Emergency Medicine
Board Review

Coccidioidomycosis pulmonary infection can be asymptomatic or cause influenza-like symptoms, with the possibility of persistent constitutional symptoms. Infections can be accompanied by erythema multiforme or erythema nodosum. Disseminated infection involving the bones, joints, and the central nervous system is rare, but it is more common in infants.

The infection is acquired by inhaling fungal spores from contaminated soil. Coccidioides fungi are endemic to some parts of the United States such as New Mexico, California, Texas, as well as parts of Central and South America.

Serologic tests are useful to confirm the diagnosis. Treatment is controversial because the infection is often self-limited. Children with severe primary infection or those at risk for severe disease are usually treated with an antifungal such as fluconazole or itraconazole for several months.

Reference:

American Academy of Pediatrics. Red Book: Report of the Committee on Infectious Diseases. 29th ed., 2012.

Educational Objective:

Identify the classic presentations of various types of sinusitis.

Key Point:

Any infection that becomes established in a sinus cell can erode into surrounding structures.

Explanation:

Classically, ethmoidal sinusitis (canthal pain on the medial side of the orbital socket) is associated with orbital cellulitis. Sphenoid sinusitis (occipital pain) can evolve into cavernous sinus thrombosis; frontal sinusitis (forehead pain) into Pott puffy tumor or frontal lobe abscess; and maxillary sinusitis (cheek or dental pain) into maxillary osteomyelitis (the mastoid sinuses drain into the ears, not the nose). Each sinus can also cause other complications, but memorizing these classic associations is a good start to recognizing early complications of sinusitis.

The nasopharynx can be thought of as an elongated, rectangular room--similar to a box of matches--that is "shoved" between the 2 orbits for the entire length of the orbits. The maxillary sinuses are frontal structures on either side of the most anterior portion of this "box of matches" and inferior to the outermost rim of the orbits. The ethmoidal air cells are more posterior, superior, and medial, occupying the space between the medial wall of the orbit and the lateral wall of the nasopharynx. If one were to poke a finger into the orbit medially to the eye to palpate the medial wall of the orbit itself, one would be touching the lateral wall of the anterior ethmoidal air cells. The sphenoid sinuses are located posterior (and superior) to the entire "box of matches," deep inside the brain and straight back from the visual area of the nose/forehead located between the eyes. The frontal sinuses are superficial--similarly to the maxillary sinuses--and sit superiorly and laterally to the most anterior aspect of the box of matches.

All of these sinuses drain through openings into the lateral or posterior wall of the nose; thus, they can become coinvolved in nasal infections.

Complications of sinusitis are included in Figures 1 and 2.

Figure 1. Acute sinusitis complicated by orbital abscess.

Figure 2. Frontal sinusitis and prefrontal facial edema (also known as Pott puffy tumor).

References:

Andrews CM, Hawk HE, Holmstedt CA. Case report: septic cavernous sinus thrombosis. Neurol Clin Neurosci. 2014;2(4):117-118.

Korchi AM, Cuvincius V, Caetano J, Becker M, Lovblad KO, Vargas MI. Imaging of the cavernous sinus lesions. Diagn Interv Imaging. 2014;95(9):849-859.

The mortality rate for chronic salicylism is approximately 25%, whereas the mortality rate for acute aspirin poisoning is 1% or below. Many factors account for this, including the fact that the diagnosis is often not considered until late in the patient's course, chronic toxicity often occurs in chronically ill elderly individuals, and chronic salicylism can be easily confused with other entities. Sepsis could be considered far more likely in an elderly patient with dehydration, altered mentation, and an elevated temperature, which is a misleading sign of salicylate toxicity. Diabetic ketoacidosis would likely be the diagnosis if the patient presented with hyperglycemia and an anion gap metabolic acidosis. Due to altered mental status, history is often unobtainable in patients with chronic aspirin poisoning. In addition, rarely is a history of actual ingestion per se actually present, just "routine use."

Chronic aspirin toxicity is often a disease of the elderly but it has been reported in younger adults, teens, and even children.

Salicylate levels in chronic aspirin poisoning are often low or even normal. This is true even though the tissue burden of salicylate is quite high.

Activated charcoal either in a single or multidose is of unproven benefit in most poisonings. If  a reason to suspect ongoing salicylate absorption is present (e.g., bezoar formation), then multidose activated charcoal may have a role in preventing ongoing absorption. It does not enhance salicylate elimination in chronic salicylism.

Because there is no large salicylate concentration acutely irritating the stomach in cases of chronic salicylism, gastrointestinal distress is uncommon.

References:
Kerr F, Krenzelok EP. Salicylates. In: Shannon MW, et al., eds. Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose. 4th ed., 2007:835-848.

Educational Objective:

Summarize the appropriate treatment for severe chilblain.

Key Point:

Management for mild to moderate chilblain (no blisters) is usually supportive, whereas severe chilblain (blisters) benefits from a course of oral nifedipine (20 mg po tid)

Explanation:

This patient has severe chilblain, which is a cold-induced vasospastic inflammatory disorder that appears in a delayed fashion 12-14 hours after cold exposure. Severe cases present with blistering or ulceration, whereas milder cases appear as erythematous or purplish plaques/papules. They are usually accompanied by intense burning, itching, or pain, which can become more intense when going into a warm room.

Mild to moderate chilblain benefits from supportive care, which consists of gentle massage of the area (and drying if still damp). The skin should NOT be warmed above 86 °F (30 °C) because this will worsen the vasculitis. 

In severe cases, nifedipine is very effective in increasing the rate of resolution. If it is taken during the winter (10 mg tid), nifedipine can also prevent chilblain. Blood pressure should be monitored at the start of treatment and at return visits. 

Chilblains last about seven days and usually get better within a couple of weeks on their own if the patient avoids exposure to cold, without permanent damage. Some cases may flare up whenever the weather gets cold again.

Heparin and tPA as not indicated for the treatment of chilblain.

See the Schiazza reference for a very detailed discussion.

References:

Imray CHE. et al. Non-freezing Cold-Induced injuries (chapter 10). In: Auerbach PS, et al. Auerbach's Wilderness Medicine. 7th ed., 2017:222-234.e3

Zafren K. Danzl DF. Frostbite and nonfreezing cold injuries (chapter 131). In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:1735-1742.

Schiazza L. Chilblains. June 11, 2015. http://www.lucianoschiazza.it/documenti/Chilblains_eng.html

There are three liaisons to the incident commander:  The PIO or public information officer, who is responsible for all media relations, the safety officer who has the job of ensuring safety of the staff and patients of the hospital, and the Liaison officer, who is responsible for maintaining two-way communications with law enforcement, fire, city administration and other bodies responding to the disaster.

The CEO may, or may not be the incident commander (he/she may be on vacation at the time of the disaster).  The Incident commander may take the mike to hold a special conference, but generally will defer to the PIO for media briefings.  The director of the emergency department generally won’t be meeting with the media.

The PIO has the following duties:

Establishes and maintains a list of media contacts in the local area;

Strives to establish and maintain personal contacts with appropriate representatives of those media (e.g., editors, news directors, science reporters, etc.);

Assures that editors/reporters who need information about the hospital know where to find it. 

Deals with and minimize any negative publicity about the hospital and to correct any negative stories which are incorrectly ascribed to hospital staff.

REFERENCE:

 IS-100.HCB: Introduction to the Incident Command System (ICS 100) for Healthcare/Hospitals