STI Treatment (another update)

For treatment of uncomplicated Chlamydia use:

Azithromycin 1 gram po x 1 dose

For treatment of uncomplicated Gonorrhea use:

Ceftriaxone 250mg IV/IM x 1 dose (best, least resistance)

or

Cefixime 800 mg po x 1 dose (dramatically increasing resistance)

Please refer to a Health Canada alert from December 2011 that addresses the recommendation for the increased dose of Cefixime http://www.phac-aspc.gc.ca/std-mts/sti-its/alert/2011/alert-gono-eng.php  Please note that because of the increasing resistance mentioned, Ceftriaxone is still recommended as the preferred choice.

Also, refer to this CDC document from August 2012, outlining that cefixime is no longer recommended in the US for treatment of GC. http://www.cdc.gov/nchhstp/newsroom/docs/2012/GonorrheaTreatmentGuidelinesFactSheet8-9-2012.pdf

** NOTE: it is recommended that you always also treat with Azithromycin because GC and Chlamydia often occur at the same time (even if it has not been proven via culture), and there is a theraputic effect of using both a cephalosporin and azithromycin together for GC (both above links address this).

In order for the patient and their partner to get the medication free of charge from the pharmacy,

write "Case K" for the index case (the person you have made the diagnosis on),

and "Case L" for the contact you are giving the other prescription for.

The MCH divisions of Infectious Diseases and Adolescent Medicine are currently working at coming up with a consensus on the treatment of STIs (mainly whether cefixime should no longer be used at all for this indication), stay tuned...

Contacting the Coroner

As some of you may or may not know, when we have a death in the ED we are supposed to contact the coroner's office to make sure with them as to whether they want to retain the case as a coroner's case or not. I won't go into the details here, but most often when the death is either unclear or unexpected, they will likely retain the case (and according to our MCH pathologist Dr. Chantale Bernard, they should). If the coroner retains the case, then they have the power to require an autopsy without parental consent.

In the context of a recent difficult case I have learned that if you ever have a case that is not retained by the coroner, and you feel it should have been (cause of death is not clear), you can always call the coroner's office back and ask to speak to the Chief Coroner. Both Dr. Bernard, and our PICU colleagues have informed me of this, and indicated that the Chief Coroner himself has met with them as a group and expressed the importance of us doing this whenever we feel we are uncomfortable with the coroner's plan with a case.

ASIA spinal cord injury sheet

In follow-up to Thursday's rounds I am adding a link to the ASIA standard neurological impairment in spinal cord injury sheet. I will also ask Johanne to add a version to our online database.

http://www.asia-spinalinjury.org/publications/59544_sc_Exam_Sheet_r4.pdf

The Dermatomes

I had a request to post the dermatomes, for ease of reference.  I looked around, and this was one of the clearest diagrams I was able to find. If someone knows of a better one, by all means let me know and I will update the post. I will also ask Johanne to add a version to our online database.

Medication & QT

As a reminder from the talk given today by Dr. Boutin, this is the link to the site she mentioned where you can search medications that may be associated with risks of prolonged QT/Torsades des Pointes:

http://www.azcert.org/medical-pros/drug-lists/drug-lists.cfm

Vision Test

If you have an iPhone... then this post is for you, and if you are one of those that doesn't have one yet, you will eventually so this will be useful to you one day...

In case you aren't aware, there is a FREE vision test app made by 3 sided cube that was rated the #1 medical app for 2010. I don't have an iPhone (yet), but my husband does, and I tried it out. I think it is a very simple vision screening tool that you can use at the bedside, thereby saving you the time of dragging the patient into the hall to use the wall chart.

Taking pictures for youth protection purposes

If you need to use the departmental camera to document possible physical evidence of abuse, these are the steps to follow:

1. If you are seeing the patient on a regular weekday, pictures should be taken by audiovisual.  Call loc. 22368 to make arrangements for where the pictures will be taken.  Fill out the audiovisual form indicating what you want them to take a picture of, and a signed consent to take the picture (keep in mind that the only people who have the right to consent are legal guardians such as parents, or the DYP worker if they have been given the mandate to do so).
2. If you are seeing the patient off hours when audiovisual services are not available, the patient is able to return the following morning and it is unlikely the evidence you wish to photograph will change substantially, then you should prepare the above papers, and have them return to audiovisual the following morning. Social services should always be consulted for child protection cases and will serve as the patient liaison if you are having someone return the following day to get pictures taken in audiovisual.
3. If having the picture taken by audiovisual is not possible, the ED camera is available in the upper cupboard closest to the secretary’s station in the physician’s area.  The key to this cupboard is at the secretary’s desk; ask them for it.
4. Before you take any pictures make sure to obtain a signed consent.  Review the images and delete obviously unhelpful shots.  Then clearly document the patient’s unit #, the number of pictures you took, and that they were for youth protection purposes in the binder accompanying the camera.
5. After you have taken your pictures, remove the memory card from the camera and place it in one of the available small envelopes, fill out the identifiers on the envelope, seal it, and leave this envelope in the box that contains the camera, envelope and extra memory cards.
6. Either call to involve social services in your case (if indicated) and at the very least make sure to leave a message with social services (loc. 22508) indicating that you have taken photos, so that someone is sure to pick them up from the camera box the following day.
7. Our social workers are a very important and valuable resource.  They should always be consulted for child protection cases. In addition, there is always a physician on call for child protection at the MCH.  You can have them paged should you have any questions about the most appropriate way to manage a specific case.
8. If you feel that it is vitally important to take photographs and the parents are refusing consent; alternatives are for DYP to sign or to consider involving the police as they are permitted by law to take the pictures without consent.

Thank you to Dr. Laurel Kimoff of the MCH Child Protection Service for this information.

Nebulized 3%NaCl for bronchiolitis

A few key points to remember:

• Nebulized 3%NaCl to be used for children with bronchiolitis, ie. mainly < 2 years of age (no lower age limit)
• No contraindications
• While studies have used anywhere from 2-4 ml /nebulization, as there is no down side, I would recommend we all use 4 ml
• The theory is that it breaks up the thick mucous that is stuck in the bronchioles, therefore it has the ability to improve oxygen saturation, decreased work of breathing (both respiratory effort and RR), therefore you gauge efficacy based on any improvement in these parameters. There is no benefit to using it "back to back", it either works or doesn't. If it works you can use it again if whatever parameter that had improved before worsens again. Based on what I have read (as I do not have much personal experience with it), it seems that if it works, the mucous does not build back up to the previous level that quickly, and you probably won't be using it more often that every several hours (though you can, it is safe). 
• There is a theoretical risk of it inducing bronchospasm, and the way you would detect this is your patient's respiratory status worsening after the treatment. While this is always sited as a theoretical risk, newer studies have shown that it is in fact not really that much of an issue clinically. Therefore, know it can happen, but don't worry about it too much. If you think you are seeing it frequently, you are probably overcalling something…
• Keep in mind the most compelling evidence is that it decreases length of admission, therefore we should be using it for patients who require admission, or who might require admission, but not in those patients who are well enough for discharge home.

Group A strep pharyngitis

As you all know, penicillin V in oral suspension has been off the market for some time. Since that time we have largely been prescribing amoxicillin for patients with suspected GAS pharyngitis, for them to fill if their culture ends up being positive.

It seems the new check form prescriptions are at the printers, and will be stocked in the ED in short order.

In the meanwhile, I wanted everyone to know what we should be prescribing to these patients, both for simplicity's sake, and to assist in standardizing our practice for this common problem.

For penicillin non-allergic patients give:

• <27kg, amoxicillin suspension or chewables, 250 mg po BID x 10 days
• >27kg, amoxicillin suspension, chewables, or tabs, 500 mg po BID x 10 days

For penicillin allergic patients give:

• azithromycin suspension or tabs, 12 mg/kg/day, in a single daily dose x 5 days (max. 500 mg/day)

Thank you to Dr. Ilana Greenstone for her work on this initiative, and for providing the information included within.

Seborrheic Dermatitis

Since I was on a roll with Dr. Jafarian (MCH Dermatology), I decided to tap into her expertise for one other common problem we encounter in the ED and oftentimes likely manage sub optimally, and that is seborrheic dermatitis.

While I won't go into how you diagnose seborrheic dermatitis, she wanted me to emphasize that this is a problem found exclusively in young infants within the first couple of months of life.

The reason seborrheic dermatitis is often not treated appropriately, is that people tend to forget that even though there is inflammation present, it is commonly associated with a fungal infection as well (M. Furfur).

If the family does not have private insurance, ie. has to pay out of pocket (because the government plan does not cover mixtures), then prescribe (the less expensive alternative):

• a custom mixture of 1% hydrocortisone cream in Loprox cream, mixed 1:1, applied BID for 1-2 weeks (most often effective).

If the family does have private insurance, this mixture is ideal because it does not reduce the concentration of either component used (apparently costs about $30-40):

• a custom mixture of 1% hydrocortisone powder in Loprox cream, applied BID for 1-2 weeks (apparently this tends to be more reliably effective).

Thank you to Dr. Jafarian, MCH Dermatology for her advice.

Warts

As we likely all know, Dermatology no longer accepts routine consults for warts.

If you have a patient who has any of the following scenarios, they will agree to see them, but these factors have to be very clearly indicated on the consult:

• warts on the face
• warts on the genitals
• the patient is immunocompromised

Otherwise, they say that topical Soluver Plus for plantar warts, and regular Soluver for warts elsewhere has been definitively proven to be as effective as cryotherapy, provided it is done properly. This is what they recommend:

• the wart cannot be properly treated unless it properly exposed (i.e. it is often covered by too many layers of thick skin for the therapy to penetrate effectively)
• the area of skin first needs to be well soaked, and then exfoliated aggressively (especially for plantar warts) with a pumice stone, ideally removing all of the overlying scale
• the therapy oftentimes needs to be done daily for a duration of 2-3 months

This preparation does not require a prescription. Note that in general any of the salicylic acid preparations are very effective, the Soluver happens to be our Dermatologist's preference.

Note that the above is the recommended therapy if the family decides they want to treat the wart, otherwise, simple warts are generally self-limited, and will resolve on their own with time.

Thank you to Dr. Jafarian, MCH Dermatology for her advice.

Tinea Capitis (& Corporis)

Doing results recently I noted numerous scalp scrapings coming back positive for tinea, and the physician who initially saw the patient had not started the patient on treatment. Therefore, I decided to check with dermatology as to their recommended approach.

If you have a patient who you think has tinea capitis:

1. Culturing the lesion is important because sometimes it can be a more unusual, difficult to treat fungal pathogen.
2. If the lesions are scaly, take a scraping (scrape off as many flakes as you can, and put them between 2 glass slides, tape up the edges of the glass slide, and label it). Send this to microbiology for KOH stain and fungal culture. 
3. If the scalp lesion is boggy and wet (as can happen with a kerion), use a regular culture swab (like for strep) and culture as much of the oozing stuff as possible. Send this for fungal culture (KOH cannot be done on this sample). 
4. Draw off a baseline CBC and LFTs (even though the risk of problems with Lamisil treatment is very low in children, Dermatology recommends this). Needs to be done in all cases (whether you are sure or unsure of the diagnosis), so that if we have to call the patient back to start the therapy after a positive culture, we don't have to bring them back to get this done. 
5. If you are not sure of the diagnosis, then just start the patient on Loprox cream for the lesion, and Nizoral shampoo for the rest of the family, pending the culture results. Keep in mind that tinea capitis can only be treated with oral therapy, therefore this is just a temporizing measure hoping to limit spread of the infection pending the culture result. 
6. If you are sure you are dealing with tinea capitis, then start the patient on oral Lamisil:

• Griseofulvin no longer exists
• Lamisil only comes in pill form, but it can be crushed and given in a puree or other food, and Dermatology uses the following dosing guideline in all patients
• < 20 kg, 62.5mg (1/4 pill) qday x 6 weeks
• 20-40 kg, 125mg (1/2 pill) qday x 6 weeks
• > 40 kg, 250mg (1 pill) qday x 6 weeks

1. Follow-up CBC and LFTs are recommended 4 weeks into the therapy, Follow-up can with be done through the primary care physician, or the patient can be referred to Dermatology. If you send them to Dermatology, indicated that follow-up is requested in 4 weeks, and give the family a requisition to get the CBC and LFTs done prior to the appointment. 

As an added note, tinea corporis is much easier to treat. If the lesion is scaly and can easily be cultured, do so as above for tinea capitis. If it is not easily cultured, do not worry, it is not as critical. Tinea corporis responds easily to topical therapy. Dermatology recommends Loprox cream BID for 2-4 weeks (they say better than Lamisil cream), and that it works every time!

Thank you to Dr. Jafarian, MCH Dermatology for her advice.

Measles

As most of you are aware, there has been a measles outbreak in Quebec since the spring. As the problem is ongoing public health authorities have recently distributed reminders to both physicians and the lay press.

These are the links to the information that was recently sent out to all physicians:

The first link is the information letter sent to physicians:
http://media.ofsys.com/T/OFSYS/H/508274/09nZ11/Lettre-DrPoirier-rougeole.pdf

The second link is measles information from the Quebec government website:
http://www.msss.gouv.qc.ca/sujets/prob_sante/rougeole/rougeole.php

A brief reminder of the symptoms you are looking for:

1. fever
2. rash
3. conjunctivitis/coryza
4. cough

This is a link to some photos, and management information:
http://media.ofsys.com/T/OFSYS/H/508102/M2VAy0/Infolettre-affiche.pdf

Here is some practical information on what to do if you have a suspected case in our ED:

1. Patient should wear a mask, and be isolated ideally in a negative pressure room, and if unavailable, at least in a room with the door closed
2. Obtain a sample to confirm the diagnosis (IgG & IgM in the serum, and if possible an NPA or a urine sample for measles culture - clearly label all specimens as being for measles)
3. Update (Jan 12/2012), as serum IgM is less sensitive if the patient has had rash for < 72 hours, this is where PCR is most useful. Therefore when you send a sample for PCR, clearly mark this or other relevant clinical information on the pink virology form (i.e. also useful if patient is the contact of a known case of measles).
4. Inform the public health authorities (this is not an emergency, so only call public health and ask to speak to the ID MD during regular working hours at 514-528-2400, also call our infection control during regular working hours at 514-934-1934, x 23149, and after hours leave a message at 514-412-4485 with the patient's name and MRN, and whether they were in contact with any patients of concern, ie. under 12 months of age or immunocompromised (where Ig may be indicated). The lab will also report the disease once it is confirmed, but it is important to report it as soon as you suspect it clinically.
5. Inform the patient to stay home for a period of 4 days after the onset of the rash

Thank you to Drs. Caroline Quach & Jesse Papenburg for the added information above.
Our ID physicians remain your resources for additional information.