His coach informed you that he started “behaving strangely” and responding inappropriately to questions a few hours ago during a practice session on the football field. His initial vital signs are BP 80/50 mmHg, HR 115 bpm, RR 24 bpm, T 41.5oC, and SpO2 98%. His GCS is 13 (E3V4M6).

What do you need to know?

Climate change is widely considered the greatest threat to human health globally in the coming decades [1]. According to the assessment of the Intergovernmental Panel on Climate Change (IPCC), the next decades might witness global warming above 1.5 °C, exceeding the goals of the Paris Agreement [2]. Concomitantly, heat-related mortality has developed as a growing public health concern. Populations with pre-existing chronic diseases are more sensitive to climate change, warranting closer attention and more effective interventions to manage heat-related health risks [3]. Therefore, a comprehensive medical understanding of heat-related illnesses is required as the world faces climate change [1].

Heat-related illnesses include a spectrum of diseases, ranging from mild and self-limiting conditions such as heat edema, heat cramps, and heat stress to the life-threatening condition known as heat stroke. These conditions occur when the body’s thermoregulatory mechanisms fail to keep body temperature within normal limits in a hot and humid environment [4].

The emergency physician needs to have a high index of suspicion for heat stroke because these patients can mistakenly be diagnosed with other conditions that may present similar to heat stroke.  Some examples are sepsis, intracranial bleeding, stroke, thyroid storm, anticholinergic toxicity, or other conditions where patients may have high fevers or altered mental status, similar to heat stroke. The most critical initial intervention in heat stroke is rapid cooling to <39°C. A misdiagnosis can result in a delay in rapid cooling.  Failing to implement this intervention results in higher mortality [5].

According to the World Health Organization, more than 166,000 people died due to extreme temperatures between 1997 and 2017.  This includes 70,000 deaths in the 3-month European heatwave of 2003 and 53,000 deaths in the 44-day Russian heatwave of 2010 [5]. A 2003 prospective study from France reported a 28-day and 2-year mortality rate of 58% and 71%, respectively, for patients diagnosed with heat stroke [6].

Body temperature is controlled by the hypothalamus. The body gains heat from metabolism and the environment, and this heat must be dissipated to maintain core body temperature between 36°C and 38°C (96.8°F and 100.4°F). Thermoregulation relies on four primary mechanisms: dilatation of blood vessels, particularly in the skin, increased sweat production and subsequent evaporation, decreased heat production, and behavioral heat control. Vasodilation contributes to the orthostatic pooling of interstitial fluid in the lower extremities, as seen in heat edema. When these processes are overwhelmed, core temperature will rise and may result in heat stress [4].

Cellular injury can begin when the core body temperature exceeds 39oC, especially if the elevation in temperature is sustained [7]. As the body temperature rises to 40°C, an acute phase response is elicited from heat-stressed cells.  This involves the release of cytokines and heat shock proteins, materials that can cause damage to organ systems and result in heat stroke [4,8]. The incremental damage to cells and organ systems as body temperature rises above 39oC exemplifies the importance of rapid cooling in a patient with hyperthermia.

Heat stroke due to high external temperature and humidity without much contribution from physical exertion is termed classical heat stroke (CHS).  Heat stroke is due to increased heat generation from strenuous physical activity, usually under extreme heat conditions and in a poorly acclimatized and conditioned body, and is termed exertional heat stroke (EHS). For example, classical heat stroke may be seen in elderly individuals sitting in poorly cooled and ventilated homes during the summer; exertional heat stroke may be seen in athletes exercising hours in the sun during a prolonged sporting event or race. Another heat-related illness that may be encountered in the athlete patient is heat cramps. These cramps occur from relative deficiencies in electrolytes such as sodium, potassium, and magnesium brought about by replenishing lost fluids with hypotonic drinking solutions after vigorous physical activity. This leads to painful involuntary contractions of skeletal muscles, most commonly the calves [4].

The exercising body has thermoregulatory mechanisms it utilizes when exposed to prolonged heat. During exercise, blood vessels dilate to release heat, the heart rate increases, and stroke volume decreases. Sweat production and evaporation from the skin surface also assist in cooling the body during exercise. These mechanisms may be diminished in patients with underlying cardiovascular disease (e.g., congestive heart failure) or those taking certain medications (e.g., beta-blockers or anticholinergic medications). These patient groups are at increased risk of heat-related illnesses during exercise [9].

Medical History

Ask patients with heat edema about exposure to hot and humid environments. The presence of other symptoms, such as dyspnea, easy fatigability, orthopnea, paroxysmal nocturnal dyspnea, and oliguria, are red flags that may point to alternative causes of the edema, such as congestive heart failure or kidney failure [4].

For patients with heat cramps, verify recent participation in strenuous activities, such as sports events and practices, military exercise, or procession-like activities. Ask if the patient took fluid during exertional activities and, if so, what type of fluid was consumed. Drinking hypotonic solutions, such as plain water, puts patients at risk for relative deficiencies in electrolytes and subsequent heat cramps. Ask about vomiting, diarrhea, and medications, like diuretics or antihypertensives, which can also put the patient at risk for electrolyte disturbances [4].

Heat stress is a diagnosis of exclusion because patients usually come in febrile with non-specific symptoms such as nausea, headache, weakness, and dizziness [4]. Again, patients with a recent history of exposure to hot and humid environments are at increased risk of heat stress. Still, the emergency physician should be aware of other more dangerous conditions, such as sepsis, CNS infection, endocrine dysfunction, myocardial infarction, and drug overdose. Ask for recent history of dyspnea, cough, dysuria, and headache, which may point to infectious diseases such as pneumonia, urinary tract infection, and CNS infection.

To diagnose heat stroke, the patient must have both Central Nervous System (CNS) impairment and a core temperature greater than 40°C. The spectrum of neurological abnormalities ranges from mild confusion to coma with a GCS of 3. Situational awareness is a vital skill for emergency physicians, as one should be aware of days with high ambient temperatures and high humidity that can increase the risk of CHS. Usage of medications that impair sweating, like anticholinergic medications, is another risk factor for developing heat illnesses. Generally speaking, CHS is uncommon in geographical areas where the average temperature throughout the year is high, as communities living there will develop behavioral tactics to avoid the heat. Intense exercise, military training, sports competitions, or prolonged labor, on the other hand, puts patients at risk for EHS. Patients not trained in hot environments may not be physiologically acclimatized, increasing their risk for EHS [4].

Physical Examination

Whenever heat illnesses are considered in the differential diagnosis of a given patient, measuring a core body temperature (e.g., rectal temperature) is the most important physical assessment. Using the physical exam to evaluate for other causes of elevated body temperature is important.  Physical signs of infection (e.g., cellulitis, abscess, drainage from wounds, asymmetric breath sounds), intoxication (e.g., dilated pupils), and endocrine dysfunction (e.g. goiter) should be assessed.

Obtaining an accurate and continuous core body temperature is a crucial part of the physical examination. Core temperature should be assessed and monitored using rectal, bladder, or esophageal probes. Peripheral temperature measurements, like oral, axillary, or temporal temperatures, are unreliable and may not reflect actual core temperatures. A common pitfall in measuring rectal temperature is not inserting the probe to a sufficient depth, rendering readings inaccurate, mainly if ice packs have been applied to the groin area for cooling. Rectal probes, in general, have to be inserted 15 cm inside the rectum to mitigate the effects mentioned above, but manufacturers may recommend different depths.  Note that unlike heat stroke and heat stress, heat edema, and heat cramps will not have an increased core temperature [4]. Tachycardia and hypotension may be seen on examination as a response to thermoregulatory peripheral vasodilation. This phenomenon contributes to other heat illnesses, such as heat edema and heat syncope.

After vital signs, a head-to-toe physical exam should be conducted with special care in conducting a thorough neurological examination. A hallmark finding of heat stroke, other than a core temperature above 40°C, is an abnormal neurological exam. CNS effects might range from mild confusion to deep coma. Ataxia and slurred speech may also be seen. CNS effects help distinguish heat stress from heat stroke, as only heat stroke will have CNS changes [4].

Assess for neurologic signs such as nuchal rigidity, lateralizing spasticity, and pathologic reflexes (e.g. extensor toe reflex) to determine the possibility of a central neurologic etiology. Seizures, in general, are common in heat stroke and might be confused with shivering during cooling.  Both seizures and shivering should be treated for neural protection and prevention of heat generation, respectively.  Benzodiazepines are appropriate for treating both conditions.

Alternative Diagnoses

Minor heat illnesses, like heat cramps and heat edema, can be diagnosed clinically based on the history. Alternative diagnoses for heat edema include congestive heart failure, renal failure, and chronic hepatic disease. The presence of exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea would suggest congestive heart failure. Progressively decreasing urine output and generalized edema would suggest renal failure. A jaundiced patient with progressively enlarging abdomen would indicate a chronic hepatic disease. Alternative diagnoses for heat cramps are infectious conditions and electrolyte derangements. Many viral syndromes, like influenza, COVID-19, or Dengue, can be associated with myalgias.  Other conditions, like Leptospirosis, can also present with lower extremity myalgia and calf tenderness. However, the absence of decreasing urine output, fever, and jaundice would make this diagnosis unlikely.

Heat stroke, with its cardinal features of hyperpyrexia and altered sensorium, has numerous alternative diagnoses.  Some important diagnoses to consider are sepsis, CNS infections, thyroid storm, sympathomimetic or anticholinergic toxidromes, serotonin syndrome, alcohol withdrawal, stroke, or status epilepticus. Investigate accordingly for a focus of infection for these patients. Thyroid storm patients may also present with atrial fibrillation, diarrhea, and a trigger (e.g., missed thyroid medications, infection, or surgery). The presence of signs and symptoms such as sudden-onset lateralizing weakness, slurring of speech, headache, nuchal rigidity, and recurrent seizures despite adequate cooling may suggest central neurologic etiology for the patient’s condition. It may require a more tailored neurologic work-up.  Reported illicit substance or alcohol use, or lack thereof, would support intoxication or withdrawal. Epilepsy history, missed doses of antiepileptic medications, or active seizure activity during the exam would support status epilepticus as a diagnosis.

Acing Diagnostic Testing

Heat stroke and other heat illnesses are diagnoses made clinically.  However, diagnostic testing can help rule out alternative diagnoses and evaluate for concurrent organ dysfunction and metabolic derangements.

Immediately test point-of-care glucose because hypoglycemia is a common and easily reversible cause of altered sensorium. Hypoglycemia also sometimes accompanies exertional heat stroke since glucose reserves may become depleted from physical activity. Blood work-ups can include a complete blood count to evaluate for infection, creatinine to rule out acute kidney injury, and metabolic profile to assess for electrolyte imbalance. Hypernatremia may be present in severe dehydration. Hyponatremia and hypercalcemia may be present in patients who are dehydrated with hypotonic solutions after extreme physical activity. Hyperkalemia may be associated with acute kidney injury.

Blood gas analysis may help differentiate classical and exertional heat stroke. Classical heat stroke usually presents with respiratory alkalosis from hyperventilation as a compensatory mechanism to extreme heat. In contrast, exertional heat stroke may present with lactic acidosis from repeated muscular contractions from physical exertion [4]. Moreover, elevation of liver enzymes is very common in both EHS and CHS, mainly due to direct thermal injury and hypoxia from splanchnic vascular redistribution. Hepatic damage is almost always mild and reversible despite rare reports of fulminant hepatic failure from heat stroke [4,10].

Concerns for a central neurologic etiology for the patient’s encephalopathy can be assessed with CT brain imaging and CSF analysis.  These studies should be especially considered if focal neurologic deficits, slurring of speech, nuchal rigidity, or meningeal signs persist despite lowering the core temperature.

Risk Stratification

Minor heat illnesses are generally self-limited and have good outcomes. Heat stroke, on the other hand, is a life-threatening emergency. Mortality rate is correlated with the maximum core temperature and time to initiate cooling methods [4]. A study in 2018 also showed that the presence of disseminated intravascular coagulation is an independent prognostic factor for hospital mortality in patients with heat stroke [11]. Patients suffering from multiple organ injuries due to thermal injury also have poorer prognosis, so it is imperative to closely monitor renal, hepatic, and cardiovascular status of heat stroke patients [10,12].

Management

A core temperature above 40°C should prompt the clinician to consider heat stroke and initiate rapid cooling. 

Heat stroke is a time-sensitive condition where cooling takes precedence over everything else, including confirmation of the diagnosis. Every patient should be approached with the ABCDE assessment to ensure that all critical decisions are made promptly. Heat stroke is not an exception to this role, as the disturbance in consciousness could result in significant airway complications. A complete airway assessment should be immediately performed when the patient arrives in the emergency department while cooling measures are being set up. Many heat stroke patients may have a depressed level of consciousness, but the decision to intubate is ultimately clinical and based on local resources. Airway protection is paramount and should take priority over any other diagnostic or therapeutic procedures. Peripheral blood pooling is a component of heat stroke pathology, so hypotension is common in these patients. Intravenous fluid administration should be judicious, as blood pressure usually picks up as the core temperature drops. Aliquots of 250cc of crystalloids should be used when fluids are needed, and repeated dosing should take place after volume status assessments.

In heat stroke, external cooling methods are the main pillar of therapy. Antipyretics, such as Paracetamol, have no proven benefit in such cases. The fastest way to cool patients is through conduction, the direct transfer of heat between molecules. Full body water immersion can do this, and although this is theoretically the best cooling method, it is clinically challenging. Immersion of the patient in water poses a risk of aspiration and renders the patient’s accessibility quite difficult. Alternatively, ice packs can be placed on the patient’s neck, axilla, and groin areas. Convection, heat loss due to gas movement around the body, combined with evaporation, can achieve a cooling speed similar to full-body immersion. This combination can be achieved by spraying the patient with lukewarm water followed by fanning with warm air. Mist fans are very convenient and have the added benefit of their ability to fan multiple patients at once.

Figure 1- monitor showing the current vitals while the patient is cooled.
Figure 2. The row of beds with mist fans in a sunstroke unit. A cooling unit can be seen at the far right.
Figure 3. Fiberglass grooved beds with waterproof mattresses in a sunstroke unit.

One complication of these cooling maneuvers is shivering. Shivering needs to be controlled as it increases internal heat generation. This can be overcome by administering benzodiazepines. It should be noted that high ambient temperature and high humidity make convection and evaporation less effective. For this reason, if these patients are encountered in the prehospital setting, the first priority is to remove them from the hot and humid environment [4,7].

Internal cooling procedures, such as cold IV fluids and internal cold fluid lavages, do not have high quality to support their safety and efficacy in heat stroke patients [4]. Internal cooling with cardiopulmonary bypass can be considered in severe cases that do not respond to typical cooling methods. However, it is costly, resource-intensive, and unavailable in many contexts [4]. Rapid and aggressive external cooling with evaporative cooling, cold water immersion, and ice packs should be prioritized as the initial preferred cooling methods. Invasive measures, like thoracic, bladder, rectal, or peritoneal lavage, should only be used when other measures fail.

Special Patient Groups

Patients at extremes of age are at increased risk for heat-related illnesses and should be carefully considered for these conditions when presenting with fever [4].

Pediatrics

Classical heat stroke can occur in pediatric patients, but these patients are also at risk of another type of heat stroke known as confinement hyperpyrexia. This happens when a child is left inside a vehicle with poor ventilation during extreme heat. Pediatric patients are especially susceptible to heat stroke because they still lack adequate thermoregulatory mechanisms and the instinctive capacity to replace their fluid losses [4]. Child abuse should be considered, and necessary actions should be taken to protect the child from abuse or maltreatment.

Pregnant Patients

Pregnant individuals are particularly vulnerable to heat-related illnesses due to physiological changes that increase metabolic and cardiovascular demands. Conditions such as heat cramps, heat exhaustion, and heat stroke can arise from prolonged heat exposure, posing risks to both maternal and fetal health, including preterm birth and low birth weight. Management involves moving the patient to a cooler environment, ensuring hydration with non-caffeinated drinks or intravenous fluids if needed, applying cooling measures like wet cloths and fans, and monitoring vital signs closely. Preventive measures are crucial and include staying hydrated, wearing lightweight clothing, avoiding outdoor activities during peak heat, and utilizing air-conditioned spaces. Recognizing early symptoms, such as excessive sweating, dizziness, or confusion, and seeking immediate medical care when necessary are critical to preventing complications.

Geriatrics

Geriatric patients may have comorbidities or take daily medications that impair thermoregulation or mobility, making them prone to heat-related illnesses. This population has a higher heat stroke mortality rate and is more likely to experience complications of heat stroke [4]. Advocating for closer community ties, monitoring by family or peers, and improved socioeconomic support may help elderly patients evade health-related illnesses.

Mass Gatherings

Preparing for a mass gathering event should involve mitigation measures for a possible mass casualty incident of heat stroke and heat exhaustion patients, especially during hot or humid summer months. Public education should be employed to seek shade, drink enough fluids, and use umbrellas. Preparations should also include installing mist pipes, vent fans, and nearby cooling stops.

When to admit this patient

Patients with minor heat illness (e.g., heat edema, cramps, and stress) can generally be discharged home. They should be advised to refrain from strenuous activities during extreme heat conditions, drink plenty of fluids, and wear light and loose-fitting clothing. Those who suffer from heat cramps should be advised to avoid hypotonic solutions for fluid replacement to prevent relative electrolyte deficiencies [4].

Consider admission for patients with minor heat illness but have comorbidities, such as congestive heart failure and renal failure, and those with severe electrolyte abnormalities. Patients suffering from heat stroke must be admitted after resuscitation and rapid cooling in the emergency department.  Heat stroke patients need admission to adequately monitor core temperature and possible occurrence of late complications, such as renal failure, hepatic injury, and electrolyte abnormalities. Patients who are intubated or unstable hemodynamically require ICU admission for closer monitoring [4].

Revisiting Your Patient

You immediately assess the patient’s ABCDEs as part of the primary survey. You assess the patient’s airway for the presence of stridor and pooling of oral secretions. The airway is normal. The patient is able to speak in sentences, albeit confused. He is tachypneic but has normal work of breathing and clear breath sounds. Again, you note that the patient is hypotensive at BP 80/50, tachycardic at HR 115, and hyperthermia at 41.5oC. You start infusing 500 mL of normal saline intravenously as a bolus. The patient was confused but did not exhibit lateralizing weakness, slurring of speech, or nuchal rigidity. Point-of-care glucose was done to rule out hypoglycemia, which revealed 146 mg/dL. You did not elicit any history of trauma, and you did not note any obvious abrasions, lacerations, or bleeding. After the IV bolus, reassessment was as follows: BP 90/60, HR 110, RR 24, T 41.5oC, SpO2 98%, and GCS 13 (E3V4M6)

On further history taking, you elicit that the patient has no allergies, no daily medications, no known comorbidities, and last ate 3 hours ago. You learn the patient was at football team practice for 2 hours at noon today when they noted that the patient had decreased verbal responses, responded inappropriately, and was extremely warm to touch. There was no vomiting, headache, lateralizing weakness, or trauma noted during the incident. There was no history of cough, dyspnea, and fever in the preceding days. The coach said the patient had only joined the football team 4 days prior. You insert a rectal thermometer and note a temperature of 42.0oC. With this information, you suspected that the patient may be suffering from an exertional heat stroke and decided that the goal was to decrease the core temperature to less than 39oC as soon as possible. You immediately remove the patient’s clothing while still maintaining modesty. You direct a vent fan to the patient by incorporating water sprays and placing ice packs on the patient’s neck, axillary, and groin areas.

After 30 minutes of cooling, you observe shivering. To decrease the internal heat production that shivering may cause, you administer diazepam 2.5 mg IV, and the shivering subsides. A cardiac monitor with pulse oximetry is connected, and blood samples are drawn to evaluate for organ dysfunction and possible sepsis. After reaching a rectal temperature of 39°C, you direct your team to dry cover the patient with a light bed sheet. Upon subsequent examination, the patient was conscious, alert, and oriented. Vitals are BP 110/60, HR 105, RR 22, T 38.5oC O2Sat 96% on room air. Laboratories are remarkable for metabolic acidosis and elevated liver enzymes. Complete blood count is unremarkable. You admit the patient to a general medical ward for further monitoring and management.

Authors

Picture of Patrick Joseph G. Tiglao

Patrick Joseph G. Tiglao

Dr. Patrick Joseph G. Tiglao, FPCEM is a practicing Emergency Medicine Physician at the University of the Philippines - Philippine General Hospital. He is also affiliated with DOH regional hospitals in the other parts of the Philippines namely, Corazon Locsin Montelibano Memorial Regional Hospital in Bacolod City, Negros Occidental and Eastern Visayas Medical Center in Tacloban City, Leyte Province.

Picture of Rhodney P. Canada

Rhodney P. Canada

Dr. Rhodney P. Canada graduated, being the top of his class, Doctor of Medicine from the University of St. La Salle – Bacolod in 2018. He spent a year of post-graduate internship at the University of the Philippines Manila – Philippine General Hospital from 2018-2019. Currently, he is a senior 4th year and Chief Resident of the Department of Emergency Medicine in Corazon Locsin Montelibano Memorial Regional Hospital, Bacolod City, Negros Occidental, Philippines.

Picture of Emmanuel Luis S. Mangahas

Emmanuel Luis S. Mangahas

Philippine General Hospital

Acknowledgement

The authors would like to express their utmost gratitude to Dr. Abdulaziz Al Mulaik, the author of this chapter in the previous edition.

Listen to the chapter

References

  1. Zhou L, He C, Kim H, et al. The burden of heat-related stroke mortality under climate change scenarios in 22 East Asian cities. Environ Int. 2022; 170
  2. Tollefson J. Top climate scientists are sceptical that nations will rein in global warming. Nature. 2021; 599(7883):22-24.
  3. Yang J, Zhou M, Ren Z, et al. Projecting heat-related excess mortality under climate change scenarios in China. Nat Commun. 2021; 12 (1039)
  4. LoVecchio F. Heat Emergencies. In Tintinalli J, ed. Emergency Medicine A Comprehensive Study. 9th ed. USA: McGraw Hill; 2020: 1345-1350
  5. Heat and Health. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/climate-change-heat-and-health. Published June 2018. Accessed April 2023.
  6. Argaud L, Ferry T, Le QH, et al. Short- and long-term outcomes of heatstroke following the 2003 heat wave in Lyon, France. Arch Intern Med. 2007;167(20):2177-2183
  7. Beltran G. Heat-related Illneses. In Cone D, ed. Emergency Medical Services Clinical Practice and Systems Oversight. 3rd ed. New Jersey, USA: John Wiley & Sons; 2021: 403-409
  8. Benedetto W. Heat Stroke. In Parsons P, Wiener-Kronish J, ed.Critical Care Secrets. 5th ed. Mosby; 2013: 541-544
  9. Hifumi T, Kondo Y, Shimizu K, Yasufumi M: Heat stroke. J Intens Care. 2018: 6(30)
  10. Grogan H, Hopkins PM. Heat stroke: implications for critical care and anaesthesia. BJA. 2002: 88(5):700–707
  11. Hifumi T, Kondo Y, Shimazaki J, et al. Prognostic significance of disseminated intravascular coagulation in patients with heat stroke in a nationwide registry. J Crit Care. 2018;44:306-311
  12. Liu S, Xing L, Wang J, et al. The Relationship Between 24-Hour Indicators and Mortality in Patients with Exertional Heat Stroke. Endocr Metab Immune Disord Drug Targets. 2022;22(2):241-246

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Reviewed and Edited By

Picture of Joseph Ciano, DO, MPH, MS

Joseph Ciano, DO, MPH, MS

Dr. Ciano is a board-certified attending emergency medicine physician from New York, USA. He works in the Department of Emergency Medicine and Global Health at the Hospital of the University of Pennsylvania. Dr. Ciano’s global work focuses on capacity building and medical education and training in low-middle income countries. He is thrilled to collaborate with the iEM Education Project in creating free educational content for medical trainees and physicians.

Picture of Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Headache (2024)

~ iEM Education Project Team ~ Leave a comment

by Shailaja Sampangi Ramaiah

Authors
Listen

You have a new patient!

A 60-year-old male is brought to the Emergency Room by a family who gives a history of sudden onset severe headache with vomiting and right-sided weakness. The symptoms began one hour ago. He is a known diabetic on Metformin and has been hypertensive on Losartan for the past 20 years. The patient has poor compliance with his home medications. The family denies any history of trauma, seizures, or antiplatelet or anticoagulation drug intake.

On examination, the patient is unresponsive with HR -98/min, BP: 210/120 mmHg, RR: 16/min, oxygen saturation: 80% room air, and temperature: afebrile.  The GCS is 5 (E1V1M3), and the patient has right-sided weakness 0/5, absent deep tendon reflexes, glucose is 198mg/dl, and pupils are bilaterally midsized, equal, and reactive to light.

What do you need to know?

Headache is a common complaint in the Emergency Room (ER). It constitutes 1 – 4 % of all ER visits [1]. The true global prevalence of headache is unknown because the pathophysiology and causes of headache are broad. Headache disorders collectively constitute the seventh highest cause of years lived with disability (YLDS) [2].

Headaches are classified as primary headache disorders (when pain is the disease) and secondary headache disorders (when headache is a symptom of another disease). Primary headache disorders include migraine, tension headache, and cluster headache. Secondary headache disorders are listed below in Table 1.

Table 1 – Secondary headache disorders

Pathology

Examples

Headache attributed to head or neck trauma

Post-traumatic headache

Concussion

Headache attributed to cervical or cranial vascular disorders

Subarachnoid hemorrhage

Intraparenchymal hemorrhage

Subdural or epidural hematoma

Cavernous/venous sinus thrombosis

Arteriovenous malformation

Temporal arteritis

Carotid/vertebral artery dissection

CNS infections

Meningitis

Encephalitis

Cerebral abscess

Intracranial non vascular space occupying lesions

Tumors

Parasitic or inflammatory lesions

Headache attributed to substance or withdrawal

Nitrates and nitrites

Mono amine oxidase inhibitors

Alcohol withdrawal

Abuse of analgesics

Headache or facial pain due to head, ears, eyes, nose, or throat disorders

Glaucoma

Sinusitis

Optic neuritis

Iritis

Headache attributed to altered homeostasis

Fasting headache

High altitude cerebral edema

Hypoxia

Hypercarbia

Hypothyroidism

Obstructive sleep apnea

Miscellaneous causes

Preeclampsia

Post dural puncture headache

Most patients presenting to the ER with headache have a primary headache disorder, with migraine being the most common [3]. However, it is vital to evaluate for headache signs and symptoms that point towards secondary causes.  The SNNOOP 10 list in Table 2 reviews important red flag signs and symptoms to consider in a patient with headache [4].  

Table 2 – Red flag signs and symptoms of headache (SNNOOP 10 list)

Sign or symptom

Related secondary headache cause

Systemic symptoms including fever

Headache attributed to infection or nonvascular intracranial disorders, like carcinoid or pheochromocytoma

Neoplasm in history

Neoplasms of the brain, metastasis

Neurologic deficit or dysfunction (including decreased consciousness)

Headaches attributed to vascular, nonvascular intracranial disorders; brain abscess and other infections

Onset of headache is sudden or abrupt

Subarachnoid hemorrhage and other headaches attributed to cranial or cervical vascular disorders

Older age (after 50 years)

Giant cell arteritis and other headache attributed to cranial or cervical vascular disorders; neoplasms and other nonvascular intracranial disorders

Pattern change or recent onset of headache

Neoplasms, headaches attributed to vascular, nonvascular intracranial disorders

Positional headache

Intracranial hypertension or hypotension

Precipitated by sneezing, coughing, or exercise

Posterior fossa malformations; Chiari malformation

Papilledema

Neoplasms and other nonvascular intracranial disorders; intracranial hypertension

Progressive headache and atypical presentations

Neoplasms and other nonvascular intracranial disorders

Pregnancy or postpartum

Headaches attributed to cranial or cervical vascular disorders; post dural puncture headache; hypertension-related disorders (e.g., preeclampsia); cerebral sinus thrombosis; hypothyroidism; anemia; diabetes

Painful eye with autonomic features

Pathology in posterior fossa, pituitary region, or cavernous sinus; Tolosa-Hunt syndrome; ophthalmic causes

Posttraumatic onset of headache

Acute and chronic posttraumatic headache; subdural hematoma and other headache attributed to vascular disorders

Pathology of the immune system such as HIV

Opportunistic infections

Painkiller overuse or new drug at onset of headache

Medication overuse headache; drug incompatibility

Primary Headache Disorders

Migraine

Migraines are one of the most common primary headache disorders.  Migraines affect females more than males and are more common in the third and fourth decade of life. The clinical presentation includes unilateral or bilateral pulsating pains with moderate to severe intensity.  Migraines may have associated auras, photophobia, phonophobia, blurred vision, lightheadedness, vertigo, nausea, and vomiting. Most patients seek dark, quiet rooms. The triggers for migraines include sleep deprivation, hunger, hormonal changes during menstruation, and certain medications (e.g., nitrates and oral contraceptive pills) [5].

Cluster Headache

Cluster headaches occur suddenly, last 15 minutes to 3 hours in duration, and tend to occur repeatedly during a defined time interval.  This type of headache is more common in men than women. Precipitating factors include ingestion of alcohol, stress, and climate change. The headache begins as unilateral sharp stabbing pain in the eye, exclusively in the trigeminal territory, accompanied by ipsilateral autonomic symptoms such as ptosis, miosis, forehead, and facial swelling [5].

Tension Headache

Tension headaches, like migraines, are a common cause of primary headaches and affect women more than men. Tension headaches may last from minutes to days. Physical examination reveals tender areas on the scalp and neck. Patients complain of a tight, band-like discomfort around the head that is non pulsating and dull in nature. The headache does not worsen with physical activity. Anxiety and depression may coexist with chronic tension type headaches [6].

Secondary Headache Disorders

There are various secondary causes of headaches, ranging from benign to severe. This section will focus on a small list of etiologies relevant to the emergency medicine practitioner.

Subarachnoid Hemorrhage (SAH)

SAH is a life-threatening cause of headache that should be considered in all ER patients with headache. Accumulation of blood in the subarachnoid space activates meningeal nociceptors, causing headache and meningismus. Causes for non-traumatic SAH include ruptured saccular aneurysms, arteriovenous malformations, cavernous angiomas, and coagulopathy. The risk of brain aneurysmal rupture increases with age, hypertension, smoking, excessive alcohol consumption, and use of sympathomimetic drugs [7].

Patients with SAH historically present with a severe, acute onset headache that is maximal intensity at onset (thunderclap headache). The onset of headache may be spontaneous or after physical exertion. Associated signs and symptoms are nausea, vomiting, neck stiffness, photophobia, seizures, depressed consciousness, and focal neurological abnormalities. Retinal hemorrhage may be present on fundoscopic examination. SAH patient prognosis can be predicted with the Hunt and Hess classification system [7], as shown in Table 3.

Table 3 – Hunt and Hess classification of cerebral aneurysms and subarachnoid hemorrhage

Grade

Condition

0

Unruptured aneurysm

1

Asymptomatic or minimal headache and slight nuchal rigidity

2

Moderate or severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsy

3

Drowsiness, confusion or mild focal deficit

4

Stupor, moderate to severe hemiparesis

5

Deep coma, decerebrate posturing, moribund appearance

  • Grades 1 or 2 – good prognosis
  • Grade 3 – moderate prognosis
  • Grades 4 or 5 – poor prognosis

Intracranial Neoplasms

Headache is a common presenting symptom of patients with a brain tumor, but the symptoms are variable.  Symptoms depend on the site of tumor, traction on meninges or large vessels, increase in intracranial pressure, or hydrocephalus.  Other than headache, patients may have sleep disturbances, nausea and vomiting, seizures, focal neurologic deficits, alterations in consciousness, personality disorders, and cognitive difficulties [8].

Meningitis

Acute bacterial meningitis may present with headache, fever, nuchal rigidity, nausea, vomiting, photophobia, new skin rash, seizures, focal neurologic deficits, or alterations in consciousness. The most common pathogens causing bacterial meningitis in adults are Streptococcus pneumoniae and Neisseria meningitidis. Bacterial meningeal invasion occurs when bacteria colonize host mucosal epithelium, invade and survive within the bloodstream, cross the blood-brain barrier, and multiply within the CSF. Once inflammation is initiated, a series of injuries occur to the endothelium of the blood-brain barrier that result in vasogenic brain edema, loss of cerebrovascular autoregulation, and increased intracranial pressure. This results in localized areas of brain ischemia, cytotoxic injury, and neuronal death [9].

Giant Cell Arteritis (GCA, or Temporal arteritis)

GCA is an inflammatory vasculopathy affecting mainly the extracranial branches of the carotid artery (temporal and occipital). The common features of giant cell arteritis are advanced age, female gender, headache, visual symptoms, jaw claudication, temporal artery tenderness, and systemic symptoms (e.g., fever, weight loss, fatigue).  One of the most serious complications of GCA is blindness, but a range of visual symptoms and signs may occur, such as diplopia, visual field deficits, amaurosis fugax, or an afferent pupillary defect. Typical GCA headaches are worse in the morning than later in the day and can be constant or intermittent. Other complications include transient ischemic attacks, peripheral neuropathies, and stroke. Palpation of the temporal artery may reveal absent pulses, erythema, and nodular swellings [10].

Carotid and Vertebral Artery Dissection

The classic symptoms of carotid artery dissection include:

  • Unilateral headache or neck pain.
  • Ipsilateral partial Horner’s syndrome.
  • Blindness (dissection into retinal artery).
  • Contralateral motor deficits.

Vertebral artery dissection may also present with severe unilateral headache or neck pain.  Dissection along the vertebral artery may result in brainstem or cerebellar ischemia, causing vertigo, vomiting, diplopia, ataxia, tinnitus, unilateral facial weakness, alterations in consciousness, or cranial nerve deficits.

Both carotid and vertebral artery dissection should be considered in a patient presenting with headache or neck pain with a history of recent head or neck trauma, sudden neck movement, neck torsion, coughing, chiropractic manipulation, minor falls, weight lifting, basketball, volleyball, or a motor vehicle collision [11].

Cerebral Vein Thrombosis (CVT)

Patients with this diagnosis often have a headache lasting days to weeks, along with other signs and symptoms, like seizures, focal neurologic deficits, orbital pain, proptosis, chemosis, and papilledema. Symptoms are due to raised intracranial pressure from occlusion of the cerebral venous system, causing ischemia, infarction, or hemorrhage.

Major risk factors for CVT include pregnancy, post-partum state, malignancy, head trauma, recent surgery, parameningeal infections, oral contraceptives, history of vasculitis, inflammatory bowel disease, and connective tissue disease [12].

Initial Assessment and Stabilization (ABCDE approach)

When a patient presents with headache to the ER, it is vital to follow the ABCDE sequence of initial assessment.  

  • Airway: look for airway patency.  Assess if the patient is talking normally or if there are signs of airway obstruction or aspiration. Patients with SAH, intraparenchymal bleed, CVT, or recent seizure may have airway compromise due to poor GCS.  These patients may require interventions, such as manual opening of the airway with a head-tilt-chin lift or jaw thrust maneuver, insertion of an oropharyngeal or nasopharyngeal airway, or suctioning of secretions or vomitus from the airway.  Patients with GCS under 8 should be considered for supraglottic airway insertion or endotracheal intubation.  
  • Breathing: look for tachypnea or bradypnea, changes to oxygen saturation, and abnormal breath sounds. Intracranial bleeds or mass lesions may influence the central respiratory center, causing decreased, abnormal, or absent respirations [7]. Administer supplemental oxygen for hypoxia.  Consider oxygen via face mask, positive pressure bag valve mask ventilation, or intubation, based on respiratory effort, GCS, and concern for aspiration.  
  • Circulation: check the heart rate, blood pressure, peripheral and central pulses, and capillary refill time. Severe hypertension with headache and altered mentation should raise concern for intracranial bleeding [7]. Headache with severe hypertension in a pregnant patient should raise concern for pre-eclampsia or eclampsia. Fever with headache should raise concern for infectious conditions, like meningitis or encephalitis.  Intravenous antihypertensive medications should be initiated during this step if needed.  Monitor for bradycardia, hypertension, and abnormal breathing, which can indicate impending brain herniation from elevated intracranial pressure.
  • Disability: check pupillary size and reactivity, calculate a Glasgow coma score, and check a glucose level.  Perform a focused neurological examination with assessment of the cranial nerves, sensory and motor function, and cerebellar signs. Patients with complex migraine headaches may exhibit photophobia, diplopia, paresthesias, dysarthria, tinnitus, or vertigo. Patients with stroke, intraparenchymal bleeding, subarachnoid hemorrhage, CVT, carotid or vertebral artery dissection, intracranial space-occupying lesions, and encephalitis may present with focal neurological deficits and varying levels of GCS [7,8].
  • Exposure: Fully undress your patient and perform a head-to-toe examination. Any signs of head trauma, including headache, should raise suspicion for intracranial bleeding. Petechiae and purpura on the skin may point towards infective pathologies, like septicemia or meningococcal meningitis [13].

Medical History

A detailed history in a patient with headaches can provide clues to the cause. Ask your patient about the time of symptom onset, pain location, headache characteristics, and associated symptoms. Ask about past medical history, surgical history, relevant family history, and drug or alcohol use.

  • Time of onset: sudden onset symptoms may be seen in subarachnoid hemorrhage, ischemic or hemorrhagic strokes, or carotid artery dissection. Gradual onset of symptoms is more common in migraine, cluster headache, tension headache, headaches due to infective pathology, and CVT [5,6].
  • Site of headache: Most migraine and cluster headaches present with unilateral pain with cluster headache involving branches of the trigeminal nerve (around orbit). Tension headaches present more often as bilateral head pain.  Sinus headaches have pain behind the maxillary and frontal sinuses [5,6].
  • Characteristics and associated symptoms: Migraines are associated with auras, photophobia, phonophobia, blurred vision, lightheadedness, nausea, or vomiting [5]. Cluster headaches may have ipsilateral autonomic symptoms, such as ptosis, miosis, eye tearing, or facial swelling [5]. Tension headaches may present with tender areas on the scalp and neck [6]. Ask about associated symptoms for secondary headaches, like fever and neck stiffness (meningitis), vision changes (acute glaucoma, giant cell arteritis), new seizures, vomiting, or focal motor or sensory changes (space-occupying lesion, intracranial bleeding, CVT, etc.) [8-10,12].
  • Risk factors:
    • Intraparenchymal Bleeding: hypertension, smoking, alcohol abuse, anticoagulation medication usage, recent head trauma [3,7].
    • Subarachnoid Bleeding: hypertension, smoking, cocaine use, family history of brain aneurysms in close relatives, polycystic kidney disease, Marfan syndrome, Ehlers-Danlos syndrome [7].
    • Carotid Artery Dissection: recent neck trauma, recent neck torsion during sporting activities or medical treatments (e.g., chiropractic maneuvers) [11]
    • Cerebral Venous Thrombosis: pregnancy, recently postpartum, oral contraceptive use, hypercoagulable conditions (thrombophilias, antithrombin III, protein C and S deficiency, factor V Leiden mutation, antiphospholipid syndrome, malignancy), recent surgery [12].
    • Post Dural Puncture Headache: recent lumbar puncture

Physical Examination

Patients presenting with headache should undergo a thorough head-to-toe physical exam after the ABCDE assessment.  Special care should be taken in examining the head, ears, eyes, neck, and throat, as well as in performing a focused neurological exam.  The neurological exam should include calculating a Glasgow coma score, cranial nerve testing, assessment of motor and sensory deficits in the extremities, and assessment of gait and coordination. A full set of vitals, including a temperature and glucose level, should be taken.

When To Ask Your Senior for Help

If you are immediately concerned about a life-threatening condition, or if the patient needs any interventions during the ABCDE assessment, you should notify a supervising doctor.

Patient details that should trigger you to alert your senior:

  • Inability to talk or
  • Altered breathing pattern or use of accessory muscles of respiration
  • Severe hypertension, hypotension, or hypoxia
  • Asymmetric pupillary sizes 
  • Severe headache with acute onset
  • Signs of meningeal irritation or raised intracranial pressure

Not-To-Miss Diagnoses

Headaches have many causes. As an emergency medicine provider, it is important not to miss certain diagnoses that have a high rate of morbidity or mortality. Some diagnoses to always consider in the patient with headache are intraparenchymal bleeding, subarachnoid bleeding, giant cell arteritis, acute glaucoma, meningitis, encephalitis, cerebral vein thrombosis, carotid and vertebral artery dissection, brain malignancy, and pre-eclampsia.

Acing Diagnostic Testing

The investigations you order for your headache patient will depend on your history, physical exam, and top conditions on your differential diagnosis list.

Some investigations to consider in headache patients:

  • Glucose testing should be ordered in any patient with headache plus altered mental status, focal neurologic deficits, or seizures.
  • Urine pregnancy testing should be ordered for any female of child-bearing age presenting with headache.
  • ECG abnormalities in the form of arrhythmias and non-specific ST-T wave changes can be seen in patients with intracranial bleeding or space-occupying lesions
  • Complete blood count can help support infective etiologies if leukocytosis is present.
  • Serum chemistry is used to evaluate for any electrolyte abnormalities in patients with new seizures or vomiting.
  • ESR or CRP is considered if you are concerned about Giant cell arteritis [10]
  • HIV testing is considered based on the history and physical exam if there are clinical signs of immunocompromise
  • CT or MRI imaging is often unnecessary in a patient with a primary headache.  It should be ordered based on patient history and physical exam, particularly with concerns for SAH, intracranial bleeding, or a space-occupying lesion should have non-contrast CT brain imaging [7,8]. Patients with concerns for carotid or vertebral artery dissection should have a CT angiogram of the neck and head [11]. Patients with concerns for cerebral venous thrombosis should have an MR venogram or CT venogram [12].

Examples of CT images of patients with conditions that may present with headache are below.

Figure 1a
Figure 1b

Figure 1a (left) and Figure 1b (right): Subarachnoid bleed on CT brain without contrast.  Acute bleeding is demonstrated as a bright white (radio-opaque) substance.  The distribution of blood seen in Figure 1a is sometimes termed the “starfish of death.”

Figure 2 - Acute epidural bleed on CT brain without contrast. Note the biconvex shape that is characteristic of epidural hemorrhages.
Figure 3 - Acute subdural bleed on CT brain without contrast. Note the sickle shape that is characteristic of subdural hemorrhages.
Figure 4 - Acute intra-parenchymal bleed on CT brain without contrast. A white arrow identifies the bleed on the left-hand image. Note the midline shift on the right-hand image.
Figure 5 - Large brain mass. CT brain without contrast, sagittal cut.

Empiric and Symptomatic Treatment

Medications for symptom control should be considered for any patient with headache and other associated symptoms. Table 4 below lists some common medications to consider for migraine headaches.

Table 4- Medications for migraine headaches

Drug

Dose

Comments

Acetaminophen

500 – 1000 mg PO every 6hrs

Safe in pregnancy

Ibuprofen

600 -800 mg PO every 6hrs

Can cause GI upset

Avoid in pregnancy

Caution in patients with renal insufficiency

Ketorolac

15-30 mg IV or IM every 6hrs

Same as ibuprofen

Metoclopramide

10 mg IV or IM every 6hrs

Administer slowly to avoid extrapyramidal symptoms

Diphenhydramine

25-50 mg IV or IM every 6hrs

May cause drowsiness

Dihydroergotamine

1 mg IV or IM

Maximum 3mg/24hours

Contraindicated in pregnancy, uncontrolled HTN, or coronary artery disease 

Sumatriptan

6 mg SC injection x 1

(max 12mg SC/24hrs)

Same as Dihydroergotamine

Basic analgesics, like acetaminophen or NSAIDs, are first-line treatments for tension headaches [6]. High-flow oxygen therapy via a non-rebreather mask at 12-15 liters/min is the first-line treatment for cluster headaches [5].

Patients with signs and symptoms of elevated intracranial pressure (e.g., asymmetric pupil size, depressed GCS, vomiting, etc.), brain edema on CT imaging, or impending herniation on CT imaging should receive IV mannitol, IV 3% NaCl, or IV steroids, in consultation with a neurosurgical specialist [8]. High-dose IV steroids are also used in patients with giant cell arteritis [10].

There is no role for routine prophylactic antiepileptic medications in patients with headache and most types of intracranial bleeding.  However, antiepileptics, like Levetiracetam, are generally well tolerated and are sometimes recommended by neurosurgical specialists for seizure prevention.  For most patients with headache and seizure, IV benzodiazepines should be first-line for seizure treatment.  One exception is eclampsia, where IV magnesium is the preferred therapy.

Anticoagulation, such as IV unfractionated heparin, should be administered in patients with cerebral venous thrombosis and for extracranial carotid or vertebral artery dissection [11]. Patients presenting with headache and signs of ischemic stroke may be candidates for thrombolysis with IV Alteplase or Tenecteplase, depending on local resources and the time since symptom onset. IV antibiotics should be administered empirically for patients with headache with suspected meningitis or encephalitis [3,9].

Procedures

Lumbar Puncture [14]

  • Indications for the procedure: CSF collection with a lumbar puncture can help to evaluate for a CNS infection, such as meningitis. This procedure can also assist in assessing for subarachnoid hemorrhage. CT head is highly sensitive in detecting SAH in the first 6 hours after headache onset, but the sensitivity diminishes beyond hour 6.  A lumbar puncture can be considered in a patient with deep clinical concern for SAH and a negative CT scan with symptoms over 6 hours [7].
  • Contraindications: Raised intracranial pressure (e.g., brain mass or intracranial bleeding with midline shift on CT), coagulopathy, or trauma or infection at the site of needle insertion
  • Complications: Bleeding, infection, post-dural puncture headache, pain during the procedure

Before the procedure:

  1. Explain the procedure, obtain consent, and gather materials (Figure 6) to maintain aseptic precautions.
  2. Place the patient in the lateral decubitus or seated position.
  3. Identify the highest points of iliac crests bilaterally.

The equipment needed for a lumbar puncture procedure includes a sterile lumbar puncture tray, which typically contains a spinal needle with stylet (commonly 20G–22G), local anesthetic (e.g., lidocaine), antiseptic solution (e.g., povidone-iodine or chlorhexidine), sterile gloves, drapes, and gauze. Additionally, a manometer with tubing is required for measuring cerebrospinal fluid (CSF) pressure, along with collection tubes for CSF sampling. Optional items may include a face mask, eye protection, and an assistant for patient positioning and monitoring.

Figure 6 – Equipment for a Lumbar Puncture

To identify the L4 interspace for a lumbar puncture (Figure 7), start by positioning the patient appropriately—either sitting and leaning forward or lying in the lateral decubitus position with knees drawn to the chest and the back flexed to maximize exposure of the vertebral spaces. Palpate the iliac crests on both sides, noting their highest points. Draw an imaginary line connecting these points, known as the intercristal or Tuffier’s line, which usually crosses the spinous process of the L4 vertebra. The L4-L5 interspace is located just below this line. Confirm the space by palpating the spinous processes to ensure accurate identification before proceeding.

Figure 7 – Landmark of L4 Space

This level corresponds to L4-L5 intervertebral space where the spinal needle should be inserted.  Instruct the patient to arch their spine posteriorly to open the interspinous spaces. Clean and drape the area. Administer local anesthesia to the planned site of the procedure. Prepare four marked containers to collect the CSF.  Using aseptic technique, advance the spinal needle at the L4-L5 interspace until a popping sensation is felt and CSF drips from the spinal needle. Measure CSF opening pressure by connecting a manometer as soon as fluid appears and note the reading. Collect about 1 mL of CSF in all 4 marked containers in a consecutive fashion (Figure 8). Once sufficient CSF is collected, place the stylet back in the needle, remove the spinal needle, and cover the site with gauze or a Band-Aid.  Send the CSF to the laboratory for analysis, re-evaluate your patient, and provide advice regarding puncture headache [14].

Figure 8 – Collection of CSF in serial numbered containers (tubes)

The chart below describes how CSF is interpreted by the clinician once it is analyzed by the laboratory.

Table 5 – CSF interpretation [15]

 

Normal

Bacterial Meningitis

Viral Meningitis

Subarachnoid Hemorrhage

Opening pressure (mmHg)

7-18

>30

Normal

Increased

Appearance

Clear, colorless

Turbid

Clear

Xanthochromia present

Protein (mg/dl)

23-38

Increased

Normal to decreased

Increased

Glucose

2/3rd of serum glucose

Decreased

Normal

Normal

Gram stain

Negative

Positive

Negative

Negative

WBC count

<5 cells

Predominantly neutrophils

Predominantly lymphocytes

May be increased due to bleeding

Special Patient Groups

Pregnant Patients

Pregnant patients with headache are at increased risk for some diagnoses more than nonpregnant women due to pregnancy being a hypercoagulable state. Pregnant patients with headaches are unable to receive all the same medications as nonpregnant patients. Headache medications that are safe in pregnancy are paracetamol, metoclopramide, diphenhydramine, magnesium, and opioids for severe pain. Drugs to avoid during pregnancy include ergotamine, NSAIDS, valproate, lithium, and topiramate [16]. Specific causes of headache to consider in pregnancy are pre-eclampsia, eclampsia, cerebral venous thrombosis, and stroke. Treatment of headache should primarily focus on the cause [16].

Children

Headache is a common cause of ED visits in the pediatric population [17]. The causes of headaches in the pediatric population range from more benign primary headache etiologies to more secondary severe etiologies. CT imaging should be limited to cases where more serious signs and symptoms are present, such as change in behavior, confusion, unexplained vomiting, unexplained high fevers, head trauma, or focal neurologic deficits [17]. Medications for pediatric headaches are weight-based in their dosing. The standard pediatric dose for ibuprofen is 10 mg per kilogram (mg/kg) of body weight per dose. This dosage can be administered every 6 to 8 hours as needed, with a maximum of three doses in a 24-hour period. It’s important not to exceed a total daily dose of 40 mg/kg or 1,200 mg, whichever is less. For acetaminophen, the recommended pediatric dose ranges from 10 to 15 mg/kg per dose. This can be given every 4 to 6 hours as needed, with a maximum of five doses in 24 hours. The total daily dose should not exceed 75 mg/kg or 3,000 mg, whichever is less.

Elderly

Elderly patients experiencing headaches may have additional health conditions that raise the risk of serious underlying causes, such as a history of hypertension, cancer, previous brain surgeries, stroke, or the use of anticoagulant medications. When evaluating and treating these patients, it’s important to tailor your approach based on the suspected diagnosis. However, it is advisable to have a lower threshold for ordering diagnostic tests in elderly patients with unexplained headaches.

When To Admit

Primary headache disorders, like migraine, cluster headache and tension headaches, do not require admission and should be treated symptomatically in the ER.  Upon discharge, these patients should be advised to have adequate sleep, stay hydrated, consume regular meals, and avoid any headache triggers. Patients with a headache secondary to a dangerous etiology, such as meningitis or intracranial bleeding, should be admitted for further treatment and monitoring. Patients with red flag signs or symptoms of a dangerous etiology should also be admitted for further management, even without a confirmed diagnosis.

Revisiting Our Patient

You return to your 60-year-old male patient with sudden onset headache and right-sided weakness.  You note his severe hypertension, hypoxemia, right-sided motor deficits, and low GCS.

You follow your ABCDE approach to be sure not to miss any critical steps in management.

  • Airway: This patient has a depressed mental status and no gag reflex. You notice some secretions in his airway and prepare for intubation.
  • Breathing: His lungs are bilaterally clear and equal. After his airway is suctioned, you apply supplemental oxygen via a non-rebreather mask.

After the patient is intubated, you continue your assessment.

  • Circulation: The patient continues to be hypertensive to 210/120 mmHg after intubation. You administer IV labetalol 10mg and begin a fentanyl infusion for sedation.
  • Disability: The glucose is 198mg/dL. Your initial brief exam demonstrated right-sided motor deficits and normal mid-sized pupils.
  • Exposure: There are no physical signs of trauma or rashes on the exam

Once the patient is stabilized, he receives a CT head without contrast, showing an acute subarachnoid bleed.  Basic pre-operative laboratory tests are drawn and you contact the neurosurgeon on call.  The neurosurgery team recommends strict blood pressure control and admission to the ICU for operative management.  You explain the diagnosis and plan of care to the patient’s family with understanding and agreement.

Author

Picture of Shailaja Sampangi Ramaiah

Shailaja Sampangi Ramaiah

Dr. Shailaja Sampangi Ramaiah is a Professor and Head of Emergency Medicine at Father Muller Medical College, Mangalore, India. With advanced qualifications in anesthesia and medical education, she is a FAIMER fellow and ACME-certified educator. Dr. Shailaja leads initiatives in simulation training and clinical quality improvement and is a life member of several prestigious medical associations. She is passionate about advancing emergency care education.

Listen to the chapter

References

  1. Locker T, Mason S, Rigby A. Headache management–are we doing enough? An observational study of patients presenting with headache to the emergency department. Emerg Med J. 2004;21(3):327-332. doi:10.1136/emj.2003.012351
  2. GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015 [published correction appears in Lancet. 2017 Jan 7;389(10064):e1]. Lancet. 2016;388(10053):1545-1602. doi:10.1016/S0140-6736(16)31678-6
  3. Thomas K, Benjamin W.F, Rosen’s emergency medicine: concepts and clinical practice: St. Louis, Mosby; 2002. Chapter 93, Headache disorders; p.1265-77.
  4. Do TP, Remmers A, Schytz HW, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology. 2019;92(3):134-144. doi:10.1212/WNL.0000000000006697
  5. Leone, Massimo and Paola Di Fiore (2014), “Migraine and Cluster Headache.”
  6. Millea, Paul J. and Jonathan J. Brodie (2002), “Tension-Type Headache,” American Family Physician.
  7. Vivancos J, Gilo F, Frutos R, et al. Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment. Neurologia. 2014;29(6):353-370. doi:10.1016/j.nrl.2012.07.009
  8. Alentorn, Agusti, Khê Hoang-Xuan, and Tom Mikkelsen (2016), “Presenting signs and symptoms in brain tumors.”
  9. Siddiqui, Emaduddin (2012), “Neurologic Complications of Bacterial Meningitis.”
  10. Smith, Jonathan H. and Jerry W. Swanson (2014), “Giant Cell Arteritis,” Headache.
  11. Sheikh, Huma U. (2016), “Headache in Intracranial and Cervical Artery Dissections,” Current Pain and Headache Reports.
  12. Mehta, Amit, Julius Danesh, and Deena E. Kuruvilla (2019), “Cerebral Venous Thrombosis Headache,” Current Pain and Headache Reports.
  13. Bollero, Daniele, Maurizio Stella, Ezio Nicola Gangemi, L. Spaziante, J. Nuzzo, G. Sigaudo, and F. Enrichens (2010), “Purpura fulminans in meningococcal septicaemia in an adult: a case report,” Annals of burns and fire disasters.
  14. Niemantsverdriet, Ellis, Hanne Struyfs, Flora H. Duits, Charlotte E. Teunissen, and Sebastiaan Engelborghs (2015), “Techniques, Contraindications, and Complications of CSF Collection Procedures.”
  15. Gomez-Beldarrain, Marian and Juan Carlos Garcia-Monco (2014), “Lumbar Puncture and CSF Analysis and Interpretation.”
  16. Negro A, Delaruelle Z, Ivanova TA, et al. Headache and pregnancy: a systematic review. J Headache Pain. 2017;18(1):106. Published 2017 Oct 19. doi:10.1186/s10194-017-0816-0
  17. Raucci U, Della Vecchia N, Ossella C, et al. Management of Childhood Headache in the Emergency Department. Review of the Literature. Front Neurol. 2019;10:886. Published 2019 Aug 23. doi:10.3389/fneur.2019.00886
  18. Reinisch, Veronika M., Christoph J. Schankin, J. Felbinger, P. Sostak, and Andreas Straube (2008), “Headache in the elderly,” Schmerz.

Reviewed and Edited By

Picture of Joseph Ciano, DO, MPH, MS

Joseph Ciano, DO, MPH, MS

Dr. Ciano is a board-certified attending emergency medicine physician from New York, USA. He works in the Department of Emergency Medicine and Global Health at the Hospital of the University of Pennsylvania. Dr. Ciano’s global work focuses on capacity building and medical education and training in low-middle income countries. He is thrilled to collaborate with the iEM Education Project in creating free educational content for medical trainees and physicians.

Picture of Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Journal Club 10/17/22: Global Burden of Disease

~ Global EM Student Leadership Program ~ Leave a comment

The Economic Impact of Ebolavirus in West Africa: A Burden the Size of Iceland by Andrew L. Mariotti

Between 2014 and 2016, West Africa experienced an Ebola virus epidemic that resulted in 28,000 cases, 11,000 deaths, and a loss of up to $32.6 billion in gross domestic product. To put this in perspective, America’s 2021-2022 flu season culminated in 9 million cases, 5,000 deaths, and a loss of up to $8 billion in GDP. In other words, a single Ebola infection represents a nearly 1200 times greater economic cost, emphasizing the intense strain this disease places on West African nations. 

Factors precipitating these costs are multi-faceted and stem not only from the increased morbidity of Ebola but also from structural constraints. The 16 countries of West Africa represent a GDP of $726 million and struggle with a human capital index (see figure below) of 0.40, nearly 0.17 points under the global average. Given this set of conditions, it’s no wonder a disease as serious as Ebola can lead to losses greater than the size of Iceland’s economy ($24.4 billion GDP).

While many strategies to ameliorate these issues emphasize the importance of developing new infrastructure and creating jobs, it’s worth considering how treating Ebola – and reducing the associated disease burden – could palliate a gargantuan economic burden holding this region back from development. How to accomplish this aim would require an entirely new blog post. However, the thought of what a $32.6 billion investment could return for the future growth and development of these underserved populations is worth consideration.

Further Reading:

Discussion Questions:

  • What barriers to effective Ebola treatment and containment would provide the greatest benefit to individuals in endemic regions were it to be realistically mitigated?
  • How does the way we think about the importance of treating epidemics change when considering the economic impact it has on a country and could decreasing disease burden be an effective strategy for helping developing nations become more industrialized?

Chapter 4: Global Health and the Global Burden of Disease by Kelsey Yenney

In this chapter, a focus was placed on common terms used to describe the health of a population as well as discuss two ongoing projects that guide policymakers when setting priorities. Throughout this post I will refer to the ‘global burden of disease’; authors in this book have provided the definition as “quantity of diseases/conditions AND their impact on the population”. 

Describing the health of populations is done in terms of descriptive statistics and there are many reasons to quantify the burden of disease. The health of a population must be measured and understood for the healthcare system to adequately respond. Quantifying the burden of disease allows for planning, policy making, executing delivery and program evaluation. For example (as used by the author of this chapter), the Minister of Health of Malawi may learn that there were 260 new cases of tuberculosis per 100,000 people in one year. Given that the population at the time was 15.5 million, she can plan that 40,300 people will be diagnosed and treated in her country in the coming year to achieve universal coverage of TB. Descriptive statistics allow policy makers, practitioners, and other healthcare providers to attempt to stay “one step ahead” of the ebbs and flows of epidemiology. 

Understanding the burden of disease requires disease surveillance. In 1992, the World Bank commissioned WHO to quantify the global burden of disease; until that time, there was historically insufficient data with which to estimate the burden of disease in many countries, thus leading to an insufficient understanding of the global burden of diseases. In those studies, it was determined that less than 30% of the data on disease and death came from medically certified documents. A new project in 1994 (“Global Burden of Disease”) looked at 107 conditions and over 400 sequelae or secondary outcomes from disease. Diseases were grouped into different categories and countries were grouped based on their “established market economies”. Later in 1994, the term “DALY” (Disability-Adjusted Life Year) was created which describes the number of years of life that is lost or affected by disease. 

When thinking about the transitions of epidemiology, Abdel Omran named four significant concepts that describe observed shifts in the types of diseases that affect a population as economic conditions improve. For example, malnutrition becomes less frequent as a country gains food security, water sanitation, etc. However, as infrastructure and economy grow, diseases caused by cigarette smoke, processed foods, etc. can increase. The four stages of population health described by Omran were as follows:

  1. Age of Pestilence and Famine: high mortality due to infectious disease and starvation
  2. Age of Receding Pandemics: life expectancy increases as food security; access to housing and clean water improves
  3. Age of Degenerative and Manmade Diseases: fertility rate decreases, infant mortality continues to fall; major causes of death are non-communicable diseases
  4. Age of Delayed Chronic Disease: primary prevention of disease

The above stages were used by policymakers to create a prioritized stepwise process to promote the cheapest and easiest approach to targeting a country’s biggest threat based on where they “fell within the stages”. However, diseases do not occur in a stepwise approach and each country has a diverse range of disease burden. All nations, no matter the GDP, must prevent and plan for infectious disease, mental health, non-communicable disease, etc. 

In 1977, Milton Weinsten and William Stason proposed a formula that became known as cost-effectiveness to make choices between different medical interventions. They proposed that a health intervention was only cost-effective if it was to be under 3x the per capita health costs. This meant that in the US, for example, at the time, a health intervention would be cost-effective if it was less than several thousand dollars because the per capita health expenditure of the US healthcare system is high. However, in impoverished countries, a health intervention would need to fall within $5-15 to be deemed cost-effective. This does not fall anywhere close to the ideals of equity. Using cost-effectiveness as a sole model to reduce global burden of disease severely limits the right to health as it does not consider the many aspects of disease. 

Discussion Questions:

  • What are some conditions/public health concerns that may not be prevalent at the time but can be planned for?
  • For example, no matter what stage of population health a country may be in, infrastructure for flooding may be put in place. What are some major limitations you can see with the proposed cost-effectiveness model?
  • What are some ways that countries are or could be dealing with increasing chronic disease in settings still with large burdens of transmissible disease?

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these two topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings.  Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Picture of Andrew L. Mariotti, MS3

Andrew L. Mariotti, MS3

University of Colorado School of Medicine

Picture of Kelsey Yenney, MS3

Kelsey Yenney, MS3

Washington State University
Elson S. Floyd College of Medicine

Blog Editorial Team

Picture of Halley Alberts, MD

Halley Alberts, MD

PGY-2 University of South Carolina Prisma Health Midlands
Co-Director & Blog Editor

Picture of Jeff Downen, PGY2

Jeff Downen, PGY2

Blog Editor
University of Florida - Jacksonville

Picture of Mohamed Hussein, MBBCh

Mohamed Hussein, MBBCh

Trauma Research Fellow
Blog Editor

Resources

  • Drame, M.L., P. Ferrinho, and M.R.O. Martins, Impact of the recent Ebola epidemic with pandemic potential on the economies of Guinea, Liberia and Sierra Leone and other West African countries. Pan Afr Med J, 2021. 40: p. 228.
  • de Courville, C., et al., The economic burden of influenza among adults aged 18 to 64: A systematic literature review. Influenza Other Respir Viruses, 2022. 16(3): p. 376-385.
  • Joia Mukherjee. An Introduction to Global Health Delivery : Practice, Equity, Human Rights. Oxford University Press; 2018. Chapter 4: Global Health and the Global Burden of Disease 

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Journal Club 9/19/22: Medical Tourism

~ Global EM Student Leadership Program ~ Leave a comment

Telemedicine in Low-Resource Settings by Rachel Patel

Telemedicine is defined as the delivery of health care and the exchange of health-care information across distances.

The types of telemedicine are as follows:

  • Live, two-way (or real-time) synchronous audio and video allows specialists, local physicians, and patients to see and hear each other in real-time to discuss conditions 
  • Store-and-forward sends medical imaging such as X-rays, photos or ultrasound recordings to remote specialists for analysis and future consultation
  • Remote patient monitoring collects personal health and medical data from a patient in one location and electronically transmits the data to a physician in a different location 

The advantages of telemedicine in low-resource settings include:

  • Increasing health access across geographical barriers
  • Cost-effectively providing services, from radiology to dermatology to at least some of the millions of patients who lack adequate healthcare
  • Contact precautions (e.g. COVID-19 pandemic)
  • Surveillance and monitoring of medical emergencies, generating health data to inform international aid programs and policies
  • Interconnected network of data sharing as well as funding for international crises

Limitations include:

  • Patients who have emergent health conditions, or need a physical exam or laboratory testing for medical decision making
  • If sensitive topics need to be addressed, especially if there is patient discomfort or concern for privacy
  • Limited access to technological devices (e.g., phones, tablets, computers) or connectivity

Discussion Questions:

  • What are some of the ethical implications of telemedicine?
  • How do you see telemedicine factoring into medical care as we move forward in a post-COVID world?
  • Is there a place for telemedicine in emergency medicine?

The Roots of Global Health Inequity by Grace Bunemann

** A short blog post & presentation are far too brief of formats to discuss this extensive topic adequately. The following is an overview of Chapter 1 from Dr. Joia S. Mukherjee’s book entitled An Introduction to Global Health Delivery. **

To simply explain LMIC (lower middle-income country) Health Systems today, it is important to review the history of slavery and colonialism which led to years of resource extraction ultimately resulting in weak health systems seen in LMIC countries today.

Prior to World War II, the conduct of a government against its own people was considered a matter of national sovereignty, however global opinion changed following the liberation of the Nazi concentration camps. After WWII, it was believed that all people, regardless of their country of origin, have an inalienable set of human rights. These principles were upheld in the Universal Declaration of Human Rights in 1948.

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”

The same European countries that were championing human rights had little issue with the continuation of colonialism and denying those who were colonized their human rights. Importantly, only four independent African countries were able to vote for the Declaration (South Africa, Egypt, Ethiopia, and Liberia). 

In 1978, the International Conference on Primary Health Care was held in Alma Ata (currently Almary, Kazakhstan). The conference hosted 600 representatives from the 150 WHO member states and aimed to discuss models for care delivery and develop solutions for people living without access to health care.  

In parallel to the Cold War, socialist republics advocated for government funds to deliver on the promise of health as a human right by building public health systems with doctors, nurses, and hospitals while capitalist states argued that health systems could not be built until economic growth occurred and reasoned that volunteers could be used to deliver basic health services in impoverished countries. 

It is important to note a majority of delegates advocated for the public provision of health as a human right and the Alma Ata Declaration is the result. It advocated for health as a human right and included the need to address the social factors related to ill health, such as lack of food, water, and sanitation. The declaration set modest yet concrete goals like 90 percent of children should have weight for an age that corresponds to reference values, every family should be within a 15-minute walk of potable water, and women should have access to medically trained attendants for childbirth.

The concept that health demanded more resources than those available within an impoverished country’s budget and that health should be financed through international collaboration were radical notions. Several factors impacted the Alma Ata Declaration including physician opposition, Cold War geopolitics, and neoliberal reforms. 

In 1979, a proposed alternative to the Alma Ata Declaration was published in the New England Journal of Medicine entitled ‘Selective Primary Health Care — An Interim Strategy for Disease Control in Developing Countries.’ It praised the goals of Alma Ata as laudable, but ascertained the objective was unrealistic given the impoverishment of those countries with the highest disease burden. This publication countered that it is more realistic to target scarce resources to prevent and control the spread of diseases that account for the highest mortality and morbidity. Selective Primary Health Care became the new standard for global health efforts for years to come. 

“It is impossible to understand global health delivery without understanding the destructive history of slavery, colonialism, and neoliberalism that left governments impoverished and unable to fulfill the right to health.”

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these two topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings.  Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Picture of Rachel Patel, MS4

Rachel Patel, MS4

Rutgers Robert Wood Johnson Medical School

Picture of Grace Bunemann, MS4

Grace Bunemann, MS4

Campbell University School of Osteopathic Medicine

Blog Editorial Team

Picture of Halley Alberts, MD

Halley Alberts, MD

PGY-2 University of South Carolina Prisma Health Midlands
GEMS LP Co-Director & Blog Editor

Picture of Mohamed Hussein, MBBCh

Mohamed Hussein, MBBCh

Trauma Research Fellow
Blog Editor

Picture of Jeff Downen, MD, MS

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

Resources

  • Hollander JE, Carr BG. Virtually perfect? Telemedicine for Covid-19. New England Journal of Medicine 2020; 328; 1679–1681 
  • Calton B, Abedini N, Fratkin M. Telemedicine in the time of coronavirus. Journal of Pain and Symptom Management 2020; https://doi.org/10.1016/j.jpainsymman.2020.03.019external icon 
  • Ohannessian R, Duong Ta, Odone A. Global Telemedicine Implementation and Integration Within Health Systems to Fight the COVID-19 Pandemic: A Call to Action. JMIR Public Health Surveill 2020;6(2):e18810 doi: 10.2196/18810. 
  • Smith AC, Thomas E, Snoswell CL, Haydon H, Mehrotra A, Clemensen J, Caffery LJ. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID-19). Journal of Telemedicine and Telecare 2020; DOI: 10.1177/1357633X20916567 
  • Tuckson, R., Edmunds, M., Hodgkins, M. Telehealth. New England Journal of Medicine 2017; 377:1585–1592. Retrieved from https://www.nejm.org/doi/full/10.1056/NEJMsr1503323 
  • Tolone S, et al. Telephonic triage before surgical ward admission and telemedicine during COVID-19 outbreak in Italy. Effective and easy procedures to reduce in-hospital positivity. International Journal of Surgery 2020; 78 : 123–125. 
  • Perez Sust P, et al. Turning the Crisis Into an Opportunity: Digital Health Strategies Deployed During the COVID-19 Outbreak. JMIR Public Health Surveill 2020;6(2):e19106) doi: 10.2196/19106 
  • Project ECHO: Provides resources to connect frontline healthcare professionals with experts for distance learning and consultation
  • Joia Mukherjee. An Introduction to Global Health Delivery : Practice, Equity, Human Rights. Oxford University Press; 2018. Chapter 1: The Roots of Global Health Inequity.
  • Boston 677 HA, Ma 02115 +1495‑1000. ALMA-ATA at 40: A Milestone in the Evolution of the Right to Health and an Enduring Legacy for Human Rights in Global Health. Health and Human Rights Journal. Published September 6, 2018. https://www.hhrjournal.org/2018/09/alma-ata-at-40-a-milestone-in-the-evolution-of-the-right-to-health-and-an-enduring-legacy-for-human-rights-in-global-health/
  • Alma-Ata 40 years on | Health Poverty Action. http://www.healthpovertyaction.org. Accessed February 22, 2023. https://www.healthpovertyaction.org/news-events/alma-ata-40-years-on/

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Project Proposal 12/20: Developing a Community Education Program to Combat Envenomation in India

~ Global EM Student Leadership Program ~ Leave a comment

Problem Statement

The WHO classified snakebite envenomations as an NTD in 2017 for causing enormous suffering, disability, and premature death worldwide. Bites by venomous snakes can cause paralysis, fatal hemorrhages, irreversible kidney failure, tissue damage and more, leading to permanent disability and limb amputation. Over half the world’s envenomation events and deaths occur in India; this epidemic has been termed “the neglected famer’s tragedy” due to a disproportionate increase in agricultural areas, and a “therapeutic black hole” due to ineffective or unavailable interventions within the region. With 5.8 billion people at risk of encounters, and 2.7 million reported cases of envenomings, it is estimated that there are between 81,000 to 138,000 deaths and countless more debilitating injuries each year in the country. 

The WHO developed the Snakebite Envenoming Strategic Plan which calls for a 50% reduction in mortality and disability caused by snakebite envenoming by 2030 through 4 goals: 

  1. Empower and engage communities.
  2. Ensure safe, effective treatment.
  3. Strengthen systems.
  4. Increase partnerships, coordination, and resources through strong collaboration.

Project Proposal

Our project focuses on the first WHO goal; Empower and engage communities.  However, it includes aspects of all the 2030 goals by creating an education system that will help prevent envenomations and arm the community with a safe plan to approach such events to reduce morbidity and mortality. The project will focus on educating and engaging community leaders, to promote sustainability and community engagement.  These community leaders will be trained to teach and discuss topics including characteristics of venomous and non-venomous snakes, dispelling, and discussing common misconceptions surrounding proper envenomation management, first-aid, initial management, and stabilization.  Community leaders and community members will also be connected with national partners like the National Snake Bite initiative (NSI) as well as international partners like WHO through The Platform, an interactive Application that allows the public to participate in reporting events and venomous snake sightings, slowly creating a regionalized database. 

Qualitative surveys before and after educational campaigns on community knowledge, perceptions, sociocultural and spiritual understanding and depiction of snakes and snakebite envenoming can help to measure how receptive communities have been to the program. Since envenomation events are underreported, it is difficult to assess any qualitative differences (hospital admission events), however, since we plan to implement this program on a community-by-community basis it may be possible to investigate numbers through local health ministries, clinics, and hospitals to assess different trends before and after program implementation.

Based on the WHO Snakebite Working group budget we estimate this project would not cost more than $15,000 USD, with much of the funds allocated to program creation, program coordinators and educators, community leaders, and program creation.  The WHO allocated over $140 million USD over 10 years worldwide to this problem and $650,000 USD to community education in 10 countries.  Using this logic, we estimated that more than $65,000 would be allocated to a country like India.  If this project were to pilot its educational campaign in a specific region, we estimate no needing more than $15,000 USD. 

By partnering with national partners on the ground like the NSI and community leaders who will continue to train and educate, this program will become sustainable through working with those that are inherently invested in more positive outcomes through education in their own communities. Additionally, the WHO’s Platform application will be promoted during educational programming to further engage and empower the community to take an active role in their own education and safety by sharing photos of potentially venomous snake sightings along with their location data. By promoting effective interventions involving education surrounding proper venomous snake identification, snake education, medical interventions, and effective reporting this program will reduce snake bite deaths and long-term disability and empower at risk communities in India to take their safety into their own hands.  

Discussion

After presenting the proposal to the group, we engaged in discussion on this proposal. One of the questions that sparked deep and insightful conversation was “Why is the focus of this project education, and not ensuring that are adequate and strategically placed life saving anti-venom available?”

Below is a summary of the most pertinent ideas posed:

1. Many companies producing have stopped/gone out of business and even if there was plentiful supply it would still not help with preventing or addressing the problem when most cases of snakebite envenomation that occur are not reported.

2. With an educational campaign the people are able to take power into their own hands.

3. The cost benefit ratio of this method is extremely low. Many people reside far away from any form of health care and in India, the cost of initial treatment has been reported to be as high as USD$ 5,150, which makes investments in anti-venom unsustainable. 

References

  1. https://www.who.int/health-topics/snakebite#tab=tab_1

  2. https://www.who.int/activities/preventing-and-controlling-snakebite-envenoming

  3. https://www.who.int/publications/i/item/9789241515641

  4. https://www.who.int/india/health-topics/snakebite

  5. https://www.nature.com/articles/d41586-020-03327-9#ref-CR

  6. Kasturiratne A, Wickremasinghe AR, de Silva N, et al. The global burden of snakebite: a literature analysis and modelling based on regional estimates of envenoming and deaths. PLoS Med. 2008;5(11):e218. doi:10.1371/journal.pmed.0050218

  7. Yanamandra U, Yanamandra S. Traditional first aid in a case of snake bite: more harm than good. BMJ Case Rep. 2014;2014:bcr2013202891. Published 2014 Feb 13. doi:10.1136/bcr-2013-202891

  8. Chauhan V, Thakur S. The North-South divide in snake bite envenomation in India. J Emerg Trauma Shock. 2016;9(4):151-154. doi:10.4103/0974-2700.193350

  9. International Journal of Mental Health Systems, vol. 9, no. 1, 12 Mar. 2015, 10.1186/s13033-015-0007-9. Accessed 13 June 2020.

About GEMS LP project proposals

These project proposals are completed by our mentees, who are medical students, to encourage independent thinking from a global perspective.

Thank you to our authors and presenters!

Nikkole Turgeon, MS4

University of Vermont Larner College of Medicine

Picture of Racheal Kantor, MS4

Racheal Kantor, MS4

Medical School of International Health, Ben-Gurion University

Nicholas Imperato, MS4

Philadelphia College of Osteopathic Medicine

Blog Editorial Team

Picture of Halley Alberts, MD

Halley Alberts, MD

PGY-2 University of South Carolina Prisma Health Midlands
Co-Director & Blog Editor

Picture of Jeff Downen, MD, MS

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

Picture of Mohamed Hussein, MBBCh

Mohamed Hussein, MBBCh

Trauma Research Fellow
Blog Editor

Keep in Touch:

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Project Proposal 12/20: Establishing an Objective Risk Assessment for Road Traffic Accidents in Ghana

~ Global EM Student Leadership Program ~ Leave a comment

Background

Worldwide, road traffic accidents (RTAs) account for about 1.3 million fatalities and, on average, 3% of a given country’s GDP. Over half of these deaths occur among vulnerable road users, such as pedestrians, cyclists, and motor cyclists. Approximately 93% of all of the world’s RTA-associated mortalities occur in middle- to low-income countries, even though they have only 60% of the world’s vehicles. Road traffic injuries cause considerable economic losses to individuals, their families, and to countries as a whole that take a considerable toll even years or decades after the incident occurred. These losses arise from the cost of treatment as well as lost productivity for those killed or disabled by their injuries, and for family members who need to take time off work or school to care for the injured.

 The country of Ghana experiences, on average, 2,000 RTA-associated deaths and 14,000 RTA associated injuries annually. At the Korle-Bu teaching hospital in Accra, Ghana, the largest health facility and teaching hospital in Ghana and the main referral site for all of southern Ghana, between 2016 and 2017, 62% of deaths in the hospital’s accident center were related to RTAs. These RTA-associated deaths and injuries cost the country around 1.6% of its GDP, which amounts to over $1.3 million per year.

In the early 2000s, the Ghanaian government began to recognize the serious socio-economic impact of RTAs on its country. To address the issue, the National Road Safety Commission (NRSC) was established to collect data on RTAs and propose solutions and policies in response. Various data was collected, such as the number of annual deaths and injuries and road user classes associated with these fatalities. Data collected demonstrated that, in Ghana, the road user class with the highest share of fatalities was consistently  pedestrians (824; 39.5%) followed by motorcycle users (437; 21%) and bus occupants (364; 17.5%). Considering RTAs in the context of emergency care, studies showed that, again at the Korle-Bu Teaching Hospital, almost 40% of emergency care visits were from RTAs, followed distantly by falls and interpersonal violence. Of the victims that died upon or after arrival to the hospital, 50% were pedestrians, 31% were passengers, and 18.7% were motorists.

From the numbers provided, it’s readily apparent that deaths caused by injuries, and, specifically, RTA-associated injuries, rank among the top ten causes of death in Ghana. It was concluded that underlying drivers of this issue were broadly two-fold: there was a high proportion of RTA-associated injuries due to poor road conditions and unregulated driving practices, and emergency care providers were lacking in proper, formal trauma-based care, both prehospital and when they arrived to an emergency care facility.

To address these shortcomings, various sizable mitigation measures were adopted by Ghana’s government in an attempt to decrease the number of RTAs and their associated costs. In 2004, Ghana established a National Ambulance Service (NAS), providing over 200 ambulances staffed with formally trained, BLS-certified EMTs for pre-hospital care. Ghana’s first EM residency program was established in 2009, followed one year later by its first 2-year Emergency Nursing degree program. More recently, in 2019, the NRSC passed the National Road Safety Authority Acts that were designed to promote and mandate best road safety practices, both in road users and road developers. However, despite these resolutions, RTAs and their associated injuries and deaths continue to remain consistently high in the country.

A literature review of available research on Ghanian RTAs revealed several limitations in the studies. While the NRSC has been instrumental in collecting RTA data and devising protocols to mitigate RTAs, there is still a lack of detailed, objective research on RTAs in Ghana. Additionally, there are significant inconsistencies in the source of the data and whether it is a registry-based report or a population-based study. The causes of accidents are not well-documented, and there is limited data available detailing where the majority of RTAs occur aside from the regions most heavily affected. According to data from 2016, over 75% of RTAs occur in 5 regions (Ashanti, Greater Accra, Eastern, Central and Brong Ahafo), of which four of the five regions correspond to the four most populous regions (with the exception of Ahafo, which is the least populated). Interestingly enough, however, about 60% of RTA fatalities were in non-urban sections of the road networks. Despite this information, we were unable to find details regarding where the specific accidents occur within each region.

Research collected by the University of Ghana’s School of Public Health identified the following risk factors that were highly associated with RTAs: stop-light violations, improper signaling, speeding. However, we believe that the study used to determine these risk factors relied too heavily on subjective analysis, leading to potentially erroneous and biased data. Therefore, we propose utilizing traffic cameras for gathering objective data in areas with a high burden of RTAs. This analysis will allow local authorities to identify risk factors that lead to RTAs, resulting in the utilization of emergency medicine services.

In short, an objective method of identifying common risks, causes, and associations of RTAs is crucial in order to decrease morbidity and mortality as well as the need for emergency care. This is especially important, as Ghana spends over $130 million USD each year on RTA-related injuries alone.

Project Proposal

We believe one way to do this is to utilize traffic cameras that are already in place in these high traffic areas to analyze accidents. As the infrastructure is already in place for surveillance – all we need to do is collect and analyze the footage, which has limited costs associated with it. We would need to pay salary to 1-2 data analysts in order to analyze the information. If more cameras were needed, this would cost anywhere from $65-80,000 USD per camera installation. After installation and retrieval of the camera data, what information will we collect? First, we would like to identify what specific intersections and roadways are involved in RTAs. We also would collect temporal statistics such as day of the week, month and time of day as well as weather conditions. The type and number of vehicles involved in the accident as well as identifying whether the drivers are local versus nonlocal are also important characteristics. Lastly, we would look at whether drivers violated traffic laws such as running a redlight or were speeding as well as being in the incorrect driving lane.

The data collected from this proposal can be used to promote infrastructure changes to lessen the risk of future RTAs. In particular, the installation of crosswalks have been proven to mitigate incidences of motor accidents. According to a 2017 study, 68% of pedestrian fatalities from RTAs in Ghana are related to “pedestrian crossing behaviors.” However, the study was limited in its ability to deduce further information from these incidents, such as the causality of the accident. The review of the stop light camera footage from the event would allow the local government to determine if more facilities such as crosswalks may be beneficial to install in populated intersections.

Conclusion

The high prevalence of RTAs in Ghana is a public health concern that dramatically burdens the emergency medical community. We believe that the data collected from traffic cameras can be used to more concretely understand the risk factors that lead to motor accidents in Ghana. Ultimately, this information can be used to improve infrastructure features to mitigate risk of future accidents.

References

  1. https://www.cdc.gov/injury/features/global-road-safety/index.html
  2. Blankson PK, Lartey M. Road traffic accidents in Ghana: contributing factors and economic consequences. Ghana Med J. 2020 Sep;54(3):131. doi: 10.4314/gmj.v54i3.1. PMID: 33883755; PMCID: PMC8042801.
  3. Blankson PK, Nonvignon J, Aryeetey G, Aikins M. Injuries and their related household costs in a tertiary hospital in Ghana. Afr J Emerg Med. 2020;10(Suppl 1):S44-S49. doi: 10.1016/j.afjem.2020.04.004. Epub 2020 May 26. PMID: 33318901; PMCID: PMC7723915.
  4. Zakariah A, Stewart BT, Boateng E, Achena C, Tansley G, Mock C. The Birth and Growth of the National Ambulance Service in Ghana. Prehosp Disaster Med. 2017 Feb;32(1):83-93. doi: 10.1017/S1049023X16001151. Epub 2016 Dec 12. PMID: 27938469; PMCID: PMC5558015.
  5. https://ugspace.ug.edu.gh/bitstream/handle/123456789/36413/Injury%20Patterns%20and%20Emergency%20Care%20in%20Road%20Traffic%20Accidents%20in%20Accra.pdf?sequence=1&isAllowed=y

About GEMSLP project proposals

These project proposals are completed by our mentees, who are medical students, to encourage independent thinking from a global perspective.

Thank you to our authors and presenters!

Picture of Holly Farkosh, MS4

Holly Farkosh, MS4

Marshall University Joan C. Edwards School of Medicine

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Andrew McAward, MS2

Marshall University Joan C. Edwards School of Medicine

Tram Lee, MS3

University of Oklahoma Health Sciences Center

Blog Editorial Team

Picture of Halley Alberts, MD

Halley Alberts, MD

PGY-2 University of South Carolina Prisma Health Midlands
GEMS LP Co-Director & Blog Editor

Picture of Jeff Downen, MD, MS

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

Picture of Mohamed Hussein, MBBCh

Mohamed Hussein, MBBCh

Trauma Research Fellow
Blog Editor

Keep in Touch:

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Project Proposal 12/20 :Creating Culturally Appropriate Mental Health Care Programs After Disasters

~ Global EM Student Leadership Program ~ Leave a comment

Mental health conditions are the leading cause of disability worldwide, accounting for an estimated 175.3 million years lost to disability (Figure 1). Inequalities in access to or quality of mental health care globally are directly related to social, structural, and economic determinants. Increasingly, research suggests that these socioeconomic inequalities lead to health issues not just for disadvantaged populations but for all those involved in unjust or unequal societies. In addition, most of our information on global access to mental health care is limited to formal psychiatric care, which discounts other forms of local or indigenous healing practices.

Disasters have countless impacts on communities and can cause stress due to feelings of powerlessness, loss of community life and culture, and destruction and physical displacement. An estimated 1 in 3 highly exposed trauma survivors may experience post-traumatic stress disorder (PTSD), and 1 in 4 may experience major depression. Psychological distress, which does not meet the criteria for another formal psychiatric diagnosis, is nearly universal after exposure to a disaster and deserves significant attention as well.

It is also crucial to ensure that mental health responses after disasters are conscious of unique local contexts. Previously, priorities in disaster responses have primarily been defined by mental health professionals mostly by nations of the Global North, which gives insufficient attention to locally-defined priorities. These established programs focus mainly on major neuropsychiatric disorders as defined by Western professionals and assume that the features, courses, and outcomes will mirror those seen in the cultures where they were initially developed. Existing programs and literature also tend to focus on PTSD, with other forms and manifestations of psychological distress falling through the cracks. This focus on applying formal diagnosis and treatment assumes that they are generalizable across cultures and may marginalize indigenous forms of healing that could be vital to the community.

Key Priorities

With these concerns in mind, we want to highlight some key priorities in creating a culturally sensitive mental health care program in the post-disaster setting. First, we need to remember that systemic factors such as structural violence and poverty are important determinants of mental health outcomes (Figure 2). Thus it is imperative to first support efforts addressing basic socioeconomic needs and promote physical safety of the population. In addition, mental health programming may be carried out in tandem with medical colleagues addressing other problems to increase coverage and decrease the need for additional infrastructure.  

Figure 2: Proximal and distal factors of the social determinants of mental health with sustainable development goals mapped onto the different domains. 

In assessing the community’s mental health needs, there should be an effort to learn and adapt to the local context, as an individual’s response to suffering is likely influenced by the religious, spiritual, and moral context of the local community. In addition, classification systems used in mental health evaluation (i.e., DSM-5) should be modified to integrate the knowledge of culturally specific idioms of stress, taking into account also differences related to class, gender, age, sexuality, minority/majority position. Lastly, special attention must be given to those with existing psychopathology as these individuals are at risk of having worse outcomes in response to disasters. 

Proposed Solution

Guided by these principles, we proposed examples of programming components that partner with the local community and integrate an understanding of local resources and traditions of healing. 

  1. Work with psychologists, community health workers, and local religious leaders to facilitate memorial services in response to possible losses in the community.
  2. Promote education on when and where to seek service, especially in social settings that communities frequently gather. 
  3. Develop programs that go beyond the toolkit of professionals and mobilize indigenous resources and family-specific social activities to encourage people to also rely on support from immediate social networks. 
  4. Partner with specialists to support task-shifting to local non-specialist providers.
  5. Establish screening protocols for aid workers and staff working in disaster settings as these individuals are also at risk for mental health issues.

We want to have a continuous evaluation of the program in four outcomes areas, each with different indicators:

  • Relevance (indicated by population need and cultural and contextual fit)
  • Effectiveness (indicated by mental health outcome)
  • Quality (indicated by adherence, competence, and attendance)
  • Feasibility (indicated by coverage and cost)

While some of the indicators, such as coverage, helps to define operational characteristics of the program, other factors, such as cultural and contextual need, support the program by engaging with local stakeholders. Information regarding these indicators can be obtained using various methods, including community surveys, national health system records, cohort studies, and observational studies.

Though the world’s mental health burden is experienced heavily in low and middle-income countries (LMICs), often only a tiny portion of the annual operating health budgets in these countries will go toward addressing mental health issues. For example, the Emerald (Emerging mental health systems in LMICs) study, which was a multinational study conducted to assess the infrastructural and policy needs for expanding mental health services in Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda, revealed that in some LMICs, there is less than $0.25 per person per year available for mental health budgeting. In addition to limited resources and finances, mental health programs face other challenges related to sustainability, such as poorly trained staff and a lack of understanding about service delivery processes and quality improvement. High turnover of senior-level policymakers can prevent longitudinal advocacy and agenda-setting, and low community participation can also be a barrier.    

While the exact cost for our program is difficult to predict given system collapse and displacement of populations in the post-disaster setting, here we provide an estimation of a possible budget using the operating budget of the NGO Médecins Sans Frontières (MSF) in 2020 as a starting point. 

  • MSF Operating Budget 2020 = €550,000,000 Euros, with 80% spent on programming spending (€440,000,000)
    • €440,000,000 spent across 10 countries = €44,000,000/country in 2020
    • *Presuming 2% for mental health budget allocation = €880,000 for mental health budget/country/year
  • ~350,000 Mental Health Consultations across 10 countries
    • ~35,000 Mental Health consultations annually per nation engaged 
  • €880,000 / 35,000 consultations = €25/consultation (used for medications, counseling, etc) 

Even assuming just 2% of the operations budget is allocated to mental health programming, it can be estimated that major NGOs may be able to make a more significant fiscal investment in mental health than what public services can currently offer in LMICs. In the emergent setting, the surge of financial resources from these agencies towards affected groups presents new opportunities and motivation for development. Additionally, the destruction or collapse of health systems amidst destabilization may provide opportunities to build more equitable and person-centered care systems. Furthermore, media attention can stir public interest and political willpower to dedicate more resources to mental health treatment systems. 

Historically, international health actors have not prioritized the transition of care from transient emergent systems to nascent local infrastructure. Thus two types of investment are needed to ensure a smooth transition and subsequent strengthening of the local health system. Initially, startup investment from aid organizations is needed to maintain operating budgets amidst transitions. Then continuous funding for long-term service delivery from health departments or public agencies is required to promote infrastructure longevity and tackle some of the previously mentioned system-level challenges impeding sustainability of programming. 

Summary

  In summary, our current understanding of and approach to global mental health focus on priorities does not pay sufficient attention to local priorities and marginalizes indigenous healing techniques. Guided by an understanding of the social determinants of mental health, at-risk populations in disaster settings, and the crucial importance of adapting to local contexts, we proposed several priorities in infrastructure support, assessment, and intervention when establishing culturally sensitive mental health care programs. Outcomes of the program will then be evaluated in its relevance, effectiveness, quality, and feasibility and used to modify the program in response to changing needs in the post-disaster setting. While the increase in support from NGOs during times of disaster will likely result in increased resources available for mental health programming, transition, and down-scale of post-disaster services to local health systems will never be sufficient nor sustainable without addressing systems-level problems. 

References

  1. Bischoff, R.J., Springer, P.R., Taylor, N. (2017). Global Mental Health in Action: Reducing Disparities One Community at a Time. Journal of Marital and Family Therapy, 43, 276-290. doi: 10.1111/jmft.12202
  2. Kirmayer, L.J., Pedersen, D. Toward a new architecture for global mental health. Transcultural Psychiatry. 2014;51(6):759-776. doi: 10.1177/1363461514557202
  3. North, C.S. Pfefferbaum, B. Mental Health: Response to Community Disasters: A Systematic Review. JAMA. 2013;310(5):507-518. doi: 10.1001/jama.2013.107799 
  4. Jordans, M., & Kohrt, B. (2020). Scaling up mental health care and psychosocial support in low-resource settings: A roadmap to impact. Epidemiology and Psychiatric Sciences, 29, E189. doi:10.1017/S2045796020001018
  5. Lund C, Brooke-Sumner C, Baingana F, Baron EC, Breuer E, Chandra P, Haushofer J, Herrman H, Jordans M, Kieling C, Medina-Mora ME, Morgan E, Omigbodun O, Tol W, Patel V, Saxena S. Social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews. Lancet Psychiatry. 2018 Apr;5(4):357-369. doi: 10.1016/S2215-0366(18)30060-9. 
  6. Bredström, A. Culture and Context in Mental Health Diagnosing: Scrutinizing the DSM-5 Revision. J Med Humanit 40, 347–363 (2019). 
  7. Raviola G, Eustache E, Oswald C, Belkin GS. Mental health response in Haiti in the aftermath of the 2010 earthquake: a case study for building long-term solutions. Harv Rev Psychiatry. 2012;20(1):68-77. doi:10.3109/10673229.2012.652877
  8. Semrau, Maya, et al. “Strengthening Mental Health Systems in Low- and Middle-Income Countries: The Emerald Programme.” BMC Medicine, vol. 13, no. 1, 10 Apr. 2015, 10.1186/s12916-015-0309-4. Accessed 7 May 2019.
  9. Epping-Jordan, JoAnne E, et al. “Beyond the Crisis: Building Back Better Mental Health Care in 10 Emergency-Affected Areas Using a Longer-Term Perspective.” International Journal of Mental Health Systems, vol. 9, no. 1, 12 Mar. 2015, 10.1186/s13033-015-0007-9. Accessed 13 June 2020.

About GEMSLP project proposals

These project proposals are completed by our mentees, who are medical students, to encourage independent thinking from a global perspective.

Thank you to our authors and presenters!

Picture of Alison Neely, MS4

Alison Neely, MS4

Albert Einstein College of Medicine

Picture of Luxi Qiao, MS4

Luxi Qiao, MS4

Washington University School of Medicine

Jacob Reshetar, MS4

University of Minnesota School of Medicine

Blog Editorial Team

Picture of Halley Alberts, MD

Halley Alberts, MD

PGY-2 University of South Carolina Prisma Health Midlands
Co-Director & Blog Editor

Picture of Jeff Downen, MD, MS

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

Picture of Mohamed Hussein, MBBCh

Mohamed Hussein, MBBCh

Trauma Research Fellow
Blog Editor

Keep in Touch:

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Two Roads, One Path: Academic vs. Non-Academic EM – Part 1

academic emergency medicine vs non-academic emergency medicine
~ Anthony Rodigin, USA ~ Leave a comment

Are academic and non-academic emergency medicine (EM) really two completely different worlds?

With this post I want to start a short series on this topic, hopefully with a little twist in the approach.

Why even question?

How and why do you question a distinction that is on the one hand very apparent and real, and on the other is very customary and traditional and may be true for all medical specialties?

Part of the answer is that in order to plan a fulfilling life in EM (not everyone believes in a “career”), it is best to understand the entire landscape – not only regionally and nationally, but also globally. To this end, perhaps more innovation, ingenuity and out-of-the-box thinking is needed to benefit future EM trainees than what habitual teachings on the subject offer.

Are we really committed for life to whatever we pick out of residency?  Is the decision regarding a fellowship for a senior registrar a now-or-never decision? Is there such an age as “too late” for academics and vice versa? Is the connection between academic and non-academic EM a one-way street? Is it true that once in EM you cannot do anything else because “you don’t know how to do anything else”, according to some?

Today we will begin by looking at a few labels and presuppositions that may be cemented in the collective EM subconscious. It is my intuitive suspicion that only by uncorking, uncovering or by altogether removing some of these, will we be able to get to the real deal underneath.

As they say, the devil is in the details.

Discussion One:  Smoke and Mirrors

Where will you work at and who will you work for?

First, academic vs. non-academic EM identity can to a large extent be affected by how your nation’s overall healthcare system is set up.

In countries with predominantly socialized medicine, “community practice” – very possibly a US-driven term – may simply indicate not being employed at one of the largest tertiary urban centers available, which carry all the prestige and concentrate all of research efforts. In such nations a classically proposed counterpart to academic medicine, a business-driven private EM enterprise, may be lacking completely.

If everyone works for the government, be it local or federal, then becoming “academic”, equally or more so than due to one’s personal talents and inclinations, may be the outcome of having urbanization, luck, connections or some other ability to find a bigger place to work. At one point or another one simply wins the lucky lottery ticket to move and “move up”. In essence, the EM physician is a large capital city’s teaching hospital worker first, and an academician largely by default. Such career aiming of course succumbs to the philosophy that urban and central is always better than rural and peripheral.

Second, let’s consider “community practice” as a kind of a weird term: if you are in academic EM, who else are you serving if not some community or communities? These may be communities of colleagues, trainees, organizations and researchers in addition to patients, but they are communities nonetheless.

Equally, if an EM physician is truly and solely in non-academic practice, does she really envision and lead her professional life without any engagement in research, publications, teaching, administration, local and international networking? What would the website “Life in non-academic EM” look like – a steady picture of a work mule without links or content?

Both terms academic and non-academic EM may be infused and muddied with other meanings like institutional- or government-affiliated practice, private practice, non-teaching, and so on.

In real life, both type of endeavors (if the distinction between academic and non-academic is genuine) can be conducted in very urban or in rather rural environments; and either practice type may be institutionally affiliated or tied to NGOs, governments or businesses. In the United States some recent criticism has sprung related to the so-called inbred residencies – EM training programs created and operated by large corporate entities.

More importantly for a future trainee: both types of EM practices may or may not involve exclusive night shifts, overtime, faraway travel, being underpaid, unfair seniority, feeling unappreciated and cogwheelish (new word for you), without a clear sense of direction or belonging.

Don’t get ridiculous with cliches.

Now to some cliches, most of which are from the trainees themselves.

One: the sigh “I love teaching, but I hate research” from those choosing non-academics.

Let me ask a provocative question: are all of the globally famous EM research superstars you and I know necessarily brilliant teachers? It appears that “I love research, but I hate teaching” never stopped anyone from an academic road. This, of course, is poor logic either way.

Teaching is a hard thing to do well, and there is a distinction between bedside and classroom teaching, but so is research! Just like the so-called charisma of say a journalist, perhaps some abilities one can be born with (in the words of Professor Snape, “possess the predisposition”). Yet, vast majority of skills can be and have to be acquired.

So instead of anguishing over your inborn leanings and phobias, think rather of what you would prefer to be doing, once you learn it, during any typical week of the next five or more years after residency. Now, how can you realistically translate that into life, given the types of attainable EM jobs out there in your current or anticipated environment?

Two: “get in, get out (of the ED), and enjoy the rest of your life!”

Often the EM backpack mentality, as bumper-stickered above, is sold as the prime appeal of non-academic work.

All true – academicians, when not at work, do not enjoy their lives to any significant extent. They spend most of their free time in dusky library dungeons and at other EM-bound noble activities, while those outside of academics enjoy hundreds of free hours sailing the high seas or YouTube.

As a very weak truism, non-academic EM may sometimes open up more free time for non-EM related activities of one’s life. But is wastage of time laying on a couch an activity, and are you susceptible?

On the contrary, it may be plausible that academicians may enjoy fewer and shorter shifts, more diverse practices, more immediate access to cutting edge innovations and articles, fuller specialist call panels and fewer unfinished charts to review and sign at home.

Three: “One should only do a fellowship if planning an academic career…in which case, you better get into one!”

No, you should probably do a fellowship primarily because you are very interested in what the fellowship is about. Everything else is an extra, albeit a welcome one – like perhaps natural entry into an academic institution or a network of contacts for expanded career options.

It is also completely legitimate to consider the burden and the years of your medical training so far. In some countries just getting to a recognized EM residency (which may be abroad!) has already cost you several years post medical graduation. In such cases, ambivalent feelings towards adding even more years via a fellowship to the perpetual student status are fully valid.

On the other hand, it may very well be that in the near future (if not already), all EM docs without a fellowship, whether entrepreneurial or in public service, academic or not, will become non-competitive for best jobs.

Is doing a fellowship straight off the bat after residency the only option? What if you are not interested in any during training, but become interested later?

To be fair, right after residency makes not only intuitive sense, but typically the system is set up that way, especially fellowship funding. Still, one has to be careful, as not all of fellowships are funded, nor are all fellowships accredited. Viewed in a constructive light, this creates not only constraints but also degrees of freedom for making choices.

True, if years pass, an entire family’s lifestyle dependent on attending level salary may not be very compatible with the salary of a fellow even with all the moonlighting in the world. But is the latter income difference profound in your country, or are the main barriers to a delayed fellowship of a different sort – e.g., government rules written in stone, the mass competition from the youngsters or some unspoken negative culture towards old-timers in their forties among fellowship directors?

Overall, nothing is insurmountable if given enough will, persistence and preparation. Otherwise, there would have been no people in their forties in my medical school class or residency.

Which professional currency would you rather deal in?

All mentioned above is not to be construed to say that some harsh realities do not exist.  One problem with cliches is that they are very zonal, while proclaiming to be universals.

The simple overhanging truth is that every field has its own currency, and both academic and non-academic EM are no exceptions.

For future EM trainees this is pertinent and applicable not only because of the obvious choices you will have to make after formal training, but also because of the need to gear and adjust your preferences while still in training.

Grant funding and publications are absolutely the ubiquitous currency in academics. Productivity, billing and people management (aka “leadership”) skills are the hardcore coinage in business-driven EM. Advancement and promotion within socialized medicine systems may call for yet another set of valuables altogether.

Still, thinking in terms of such hard constraints will tend to corner you in at least two ways.

First, it is not to be implied that ability to generate grants or publications never helps or is not useful in non-academics, or that no academician has to keep track of her billing and productivity metrics.

Second, if cornered, you will be liable to forget the correct reasons for choosing a certain path – the ones that spring from your deep interests and curiosities. These reasons miraculously happen to be the same ones to keep you out of burnout and disappointment years later, no matter what type of practice.

I am proposing a much simpler approach to the above dilemma. Choose currencies that will create the least disdain and subconscious resistance (manifested by nausea and wanting to do what your dog does after it gets wet), and then ones for which you think you already have more inborn propensity if not talent.

Finally, are you really ego-, career- and promotion-driven?  How would you define your own future success in EM?

Enough from me for now.

In future discussions and interviews we will try to elicit opinions of other EM physicians to shine different shades of light on the intriguing sub-topics this topic uncovers.

Stay tuned!

 

Journal Club 3/21/22: Mental Health in the International Community

~ Global EM Student Leadership Program ~ Leave a comment

Prevalence of burnout among university students in low- and middle- income countries: a systematic review and meta analysis - presented by Jonathan Kajjimu

Burnout is a form of distress that manifests with features of emotional exhaustion, depersonalization, and reduced personal/professional accomplishment. Emotional exhaustion or unsuccessful coping with stressors, is the fatigued feeling that develops as one’s emotional energies are drained. Depersonalization refers to a student’s indifference, negative or cynical attitude. Reduced personal accomplishment is a negative self-evaluation of one’s abilities which manifests itself with feelings of failure. University education is an intrinsically demanding time which puts university students at risk for burnout, coupled with other burnout risk factors such as individual/personal factors and extracurricular factors. Burnout causes significant physical, emotional, psychological, and spiritual damage to students.  

However, from this article there had been paucity of and discrepancies in data on the overall prevalence of burnout in university students from low- and middle-income countries (LMICs). Students pursuing health-related programs in mostly high-income countries (HICs) had been mostly studied previously.

In this review, 55 articles were included, with a total of 27,940 (female: 16,215, 58.0%) university students from 24 LMICs. The Maslach Burnout Inventory (MBI) was found to be the most widely used tool for measuring burnout in 43 studies (78.2%). The pooled prevalence of burnout was 12.1% (95% CI: 11.9–12.3; p = < 0.001). Pooled significant prevalence of emotional exhaustion, cynicism, and reduced personal/professional efficacy were 27.8% (95% CI 27.4–28.3), 32.6% (95% CI: 32.0– 33.1), & 29.9% (95% CI: 28.8–30.9) respectively. Burnout pooled prevalence was highest among the African region at 35.4%, followed by the Asian region at 30.2%, and the European region at 20.7%. 


Figure 1: Forest plot for the prevalence of burnout in LMICs

In this review, burnout rates found in LMICS were lower than those in HICs, which the author believed to be due to publication bias. Authors further recommended low cost interventions that were needed more in low income countries than in middle income countries for managing burnout. These included mindfulness practices, yoga exercises, and group discussions. The current COVID-19 pandemic was also highlighted as having been found to put university students at a higher risk of burnout. Consequences of burnout in students include absenteeism, drop out, reduced academic performance, depression, alcohol and drug abuse, suicide, professional impairment and dissatisfaction, increased incidence of errors and near-misses.

Discussion Questions:

  • How can medical schools focus more on mental health of medical students?
  • How can we ensure that medical students always have their wellbeing in check? 
  • Do you think medical students actually get burnt out or are they just morally injured?

Some of the great recommendations received were having wellness days, “Opt out sessions”, and free counselling sessions in medical school for openly bringing out mental health issue discussions. However, one student confidently believed it would be difficult for schools to focus on mental health of students despite other discussants’ optimism.

Med students can: Focus on reducing energy drain. Identify what you can change – and what you can’t.  Align your goals, values and beliefs. Set limits and delegate. Create new challenges that are aligned with your values. Give yourself frequent breaks. Seek support. Monitor your energy level and emotional state. Eat energy and brain foods. Pace yourself. Build problem-solving skills. Lighten the situation with humor. Having regular physical exercise. 

Medical schools can: Advocate for student autonomy i.e. ability to influence student environment and schedule control. Provide adequate support services such as counselling, secretarial, administrative, social work, and financial. Encourage collegial work environments, healthy relationships and sharing of common goals. Minimize school-home interference. Promote proper work-life balance. Ensure vacation time and limit overtime. Establish mentoring. Consider periodic sabbaticals.

Kaggwa MM, Kajjimu J, Sserunkuma J, Najjuka SM, Atim LM, Olum R, et al. (2021) Prevalence of burnout among university students in low- and middle-income countries: A systematic review and meta-analysis. PLoS ONE 16(8): e0256402. https://doi.org/10.1371/journal. pone.0256402

Mental Health in the International Community - Presented by Alexander Gallaer

Mental illness is a topic that is still gaining awareness, acceptance, and understanding in many parts of the world. While western medicine, most notably the DSM-V, has sought to carefully categorize and define mental disease, the definition of what constitutes mental illness is still very much disputed globally. Unfortunately, many global populations may suffer from unaddressed mental health struggles as a result of these varying attitudes. Notably, post-traumatic stress disorder (PTSD), as defined by the DSM-V, is a disease that has an enormous global burden. As emergency physicians increasingly become the sole health care providers, especially in marginalized populations, it is important to have awareness of what groups may need special attention or follow up to diagnose or address underlying PTSD. Some of these groups include male military veterans (lifetime prevalence of 30.9% (1)), emergency healthcare providers (up to 15.8% (2)), and, most notably here, refugee populations (up to 62% in some Cambodian cohorts (3)). Early recognition of symptoms and swift referral of patients to mental health services as soon as symptoms are identified could alleviate long term disease burden and lead to improved outcomes (4). Because refugee populations are high risk, providers can consider routinely screening for symptoms.

Discussion Questions:

  • How would you approach treating a mental health crisis in an individual who does not believe such issues exist, or that such disease processes can affect them?
  • How can we raise awareness of PTSD in populations with traditionally low recognition of mental illness? Should we do this?

References:

1) Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593.

2) Bahadirli S, Sagaltici E. Post-traumatic stress disorder in healthcare workers of emergency departments during the pandemic: A cross-sectional study. Am J Emerg Med. 2021 Dec;50:251-255. doi: 10.1016/j.ajem.2021.08.027. Epub 2021 Aug 14. PMID: 34416516.

3) Marshall GN, Schell TL, Elliott MN, Berthold SM, Chun CA. Mental health of Cambodian refugees 2 decades after resettlement in the United States.JAMA. 2005;294(5):571.

4) Fanai M, Khan MAB. Acute Stress Disorder. [Updated 2021 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-

The Unique Challenges of Mental Health and Multidrug Resistant Tuberculosis- Presented by Ellen Chiang

Calculating disability adjusted life years (DALY) aims to quantify disease burden in terms of both mortality and morbidity. This calculation is an important tool in global health work and as with all tools, it has limitations. Attempts to quantify disability from mental health disorders demonstrate the constraints of the DALY. 

Our understanding and definition of what classifies a mental illness is influenced by our sociocultural context. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is therefore impacted by politics and prejudice. While DALY calculations include sex and gender as weighted factors, many other social factors are not considered. Additionally, much of the medical research published in the major psychiatric journals center on Euro-American study populations, which limits the cross-cultural application of findings. 

Without full consideration of what is not captured by our quantitative measurement of choice, global health interventions can have unintended, significant consequences. The book chapter highlights this by discussing the emergence of multidrug resistant tuberculosis (MDTRB) from the implementation of the DOTS protocol in Peru, which was supported largely by the cost effectiveness paradigm. 

Global health experts should understand the limitations of the DALY when using it to identify priorities and create and evaluate interventions. Remaining aware of what falls outside of the DALY can help create more context appropriate health interventions and new measurements that factor in important social dimensions of disease burden

Discussion Questions:

  • Is it possible to create a metric for disease burden that accounts for social context?
  • When implementing a large-scale health intervention, what are some ways to maintain the flexibility needed to address unexpected challenges?

References:

Ji, Jianlin, Arthur Kleinman, and Anne Becker. “Suicide in Contemporary China: A Review of China’s Distinctive Suicide Demographics in Their
Sociocultural Context.” Harvard Review of Psychiatry 9, no. 1 (2001): 1– 12.

Anand, Sudhir, and Kara Hanson. “Disability-Adjusted Life Years: A Critical Review.” Journal of Health Economics 16, no. 6 (1997): 685– 702.

Sen, Amartya. “Missing Women: Social Inequality Outweighs Women’s Survival Advantage in Asia and North Africa.” British Medical Journal 304, no. 6827 (1992): 587– 588.

Wrap up!

We thoroughly enjoyed the discussion sparked by these three mentees and are proud to be to present a brief summary of their work here! Please stay tuned for more article summaries and details about our upcoming meetings.  Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Picture of Jonathan Kajjimu, MS5

Jonathan Kajjimu, MS5

Mbarara University of Science and Technology

Alexander Gallaer, MS4

University of Connecticut School of Medicine

Picture of Ellen Chiang, MS4

Ellen Chiang, MS4

UNC Chapel Hill

Picture of Jeff Downen, MD, MS

Jeff Downen, MD, MS

PGY-2 University of Florida, Jacksonville
Blog Editor

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Journal Club 1/10+1/31/22: Sustainability and Language Justice

~ Global EM Student Leadership Program ~ Leave a comment

Tropical Diarrheal Illnesses in Children by Ying Ku

Tropical diarrheal illnesses (TDIs) are major health concerns around the world, especially in resource-limiting countries, resulting in approximately 500,000 child deaths annually. TDI is a gastrointestinal infection caused by pathogens that are prevalent in the tropical regions, with diarrhea being the main presentation. Most commonly, these diseases are spread by contaminated food and water due to inadequate sanitation and poor hygiene. Among various microorganisms that can result in TDIs, Rotavirus and E. coli are the most common agents causing moderate to severe diarrhea in children in resource-limiting countries. Some common signs and symptoms are diarrhea, nausea &amp; vomiting, cramps, fatigue, fever, and chills. However, TDIs may result in death secondary to severe dehydration. When assessing TDI patients, it is crucial to determine  dehydration status and identify the type of diarrhea (watery or dysentery) given the different treatment approach. The most important treatment is rehydration with oral rehydration salts (ORS). ORS can be made with: 1 L water + ½ tsp salt + 6 tsp sugar. The more detailed treatment algorithm can be found in the Clinical Care Guideline for Integrated Management of Childhood Illness. Strategies in preventing TDIs can be summarized into blocking common transmission factors such as feces, fingers, flies, fields, fluids, and food via proper sanitation and hygiene. Lastly, we can help with this global health concern via donation/fundraiser for the organizations working to improve access to safe drinking water and sanitation, as well as being involved in projects to help develop prevention and control strategies in different locations.

Discussion Questions:

  • What are the challenges in promoting better hygiene in developing countries?
  • Despite the widespread use of ORS, mortality associated with severe dehydration in children remains significant. What are some factors contributing to this challenge?

Language Barriers and Epistemic Injustice in Healthcare Settings by Savanna Hoyt

  • Introduction
    • Language injustice is one of the most significant challenges facing national health systems.
    • Language barriers between patients and practitioners can have significant adverse impacts on quality of care.
    • Every phase of the healthcare process relies on effective communication.
  • Language and Healthcare: Complex Dynamics
    • In diverse societies, healthcare challenges stem from the fact that while language is a human commonality, it manifests through a wide range of languages.
    • Culture influences every aspect of illness, including interpretations of symptoms, explanations of illness, seeking help, adherence to treatment, and patient-provider relationships.
  • Linguistic Epistemic Injustice:
    • An example of testimonial injustice (misjudgement of how a person speaks), is when a patient and physician do not share a first language, but must communicate in it due to a lack of translation services.
    • Different concepts of illness across languages can result in hermeneutical injustice (misjudgement of what a person says).
  • Linguistic Epistemic Humility:
    • Linguistic epistemic injustice can be countered by linguistic epistemic humility.
    • In healthcare, epistemic humility involves becoming aware of your own capacities within your own language, with other languages, and actively searching for ways to overcome language barriers.
    • When considering patient-physician relationships across language barriers, the physician can facilitate positive relationships and deliver better care by recognizing their own language ability, acknowledging language needs of the patient, and attempting to correctly pronounce the patient’s name.
  • Conclusion
    • A more language-aware healthcare process can further advance the health of the general population, ensuring practice and research are carried out in a more equitable manner.

Discussion Points:

  • How can we as future physicians work towards eliminating language barriers in healthcare?
  • What are the possible outcomes of addressing language barriers in healthcare?

Social Forces and their Impact on Health Presented by Sreenidhi Vanyaa Manian

In medical school, we learn about the causes of various diseases usually falling into categories of infectious, genetic or immune-mediated processes. However, when it comes to causes often it is enclosed under the broader umbrella of social forces that impact health—defined as the social ‘determinants’ of health.  

“The unequal distribution of power, income, goods , services, globally and nationally, the consequent unfairness in the immediate visible circumstances of people’s lives-their access to healthcare, schools, and education , their conditions of work and leisure , their homes , communities, towns and cities – and their chances of leading flourishing life.”

We witness these social forces everyday and millions across the globe experience its impact on health. Insufficient food, inadequate safe water and discrimination based on race, gender and ethnicity are obstacles on the road to health. 

Rudolph Virchow investigated a typhus epidemic which he later called the ‘artificial epidemic’ as he identified the role played by factors such as lack of access to food, education, employment, as well as political isolation with the spread of disease rather than the microbe itself. 

“Medicine is a social science and politics (is) nothing but medicine on a grand scale”

Who LIVES? Who dies? 

Structural violence creates and perpetuates ill health, suffering and death. It is an unfair and evil entity that victimizes the underserved communities creating a lasting impact on their emotional, social, physical and mental well-being. Structural violence is inherently political and is fundamentally about resources and power. 

Poverty constrains choice, often in a brutal fashion.

 

Communities with lower socioeconomic status have been shown to have higher rates of accident, drug use depression and anxiety compared to those in higher socioeconomic groups. 

In 1848 Rudolf Virchow identified the lasting impact of social forces on health. How do we combat this? The answer is biosocial approach to global health wherein the healthcare provider attempts to understand the patient’s experiences, including the social forces present in the life of the person; as well as the impact of illness in the context of his/her daily life. This necessitates a deep historical, political and social understanding of the community

We all have heard the quote “Health is Wealth.” But we must understand that some degree of wealth is required in order to attain health that gives people a fair chance on their journey to liberty, peace and the pursuit of happiness.  

Discussion Points:

  • Any social movements that you know that led to better chances for good health in your community?
  •  What will you suggest (given the power) to the government to mitigate adverse social determinants?
  • What do you think is the greatest barrier to achieve equitable health?
  • During history taking, what are the other questions that can be asked to the patient for a more holistic approach to treatment?

Wrap up!

As you can imagine, our mentees had a wonderful discussion surrounding these three topics! We are thrilled to be able to present a brief summary of their work here. Please stay tuned for details about our upcoming meetings.  Connect with us through one of our contact options listed below if you are interested in attending!

Thank you to our authors and presenters!

Picture of Ying Ku, MS3

Ying Ku, MS3

Campbell University School of Osteopathic Medicine

Picture of Savanna Hoyt, MS2

Savanna Hoyt, MS2

Northeast Ohio Medical University

Picture of Sreenidhi M Vanyaa, MS4

Sreenidhi M Vanyaa, MS4

PSG Institute of Medical Sciences and Research

Picture of Halley J Alberts, PGY2

Halley J Alberts, PGY2

Blog Editorial Lead
University of South Carolina
Prisma Health Midlands

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