7/31/2019 Emu Sept 2012

1/41

EMERGENCY

MEDICINE UPDATE

SEPT 121)

141

http://www.ncbi.nlm.nih.gov/pubmed?term=41%5Bvolume%5D+AND+2%5Bissue%5D+AND+124%5Bpage%5D+AND+Kei%5Bauthor%5D&cmd=detailssearch

7/31/2019 Emu Sept 2012

2/41

EMERGENCY

MEDICINE UPDATE

2)

241

http://www.ncbi.nlm.nih.gov/pubmed/21312328http://www.ncbi.nlm.nih.gov/pubmed/19272734

7/31/2019 Emu Sept 2012

3/41

EMERGENCY

MEDICINE UPDATE

3)

Public health danger from counterfeit medications and

adulterated food supplementsBy Mickey Arieli Pharmacist, Director of Division of Enforcement and Inspection, MOH, Israel

AlinaPoperno Pharmacist, MPH, Division of Enforcement and Inspection, MOH Israel

Counterfeit medicines and supplementsposean enormous public health threat. The World Health

Organization estimates that 10% of global pharmaceutical commerce is in fakes [1].Apart fromcounterfeit prescription medicines there are products labeled "natural supplements" that are illegally

341

http://www.ncbi.nlm.nih.gov/pubmed/20456902http://www.ncbi.nlm.nih.gov/pubmed/20456902

7/31/2019 Emu Sept 2012

4/41

EMERGENCY

MEDICINE UPDATE

adulterated with active pharmaceutical ingredients, such as, sibutramine,PDE-5

inhibitors(sildenafil,tadalafil and vardenafil), lidocaine, benzocaine, benzodiazepines, SSRIs,

phenolphthalein and more. The most common weight loss and anti-impotence adulterants found on

Israeli market are sibutramine and sildenafil. As a consequence of sibutramine adulteration, a few

dozen people, mainly young women, were hospitalized due to cardiovascular events, some of which

were life-threatening.In addition, there were hospitalizations following sever psychiatric events

associated withthe use of sibutramine adulterated weight-loss natural products.Health risks of

PDE-5 inhibitors adulterationsare vast, they include, headaches, sudden hearing loss, heart attack,arrhythmias, hypotension etc. The greatest risk isinpatients, to whom PDE-5 inhibitors are

contradicted so they are turning to natural remedies for impotence or when concentration of the

active ingredient/s significantly exceeds therapeuticlimits. Moreover, in recent years, clandestine

laboratories replace known pharmaceutical compounds with their chemical analogues. In many

cases, these analogues are significantly more potent than original compounds and they are much

more difficult for detection.

In the past few months, our division has confiscated quantities of new and dangerous "natural" food

supplements. Our toxicological analysis discovered in a "natural" product called "ManUp" a

combination of sibutramine and sildenafil. We have also received reports regarding two new natural

products, which claim to lower blood sugar "Balins" and "Diabetico". Toxicological analysis

revealed that these "natural" products contain a high dosage of a potent sulfanylurea drug.

Recently, anti-cancer drug, Avastin, found to be devoid of an active ingredient (Bevacizumab) so in

a number of clinics in the US cancer patients were not actually receiving a life-saving treatment.

The extent of the problem and the amount of harm from counterfeit drugs are underestimated, since

detection and clinical reports are limited. Increasing the awareness among physicians of possible

natural supplement that contain active pharmaceutical substances and effective cooperation

between health care professionalsare crucial for combating the illicit pharmaceutical trade.

We encourage cooperation and communication between health professionals and our division. We

can be contacted through following emails:Mickey.a@moh.health.gov.il (cell phone 972-506-

243137), alina.poperno@moh.health.gov.il .

References:

441

mailto:Mickey.a@moh.health.gov.ilmailto:Mickey.a@moh.health.gov.ilmailto:alina.poperno@moh.health.gov.ilmailto:Mickey.a@moh.health.gov.ilmailto:alina.poperno@moh.health.gov.il

7/31/2019 Emu Sept 2012

5/41

EMERGENCY

MEDICINE UPDATE

1. Newton PN, White NJ, Rozendaal JA, Green MD. Murder by fake drugs.BMJ. 2002

Apr 6;324(7341):800-1.

4)

5)

541

http://www.ncbi.nlm.nih.gov/pubmed?term=41%5Bvolume%5D+AND+2%5Bissue%5D+AND+223%5Bpage%5D+AND+2011%5Bpdat%5D+AND+Shah%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=15%5Bvolume%5D+AND+4%5Bissue%5D+AND+511%5Bpage%5D+AND+Reichard%5Bauthor%5D&cmd=detailssearch

7/31/2019 Emu Sept 2012

6/41

EMERGENCY

MEDICINE UPDATE

I just don't know why they'reshooting at us. All we want to do is bring them democracy and whitebread. Transplant the American dream. Freedom. Achievement.Hyperacidity. Affluence. Flatulence. Technology. Tension. The

inalienable right to an early coronary sitting at your desk while plottingto stab your boss in the back.

Your picture's in mywallet and I'm sitting on it. And if that isn't love, I don't know what is.

6)

7)

641

7/31/2019 Emu Sept 2012

7/41

EMERGENCY

MEDICINE UPDATE

8)

741

http://www.ncbi.nlm.nih.gov/pubmed?term=British+Medical+Journal%5BJour%5D+AND+2011%5Bpdat%5D+AND+Strijkers%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=50%5Bvolume%5D+AND+16%5Bissue%5D+AND+1775%5Bpage%5D+AND+Lee%5Bauthor%5D&cmd=detailssearch

7/31/2019 Emu Sept 2012

8/41

EMERGENCY

MEDICINE UPDATE

similar :

9)

841

7/31/2019 Emu Sept 2012

9/41

EMERGENCY

MEDICINE UPDATE

10)

941

http://www.ncbi.nlm.nih.gov/pubmed?term=Neurology%5BJour%5D+AND+77%5Bvolume%5D+AND+19%5Bissue%5D+AND+1716%5Bpage%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=Neurology%5BJour%5D+AND+77%5Bvolume%5D+AND+19%5Bissue%5D+AND+1716%5Bpage%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=42%5Bvolume%5D+AND+9%5Bissue%5D+AND+913%5Bpage%5D+AND+Luckhoff%5Bauthor%5D&cmd=detailssearch

7/31/2019 Emu Sept 2012

10/41

EMERGENCY

MEDICINE UPDATE

11)

1041

http://www.ncbi.nlm.nih.gov/pubmed?term=62%5Bvolume%5D+AND+330%5Bpage%5D+AND+2007%5Bpdat%5D+AND+Shlamovitz%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed/21762233

7/31/2019 Emu Sept 2012

11/41

EMERGENCY

MEDICINE UPDATE

1141

http://www.ncbi.nlm.nih.gov/pubmed/21762233http://www.ncbi.nlm.nih.gov/pubmed?term=186%5Bvolume%5D+AND+6%5Bissue%5D+AND+2270%5Bpage%5D+AND+hyams%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=186%5Bvolume%5D+AND+6%5Bissue%5D+AND+2280%5Bpage%5D+AND+Burgess%5Bauthor%5D&cmd=detailssearch

7/31/2019 Emu Sept 2012

12/41

EMERGENCY

MEDICINE UPDATE

12)

13) paracetamol

paracetamol

1241

http://www.ncbi.nlm.nih.gov/pubmed?term=186%5Bvolume%5D+AND+6%5Bissue%5D+AND+2152%5Bpage%5D+AND+Pontari%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=114%5Bvolume%5D+AND+3%5Bissue%5D+AND+209%5Bpage%5D+AND+Rushwan%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=96%5Bvolume%5D+AND+12%5Bissue%5D+AND+1175%5Bpage%5D+AND+Purssell%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=96%5Bvolume%5D+AND+12%5Bissue%5D+AND+1175%5Bpage%5D+AND+Purssell%5Bauthor%5D&cmd=detailssearch

7/31/2019 Emu Sept 2012

13/41

EMERGENCY

MEDICINE UPDATE

14)

15)

1341

http://www.ncbi.nlm.nih.gov/pubmed?term=47%5Bvolume%5D+AND+1%5Bissue%5D+AND+211%5Bpage%5D+AND+2012%5Bpdat%5D+AND+Johnson%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed/21866303

7/31/2019 Emu Sept 2012

14/41

EMERGENCY

MEDICINE UPDATE

16)

17)

18)

1441

http://www.ncbi.nlm.nih.gov/pubmed?term=51%5Bvolume%5D+AND+8%5Bissue%5D+AND+1276%5Bpage%5D+AND+Evans%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=37%5Bvolume%5D+AND+6%5Bissue%5D+AND+951%5Bpage%5D+AND+Wasiak%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed/22696353http://www.ncbi.nlm.nih.gov/pubmed?term=Urology%5BJour%5D+AND+78%5Bvolume%5D+AND+3%5Bissue%5D+AND+662%5Bpage%5D&cmd=detailssearch

7/31/2019 Emu Sept 2012

15/41

EMERGENCY

MEDICINE UPDATE

19)

1541

http://www.ncbi.nlm.nih.gov/pubmed?term=Urology%5BJour%5D+AND+78%5Bvolume%5D+AND+3%5Bissue%5D+AND+662%5Bpage%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=29%5Bvolume%5D+AND+7%5Bissue%5D+AND+2011%5Bpdat%5D+AND+Tetanus&TransSchema=title&cmd=detailssearch

7/31/2019 Emu Sept 2012

16/41

EMERGENCY

MEDICINE UPDATE

20)

21)

1641

http://www.ncbi.nlm.nih.gov/pubmed?term=29%5Bvolume%5D+AND+7%5Bissue%5D+AND+731%5Bpage%5D+AND+Han%5Bauthor%5D&cmd=detailssearch

7/31/2019 Emu Sept 2012

17/41

EMERGENCY

MEDICINE UPDATE

Reviewers comment (GilShlamovitz): While no evidence to support this practice it has been myexperience that some blunt trauma patients go into a PEA state as aresult of spinal shock that sometimes is not that apparent especially ifthe patient has low GCS. While anecdotal, IV epinephrine followed bypressors were able to restore peripheral pulses and BP to allow further

workup and survival. Not always easy to identify those patients but agood place to start is no BP and HR lower than what one would have

1741

http://www.ncbi.nlm.nih.gov/pubmed?term=71%5Bvolume%5D+AND+3%5Bissue%5D+AND+565%5Bpage%5D+AND+Plurad%5Bauthor%5D&cmd=detailssearch

7/31/2019 Emu Sept 2012

18/41

EMERGENCY

MEDICINE UPDATE

expected, no blood in the chest or pericardium (US +/- chest tubes),no blood in the belly (US), YES blood in the big vessels (Vena Cavaand RV by US). While some of those patients might haveretroperitoneal bleeds or minimal fluid in the belly, IV fluids, bloodproducts and sometimes a #10 blade for an exlap will be indicatedbefore they can safely unergo a CT +/- an MRI to make the finaldiagnosis. Thanks Gil- very good tip!

22)

23)

1841

http://www.ncbi.nlm.nih.gov/pubmed/citmatch

7/31/2019 Emu Sept 2012

19/41

EMERGENCY

MEDICINE UPDATE

1941

http://www.ncbi.nlm.nih.gov/pubmed?term=78%5Bvolume%5D+AND+9%5Bissue%5D+AND+1079%5Bpage%5D+AND+Valavi%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=78%5Bvolume%5D+AND+9%5Bissue%5D+AND+1085%5Bpage%5D+AND+Ganguly%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed/22392179http://www.ncbi.nlm.nih.gov/pubmed/21975768

7/31/2019 Emu Sept 2012

20/41

EMERGENCY

MEDICINE UPDATE

24)

25)

2041

7/31/2019 Emu Sept 2012

21/41

EMERGENCY

MEDICINE UPDATE

26)

2141

http://www.ncbi.nlm.nih.gov/pubmed?term=66%5Bvolume%5D+AND+12%5Bissue%5D+AND+1168%5Bpage%5D+AND+2011/12%5Bpdat%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=66%5Bvolume%5D+AND+12%5Bissue%5D+AND+1168%5Bpage%5D+AND+2011/12%5Bpdat%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=85%5Bvolume%5D+AND+3%5Bissue%5D+AND+390%5Bpage%5D+AND+Rakel%5Bauthor%5D&cmd=detailssearch

7/31/2019 Emu Sept 2012

22/41

EMERGENCY

MEDICINE UPDATE

27)

2241

http://www.ncbi.nlm.nih.gov/pubmed/19582635http://www.ncbi.nlm.nih.gov/pubmed/19582635http://www.ncbi.nlm.nih.gov/pubmed/22742398http://www.ncbi.nlm.nih.gov/pubmed?term=31%5Bvolume%5D+AND+6%5Bissue%5D+AND+2011/12%5Bpdat%5D+AND+Logan%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed/20653360

7/31/2019 Emu Sept 2012

23/41

EMERGENCY

MEDICINE UPDATE

28)

2341

http://www.ncbi.nlm.nih.gov/pubmed?term=104%5Bvolume%5D+AND+12%5Bissue%5D+AND+1093%5Bpage%5D+AND+Imtiaz%5Bauthor%5D&cmd=detailssearch

7/31/2019 Emu Sept 2012

24/41

EMERGENCY

MEDICINE UPDATE

29)

30)

2441

http://www.ncbi.nlm.nih.gov/pubmed?term=48%5Bvolume%5D+AND+8%5Bissue%5D+AND+665%5Bpage%5D+AND+Murthy%5Bauthor%5D&cmd=detailssearch

7/31/2019 Emu Sept 2012

25/41

EMERGENCY

MEDICINE UPDATE

31)

Gangrenosum

2541

http://www.ncbi.nlm.nih.gov/pubmed?term=72%5Bvolume%5D+AND+8%5Bissue%5D+AND+m114%5Bpage%5D+AND+Shaw%5Bauthor%5D&cmd=detailssearch

7/31/2019 Emu Sept 2012

26/41

EMERGENCY

MEDICINE UPDATE

fluctuance

32)

2641

http://www.ncbi.nlm.nih.gov/pubmed?term=124%5Bvolume%5D+AND+1113%5Bpage%5D+AND+Gunderson%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed/21980597

7/31/2019 Emu Sept 2012

27/41

EMERGENCY

MEDICINE UPDATE

2741

7/31/2019 Emu Sept 2012

28/41

EMERGENCY

MEDICINE UPDATE

33)

2841

7/31/2019 Emu Sept 2012

29/41

EMERGENCY

MEDICINE UPDATE

Aerophilous

34)

2941

http://www.ncbi.nlm.nih.gov/pubmed?term=24%5Bvolume%5D+AND+457%5Bpage%5D+AND+2011%5Bpdat%5D+AND+Leshem%5Bauthor%5D&cmd=detailssearch

7/31/2019 Emu Sept 2012

30/41

EMERGENCY

MEDICINE UPDATE

35)

I downplay the diagnosis of PBPV in the ED because my

readings say it only lasts 10-40 seconds and as such, would be over before someone presented to the ED.The diagnosis that we are dealing with is, I believe, vestibular neuronitis -- persisting positional vertigo that can

result in a person begin hospitalized for symptom control. Cause is really unknown. If I may add mythoughts- it is true we see a lot of vestibular neuronitis in the ED,and many of us have not found re positioning maneuvers to helpmuch in the ED and end up admitting a lot of these patients. But Ido believe recurrent BPPV does occur just like biliary colic anddo succeed in sending some of these folks home. Thanks Rick for

writing. And yes-if you do not yet know who Rick is-go up to theCCME website and get a hold of his monthly programs. If you area primary care doc- he has audio programs for you too.36)

3041

http://ccme.org/ema/http://ccme.org/ema/

7/31/2019 Emu Sept 2012

31/41

EMERGENCY

MEDICINE UPDATE

all of these may pan out,

but none are ready for prime time. Large scale, well performed trials have an unfortunate tendency to destroy

promising new therapies like this. And of course we must always remember that doctors have a name fornatural supplements that work: medications

Scott and Simcha- thanks for writing, and Scott if you are stillreading let me quote HL Mencken for you as you do practice inNew York: Every great wave of popular passion that rolls up on the prairies is dashed tospray when it strikes the hard rocks of Manhattan.

H. L. Mencken

And a warm Hello to Dr. Y , our cardiology consultant(unfortunately efforts to get Amal Mattu to subscribe to EMU have

not been successful but we are still trying) whose comment onlast months' article about ST elevation with Q waves- Icommented that they also do not know when it is real and when itis an aneurysm. His comment was **&%$#@+)~@@!

3141

7/31/2019 Emu Sept 2012

32/41

EMERGENCY

MEDICINE UPDATE

37)

3241

7/31/2019 Emu Sept 2012

33/41

EMERGENCY

MEDICINE UPDATE

3341

7/31/2019 Emu Sept 2012

34/41

EMERGENCY

MEDICINE UPDATE

EMU LOOKS AT: EARs and hEARtsThis month we in honor of all our articles above from the uroliterature- we will dedicate our articles this month to kids. Howeverbefore you close the computer- these are diseases we could see inadults as well- you just missed them or didn't care. Our sources for the

essays are J Paed Child Health 45:554 and Pediatric Rheumatology9:17 2011

3441

http://www.ncbi.nlm.nih.gov/pubmed?term=45%5Bvolume%5D+AND+554%5Bpage%5D+AND+Gunasekera%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=9%5Bvolume%5D+AND+17%5Bpage%5D+AND+2011%5Bpdat%5D+AND+Falcini%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=9%5Bvolume%5D+AND+17%5Bpage%5D+AND+2011%5Bpdat%5D+AND+Falcini%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=45%5Bvolume%5D+AND+554%5Bpage%5D+AND+Gunasekera%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=9%5Bvolume%5D+AND+17%5Bpage%5D+AND+2011%5Bpdat%5D+AND+Falcini%5Bauthor%5D&cmd=detailssearchhttp://www.ncbi.nlm.nih.gov/pubmed?term=9%5Bvolume%5D+AND+17%5Bpage%5D+AND+2011%5Bpdat%5D+AND+Falcini%5Bauthor%5D&cmd=detailssearch

7/31/2019 Emu Sept 2012

35/41

EMERGENCY

MEDICINE UPDATE

1) OK smart alack, we are going to toughen you up on otitis media.This article had a real bent towards Australian indigenous childrenand I am not sure how that applies to the rest of the world(apparently there is a difference between indigenous and notindigenous children in Australia) but aside from that caveat- a welldone article. Otitis media is defined as a spectrum of three separate

entities. Acute otitis media, otitis media with effusion and chronicsuppurative otitis media. And if you understand that that is quitean accomplishment. In a recent survey of 165 clinicians they got147 different clinical definitions of AOM, with no definition agreedon by more than six clinicians. So this says: if you just say I donot know what this so I'll just slide them over to an ENT- you're arean idiot and he probably is one too, being that he is probably one ofthe 165 clinicians. Let's use their definitions. AOM requires acuteonset- less than 48 hours; fever, and middle ear fluid bulges or

absent movement of the tympanic membrane (you need apneumatic otoscopy) and redness. Think about the last time youdiagnosed AOM and tell me if you had all three of these criteria.Effusion is shows signs of fluids. Chronic suppurative OM showspus though a perforated tympanic membrane- but this is apersistent problem and usually isn't called CSOM unless two weekshave passed.2) Who is at risk for OM? Cleft palates, day care, tobacco smoke,pacifier use, and breast feeding and lack of breast feeding.

Confused? All of these "risks" are modest. And what they meantwith breastfeeding is that breast fed but not for a long time or not

3541

7/31/2019 Emu Sept 2012

36/41

EMERGENCY

MEDICINE UPDATE

at all is a risk. However a look at the relative risks finds that highestrisk- and the best p value- was family history- which is myexperience too.3) Diagnostic aids- pneumatic otoscopy is cheap and easy. If hasgood sensitivity and fair specificity. Tympanometry is like anultrasound of the ear. It has good sensitivity but poor specificity.

Curiously, this fancy equipment test is no better than the otoscopy.Tympanometry cannot be done in the presence of a discharge fromthe ear drum.4) Treatment. Watchful waiting is now acceptable. Multiple studieshave shown a minimal benefit from antibiotics which may notnegate the side effects. Mastoiditis rates do not increase in kidswho were given this approach. Otorrhea and kids under two showthe greatest benefit of antibiotic use5) Effusion- what have I not seen used for this? I have seen

diuretics, I have seen multiple courses of antibiotics, I have seendecongestants, I have seen enemas (works only for those whoseears are in that vicinity). The truth is that most will clearspontaneously after three months no matter you do or don't do.Oral antibiotics are often used after three months, but with minimalresults. Steroids- they work for everything. Antihistamines anddecongestants have a higher number needed to harm than to treat.They recommend a hearing test, and if it is affecting hearing- put intubes (no not a rectal tube- I was joking above). This is all after

three months. CSOM- use ear cleaning either by irrigation or drycleaning with a cotton tip applicator ( I was always taught not to

3641

7/31/2019 Emu Sept 2012

37/41

EMERGENCY

MEDICINE UPDATE

recommend this) and use antibiotic drops. Here is an importanttake home point- this condition is much more common than otitisexterna in kids. If you have an otitis externa that is not resolving-consider this- and check for a perforation where antibiotics mayhelp. I can't explain my twisted mind, but since I have a soft a spotfor Brits (Hi Angie), I will quote Winston Churchill, who was famous

for his bickering with Lady Astor, an American and the first womanto be seated in the House of Commons (his comment when she wasappointed was " I felt as if she had come into my bathroom and all Iwas left with was a sponge to defend myself". She was famous forher wit, once saying "I married below me- all women do". Well theyonce were verbally sparring at a weekend retreat and she stated"Winston, if I was your wife, I would put poison in your coffee" Hequipped" If I was you husband, I would drink it"

3741

7/31/2019 Emu Sept 2012

38/41

EMERGENCY

MEDICINE UPDATE

The second essay is on Kawasaki Syndrome. You never saw this? Wellsince there is no diagnostic test for this, you probably have seen it andmissed it. So you shouldn't miss it again, here it is:

And in case you are afraid you might confuse it with another entity here is the most confusing similar condition

3841

7/31/2019 Emu Sept 2012

39/41

EMERGENCY

MEDICINE UPDATE

1) So let's get started. This is as you know a necrotizingvasculitis, more commonly found in males and mostly seen in kidsfrom about half a year until 5 years old. Peak incidence of thisdisease is in less than one year in Japan where they see most ofthe cases. In the USA they see most cases in the less than twoyear old age group. As I said above you will not make this

diagnosis on a blood test- you need a prolonged fever (five days)and a rash, conjunctival injection, oral changes (lip fissuring,strawberry tongue, hyperemia) and cervical lymphadenopathywhich is the least seen.2) The current thought is that an RNA virus causes this, but itis far from clear.3) Yes there is an atypical Kawasaki. This has fever and signssuch as abdominal pain, pleural effusion, neck stiffness uveitis ora number of other signs that basically could look like anything. In

addition there is incomplete Kawasaki which has fever, 2 of theclinical criteria and coronary artery aneurysms on echo. So whatcan help you make the diagnosis in these two variants? CRP andESR can be much higher on day four or five of the illness thanother viral entities. They tend to be more irritable than other kids.And if they had BCG in the past they may have induration at theinoculation site. So you say- my patients are all irritable, and nonehave BCG inoculations. So that doesn't help. Furthermore,Idiopathic juvenile onset arthritis can look exactly like this with

the same lab findings. So what happens if you miss thediagnosis? Well, if they develop coronary artery aneurisms- you

3941

7/31/2019 Emu Sept 2012

40/41

EMERGENCY

MEDICINE UPDATE

are in deep trouble. As Greg Henry would say (that was a pictureof his Harley above) you will get a new name- not the attendingdoctor but the defendant physician. Basically I get worried aboutkids with a prolonged fever and admit them. As Leibman says -any fever over five days has to be bad.4) IVIG is the therapy- use 2 gm/kg in a ten to twelve hour

infusion, and give aspirin 50-100 mg/kg) Clopidogrel is used inaspirin allergies.5) Steroids may help (they help for everything) but this hasbeen shown in only one study.6) If that doesn't work, Infliximab and Etanercept- both TNFblockers have help in small studies,7) . If you blew it, than these patients with aneurysms will needlife long anticoagulation. How to handle these patients and whatactivity, and testing should be done in the long term can be seen

on the chart in this article. Vaccinations should be given but atleast nine months after the last IVIG.8) If there is a doubt- echo!I'll like to take this opportunity to apologize to Greg Henry who Iwas a little hard on this month. I do like him and respect him and

4041

7/31/2019 Emu Sept 2012

41/41

EMERGENCY

MEDICINE UPDATE

so I dedicate this picture to him:(and yes- Greg stills wears the suit jacket that this fellow is

wearing)9) And lastly one last M*A*S*H quote

Frank: I am a great doctor- just ask any of my patients.Trapper John: Frank, We cant dig people up just for that.