[1]

ENVIRONMENTAL EMERGENCIESFrom the Editors:

Do you remember the difference between a crotaline and an elapid snake? Neither do we. That’s why the focus of the fall edition of the PEMNetwork newsletter is environmental emergencies. Hot and cold, bites and stings, disasters and preparedness, you’ll find it all here.

September 2012

From the Site Administrator:

"Welcome to the exciting new face of the PEMNetwork. With new topic search-ability, active group forums, and more collaborative members than ever before, we continue to innovate and educate. We are looking forward to seeing you at the 2012 NCE where the PEMNetwork will hold an open meeting and present at the SOEM conferences.” 

- Angela Lumba, MD, FAAPWashington University School of Medicine

PEMNetwork.org, Head Site Administrator

Contents:

Bath Salts..........................2Lyme Disease........................3BASE Camp...........................4Hurricane Preparedness............5-6 EKG Feature: Hypothermia............7Heat Illness........................8Board Review: Bites and Stings...9-10Altitude Illness...................11Image Feature: Worms!.............12Notes from the Sub-site Editors....13

[2]

  “Bath salts” were first reported as drug of abuse to the North Texas Poison Center in 2010. Since then, Poison Centers across the United States have reported increasing numbers of calls involving “bath salts”. These “bath salts” usually contain mephedrone and methylenedioxypyrovalerone (MDPV) and are insufflated or “snorted” much like cocaine. Mephedrone is a synthetic stimulant of the amphetamine and cathionine class. Methylenedioxypyrovalerone is also a synthetic stimulant with effects similar to amphetamines. Both drugs have been reported to cause agitation, euphoria, hypertension and tachycardia. These effects resemble methamphetamine and cocaine toxicity. Patients can also develop hyperthermia and ultimately rhabdomyolysis, end organ failure and possibly death from the use of “bath salts.” So far, one death in Florida in 2011 has been attributed to the use of bath salts.

Bath salts are easily purchased on the Internet and at “head shops.” It is considered a designer drug because although mephedrone and MDPV have never been used for bath salts, they are labeled as such with the phrase “Not for Human Consumption” in order to bypass the Federal Analog Act. The Federal Analog Act of the United States Controlled

Substance Act states that any chemical "substantially similar" to a controlled substance listed in Schedule I or II is to be treated as if it were also listed in those schedules, but only if intended for human consumption. Many states such as Florida have now made the substances contained in bath salts illegal to own and sell. Also, as of September 7, 2011, The United States Drug Enforcement Administration (DEA) used its emergency scheduling authority to temporarily control mephedrone. This was deemed necessary to protect the public from the supposed hazard posed by the drug. Except as authorized by law, this action will make possessing and selling mephedrone or the products that contain it illegal in the U.S. for at least one year while the DEA and the United States Department of Health and Human Services conduct further study.

BATH SALTSSing-Yi Feng, MD FAAPAssistant Professor of Pediatrics/Medical Toxicologist

UT Southwestern Medical Center at Dallas

[3]

LYME DISEASEMatthew Thornton, MDYale University School of Medicine

Lyme Disease is the most common

vector-borne illness in the U.S. “Lyme

arthritis” was first described in 1976, with

the discovery of the causative spirochete,

Borrelia burgdorferi in 1981. Borrelia is

transmitted by the Ixodid tick and occurs

primarily in New England, New York, the

mid-Atlantic Coast, Wisconsin, and

Minnesota.

Animal studies have shown that

infected ticks must feed for 36-72 hours in

order for transmission to occur, such that

the risk of transmission from a known tick

bite is only 1-2%.

Lyme Disease is divided into 3

chronological stages, all with different

presentations and distinct pathology,

though there may be some degree of

overlap. These stages are 1) Early

localized, 2) Early disseminated, and 3)

Late disseminated.

Early localized disease occurs 1-55

days after a bite, involving the classic

erythema chronicum migrans (EM) rash at

the site of the bite, and may also include

flu-like symptoms. A characteristic rash

and possible tick exposure are all that is

required for diagnosis and treatment.

Early disseminated disease occurs

3-10 weeks after a bite when the

spirochetes spread via blood or

lymphatics to bone, synovial tissue, CNS,

heart, or skin. 25% of patients will have

multiple EM. Fever and myalgia are also

common. Meningitis, cranial

neuropathies, and carditis are more

serious complications. Heart block

responsive to antibiotics is the most

common manifestation of carditis.

Late disseminated disease causes

“Lyme arthritis”, typically in the knee.

Arthritis resolves in 1-2 weeks, but even

untreated cases will eventually resolve.

Recurrences are not uncommon.

Serologic testing is an adjunct to

clinical diagnosis in disseminated disease.

ELISA for IgM and IgG may be sent, and if

positive, followed by confirmatory Western

Blot. False-positive ELISA is extremely

common.

Treatment of Lyme disease is a bit

tricky, with regimens differing based on

disease stage and manifestations. Tick

bite prophylaxis is not recommended,

even in Lyme endemic regions, unless the

tick has been attached for >36 hours and

the patient is able to take doxycycline.

Early localized disease is treated with oral

doxycycline, amoxicillin, or cefuroxime for

14-21 days. Doxycycline has the

advantage of being active against possible

coexisting ehrlichiosis. Disseminated

disease causing multiple EM or an isolated

nerve palsy requires a longer treatment of

21-28 days. Meningitis/encephalitis and

symptomatic carditis with heart block

require IV therapy with ceftriaxone, as

does persistent or recurrent arthritis.

1. Steere AC. Lyme disease. N Engl J Med 2001; 345:115.2. Shapiro ED, Gerber MA. Lyme disease. Clin Infect Dis

2000; 31:533.3. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of lyme disease,

human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of

America. Clin Infect Dis 2006; 43:1089.4. Centers for Disease Control and Prevention: Lyme Disease.  Accessed 7/3/12.  http://www.cdc.gov/lyme/

Manifestations

Erythema migrans rash (top)is caused by local spread of spirochetes. It is nonpruritic and nonpainful and lasts 1-2 weeks. Bells palsy (middle) in early disseminated disease. Lyme arthritis (above) is a late manifestation.

LYME DISEASE

Incidence of Lyme (per

100,000 pop.)

[4]

Kevin Ching, MDWeill-Cornell Medical Center

In the fast-paced practice of emergency medicine, fellows must develop critical skills and behaviors swiftly. From day one, PEM fellows are expected to develop an ability to lead a team under crisis conditions, while possessing the technical proficiency to perform a staggering number of complex procedural skills. Yet, with only a 4-month pediatric residency requirement for acute care, there is no guarantee that graduating residents have been adequately prepared for this challenge. The probability is high that a new fellow has never had the opportunity to insert a chest tube or manage an infant in cardiopulmonary arrest. In addition to technical competency, fellows must develop team leadership and crisis management skills, neither of which are likely to fully develop in residency. The ACGME requires that fellows “learn the skills necessary to prioritize and simultaneously manage the emergency care of multiple patients,” and that “they must have supervised experiences using their technical/procedural and resuscitation competency skills.” Such skills have traditionally been acquired through “trial by fire” in the emergency department—with all the risks related to such practice.

BASE Camp: Basic Training for Pediatric Emergency Medicine Fellows was developed to offer a high-impact, immersive, and standardized learning solution that would level the playing field for incoming fellows and prepare them for the challenges of an EM fellowship. BASE camp brings together new first-year PEM fellows to collectively introduce, review, and provide opportunities to practice teamwork behaviors and critical emergency procedural skills. The first PEM “boot camp” of its kind in the Northeast, the inspiration for BASE Camp grew out of a pediatric critical care program inspired by Nishizaki at the Childrenʼs Hospital of Philadelphia.

In order to provide similar experiences for PEM fellows, BASE Camp assembled a collaborative group of expert PEM faculty from 10 universities to develop an intensive two-day multidisciplinary training program. Using state-of-the-art simulation technology, BASE Camp provides new fellows with an opportunity to begin developing hands-on experience and proficiency in crucial teamwork and procedural domains. Before arriving at BASE Camp, fellows are provided online an interactive pre-conference introduction and overview of teamwork concepts, emergency trauma procedural skills, the approach to a difficult pediatric airway, and advanced airway techniques to establish a cognitive framework for the 2-day course. In the course, fellows are challenged to collaborate in teams, often as leaders, in varied resuscitations. Fellows are given ample opportunities to learn, practice, and apply advanced airway maneuvers, like the use of an intubating-LMA in a child with a retropharyngeal abscess, or the video laryngoscope in an adolescent with laryngeal edema in anaphylaxis. Emergency trauma procedural skills like cricothyroidotomy, chest tube thoracostomy, and pericardiocentesis are practiced first on advanced trauma simulators, then human cadavers and animal tracheas, before applying these skills together as teams during a large-scale multi-casualty trauma simulation. Last year, BASE Camp hosted its 2nd annual conference, training 24 first-year PEM fellows from 13 fellowships across 8 Northeastern states. Preliminary data has shown that even among this population of highly motivated learners, the opportunities to acquire experience as team leaders in a resuscitation or inserting a chest tube are limited. As BASE Camp looks forward to introducing new educational strategies for its 3rd year this Fall, the hope is not only to provide experiences that foster complex thought and decision making within a teamwork domain, but to provide practice in rare but critical emergency procedural skills.

BASE CAMP

For more information, see: PEMBasecamp.com

BASE Camp: A Multi-Institutional Teamwork and Procedural Skills Simulation Training Conference for Pediatric Emergency Medicine Fellows

[5]

The 2012 hurricane season runs

from June 1 through November 30. This

year’s season is marked by the 20th

anniversary of Hurricane Andrew, the

catastrophic category 5 hurricane that

barreled through South Florida on

August 24, 1992. Andrew caused an

estimated 20-40 million dollars in

damage and killed at least 60 people.

For those living in hurricane prone areas,

knowledge of hurricane readiness and

evacuation procedures is not only

prudent but essential. The Centers for

Disease Control and the American

Academy of Pediatrics have outlined

specific steps for hurricane readiness

that will arm the prescient citizen with

the knowledge to protect one’s family

and vulnerable members of the

community.

Emergency care places the ABCs

paramount during an initial evaluation of

any patient. Similarly, hurricane

preparedness carries its own critical

reflexive moves: 1) Taking the first steps,

2) Preparing to evacuate, and 3)

Completing your family disaster plan.

Taking the first stepsIf you are under a hurricane watch or

warning, the CDC advises the following:

• Learn about your community’s

emergency plans, warning signals,

evacuation routes, and locations of

emergency shelters

• Inform local authorities about any

special needs. For children with

special health care needs it is

important to complete a health care

summary, including names/contact

information for the child’s medical care

providers. A two-week supply of

medications, equipment, supplies, and

foods for special diets is also

recommended.

• Locate and secure important

documents

• Stock your home with emergency

supplies. At minimum, this should

include a 3-5 day supply of water (5

gallons/person) and non-perishable

food, first aid kit, battery-powered

radio, flashlights, batteries, sleeping

bags/blankets, water-purifying

supplies (chlorine, iodine tablets, etc.),

baby food/supplies, toiletries, and an

emergency kit for the car with food,

flares, booster cables, maps, tools, a

first aid kit, fire extinguisher, etc.

Preparing to evacuateIf the forecast calls for a hurricane,

expect the need to evacuate and

Mass flooding prompts helicopter rescues after Hurricane Katrina (top, center); Hurricane Victim holds a meal package administered by U.S. Army (above).

Specific steps to ensure food and water safety during hurricanes, power outages, and floods can be found at www.fda.gov.

HURRICANE PREPAREDNESSDaniel Park, MDMedical University of South Carolina

[6]

prepare for it. When a hurricane watch is issued you

should:

• Never ignore an evacuation order

• Fill up your car’s gas tank/arrange for transport

• Fill up clean water containers

• Prepare an emergency kit for your car

• Cover windows and doors with plywood or boards

to reduce risk of flying glass

• Place pets and livestock in safe areas. Often,

animals are prohibited from emergency shelters.

• Fill sinks and bathtubs with water for washing

If ordered to evacuate:

• Take only essential items with you

• Make sure the car’s emergency kit is ready

• Follow designated evacuation routes

• Stay indoors until authorities declare the storm over;

if possible take shelter in a windowless, interior room or

closet. Stay away from all windows and exterior doors.

After the storm has passed, the American Academy of

Pediatrics recommends the following before children are

returned to areas impacted by flooding and/or hurricanes:

• Basic utilities and public services should be reliably

re-established

• Living and learning spaces (including homes,

schools, and day-care facilities) are free from physical

and environmental hazards to children

• Spaces where children play should be clear of

debris and free from environmental hazards to children

Completing your family disaster plan It is important to meet with your family before a

disaster occurs to discuss the importance of preparation.

If developmentally appropriate, discuss with children what

to do if the family is separated. Practicing the disaster

plan is both a practical and essential exercise not only for

hurricanes, but for any emergency.

Sources:

1. AAP Children and Disasters: Disaster preparedness to meet

children’s needs. Retrieved June 30, 2012, from http://www2.aap.org/

disasters/hurricanes-storms.cfm

2. AAP: Clinician Recommendations Regarding Return of Children

to Areas Impacted by Flooding and/or Hurricanes. Retrieved June 30,

2012, from http://www2.aap.org/disasters/pdf/Hurricanes-

ReturnofChildren.pdf

3. CDC Emergency Preparedness and Response. Retrieved June

30, 2012, from http://www.bt.cdc.gov/

4. Food Facts from the U.S. Food and Drug Administration: What

Consumers Need to Know About Food and Water Safety During

Hurricanes, Power Outages, and Floods. Retrieved June 30, 2012, from

http://www.fda.gov/Food/ResourcesForYou/Consumers/ucm076881.htm

[7]

EKG FEATURE:Rahul Kaila, MDUniversity of Minnesota Amplatz Children's Hospital

This is a case of 14 y/o male who had altered mental status and was found to be hypothermic with a temperature of 91 F on the street. His EKG showed Osborne or J wave ( marked in the EKG ) which is the upward deflection at the junction of QRS and ST representing distortion in the earliest phase of repolarization. J waves are usually observed in people suffering from hypothermia with a temperature of less than 32 C though they may also occur in people with high blood levels of calcium, brain injury, vasoplastic angina.

J-waves

J-waves were noted on the EKG (above), with resolution on the repeat EKG (right) after rewarming.

BABY, IT’S COLD OUTSIDE!

[8]

Heat illness is defined as “the

inability to maintain normal body

temperature because of excess heat

production or decreased heat transfer

to the environment.” Heat stroke

occurs when the excess body

temperature results in cellular injury,

and is a common cause of morbidity

and mortality among athletes, with

mortality rates of nearly 10%.

Acclimatization, or lack thereof,

can play a significant role in the risk for

heat illness. With prolonged exposure,

sweating rates increase, promoting

effective cooling as well as triggering

increased aldosterone secretion (and

thus decreased sodium losses). Un-

acclimatized people are prone to

significantly greater salt losses and

less effective sweating.

Heat illness can progress from

mild to severe depending on a variety

of factors, including acclimatization

and conditioning. Heat cramps are a

relatively minor condition occurring in

well-acclimatized and conditioned

patients. Severe muscle cramps

occur upon relaxation, contact with

cold, or passive extension of a flexed

limb. This occurs after inadequate salt

replacement causes electrolyte

depletion.

Heat exhaustion occurs primarily

in un-acclimatized patients who have

either inadequate fluid or salt

replacement. It is characterized by

profuse sweating, fatigue, weakness,

thirst, headache, vomiting, mild

hyperthermia (38-40*C),

and incoordination.

Heat stroke is a life-

threatening emergency, defined

as severe hyperthermia (>40*C),

with severe CNS dysfunction.

Patients with heat stroke present

with hot, dry, ashen skin and can have

significant end-organ involvement.

Profound peripheral vasodilation and

thermal damage to the myocardium

leads to decreased cardiac output and

shock. Acute tubular necrosis leading

to renal failure, rhabdomyolysis,

hepatic failure, and DIC are common

manifestations. The major outcome

determinant in heat stroke victims is

the duration of hyperpyrexia.

Management of heat cramps and

heat exhaustion involve simple,

practical measures of removal from

heat, rest, and oral or IV fluid and salt

replacement. Management of heat

stroke involves immediate, active

cooling to a temperature of 38.5*C.

This may be achieved by ice packs to

the neck, groin, and axilla, submersion

in ice water, cooling blankets,

convection cooling with fans and mist,

cooled IV fluids, and lavage (gastric,

bladder, peritoneal, thoracic) if

necessary. Ice water submersion is

most effective, but may be impractical,

with evaporative cooling the most

effective next choice. Sedation and

paralysis may be used to decrease

metabolic heat production. Heat

stroke patients often have insufficient

cardiac output due to massive

peripheral vasodilation and a stressed,

dysfunctional myocardium (resulting

from thermal damage). Patients do

not often require aggressive volume

resuscitation as they are not typically

severely dehydrated. Inotropic

support (specifically dobutamine,

which increases contractility while

maintaining peripheral vasodilation

and thus cooling) should be

considered early, with a goal to

maintain UOP>1mL/kg/hr.

Chemistries, creatine kinase, coags,

and urine should be used to assess for

end-organ involvement.

References:Council on Sports Medicine and Fitness

and Council on School Health. Climatic Heat

Stress and Exercising Children and Adolescents.

Pediatrics. 2011;128(3):e741-7.

Ewald MB, Baum CR. Environmental

Emergencies. In Fleisher GR and Ludwig S 6th

Edition Textbook of Pediatric Emergency

Medicine (783-6, 791-4). 2010. Philadelphia:

Lippincott Williams and Wilkins.

McLaren C, Null J, Quinn J. Heat Stress

From Enclosed Vehicles: Moderate Ambient

Temperatures Cause Significant Temperature

Rise in Enclosed Vehicles. Pediatrics. 2005;

116:e109-112.

Smith JE. Cooling Methods Used in the

Treatment of Exertional Heat Illness. British J. of

Sports Med. 2005;39:503-7.

HEAT-RELATED ILLNESSAmanda Greuter, MDChildrens Medical Center of Dallas

The major outcome determinant in heat stroke is duration of

hyperpyrexia.

[9]

1. Which of the following crotaline snakes causes

significant neurological toxicity with or with- out local

tissue damage and hemotoxicity?

a.Cottonmouth snake

b.Eastern Diamondback Rattlesnake

c.Mojave Rattlesnake

d.Copperhead snake

2. Which of the following is a common finding following

black widow spider envenomation?

a. Severe local tissue damage at the site of the bite

b.Muscle pain and cramping

c.Respiratory failure

d.Thrombocytopenia

3. What is one of the most common toxicities following

brown recluse spider envenomation?

a.Dermatonecrosis

b.Neuromuscular weakness

c.Respiratory failure

4. What is the most appropriate treatment for rapidly

progressing local tissue swelling and hemotoxicity

following crotaline envenomation?

a. Fasciotomy

b.Corticosteroids

c.Constrictive tourniquet of affected extremity

d.CroFab® antivenom administration

5. Which toxic species and matching distinguishing

physical characteristic is correct?

a. Eastern coral snake: red on black on yellow bands

b. Crotaline snake: triangular head, elliptical pupils

c. Brown recluse spider: red hourglass -shaped mark

on ventral abdomen

d.Black widow spider: violin-shaped mark on dorsal

thorax

6. Which of the following statements regarding

Centruroides exilicauda scorpion stings is correct?

a. Local pain and paresthesias are decreased by

percussion over the affected area

b.Young children are least severely affected

c. Severe cases include fasciculations, uncontrolled

muscle movements, and cranial nerve dysfunction

7. Which of the following is the best treatment modality

for dermatonecrosis caused by brown recluse spider

envenomations?

a. Good local wound care, analgesia, and tetanus

prophylaxis

b.Hyperbaric oxygen therapy

c.Electric shock therapy

d. Dapsone or colchicine

8. Which of the following are important aspects for

treatment for coral snake envenomation?

a. Careful monitoring and support of respiratory

function

b. Repeated monitoring of coagulation profiles

c. Careful monitoring of the site of envenomation for

severe tissue damage

Snakes, Spiders, and ScorpionsQuestions used with permission by Jennifer Pai, MD, editor of Pediatric Emergency Medicine Practice.

For full text and more review topics, visit EBMedicine.net.

see p. 9 for answers and discussion

BOARD REVIEW: BITES AND STINGS

[10]

Bites and Stings Answers

1. c. While local tissue damage is

the most common complication of

most crotaline bites, the venom of

the Mojave Rattlesnake contains a

potent neurotoxin, with clinical

presentation similar to coral snake

(elapid) envenomation.

2. b. Black widow spider venom

lacks cytotoxic agents, so there is

little to no local tissue injury.

Instead, the venom decreases

acetylcholine reuptake, resulting in

severe muscle cramps, abdominal

pain and muscle spasm. Symptoms

can be managed with opioids and

benzodiazepines.

3. a. Brown recluse venom

contains many cytotoxic digestive

enzymes, thus the hallmark of bites

is local tissue necrosis ranging from

mild to extensive.

4. d. Antivenom, while not able to

reverse pathology at the site of

envenomation, does halt progression

of local toxicity, systemic

dysfunction, and coagulopathy.

Repeat dosing may be needed in

severe cases. CroFab® is a

fragmented antibody which is less

antigenic than previous formulations,

with lower risk of serum sickness.

Fasciotomy, steroids, and

tourniquettes are not recommended,

as these treatments may worsen

outcomes.

5. b. Crotaline snakes, or pit

vipers, account for 99% of

venomous snake bites in the U.S.

They are identified by their triangular

head, elliptical pupils, and fangs.

Eastern Coral Snake has red on

yellow on black bands but is easily

confused with the nonvenomous

King Snake, leading to the saying,

“red on yellow, kill a fellow; red on

black, venom lack”. The black

widow spider is characterized by a

red hourglass-shaped mark on its

abdomen, while the brown recluse

has a violin-shaped mark on its

thorax.

6. c. The neurotoxins of C.

exilicauda scorpions cause

sympathetic and parasympathetic

overstimulation, which may be

mistaken for seizure activity.

Catacholamine release may result in

myocardial damage and

dysrhythmias as well.

7. a. Tetanus status should be

addressed in all bites and stings.

Rest and elevation to decrease

venom spread, analgesics, and

antihistimines for pruritis are typically

the only necessary care. Steroids,

antibiotics, dapsone, and hyperbaric

oxygen have been reported but not

shown to be effective.

8. b. Coral snake venom

produces systemic neurotoxicity,

which may be delayed up to 18

hours after envenomation.

Envenomation can lead to loss of

muscle strength and paralysis, thus,

patients with a history of an elapid

bite should be observed in the

hospital for neurologic abnormalities.

Stay Away from these Bad Boys!

Pictured above are a watermoccasin (top), scorpion, and diamondback rattlesnake. Both snakes are of the crotaline class.

BITES & STINGS

EBMedicine.net CME Reviews >3

years old are downloadable

for free.

[11]

Lilia Reyes, MDNYU Medical Center

Altitude illness is defined as the cerebral and

pulmonary syndromes resulting from an ascent to high

altitude, and represents a broad spectrum of pathology,

ranging from mild to life threatening. Hypobaric hypoxia

results in a broad range of physiologic responses, including

increased sympathetic activity (with increased cardiac

output), pulmonary vasoconstriction, and diuresis,

with eventual increase in hematocrit to increase

oxygen-carrying capacity. Three major

factors influence the incidence and severity

of altitude sickness; rate of ascent, altitude

achieved, and length of stay.

Acute Mountain Sickness (AMS) is the

most common form of altitude sickness,

occurring in approximately half of lowland-

living individuals who ascend to >14,000 ft. It

presents (in order of prevalence) with headache, fatigue,

shortness of breath, dizziness, anorexia, and nausea/

vomiting. AMS typically occurs 8-36 hours after arrival at

altitudes above 8200 ft (2500m). Of note, children are at

greater risk of AMS due to increased susceptibility to

hypoxia and V/Q mismatch. Age less than 1 year,

prematurity, systemic disease, and respiratory infections

are all risk factors.

Treatment of AMS consists of halting further ascent

until symptoms resolve, or descent to lower altitude if

symptoms are not improving. Acetazolamide can also be

used as treatment or as a preventative medication, acting

by causing a mild metabolic acidosis, increasing ventilatory

rate and thus the PaO2.

More serious altitude related illnesses include high

altitude cerebral edema (HACE) and high

altitude pulmonary edema (HAPE). HACE is

the most severe form of altitude sickness in

which hypoxia increases cerebral blood

flow, resulting in edema and decreased

integrity of the blood-brain barrier. It occurs

in 1-2% of individuals who ascend without

acclimatization and progresses from confusion

and truncal ataxia to coma, with a 60% mortality

rate among patients with coma. HAPE also occurs after

excessive hypoxia, with edema resulting from alveolar

capillary membrane leak, increased ADH and resultant

overload, and inflammatory cytokine release. Treatment of

both consists of descent from altitude, oxygen, bed rest,

and dexamethasone. Dexamethasone’s mechanism of

action is unknown, but has been proven somewhat

effective in management of altitude illness.

Bogota, Colombia (above) 8,661 ft (2640m) above sea level. As a point of reference, the elevation of Denver, CO is 5280 ft (1609m).

Children are at greater risk of AMS than adults due to

increased susceptibility to

hypoxia.

HIGH ALTITUDE ILLNESS

[12]

Ascariasis is a nematode (roundworm) and one of the most common human parasitic infections worldwide.

Transmssion occurs via ingestion of contaminated water or food, or less commonly, contaminated soil. Its prevalence

is greatest in tropical climates, with the majority of infections in Asia, Africa, and South America. Often, there are no

symptoms with an A. lumbricoides infection. However, in the case of a particularly bad infection, symptoms may

include bloody sputum, cough, fever, abdominal discomfort, or passing worms. Most diagnoses are made by

identifying the appearance of the worm or eggs in feces. Due to the large quantity of eggs laid, physicians can

diagnose using only one or two fecal smears.

Infections can be treated with drugs called ascaricides. The treatment of choice is mebendazole. The drug

functions by binding to tubulin in the worms' intestinal cells and body-wall muscles.

FEATURE PHOTO: NAME THAT PARASITESanti MintegiPediatric Emergency Department. Cruces University Hospital. BilbaoProfessor of Pediatrics. University of the Basque Country

Ascaris lumbricoides

“A fellow came one night

some months ago to my

office showing me what I send to you. She told me

that boy's parents found it in

the stools. Grandpa is a

hunter.”

[13]

From the Fellowship Corner:

Hello everyone,

Over these past few weeks, we

have been hard at work updating the

fellowship subsection of

PEMNetwork.org so that it contains

even more helpful information for the

upcoming PEM fellowship application

season.

 The Applicant's Corner has been

updated to include the application

timeline for the 2012 season. We have

also included a variety of topics to

help you through this application

season. We have included general

application tips, advice on how and

when to ask for letters of

recommendation, and suggestions on

what to include in your personal

statement. We have also included a

list of suggested questions to ask on

your interview days along with some

helpful tips on how to schedule

interviews and even arrange your

travel plans.

 We look forward to hearing your

suggestions on how we can continue

to improve the Applicant's Corner. 

- Saranya Srinivasan, MD

Boston Combined Residency

Program in Pediatrics

NOTES FROM OUR SUB-SITE EDITORS

Send Us Your Cases!

We are currently accepting case reports, interesting photos, radiographic images, and EKGs for our winter newsletter.

Editors:

Purva Grover Michelle Alletag Angela Lumba

From the Ultrasound Subsite:

The PEM Fellows ultrasound

subsite includes a list of ultrasound

fellowships, cases and teaching

points.  We welcome submissions

for interesting cases and hope to

see the subsite continue to grow.

- Catherine Chung, MD

Inova Fairfax Hospital for Children