Volume 33 Number 7 July 2019

Observation Deck
Observation units are increasingly used to manage
acute presentations when safe discharge is in doubt
and the need for inpatient admission is unclear. While
there are a number of existing models for this approach
to care, emergency departments have become keenly
invested in the surge of new, protocolized observation
units. As such, clinicians must be prepared to maximize
this safety net by selecting appropriate patients for
monitoring and using interdisciplinary protocols to
manage their conditions.

Warning Shots
The relative rarity of measles, mumps, pertussis,
varicella, and tetanus can make it particularly difficult
to recognize and appropriately treat these potentially
deadly illnesses. While herd immunity provides
significant protection against most of these diseases,
a recent decrease in vaccination rates and a rise in
international travel have created the opportunity
for new outbreaks. As such, it is vital for front-line
clinicians to renew their understanding of vaccine-
preventable illnesses and be prepared to manage them.

THE OFFICIAL CME PUBLICATION OF THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS

IN THIS ISSUE
Lesson 13 n Vaccine-Preventable Illnesses . . . . . . . . . . . . . . . . . . . . . . . . 3
Critical ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Critical Decisions in Emergency Medicine is the official
CME publication of the American College of Emergency
Critical Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Physicians. Additional volumes are available.
Critical Cases in Orthopedics and Trauma . . . . . . . . . . . . . . . . . . . . . . . . . 16
EDITOR-IN-CHIEF
Critical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Michael S. Beeson, MD, MBA, FACEP
Lesson 14 n Emergency Department Observation Care . . . . . . . . . . . 19 Northeastern Ohio Universities,
Rootstown, OH
LLSA Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
SECTION EDITORS
CME Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Joshua S. Broder, MD, FACEP
Drug Box/Tox Box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Duke University, Durham, NC
Andrew J. Eyre, MD, MHPEd
Contributor Disclosures. In accordance with the ACCME Standards for Commercial Support Brigham & Women’s Hospital/
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over CME content (including but not limited to staff, planners, reviewers, and authors) must John Kiel, DO, MPH
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This educational activity consists of two lessons, a post-test, and evaluation questions;
as designed, the activity should take approximately 5 hours to complete. The participant Christian A. Tomaszewski, MD, MS, MBA, FACEP
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ISSN2325-0186(Print) ISSN2325-8365(Online)
 Warning Shots
Vaccine-Preventable
Illnesses

LESSON 13

By Prince Harrison, MBBS; and Timothy Ruttan, MD

Dr. Harrison is an assistant professor in the Department of Pediatrics in the Division
of Emergency Medicine at the University of Nebraska Medical Center in Omaha.
Dr. Ruttan is a clinical assistant professor in the Department of Pediatrics at the
University of Texas at Austin Dell Medical School.

Reviewed by Walter L. Green, MD, FACEP

OBJECTIVES
On completion of this lesson, you should be able to: CRITICAL DECISIONS
1. Recognize the signs and symptoms of measles,
n What clinical features differentiate the various
mumps, pertussis, varicella, and tetanus.
vaccine-preventable illnesses?
2. Determine which diagnostic tests are warranted.
3. Explain when to administer vaccines or n Which diagnostic tests can help identify each illness?
immunoglobulins. n How should each illness be treated, and which
4. Formulate appropriate disposition plans based on patients are at high risk for complications?
host characteristics.
n What measures can help prevent patients and
5. Summarize when to report illnesses and when to treat
susceptible contacts from becoming ill?
potential contacts of the source patient.
n What factors should be considered before
FROM THE EM MODEL discharging a patient?
10.0 Systemic Infectious Disorders

When immunization programs in the United States were introduced, the incidence of measles, mumps,
pertussis, varicella, and tetanus decreased dramatically. Many clinicians now complete their entire training without
seeing an actual case. Unfortunately, this relative rarity can make it particularly difficult to recognize these potentially
deadly pathologies and mitigate their threat to public health. While herd immunity provides significant protection, a
recent decrease in vaccination rates and a rise in international travel have created the opportunity for new outbreaks.1
As such, it is vital for front-line clinicians to renew their understanding of vaccine-preventable illnesses and be
prepared to address them appropriately.

July 2019 n Volume 33 Number 7 3

 CASE PRESENTATIONS
■ CASE ONE
A 10-month-old girl presents
with a rash that developed over the
last 2 days. Her mother explains
that it started on the child’s face,
spread to her chest on the second
day, and then spread to her arms
and legs.
On arrival, the patient has
a rectal temperature of 38.5°C
(101.3°F). Her other vital signs are
normal, and she is in no distress.
She has erythema and chemosis
of the conjunctiva, a cough, and a
maculopapular rash that covers her
whole body but is most promi­
nent on the face, neck, and
behind the ears.
■ CASE TWO
A 14-year-old girl presents
with right-sided facial swelling
for 1 day and a subjective, tactile
fever with fatigue that began
2 days ago. She has no history
of dental problems, and her
immunizations are up to date.
The physician notes tender
swelling over the right side of her
face, inferior and anterior to the
earlobe; her dentition is intact.
■ CASE THREE
A 5-week-old, full-term infant with no
significant medical history presents with
a cough that her parents say began 5 days
ago. Her father reports that she seems to
choke when coughing, turns red in the face,
and has post-tussive emesis. There is no
reported history of fever, apnea, or cyanosis.
She is feeding well and is producing wet
diapers. The infant appears nontoxic,
and her lungs are clear to auscultation.
During the clinical examination, she starts
coughing intensively, and cyanosis of the
face is witnessed. The episode resolves, and
she returns to her baseline.

CRITICAL DECISION the rash appears, the other symptoms hepatitis, myocarditis, and encephalitis.
begin to subside. The rash, which Pneumonia, which can be precipitated
What clinical features
typically resolves over the next 5 to 10 by the measles virus itself or arise from
differentiate the various vaccine-
days, may desquamate about 1 week a bacterial superinfection, presents in a
preventable illnesses? later. In vaccinated patients, the rash comparable manner to pneumonia in a
and other symptoms can be mild or similarly aged patient.
Measles
absent.3 Vaccinated individuals are also Although less routine complications
Once infected, the incubation
less likely to transmit the illness than can be more challenging to detect,
period for measles is approximately
unvaccinated patients infected with a they are important to recognize.
8 to 12 days. The initial phase of the
classic course of measles.4 Measles-related encephalitis is an
illness is characterized by a cough,
Any patient suspected of having immunologically mediated process that
coryza, conjunctivitis, and an increasing
measles must be evaluated for signs of typically begins during the rash phase of
fever. This period is followed by the
development of Koplik spots (Figure 1), complications, including otitis media, the illness. Patients present with seizures,
a pathognomonic feature that is found pneumonia, dehydration from diarrhea, lethargy, and altered mental status, with
in 60% to 70% of cases.2 These discrete,
red lesions, which typically have a bluish FIGURE 1. Koplik Spots
white center, commonly erupt on the
buccal mucosa opposite the premolars;
however, they can also involve the lips,
gingivae, hard palate, conjunctivas, and
vaginal mucosa. While Koplik spots are
pathognomonic, they are not present in
every case; the absence of this finding
should not be used to rule out measles
when a high clinical suspicion exists.
Generalized lymphadenopathy can also
develop.
An erythematous, maculopapular
rash appears 1 to 4 days later, starting
on the forehead, traveling along the
hairline to behind the ears and neck,
and then spreading down to the trunk
and extremities (Figure 2). The rash also
involves the palms of the hands and soles
of the feet in up to half of patients. Once

4 Critical Decisions in Emergency Medicine

an incidence of 1 per 1,000 measles
cases.5 When managing any patient with FIGURE 2. Measles Rash
a similar set of presenting symptoms, it
is important to remember that measles
encephalitis is a diagnosis of exclusion
that can be made only after other
etiologies, such as bacterial meningitis,
have been ruled out.
A less common and more chronic
complication of measles is subacute
sclerosing panencephalitis (SSPE), which
presents 7 to 10 years after the initial
measles illness.5 SSPE, which starts
insidiously with a progressive decline
in behavioral and intellectual abilities,
can lead to ataxia and seizures. The
prognosis for SSPE is poor, eventually
causing death.5

Mumps
After an incubation period of 15 to
24 days, mumps begins with prodromal
symptoms of fever, headache, and body FIGURE 3. Parotid Swelling in a Patient With Mumps
aches that last 1 to 2 days.6 Because
the initial phase is nonspecific, the
disease can be easily confused with
other viral illnesses. Unilateral parotid
swelling with tenderness often occurs,
becoming bilateral in 90% of patients
with parotitis (Figure 3).7 Ear pain can
also accompany parotid swelling. As
with parotitis caused by more common
etiologies, eating sour or acidic foods
can inflame the parotid gland and
worsen pain.
The opening to the Stensen duct can
also become red and edematous, and
parotid swelling can become so severe
that it obscures the angle of the jaw;
the earlobe can become displaced up
and out. Submandibular and sublingual
salivary gland swelling also occurs in
10% of patients.7 Fever is typically
moderate and lasts for up to 7 days. A disease.8 Although deafness — both Impaired fertility affects as many
nonspecific, maculopapular rash may transient and permanent — is a known as 13% of these patients, and up to
also develop on the patient’s trunk. complication of mumps, it is very rare in 50% develop an atrophied testicle.10
As when assessing other vaccine- the post-vaccine era (<1%).9 Abdominal pain in female patients,
preventable illnesses, emergency One of the more common which can be related to oophoritis, may
physicians should evaluate for complications, particularly in mimic appendicitis. Other less common
complications, including meningitis and adolescents and adults, is mumps complications include pancreatitis,
encephalitis, which present with typical orchitis, which is present in up to 40% nephritis, myocarditis, thyroiditis,
symptoms of fever, headache, vomiting, of patients. Most of these cases include mastitis, and arthritis.11
neck stiffness, or seizures. Up to 10% unilateral testicular involvement,
of patients with mumps develop aseptic although up to 30% are marked by Pertussis
meningitis, which is typically benign; bilateral symptoms. In addition to acute Symptoms of pertussis can vary
however, a small portion of these cases pain, mumps orchitis is a significant widely based on the patient’s age.
progress to more severe neurological cause of long-term fertility problems. The classically described illness is

July 2019 n Volume 33 Number 7 5

 characterized by three stages. During Adolescents and adults often respiratory illness accompanied by
the initial phase — the catarrhal stage — present without an inspiratory whoop, persistent coughing. Because the cough
patients exhibit nonspecific symptoms as classically described.13 Coughing may not be characterized by the classic
of fever and rhinorrhea, which last 1 episodes can be preceded by a feeling of whoop, these cases can be challenging to
to 2 weeks. The second stage — the strangulation and followed by a feeling diagnose. Pertussis should be considered
paroxysmal phase — begins with the of suffocation. Paroxysms of cough with in any patient with a chronic cough,
onset of a cough. Initially, the cough is post-tussive emesis, in which patients especially in the setting of potentially
dry and intermittent, but it gradually remain relatively asymptomatic between waning vaccine immunity.
becomes paroxysmal. During a violent coughing episodes, can help identify
coughing episode, a well-appearing child potential pertussis cases. Adults may also Varicella
can suddenly become anxious; experience present only with nonspecific respiratory After a 10- to 21-day incubation
a bout of repetitive, staccato coughs; and symptoms that persist for longer than period, adults and adolescents with
then immediately project a loud “whoop,” 3 weeks.14 varicella typically develop malaise and
as air is inhaled against a partially closed As with many other vaccine- fever. This prodrome is usually absent
airway. The paroxysms become more preventable illnesses, common in children, in whom the onset of a
severe and frequent as the paroxysmal complications of pertussis include pruritic rash is the first sign of illness
phase progresses over 2 to 6 weeks. The otitis media and secondary bacterial (Figure 4). The rash, which begins on the
final phase — the convalescent period pneumonia, which can be managed face and scalp and spreads centripetally
— lasts more than 2 weeks. During this according to standards of care. Seizures to the trunk and back, first manifests as
period, the paroxysms become milder and can be a symptom of pertussis-related macules but soon evolves into papules,
less frequent. encephalopathy.15 Moreover, coughing then vesicles, and finally pustules. The
In an infant younger than 3 months, paroxysms can cause subdural pustules have an erythematous base and a
the catarrhal stage can be short, lasting hemorrhage, epistaxis, subconjunctival “dew drops on a rose petal” appearance.
only a few days. A cough may be hemorrhages, pneumothorax, rib
Lesions occur in crops, passing through
inconspicuous during the paroxysmal fractures, hernia, and rectal prolapse.16
the various stages from macules to
stage, which can obscure the diagnosis.12 Despite this, older patients and
pustules to crusting. The pustules are
Infants may exhibit choking, gasping, adults with pertussis typically recover
often in various stages of healing, a
or gagging, with reddening of the face, uneventfully.
process that differs from smallpox, in
flailing of the arms, and minimal startling Particularly when managing older
which all lesions typically progress at
to stimulation. A whoop is less common. patients, it is paramount to address
the same time (Figure 5). Patients are no
Apnea and cyanosis, the most concerning public health concerns and disease
clinical features of pertussis, increase the prevention. Older patients serve as longer infectious once all the lesions have
risk of death in young infants. Moreover, the vector for disease transmission to crusted over (usually in 4-5 days).
the disease can present atypically in unvaccinated or partially vaccinated Previously vaccinated patients may
infants, resembling bronchiolitis or other children, who are at higher risk of severe have a mild, atypical disease course,
forms of respiratory distress. In neonates, and potentially fatal complications. or symptoms that resemble “standard”
the convalescent phase can be prolonged Vaccinated children, adolescents, chicken pox. In the mild form, lesions are
for several months, with the paroxysms and adults with pertussis may be more commonly maculopapular, rather
becoming paradoxically louder. asymptomatic or present with a mild than vesicular. Immunocompromised
patients are at risk for progressive
varicella, a disease characterized by
extensive lesions that continue to
develop over a prolonged period of time,
multiorgan involvement, and potential
sepsis-like symptoms. The risk of
n The initial phase of measles is characterized by a cough, coryza, complications is higher in these patients,
conjunctivitis, and an increasing fever, which may be followed by the who often require hospitalization and
development of Koplik spots. more aggressive treatment.
n Pertussis should be considered in any patient with a chronic cough, Complications from varicella include
especially in the setting of potentially waning vaccine immunity. bacterial superinfection of the skin
n Mumps begins with prodromal symptoms of fever, headache, and body lesions, direct viral pneumonia, secondary
aches that last 1 to 2 days. Because the initial phase is nonspecific, the bacterial pneumonia, acute cerebellar
disease can be easily confused with other viral illnesses. ataxia, encephalitis, and Reye syndrome
n Any patient with a potentially contaminated injury or wound should receive a (in children taking aspirin). Complication
tetanus toxoid to prevent tetanus. rates are higher in children aged less than
1 year and in adolescents and adults.

6 Critical Decisions in Emergency Medicine

 FIGURE 4. Varicella Rash
Tetanus
Tetanus is the result of a toxin
produced by Clostridium tetani. In most
cases, spores enter the patient through a
traumatic wound, where they germinate
and ultimately produce an exotoxin that
precipitates the clinical disease. The initial
wound can be relatively inconsequential,
so the patient may not even recall being
injured. The incubation period ranges
from 3 to 21 days after wound exposure.
The toxin irreversibly binds to nerves
and blocks the presynaptic release of
inhibitory agents, which causes motor
neuron discharge.
Symptoms of generalized tetanus
include trismus, facial muscle spasms
(risus sardonicus) (Figure 6), opistho­
tonos, and a rigid abdomen. Dysphagia
and neck muscle spasms can also
occur, and spasms of the laryngeal and
respiratory muscles can lead to airway
compromise. Initially, muscle spasms
occur over a few seconds to minutes,
intermixed with spasm-free intervals.
As the disease progresses, spasms become
longer and more frequent. These events
can be triggered by even minor stimuli,
such as noise or touch.
Tetanus-related autonomic
disturbances can cause tachycardia,
hypertension, diaphoresis, and dysrhyth­
mias. The illness lasts 6 to 8 weeks, and
recovery is slow if not fatal.17 Mortality
can be as high as 52% in adults and
FIGURE 5. Smallpox Rash
as high as 88% in neonates.17 With
intensive care, however, the mortality
rate may be as low as 15%.18 Sequelae
in survivors include gait abnormalities,
muscle rigidity, memory loss, and a
persistent vegetative state.17
In neonates, tetanus results from
poor hygiene of the umbilical stump.
Although this complication is extremely
rare in the US, it is relatively common
in developing countries because of
poor umbilical cord hygiene and poor
maternal immunization. Symptoms,
which usually begin within the first week
of life, include poor feeding, decreased
movement, crying, irritability, muscle
rigidity, and spasms.
Localized tetanus affects the muscles
surrounding the injury site and can
progress to generalized disease. The
mortality rate is lower when the illness
remains local.
Cephalic tetanus is a distinct type
of localized tetanus that occurs due to
injuries to the head or infections of the
ear or nose. Muscles of the eyes, face,
tongue, and pharynx are involved;
some patients also suffer from cranial
nerve palsies, which can be mistakenly
attributed to other diseases such as
Bell palsy. Overall mortality is lower in
patients with cephalic tetanus than in
those with generalized disease. Some
patients spontaneously recover, although
a significant number of cases progress to
generalized tetanus.19
CRITICAL DECISION
Which diagnostic tests can help
identify each illness?
Measles
In the absence of confirmatory
testing, a timely clinical diagnosis is
critical when evaluating for measles, an
illness with particularly important public
health ramifications. Measles can be
confirmed by serology, when indicated.
Immunoglobulin M (IgM) becomes
elevated 1 to 2 days after the appearance
of the rash and remains high for up to
1 month. Elevated immunoglobulin G
(IgG) levels in convalescent serum,
in comparison to acute-phase serum,
can also help determine the disease
timeline. Viral cultures of blood, urine,
or respiratory secretions may also be
helpful.
Real-time polymerase chain reaction
(PCR) testing on serum and throat swabs
can be used to confirm measles. An
additional urine specimen can be used
for PCR testing to increase the study’s
sensitivity.5,20 Patients may also have
a relative lymphopenia or an absolute
leukopenia, although these findings
are not diagnostic and are somewhat
nonspecific. In some cases, erythrocyte
sedimentation rates (ESR) and c-reactive
protein (CRP) levels are slightly elevated.
If there is a bacterial superinfection,
however, ESR and CRP levels are often
July 2019 n Volume 33 Number 7 7

FIGURE 6. Risus Sardonicus in a Patient with Tetanus
higher, although this is a relatively
nonspecific test.21
Differential diagnoses include, but
are not limited to, rubella, roseola,
toxic shock syndrome, Rocky Mountain
spotted fever, and Kawasaki disease.
Testing may be indicated to rule out
these alternative pathologies.
Mumps
As with measles, mumps is a clinical
diagnosis that can be confirmed by
serology. During the acute infection, the
presence of IgM antibodies corroborates
the diagnosis. Viral culture or PCR
testing can also be used to detect the
mumps virus in respiratory secretions,
urine, or cerebrospinal fluid (CSF). A
rise in IgG titers in convalescent serum
compared to acute-phase serum is also
seen. Serum amylase can be elevated
with the onset of parotitis, although this
test is optional.
Pertussis
Although a positive culture is
still considered the gold standard for
diagnosing pertussis, PCR testing is
equally sensitive and can be performed
on nasopharyngeal swab specimens.
As a result, PCR testing is growing to
become the clinical test of choice. Direct
fluorescent antibody testing has low
sensitivity and is less commonly used.
Notably, cultures can be falsely negative
later in the illness (ie, >2 weeks from
the onset of the cough) in patients who
8 Critical Decisions in Emergency Medicine
PHOTO COURTESY OF CHRISTO PHILLIP, MD
have been vaccinated or treated with
antibiotics. PCR testing for pertussis is
ideally performed within 3 to 4 weeks
of the onset of the cough; testing beyond
4 weeks can lead to false-negative
results. Serology is primarily useful for
making a late diagnosis (up to 12 weeks
from the onset of the cough).22
A CBC test that reveals leukocytosis
with absolute lymphocytosis should
increase suspicion for pertussis.
Markedly elevated leukocyte counts
can indicate a more severe course; in
such cases, hospitalization should be
considerered.23 Chest x-rays should
be considered for pediatric patients
who also exhibit signs and symptoms
of pneumonia, such as shortness of
breath, tachypnea, and hypoxemia.
Echocardiography can be used to
diagnose pulmonary hypertension in
severely ill children, although this test
is often unnecessary in the emergency
department setting.24
Varicella
Although varicella is usually
diagnosed based on clinical findings,
the disease can be rapidly confirmed by
PCR testing.25 A sample for testing can
be obtained by unroofing a vesicle and
scraping the base with a collection swab.
A crust from a lesion is a good second
choice. Varicella can also be isolated by
tissue culture, but this takes longer, is not
as sensitive as PCR testing, and is less
routinely performed. Serologic tests to
detect a rise in IgM are not typically used
due to poor sensitivity and specificity.26
Tetanus
Tetanus is diagnosed based solely on
clinical findings. Clostridium tetani is
identified in only 30% of cases; as a result,
bacteriologic confirmation is unnecessary
and often impractical. Moreover, timely
recognition is important for implementing
early supportive care measures.
CRITICAL DECISION
How should each illness be
treated, and which patients are at
high risk for complications?
Measles
Treatment for measles is typically
supportive in developed countries,
assuming complications have been
appropriately ruled out. In normal hosts,
antiviral therapies are neither required nor
of any benefit. In immunocompromised
patients, however, ribavirin may be
beneficial.27
Vitamin A therapy has been shown
to decrease morbidity and mortality from
measles and can be used in children aged
6 months to 2 years. The World Health
Organization recommends Vitamin A for
all children diagnosed with measles.28
Because measles causes relative
immunosuppression, patients are at
increased risk of developing a variety of
illnesses during the convalescent period,
including otitis media and pneumonia.
In addition, the late neurological
complication of SSPE can develop 7 to 10
years later, so appropriate counseling and
follow-up care should be arranged.
Mumps
There are no antiviral therapies
for mumps, so treatment is supportive.
Primary treatment for mumps orchitis is
scrotal support and bed rest, as needed
for pain. Interferon alpha-2b may
help reduce symptoms that can lead
to testicular atrophy and infertility.29
Intravenous immunoglobulin (IVIG),
although of no benefit for post-exposure
prophylaxis, is indicated for the
autoimmune complications of mumps,
including Guillain-Barré syndrome,
idiopathic thrombocytopenia, and post-
infectious encephalitis.7
Pertussis
When pertussis is suspected,
macrolide antibiotics should be
administered to prevent disease
transmission; however, available
evidence does not suggest that these
medications decrease the length of the
disease course.30
Trimethoprim-sulfamethoxazole is
a recommended second-line agent for
infants older than 2 months for whom
macrolides cannot be used or who have
pertussis that is resistant to macrolide
treatment.31 Exchange transfusions
have been shown to improve survival
rates in those with severe pertussis with
hyperleukocytosis.32 Extracorporeal
membrane oxygenation (ECMO) is an
option for children who have severe
pulmonary hypertension or are critically
ill, although survival rates are still poor
even with intensive treatment.33,34
Infants younger than 4 months and
any child with a history of cardiac,
pulmonary, neurologic, or muscular
disorders should be admitted to the
hospital for observation due to the risk
of complications.35 Infants older than
4 months should be considered for
admission based on the severity of the
paroxysms and any history of apnea or
cyanosis.
Varicella
Acyclovir or valacyclovir can be
used to treat varicella. To achieve the
optimal benefit, medication must be
initiated within 24 to 72 hours of the
onset of the rash. Antiviral agents
provide only a modest benefit in
otherwise healthy patients; as a result,
routine antiviral therapy is generally
n Failing to report a suspected case of measles or mumps to the local health
department.
n Neglecting to evaluate for serious complications of vaccine-preventable
illnesses, including meningitis and encephalitis.
n Overlooking apnea and cyanosis, the most concerning clinical features of
pertussis, which increase the risk of death in young infants.
n Failing to encourage families to maintain proper vaccination schedules. These
conversations should take place during unrelated health care encounters for
routine childhood illnesses.
not indicated. According to American
Academy of Pediatrics guidelines,
routine oral antivirals are recommended
only for patients considered to be
at higher risk, such as unvaccinated
patients older than 12 years, those with
chronic skin or pulmonary conditions,
and patients receiving salicylate or
corticosteroid therapy, including short,
intermittent, or aerosolized steroids.36
Oral antivirals are also used to treat
pregnant women and secondary patients
(eg, family members and close contacts)
at risk for severe illness. IV therapy is
indicated for pregnant women with
severe complications of varicella and
immunocompromised patients, including
those taking high-dose corticosteroids
for more than 14 days.36
Tetanus
Tetanus treatment has two primary
components: efforts to neutralize any
unbound toxin and supportive care.
Tetanus immune globulin (TIG) is used
to eliminate unbound toxins, and any
ongoing infections can be treated with
antibiotics that destroy Clostridium
tetani at the wound site. Surgical
debridement and wound care are also
important to decrease the bacterial load.
Spasms are controlled with muscle
relaxants, such as benzodiazepines.
Although dantrolene and baclofen are
commonly used to manage tetanus
in the ICU setting, evidence-based
guidelines are limited. In some cases,
neuromuscular-blocking agents are also
used.37 Airway management may be
required, although caution should be
used to avoid inducing spasms during
airway manipulation. In addition,
significant autonomic instability can
be a prominent feature that requires
intensive care management. On
recovery, tetanus toxoid administration
is required to provide immunity, as
a primary infection does not protect
against subsequent disease.
CRITICAL DECISION
What measures can help prevent
patients and susceptible contacts
from becoming ill?
Measles
Primary vaccinations for measles are
given at age 12 to 15 months, along with
a second dose at age 4 to 6 years. Even
during unrelated health care encounters
for routine childhood illnesses, clinicians
should seize the opportunity to
encourage families to maintain proper
vaccination schedules.
For post-exposure prophylaxis
against measles, immunoglobulin is
indicated up to 6 days after exposure
for infants younger than age 12 months,
pregnant women with no immunity
to measles, and immunocompromised
hosts. Immunoglobulin can also be used
for individuals with no immunity to
measles who have had close, prolonged
contact with the patient. Between the
ages of 6 and 11 months, vaccines can
be used instead of immunoglobulin for
post-exposure prophylaxis up to 72 hours
after exposure.5
Mumps
The full mumps vaccination consists
of two doses of the measles, mumps, and
rubella (MMR) vaccine. Its effectiveness
is an estimated 78% for a single dose
and 88% for two doses.9 With time,
however, antibody levels can wane,
and older vaccinated patients can be at
risk for developing mumps, which may
present atypically.38
The MMR vaccine may help prevent
mumps in the unvaccinated contacts of
an infected patient.39 In the event of an
outbreak, a third dose can be considered
for previously vaccinated contacts.40
Because the MMR vaccine is live, it is
contraindicated for pregnant women
and immunocompromised patients.
Immunoglobulin is ineffective for post-
exposure prophylaxis.9
July 2019 n Volume 33 Number 7 9
 cases. VariZIG should be administered
TABLE 1. Tetanus Prophylaxis for Routine Wound Management43,44 as soon as possible, ideally within
Adsorbed Tetanus Minor, Clean Wounds All Other Wounds 96 hours of exposure, although
Toxoid Doses DTaP, Tdap, or Td TIG DTaP, Tdap, or Td TIG some degree of benefit is seen when
Unknown or <3 doses Yes No Yes Yes the drug is given within 10 days.41
administered to date
IVIG can be used when VariZIG is
≥3 doses adminis­ No (if <10 years since No No (if <5 years since No
tered to date last tetanus-containing last tetanus-containing unavailable. Neonates born to mothers
vaccine dose) vaccine dose) who develop a varicella rash within
Yes (if ≥10 years since Yes (if ≥5 years since 5 days before or 2 days after giving
last tetanus-containing last tetanus-containing birth, exposed pregnant patients, and
vaccine dose) vaccine dose)
immunocompromised individuals
should all receive VariZIG, according
Pertussis fifth dose of DTaP). Children 7 years to the Centers for Disease Control and
Household members, close contacts, and older who have not had a Tdap Prevention.41
and health care workers who did dose should receive one as a booster; Oral acyclovir can be used for
not use masks during the care of a however, there is insufficient data on the prophylaxis for children with no
pertussis patient should be treated with vaccine’s effectiveness for post-exposure evidence of immunity, including those
macrolides. Contacts younger than prophylaxis.22
who are mildly immunocompromised
7 years can receive a DTaP (diphtheria, Varicella or are immunocompetent but for whom
tetanus, pertussis) dose if they have not Susceptible patients should receive prevention is desired. Acyclovir can be
already received a total of four doses. a varicella vaccine within 3 to 5 days administered 7 to 10 days after exposure
DTaP should also be administered to of exposure for optimal benefit and to prevent or reduce the severity of the
close contacts between the ages of 4 and protection.26 Varicella-zoster immune illness; however, there is limited data
6 years who have not already received globulin (VariZIG ) can also provide regarding the drug’s efficacy for post-
the second booster dose (usually the post-exposure prophylaxis in select exposure prophylaxis.36

FIGURE 7. US States with Measles Cases in 2019

Washington

Oregon New Hampshire

Massachusetts

New York
Michigan Connecticut

Iowa New Jersey

Nevada
Illinois Maryland
Indiana
Colorado
Missouri
California Kentucky

Tennessee
Arizona

Georgia

Texas

Florida

ADAPTED FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION

10 Critical Decisions in Emergency Medicine

 CASE RESOLUTIONS
■ CASE ONE
The febrile infant’s rash
was consistent with measles.
Acetaminophen and ibuprofen were
prescribed for fever control, and the
department of health was notified.
Her parents revealed that several
extended family members, including
a 9-month-old boy, also live in their
home. On the recommendation of
the emergency physician, the exposed
infant was brought to the emergency
department to receive an MMR
vaccine for post-exposure prophylaxis.
Tetanus
Any patient with a potentially
contaminated injury or wound should
receive a tetanus toxoid to prevent
tetanus. TIG may also be indicated. The
decision to immunize or administer TIG
in the emergency department should
be made based on the patient’s prior
vaccination history, the amount of time
that has passed since the last tetanus
toxoid dose, and whether the wound is
considered minor or major (Table 1).
Immunization is administered as DTaP,
Tdap, or Td based on the patient’s age
and prior vaccination history. Because
tetanus is not a contagious disease, no
prophylaxis is required for any close
contacts or medical personnel.
CRITICAL DECISION
What factors should be
considered before discharging
a patient?
Measles
Clinically suspected cases of measles
should be reported to local health
departments, which can help coordinate
care and track cases (Figure 7). To
prevent the spread of the disease,
patients and their household contacts
should use airborne isolation precautions
for approximately 4 days after the rash
begins. Due to prolonged viral shedding,
immunocompromised patients may
require isolation for the entire duration
of the disease.5,42 Moreover, exposed
health care workers with no immunity
The patient’s fever resolved after 2
more days, and the rash began to fade
after 1 week.
■ CASE TWO
The adolescent girl with facial
swelling was determined to have
mumps. Supportive management
of her fever and pain with
ibuprofen and acetaminophen were
recommended. The parotid swelling
started to decrease after 5 days and
resolved completely after 2 weeks.
should remain off work, from day 5 after
exposure to the first case to day 21 after
exposure to the last case.5
Mumps
As with measles, suspected cases
of mumps should be reported to the
local health department. The need for
hospitalization is rare in the absence of
an uncommon complication, and most
patients can be discharged home. The
highest risk of infection transmission
through respiratory droplets and saliva
occurs from 2 days before to 5 days after
the onset of parotid swelling, so isolation
precautions at home should be discussed
with patients and their family members.39
Standard and droplet precautions should
be followed when managing hospitalized
patients.39
Pertussis
Children with pertussis — even those
with severe disease — often appear normal
between paroxysms. When managing
a young infant, a paroxysm must be
witnessed to assess severity before a
discharge decision is made. When in doubt,
emergency physicians should maintain
a low threshold for admission when
evaluating infants younger than 4 months.
The vast majority of older patients can be
discharged home with appropriate follow-
up care and public health reporting.
Varicella
The severity of each varicella case
is dependent on the patient’s age and
underlying immune status. Patients with
■ CASE THREE
The cyanotic 5-week-old infant
was admitted to the inpatient floor for
observation. More episodes of coughing
and cyanosis occurred; she developed
apnea on day 2 and required intubation
and mechanical ventilation. Chest
imaging showed an infiltrate suspicious
for pneumonia. A CBC test showed a
WBC count of 50,000. Pertussis PCR
testing was positive, and the patient was
given azithromycin. She gradually made
a full recovery and was discharged home
after 16 days.
a malignancy, such as leukemia, have
a high mortality rate (approaching
30%) and should be admitted. Adult
patients with primary varicella are also
at much greater risk, with a mortality
rate that is more than 25 times that of
children. Most well-appearing patients
without other risk factors can be treated
with oral antiviral medications at
home. Anyone with severe secondary
complications, such as pneumonia,
should be admitted. Children younger
than 1 year are also at much higher risk,
but most can be managed as outpatients
if they are otherwise well appearing.
Tetanus
Patients with symptoms of tetanus
should be admitted to the ICU and are
unsuitable for discharge.
SUMMARY
Despite a global decrease in
vaccine-preventable illnesses in recent
decades, progress has stalled in certain
sectors, resulting in a growing public
health risk. It can be particularly
challenging to recognize the signs of
measles, mumps, pertussis, varicella,
and tetanus, five vaccine-preventable
diseases that carry potentially deadly
complications. It is imperative for
emergency physicians to understand
which diagnostic tests are warranted,
know when to administer vaccines
or immunoglobulins, and formulate
appropriate disposition plans based on
the characteristics of each case.
July 2019 n Volume 33 Number 7 11
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measles infections in an immune population exposed
to measles during a college bus trip. J Med Virol.
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6. Richardson M, Elliman D, Maguire H, Simpson J,
Nicoll A. Evidence base of incubation periods,
periods of infectiousness and exclusion policies for
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380-391.
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encephalitis associated with mumps infection. A 10-
year survey. Arch Dis Child. 1972 Aug;47(254):647-651.
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June 18, 2018.
10. Davis NF, McGuire BB, Mahon JA, Smyth AE,
O’Malley KJ, Fitzpatrick JM. The increasing incidence
of mumps orchitis: a comprehensive review. BJU Int.
2010 Apr;105(8):1060-1065.
11. Bengtsson E, Orndahl G. Complications of
mumps with special reference to the incidence of
myocarditis. Acta Med Scand. 1954;149(5):381-388.
12. Vittucci AC, Spuri Vennarucci V, Grandin A, et al.
Pertussis in infants: an underestimated disease. BMC
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13. Cornia PB, Hersh AL, Lipsky BA, Newman TB,
Gonzales R. Does this coughing adolescent or adult
patient have pertussis? JAMA. 2010 Aug 5;304(8):
890-896.
14. Philipson K, Goodyear-Smith F, Grant CC, Chong A,
Turner N, Stewart J. When is acute persistent cough
in school-age children and adults whooping cough?
A prospective case series study. Br J Gen Pract. 2013
Aug;63(613):e573-e579.
15. Chan MH, Ma L, Sidelinger D, et al. The California
pertussis epidemic 2010: a review of 986 pediatric
case reports from San Diego County. J Pediatric
Infect Dis Soc. 2012 Mar;1(1):47-54.
16. Watts CC, Acosta C. Pertussis and bilateral subdural
hematomas. Am J Dis Child. 1969 Sep;118(3):518-519.
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18. Trujillo MH, Castillo A, España J, Manzo A, Zerpa
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and identification of measles virus genotypes in
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26. Varicella. In: Centers for Disease Control and
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27. Roy Moulik N, Kumar A, Jain A, Jain P. Measles
outbreak in a pediatric oncology unit and the role
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28. Measles. World Health Organization website. http://
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29. Ku JH, Kim YH, Jeon YS, Lee NK. The preventive
effect of systemic treatment with interferon-alpha2B
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84(7):839-842.
30. Altunaiji SM, Kukuruzovic RH, Curtis NC, Massie J.
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7(3):893-956.
31. Pertussis (whooping cough). In: Red Book: 2018-2021
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32. Kuperman A, Hoffmann Y, Glikman D, Dabbah H,
Zonis Z. Severe pertussis and hyperleukocytosis: is it
time to change for exchange? Transfusion. 2014 Jun;
54(6):1630-1633.
33. Halasa NB, Barr FE, Johnson JE, Edwards KM. Fatal
pulmonary hypertension associated with pertussis in
infants: does extracorporeal membrane oxygenation
have a role? Pediatrics. 2003 Dec;112(6, pt 1):
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34. De Berry BB, Lynch JE, Chung DH, Zwischenberger
JB. Pertussis with severe pulmonary hypertension
and leukocytosis treated with extracorporeal
membrane oxygenation. Pediatr Surg Int. 2005 Aug;
21(8):692-694.
35. Cherry JD, Wendorf K, Bregman B, et al. An obser­
vational study of severe pertussis in 100 infants
≤120 days of age. Pediatr Infect Dis J. 2018 Mar;
37(3):202-205.
36. Varicella-zoster virus infections. In: Red Book: 2018-2021
Report of the Committee on Infectious Diseases. 31st ed.
Itasca, IL: American Academy of Pediatrics; 2018:
869-883.
37. Rodrigo C, Fernando D, Rajapakse S. Pharma­
cological management of tetanus: an evidence-
based review. Crit Care. 2014 Mar 26;18(2):217.
38. Myung NS, Kim YJ, Kim YJ, Koo SK. Complicated
mumps viral infection: an unusual presentation
affecting only submandibular gland. Am J
Otolaryngol. 2013 Sep-Oct;34(5):600-602.
39. Centers for Disease Control and Prevention (CDC).
Updated recommendations for isolation of persons
with mumps. MMWR Morb Mortal Wkly Rep. 2008
Oct 10;57(40):1103-1105.
40. Marin M, Marlow M, Moore KL, Patel M.
Recommendation of the Advisory Committee on
Immunization Practices for use of a third dose
of mumps virus-containing vaccine in persons at
increased risk for mumps during an outbreak. MMWR
Morb Mortal Wkly Rep. 2018 Jan 12;67(1):33-38.
41. Centers for Disease Control and Prevention (CDC).
Updated recommendations for use of VariZIG—
United States, 2013. MMWR Morb Mortal Wkly Rep.
2013 Jul 19;62(28):574-576.
42. Permar SR, Moss WJ, Ryon JJ, et al. Prolonged
measles virus shedding in human immunodeficiency
virus-infected children, detected by reverse
transcriptase-polymerase chain reaction. J Infect Dis.
2001 Feb 15;183(4):532-538.
43. Tetanus (lockjaw). In: Red Book: 2018-2021 Report
of the Committee on Infectious Diseases. 31st ed.
Itasca, IL: American Academy of Pediatrics; 2018:
793-798.
44. Liang JL, Tiwari T, Moro P, et al. Prevention of
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Recomm Rep. 2018 Apr 27;67(2):1-44.
 A 68-year-old man with dyspnea, hypotension, and evidence of pulmonary edema.

The Critical ECG

Sinus tachycardia, rate 125, acute anterior-lateral myocardial infarction. At first By Amal Mattu, MD, FACEP
glance, the ECG appears to reflect a wide QRS complex tachycardia. However, Dr. Mattu is a professor, vice chair, and
director of the Emergency Cardiology
leads II and V1 clearly demonstrate that the QRS complexes are narrow, and it is Fellowship in the Department of
Emergency Medicine at the University
the marked ST-segment deflections (elevations or depressions) that give the false
of Maryland School of Medicine in
appearance of wide QRS complexes. A truly wide QRS complex rhythm should Baltimore.
demonstrate wide complexes in every lead. Marked ST-segment elevation (STE)
is present in the anterior (V2-V4) and lateral (V5, V6, I, and aVL) leads, and reciprocal
ST-segment depression is present in the inferior leads and in lead V1. When diffuse
STE is present, these reciprocal changes exclude other causes of STE, such as
pericarditis, benign early repolarization, ventricular aneurysm, and left ventricular
hypertrophy.

From Mattu A, Brady W. ECGs for the Emergency Physician 2. London: BMJ Publishing; 2008. Reprinted with permission.

July 2019 n Volume 33 Number 7 13

 The Critical Image
A 62-year-old man with hypertension presents with 5 days of nontraumatic By Joshua S. Broder, MD, FACEP
neck pain. He describes severe, burning, midline cervical pain that radiates to Dr. Broder is an associate professor and the
residency program director in the Division
the back of his head. His symptoms, which are progressive and constant, are
of Emergency Medicine at Duke University
now associated with numbness in his hands. The patient also reports difficulty Medical Center in Durham, North Carolina.
swallowing solid foods but denies fever. He is a former cigarette smoker but Case contributor: Brian Nelson, MD
denies drug or alcohol use. An urgent care center performed screening x-rays
of the patient’s cervical spine before referring him to the emergency department.
His vital signs are blood pressure 168/93, heart rate 76, respiratory rate 18, temperature 37.5°C (99.5°F), and oxygen saturation
94% on room air. His cervical pain is not reproducible with palpation. His physical and neurologic examinations are otherwise
normal, and he has no stridor or drooling.
The emergency physician reviews the patient’s cervical x-ray, places him in a Miami J cervical collar, and obtains additional
imaging.

KEY POINTS A
n Cervical spine instability can result
from trauma and malignant or
infectious processes. The flexion-
extension images presented here
demonstrate subluxation of the
cervical spine, which increases the
risk of spinal cord injury.
n Flexion-extension imaging should
be performed with caution, and
— when instability is suspected —
preferably in consultation with a
C1 vertebra
spine surgeon. If flexion-extension
images are obtained, the patient
should actively perform cervical Lytic
motion, stopping immediately if any destruction
neurologic symptoms arise. of C2
n Passive cervical motion (ie, vertebral
movement of the cervical spine body
by an external operator) increases
the risk of spinal cord injuries and
should never be performed. C3 vertebra
n When malignancy is suspected, CT
with intravenous (IV) contrast can
further delineate the spinal lesion
and identify a primary mass. MRI of
the spine may also be necessary to
characterize spinal cord or epidural
involvement. A. Lateral cervical spine x-ray demonstrating lytic destruction of the C2
vertebral body. This lesion destabilizes the patient’s cervical spine and creates
a risk of spinal cord injury caused by cervical motion.

CASE RESOLUTION
The patient was admitted, and a biopsy of his renal mass confirmed renal cell carcinoma.
His cervical spine was surgically fixated, and he underwent radiation therapy.

14 Critical Decisions in Emergency Medicine

B. Flexion
B C
radiograph;
C. Extension
radiograph.
These images C1 vertebra
reveal dynamic and dens,
instability, with anteriorly
subluxation subluxed
of C1 and
the dens
C2 vertebra
relative to the
remainder of
the cervical
spine.

C3 vertebra

D. CT of the
D E cervical spine and
soft tissues of the
Dens neck, performed
with IV contrast.
With bone windows,
the extent of C2
destruction is
evident.
C1
vertebra E. Same data set
as Figure B, soft-
tissue windows.
An enhancing
soft-tissue mass in
Lytic Peripherally C2 is evident. This
destruction enhancing, finding suggests
of C2 C3 expansile, lytic metastatic disease
vertebral vertebral lesion of C2 (as opposed to
body body vertebral body osteomyelitis with
osteolysis).

F. CT of the chest, F G
abdomen, and
pelvis with IV
contrast. The test
was performed
to identify a
suspected primary
malignant lesion of
unknown location.
A heterogeneously
enhancing mass
in the left kidney
suggests renal cell
carcinoma.

G. Lateral x-ray
following internal Heterogeneously
spinal fixation. enhancing
renal mass

July 2019 n Volume 33 Number 7 15

 Critical Cases
in Orthopedics and Trauma
Malleolar Ankle Fracture
By John Kiel, DO, MPH; and Roseline Desvaristes, MD
University of Florida College of Medicine – Jacksonville

A 56-year-old woman presents after falling while walking her dog. As she fell, she twisted her
left ankle in the opposite direction of her path. She explains that she experienced an immediate
onset of pain in the extremity, and severe swelling developed 30 minutes later. In the emergency
department, an obvious ankle deformity is noted with mild, medial deviation and eversion of the
foot. The patient’s neurovascular examination is intact, and the skin is intact. She complains of
mild tenderness over the knee joint laterally.

Fracture Reduction and Splinting

FIGURE 1. Medial Malleolus Fracture
Radiographs identified a trimalleolar fracture with
anterior-posterior dislocation of the talus and a spiral
fibular neck fracture, consistent with a Maisonneuve
injury. Pain control was achieved with intravenous
fentanyl (100 mcg), an oral dose of hydrocodone, and a
hematoma block. With the patient in a supine position,
chlorhexidine was used to prepare the injection site,
which was located anteromedially between the medial
malleolus and the tibialis anterior tendon. The fracture
hematoma was aspirated with a 23-gauge needle, and
10 mL of 1% lidocaine was injected.
Reduction was achieved by grasping the midfoot
and calcaneus and applying axial traction. The talus was
further manipulated anteriorly to achieve anatomical
alignment with the articular surface of the tibia. A
combined posterior and stirrup splint was used to
stabilize the posterior ankle and foot to prevent plantar-
and dorsiflexion.

CASE RESOLUTION
Following reduction and splinting, the patient
continued to experience considerable swelling
and was strictly advised to elevate her foot
and avoid bearing weight. She was discharged
in stable condition. On follow-up, her initial
radiographs were found to be misleading;
the orthopedic staff determined that the
patient had a bimalleolar fracture rather than
REFERENCES
a trimalleolar injury. She underwent an open 1. Daly PJ, Fitzgerald RH Jr, Melton LJ, Ilstrup DM. Epidemiology of ankle fractures in
reduction and internal fixation of the medial Rochester, Minnesota. Acta Orthop Scand. 1987 Oct; 58:539-544.
2. Elsoe F, Ostgaard SE, Larsen P. Population-based epidemiology of 9767 ankle fractures. Foot
and lateral malleoli 9 days later. Ankle Surg. 2018 Feb;24(1):34-39.
3. Kalyani BS, Roberts CS, Giannoudis PV. The Maisonneuve injury: a comprehensive review.
Orthopedics. 2010 Mar;33(3):196-197.

16 Critical Decisions in Emergency Medicine

 FIGURE 2. Bimalleolar Fracture
KEY POINTS
n Malleolar injuries account for the vast majority of ankle
fractures. Lateral malleolus fractures account for 55%
of these cases, and trimalleolar fractures account for
approximately 7% to 12%.1,2
n A unimalleolar fracture, an isolated injury in one of the
malleoli (Figure 1), can remain stable if no additional
ligament injury is present. A stress-view radiograph
can further help identify instability by demonstrating
widening of the ankle mortise. A bimalleolar-equivalent
fracture (Figure 2), which involves both the medial and
lateral malleoli, should be suspected if a lateral talar
shift is present. In such cases, an additional injury to the
deltoid ligament can cause subsequent joint instability.
The trimalleolar fracture (Figure 3) is so termed because
it involves an additional fracture at the posterior edge
of the tibia.
n An ankle injury that is accompanied by a high fibular
fracture and disruption of the syndesmosis is called a
Maisonneuve fracture. This pathology is often missed
in the initial evaluation.3 Patients may be distracted by
the severity of their ankle pain and not complain of pain
proximally. Three-view radiographs are indicated; stress
views may be necessary. The Ottawa Ankle Rules can
help reduce unnecessary imaging.
n Malleolar fractures are classified by the Danis-Weber,
AO/OTA, and Lauge-Hansen classification systems.
FIGURE 3. Trimalleolar Fracture
n Supination-adduction, supination-external rotation, and
pronation-external rotation result in various malleolar
and fibular fractures and disruption of the syndesmotic
and deltoid ligaments. Supination-external rotation, the
most common cause of ankle fractures, can damage the
distal fibula and result in avulsion of the posterior-inferior
tibiofibular ligament. While this mechanism can lead to
Maisonneuve fractures, pronation-external rotation is
reported in more than half of these cases.3
n Ankle injuries can prevent patients from returning to
their previous level of activity and can result in job
loss, osteoarthritis, and chronic pain. When evaluating
these cases, the physician should perform a thorough
neurovascular examination and carefully examine the joint
above and below the site of injury.
n In general, stable ankle fractures are managed with
immobilization, elevation, and ice therapy as tolerated. A
short-leg walking cast or a cast boot worn for 4 to 6 weeks
can be useful. Unstable ankle fractures (eg, bimalleolar,
bimalleolar equivalent, trimalleolar) require immediate
closed reduction and splinting to prevent tissue ischemia,
avert articular surface damage, and help resolve swelling.
The definitive management of these injuries involves open
reduction and internal fixation. Maisonneuve fractures may
require surgical management if there is true syndesmosis
instability or compression of the superficial fibular nerve
with subsequent motor weakness.
July 2019 n Volume 33 Number 7 17
 The Critical Procedure
Starting or Stopping an Implanted
Vagal Nerve Stimulator
Benefits and Risks
On-demand VNS stimulation can
be used to stop or treat seizure activity.
Conversely, pain, coughing, and other
side effects associated with these devices
can be relieved by temporarily disabling
the stimulation they provide.
Disabling a VNS can inadvertently
induce stimulation and its associated
risks, including dyspnea, voice problems,
coughing, and pain. Rare incidents of
bradycardia and asystole have also been
reported.
Alternatives
Alternative therapies primarily focus
on resolving the complaints noted
earlier. Certain symptoms that can be
provoked by a VNS, including pain and
spasms, may be more difficult to treat.
Reducing Side Effects
It is important to understand that
the clinician can induce on-demand
stimulation by using a magnet to close
and open a switch within the VNS.
When planning to disable a device, on
the other hand, efforts must be made
to keep the magnet in place, as removal
(or position changes) will prompt
stimulation.
18 Critical Decisions in Emergency Medicine
By Steven J. Warrington, MD, MEd
Dr. Warrington is the director of the Emergency Medicine
Residency Program and academic chair of the Department of
Emergency Medicine at Orange Park Medical Center in Orange Park, Florida.
Implanted vagal nerve stimulators (VNS) can be
used to manage multiple conditions, including epilepsy,
mood disorders, and migraines, by delivering electrical
impulses along the left vagus nerve to the brain stem.
Patients frequently present to the emergency
department for acute conditions that can be
managed by triggering or disabling the device.
Special Considerations To avoid accidental stimulation,
Patients who undergo VNS implanta­ clinicians should be mindful of the
tion are typically provided with a position of the magnet in relationship
to the patient. It is also important to
bar-shaped magnet that matches the
understand that these devices do not
shape of their device. Magnets found in
provide continuous stimulation. Each
emergency departments, most of which VNS is programmed to stimulate the
are circular, may fail to stop or induce vagus nerve according to a particular
stimulation. Whenever possible, the frequency or pattern. Activating the
patient’s device-specific magnet should device simply triggers its preprogrammed
be used. stimulation sequence (eg, hourly).
TECHNIQUE
STOPPING a VNS
1. Locate an appropriate magnet,
preferably bar shaped.
2. Identify the location of the VNS by
palpating the patient’s left chest.
3. Place the magnet over the top of
the device. If the magnet is circular,
consider slowly approaching the
VNS from the side until symptoms
resolve.
4. Secure the magnet in place. (Any
movement may induce stimulation.) VNS Magnet
TRIGGERING a VNS 3. Move the magnet over the device,
1. Locate an appropriate magnet. hold it in place for 1 to 2 seconds,
2. Identify the location of the VNS by and then quickly remove it.
palpating the patient’s left chest. 4. Repeat if necessary.
 Observation
Deck
Emergency Department
Observation Care

LESSON 14

By Robert M. Bramante, MD, FACEP;

and Christopher C. Raio, MD, MBA, FACEP
Dr. Bramante is codirector of observation medicine and associate chairman of
emergency medicine, and Dr. Raio is chairman of emergency medicine at Good
Samaritan Hospital Medical Center in West Islip, New York.

Reviewed by John C. Greenwood, MD

OBJECTIVES
On completion of this lesson, you should be able to:
1. Describe the various types of hospital observation
care.
2. Explain the difference between inpatient admission
and observation status.
3. Identify patients who are appropriate for protocolized
observation care.
4. Discuss the goals of observation care.
5. Summarize the management goals and metrics
associated with observation medicine.
CRITICAL DECISIONS
n How should observation services be defined?
n Which patients should be selected for
observation?
n How can protocolized observation units be used
to streamline patient care?
n What metrics and quality data matter most when
operating an observation unit?

FROM THE EM MODEL n Who should manage the protocolized

20.0 Other Core Competencies of the Practice observation unit?

of Emergency Medicine
20.4 Systems-Based Practice

Observation units are increasingly used to manage acute presentations when safe discharge is in doubt and
the need for inpatient admission is unclear. While there are a number of existing models for this approach to
care, emergency departments have become keenly invested in the surge of new, protocolized observation care.
As such, clinicians must be prepared to maximize this safety net by selecting appropriate patients for monitoring
and using interdisciplinary protocols to expertly manage them.

July 2019 n Volume 33 Number 7 19

 CASE PRESENTATIONS
■ CASE ONE
A 51-year-old man with a
history of hypertension presents
via ambulance with moderate
chest pressure that radiates to his
left shoulder. He explains that
the symptoms began an hour ago
while he was walking to work.
The pain is nonpleuritic and
associated with mild shortness
of breath. He has no back pain,
abdominal pain, nausea, vomiting,
or diaphoresis. The patient does
not take aspirin and smokes half
of a pack of cigarettes daily. He
reports no recent immobility
or travel. His family history
is significant for hypertension
without coronary artery disease.
Paramedics administered
325 mg of aspirin while en route
to the hospital, and the patient’s
symptoms are now improving.
An initial ECG reveals isolated
T-wave inversions in leads V5
through V6 . No prior ECG is
available for comparison. His
vital signs are within normal
limits, and his lungs are clear.
His cardiac and abdominal
examinations are normal, and he
has equal pulses, no reproducible
pain, and no extremity edema.
Initial laboratory tests, including
his troponin level, are normal.
The emergency physician
informs the patient that he will be
transferred to the observation unit
for further telemetry monitoring,
provocative cardiac testing, and
frequent reevaluation.
While many observation units
were initially dedicated to the
evaluation of chest pain (Figure 1),
they have since expanded to
address numerous diagnoses that
require management, testing, and
reevaluation beyond the scope of the
emergency department. Although
observation medicine is rapidly
evolving, and the criteria for hospital
20 Critical Decisions in Emergency Medicine
■ CASE TWO
A 72-year-old woman presents
via ambulance with an episode of
slurred speech that started 5 hours
prior to arrival. She complains of
left-sided facial numbness and left
leg weakness but notes that her
symptoms are improving. She has a
history of type 2 diabetes mellitus,
hypertension, and intermittent vertigo.
Although the patient initially did not
think much of the event, a concerned
friend encouraged her to call 911 after
learning of her symptoms. She took a
325-mg aspirin prior to arrival. The
patient describes no recent trauma,
headache, or pain.
The patient’s vital signs are
significant for hypertension with a
blood pressure of 164/92. Her physical
examination is significant for 4/5
left lower-extremity strength with
normal sensation and mild dysarthria,
which equates to a National Institute
of Health Stroke Scale score of 2.
An ECG demonstrates normal
sinus rhythm with left ventricular
hypertrophy. An initial CT of her
brain is normal, with no evidence of a
stroke, intracranial hemorrhage, shift,
or mass. Her laboratory evaluation is
unremarkable, except for mild anemia
with a hemoglobin level of 11.2 g/dL.
Neurology recommends evaluating
the patient for a cerebrovascular
accident versus a resolving transient
ischemic attack. The observation unit
physician is called to further assess
the patient’s appropriateness for
observation care.
admission is becoming increasingly
rigorous, these valuable units exist in
only about one-third of US hospitals.1
The Centers for Medicare and
Medicaid Services (CMS) has continued
to increase the scope of observation,
with the addition of the Two-Midnight
Rule and new assessments of medical
necessity. Medicare defines observation
as services “that are reasonable and
■ CASE THREE
A 42-year-old man presents with
sharp, severe, left flank pain that is
radiating to his groin. He has had
two to three bouts of renal colic
over the past 6 years but has passed
stones spontaneously after receiving
treatment on all prior occasions. He
has had multiple episodes of nausea
and vomiting over the past 8 hours,
which have been nonbloody and
nonbilious. There is no chest pain
or shortness of breath. The patient
denies dysuria and gross hematuria.
He drinks alcohol socially, does not
smoke, takes no medications, and
denies other medical problems. He is
afebrile and tachycardic at 118 beats
per minute.
His physical examination is
significant for moderate distress due
to pain; he is writhing in bed and
has left flank and lower-quadrant
abdominal tenderness without rebound
or guarding. His genitourinary exam­
ination is normal. Laboratory tests
demonstrate no leukocytosis, a normal
creatinine level, and hypoka­lemia at
2.6 mEq/L. Urinalysis is positive for
blood and 1 to 2 WBC/hpf, without
leukocyte esterase or nitrites. A
focused, point-of-care ultrasound
examination reveals mild left-sided
hydronephrosis and a hyperechoic
focus measuring 3 mm with posterior
shadowing at the left ureterovesical
junction.
Despite intravenous (IV) hydration
and analgesia, the patient’s pain and
vomiting persist. The emergency
physician considers further
management in the observation unit.
necessary to evaluate the outpatient’s
condition or determine the need
of that patient’s admission to the
hospital as an inpatient.”2
In addition to providing patients
with focused care, these units help
hospitals prevent inappropriate
admissions, subsequent CMS audits,
and the loss of vital revenue.3
CRITICAL DECISION
How should observation
services be defined?
In decades past, emergency physicians
were forced to answer a binary question
when determining the disposition for each
case: Can this patient be safely discharged
home, or is inpatient admission required
for the provision of further testing and
treatment? In 1983, however, CMS
limited Medicare costs by creating a
payment system based on admission
criteria. Under this new model, Medicare
payments are based on the diagnosis,
rather than on each service rendered.4
This change, which mandates that
hospitals assume more risk, eventually led
to the development of observation care.
As opposed to inpatient services,
which are covered under Medicare
Part A, observation care is covered
under Medicare Part B. Observation is
now used to determine whether patients
receiving ongoing treatment can be
safely discharged within 24 hours or
require inpatient care. Although various
reimbursement rules have been applied to
observation care over the last 30 years,
most payers now recognize its unique
advantages and routinely cover the
services these units provide.
CMS defines observation as a
“well-defined set of specific, clinically
appropriate services, which include
ongoing short-term treatment,
assessment, and reassessment before a
decision can be made regarding whether
the patients require further treatment as
hospital inpatients or if they are able to
be discharged from the hospital.”5
While observation is a status, not a
location, this article will focus on closed,
protocol-driven observation units. There
are four distinct types of observation
care. The type 1 (scattered) model, in
which beds are dispersed throughout the
hospital, allows any provider to manage
patients under observation. This scenario
actually shifts costs from the payers to
the hospital; care proceeds as it would for
any admitted patient — only for a shorter
period of time.4,6 The type 2 (open) model
describes a distinct unit in which any
admitting clinician can place and manage
observation cases.
Type 3 (virtual) care is directed by
observation protocols, but the patients are
spread throughout the hospital without a
designated unit. Finally, a type 4 (closed)
unit is a separate, distinct space in
which clinicians develop and implement
interdisciplinary protocols for patient
care.6 This space is optimally located
within or adjacent to the emergency
department.

FIGURE 1. One Sample Algorithm for the Observation of Chest Pain

CHEST PAIN SYNDROME

OR POSSIBLE ACUTE CORONARY SYNDROME (ACS)

Possible ACS
Clinical Assessment: Definite ACS:
NOT cardiac Unstable angina
Non–ST-elevation
Age ≤75 years with no known Age ≥75 years or known
myocardial infarction
coronary artery disease coronary artery disease
ST-elevation myocardial
Consider other diagnoses infarction
• ECG and troponin at 0 hours
(follow up with ECG and troponin at 0, 3,
(if pain >6 hours ago)
primary care provider) and 6 hours
• ECG and troponin at 0 and
3 hours (if pain 3-6 hours ago) Admit/
• ECG and troponin at 0, 3, and cardiology consultation
6 hours (if pain <3 hours ago)

No recurrent angina, ECG (–)

Recurrent angina, ECG (+) and troponin(s) (–)
or troponin(s) (+)

Business hours:
Admit/ Stress test
cardiology consultation

After hours:
Dismiss with 1-3 day Abnormal Normal
cardiology follow-up for
possible stress testing

Admit/ Dismiss (follow up with

cardiology consultation primary care provider)

July 2019 n Volume 33 Number 7 21

 Regardless of the model employed,
emergency physicians must ensure
that patients receive the appropriate
level of care (inpatient vs observation
vs discharge) by contributing to the
appropriate disposition decision.
CRITICAL DECISION
Which patients should be
selected for observation?
Observation is inappropriate for
two primary populations: patients
who meet the criteria for inpatient care
and those whose emergent condition
has been treated, allowing them to be
safely discharged home directly from
the emergency department. CMS uses
standardized criteria to help determine if
an individual qualifies for inpatient care.
Several reliable triage tools, including
the InterQual Criteria and Milliman
Care Guidelines, can help determine the
need for hospital admission; however,
these protocols are not all-inclusive and
should not supersede documented clinical
judgment.
Conversely, there are two populations
that should be considered for observation
status: patients who require further
treatment and testing to determine
their need for inpatient admission and
those who need prolonged treatment or
evaluation in the emergency department
but are not well enough to be discharged
home. Examples include patients
with low- to moderate-risk chest pain
(pending serial cardiac enzyme testing),
a transient ischemic attack (pending
further advanced imaging), or asthma
that requires ongoing nebulizer treatment,
monitoring, and reevaluation.
Although emergency department
observation has historically focused on
n Plan ahead by staffing the observation unit with clinicians who are adaptable,
responsible, and understand the goals of observation medicine.
n Meet with key personnel (eg, hospital leadership, medical billing, clinical staff)
prior to initiating observation services.
n Identify a leader within the emergency department to manage the unit, follow
the metrics, and educate staff on protocolized observation care.
n The observation unit is an important safety net that also enables clinicians to
monitor emergency department care and operations.
22 Critical Decisions in Emergency Medicine
the first 24 hours of care, the average
length of stay has increased over the
past decade, as payers have directed
more complex cases toward this clinical
model.4,7 Under Medicare’s Two-Midnight
Rule, care must cross two midnights
before the case is deemed an inpatient
admission, while treatment provided
for less than two midnights must
meet additional, specific criteria to be
considered inpatient care.8 It is important
to recognize that the time spent under
observation does not count toward the
3 days a Medicare patient must spend as
an “inpatient” before becoming eligible for
skilled nursing facility coverage.
In emergency medicine–operated,
protocolized observation units, treatment
and disposition should be completed in
less than 24 hours to allow for continued
throughput and flow.4 The average
length of stay in an emergency medicine
observation unit is 15 hours; more than
80% of these patients are discharged home
after the observation period.9,10 The ideal
observation patient has a limited illness
that requires a limited intensity of care.4
CRITICAL DECISION
How can protocolized
observation units be used to
streamline patient care?
Protocolized observation units
can help hospitals avoid unnecessary
admissions and risky emergency depart­
ment discharges, increase throughput,
enhance the patient experience, and
ultimately improve clinical care.
While numerous guidelines have
been developed for the management of
observation patients, institutions can
modify these protocols or create their
own to meet their unique needs, workflow,
resources, and patient populations. The
key is to create standardized pathways that
optimize efficiency and outcomes. These
protocols have been shown to improve
care at lower costs than inpatient treatment
(Figure 2).7
Because patients with multiple, acute
problems often cannot be managed with
streamlined pathways, focused protocols
should provide specific inclusion and
exclusion criteria and outline necessary
diagnostic tests and treatment. Protocolized
care fosters clinical consistency and more
efficient patient management.10 When
developing these standards, it is important
to ask: Does this test or treatment need to
be completed during this visit?
Protocols should focus on the key
tests required to determine the need for
outpatient follow-up or hospital admission.
Unnecessary testing and procedures
can increase the average length of stay,
needlessly occupy valuable resources, and
decrease monetary returns. It is important
to note that Medicare pays facilities a fixed
fee for observation services, which means
the hospital shares the financial risk.
CRITICAL DECISION
What metrics and quality data
matter most when operating an
observation unit?
Many observation metrics closely
mirror standards used in the emergency
department. Data on the unit’s volume,
utilization patterns, average length of stay,
final disposition, and completion of care
should be tracked on a weekly, monthly,
and yearly basis. Volume data includes the
quantity of observation cases, number and
percentage of cases sorted by diagnosis
and final disposition, and the number
of observation cases compared to the
total number of emergency department
patients.4
It also helps to be aware of the
hospital’s concurrent case review and
insurance denials, as this information
may provide opportunities to increase
observation unit volume while decreasing
the hospital’s exposure to CMS audits.4,7
This information, in conjunction with the
ratio of emergency department to hospital
admissions, can help measure the effect of
observation on hospital utilization.
 Each length of stay is another crucial
metric, as patients who require less than 6
to 8 hours of care are unlikely candidates
for observation. Most cases should include
a plan for discharge or admission within
18 to 24 hours, and a typical length of
stay should be targeted at 15 hours.10,11
By carefully tracking every diagnosis,
emergency physicians can tailor the
observation unit’s priorities and resources
to the presenting patient population.
Laboratory and imaging turnaround times
are also important to monitor, as they can
add significant time to the length of stay
of inappropriately prioritized observation
patients.
While it is important to regularly
evaluate the unit’s patient volume, quality
measurements are an equally valuable
barometer of success. Quality metrics
include data about post-observation
return visits, concerns and complaints,
patient satisfaction scores, upgrades
from observation to intensive care, the
percentage of patients who decompensate
or suffer unexpected complications, and
mortality.4,10,12
Finally, units cannot function properly
without financial stability. Care should
cost less in dedicated units, which decrease
variability when protocols are used. Even if
reimbursements are unprofitable, economic
benefits can be gained by increasing
efficiency and expediting care. Additionally,
observing patients who previously had
prolonged emergency department stays
can improve throughput and help hospitals
obtain reimbursement for the additional
care provided.12
By tracking average payments by payer
(eg, Medicare, Medicaid, commercial),
emergency departments can gain a better
understanding of the unit’s payer mix and
bottom-line influence. It is key to remember
that the financial success of an observation
unit is dependent on the appropriate
selection of patients.
CRITICAL DECISION
Who should manage the
protocolized observation unit?
More than 50% of US observation
units are managed administratively by
emergency departments.13 The rationale for
this arrangement stems from the concept
that protocolized observation is a natural
FIGURE 2. Relative Costs for Observation vs Inpatient Care
EMERGENCY DEPARTMENT
OBSERVATION UNIT
2% 3% 3%
1%
3%
9%
24%
38%
7%
10%
Electrical
cardioversion Diagnostic
Laboratory Medication
Circle sizes are proportionate to the respective costs of care (40% lower for patients
managed with observation). “Inpatient” represents patients hospitalized for ≤1 day.
ADAPTED FROM THE JOURNAL OF THE AMERICAN HEART ASSOCIATION
extension of acute care. Observation
units are often located where the effects
of acute treatment can be monitored and
reevaluated, while enabling clinicians to
determine the appropriate disposition for
each case.4
The American College of Emergency
Physicians supports the use of emergency
clinicians to staff and manage observation
units.14 It is important to specifically
designate these areas as “closed”; ideally,
emergency physicians should maintain
authority over observation cases until a
final disposition can be determined.4
Emergency department observation units
typically offer shorter lengths of stay
than those managed by hospitalists, are
more cost effective, have fewer patient
handoffs, and incur fewer barriers
when transitioning between acute and
observation care. These benefits are
particularly favorable for patients placed
in observation, 80% of whom are
expected to be discharged home within
24 hours.9,10,12
By contrast, hospitalist-run
observation units can provide more
continuity of care for those converting to
inpatient status, and staff may be more
familiar with long-term care coordination
than those focused on acute care.12 Having
INPATIENT
2%
4%
17%
25%
8%
9%
35%
Emergency
Echocardiography Imaging department
Fees charged
by clinicians Room Sedation
a dedicated emergency department–
protocolized observation unit does not
preclude the hospital from offering
additional hospitalist observation
services. This option becomes useful
for cases that do not meet the criteria
for inpatient admission but also fall
outside the parameters of protocolized
observation care.
When staffing observation units, it
is imperative to select providers who are
adaptable, responsible, thorough, and
willing to learn. For many emergency
physicians, working in observation
medicine is a new role that requires
significant interaction with hospital
leadership, consultants, and colleagues.
These clinicians can play a unique role
in evaluating patient care and assessing
emergency department processes. In
addition, observation physicians who are
welcomed into the fold of an emergency
medicine group can provide constructive
feedback that helps improve practice
patterns and staff performance.
Summary
Emergency department observation
units operate best when they follow a
closed, protocolized, unit-based model.
Appropriate patient selection is crucial.
July 2019 n Volume 33 Number 7 23
 CASE RESOLUTIONS
■ CASE ONE
The hypertensive man with chest
pain was determined to have a
HEART score of 4, which indicated
that he was at moderate risk of
having a major adverse cardiac event
in the next 6 weeks. Continuous
telemetry monitoring was performed
in the observation unit, which
demonstrated no clinically significant
arrhythmia. The patient’s serial
cardiac enzymes remained negative,
and he continued to be pain-free
and asymptomatic while undergoing
frequent reevaluation. In consultation
with cardiology, he was scheduled to
undergo outpatient stress testing the
following day. He was discharged
home on daily aspirin therapy after
10 hours of observation care.
■ CASE TWO
The elderly woman’s symptoms,
including slurred speech, facial
numbness, and left leg weakness
persisted. In addition, she developed
Well-trained, experienced staff can
effectively monitor patients who require
further treatment and testing or are too
sick to be discharged home. The ideal
observation unit patient has a focused
problem and defined goal of care that can
be met in less than 24 hours.
Emergency department observa­tion
units should be managed administratively
by the emergency department staff, as
most observation patients are discharged
home without requiring inpatient
admission. This model helps facilitate
department flow and maximize the
quality of care provided. An observation
unit’s success is dependent on its ability
to monitor its volume and quality metrics
while providing ongoing medical care.
REFERENCES
1. Baugh CW, Venkatesh AK, Hilton JA, Samuel PA, Schuur
JD, Bohan JS. Making greater use of dedicated hospital
observation units for many short-stay patients could
save $3.1 billion a year. Health Aff (Millwood). 2012 Oct;
31(10):2314-2323.
2. Department of Health and Human Services;
Health Care Financing Administration. Section 455:
outpatient observation services. In: Medicare
Hospital Manual. https://www.cms.gov/Regulations-
and-Guidance/Guidance/Transmittals/downloads/
R770HO.pdf. Published February 23, 2001. Accessed
September 14, 2016.
24 Critical Decisions in Emergency Medicine
new paroxysmal atrial fibrillation.
The observation physician discussed
the case with the emergency
department attendings and reviewed
the observation unit’s admission
and protocol exclusion criteria for
transient ischemic attacks (eg, ongoing
neurologic symptoms). The patient met
the criteria for inpatient management
and was admitted to the hospitalist
service with a neurology consultation.
The following morning, an MRI
demonstrated an acute infarction with
no focal stenosis or lesions noted on
magnetic resonance angiography of
the head and neck. Echocardiography
showed mild mitral regurgitation and
left ventricular hypertrophy. A plan
for anticoagulation for the paroxysmal
atrial fibrillation was initiated.
Physical and speech therapists
evaluated the patient and determined
that she required further rehabilitation
before returning home. She was
transferred to subacute rehabilitation
on day 3 to continue treatment.
3. Exploring the impact of the RAC program on hospitals
nationwide. American Hospital Association website.
http://www.aha.org/content/16/16q1ractracresults.pdf.
Updated June 2016. Accessed September 28, 2016.
4. Brillman J, Mathers-Dunbar L, Graff L, et al. Management
of observation units. American College of Emergency
Physicians. Ann Emerg Med. 1995 Jun;25(6):823-830.
5. Hospital services covered under Part B. In: Medicare
Benefit Policy Manual. Centers for Medicare and
Medicaid Services website. https://www.cms.gov/
Regulations-and-guidance/guidance/manuals/
downloads/bp102c06.pdf. Updated December 18, 2015.
Accessed September 28, 2016.
6. Graff LG. Observation Medicine: The Healthcare
System’s Tincture of Time. Dallas, TX: American College
or Emergency Physicians; 2011.
7. Baugh CW, Schuur JD. Observation care—high-value
care or a cost-shifting loophole? N Engl J Med. 2013 Jul
25;369(4):302-305.
8. Sheehy AM, Caponi B, Gangireddy S, et al. Observation
and inpatient status: clinical impact of the 2-midnight
rule. J Hosp Med. 2014 Apr;9(4):203-209.
9. Annathurai A, Ross MA, Lemos JP, et. al. Data from the
Emergency Department Observation Unit Benchmark
n Failing to create thorough, diagnosis-specific protocols.
n Assuming that consultants, primary care physicians, and other hospital staff
understand the goals and purpose of observation units.
n Placing patients into an observation service who either can be safely
discharged or clearly meet inpatient admission criteria.
n Neglecting to clearly delineate the clinical and administrative roles and
responsibilities required for managing the observation unit.
■ CASE THREE
The 42-year-old man’s dehydration
and persistent left flank pain were
determined to be the result of renal
colic and an electrolyte disturbance
attributed to vomiting. The emergency
physician transferred him to the
observation unit, where he received
IV fluid hydration and antiemetics,
potassium repletion, and a urology
consultation. Per protocol, analgesics
were administered as needed while the
patient underwent frequent reevalua-
tions. His vomiting subsided with
treatment, and his diet was advanced.
Serial laboratory tests revealed
improvement in his electrolyte levels.
Urology recommended urine
straining, oral hydration, and
outpatient follow-up care. After a
16-hour stay, the patient was stable
enough for discharge and was given
a prescription for nonsteroidal
analgesics. He provided high
satisfaction scores via an online survey.
Alliance (EDOBA): characteristics of high volume
teaching hospital observation units. Acad Emerg Med.
2009;16:S251-S252.
10. American College of Emergency Physicians. State
of the Art: Observation Units in the Emergency
Department. Policy Resource and Education Paper.
Dallas, TX: American College of Emergency Physicians;
2011.
11. Mace SE, Graff L, Mikhail M, Ross M. A national survey
of observation units in the United States. Am J Emerg
Med. 2003 Nov;21(7):529-533.
12. Napolitano JD, Saini I. Observation units: definition,
history, data, financial considerations, and metrics.
Curr Emerg Hosp Med Rep. 2014 Mar;2(1):1-8.
13. Wiler JL, Ross MA, Ginde AA. National study of
emergency department observation services.
Acad Emerg Med. 2011 Sep;18(9):959-965.
14. Policy statement: emergency department observation
services. American College of Emergency Physicians
website. https://www.acep.org/globalassets/new-
pdfs/policy-statements/emergency-department-
observation-services.pdf. Updated October 2015.
Accessed September 28, 2016.
The LLSA Literature Review
Brief Resolved
Unexplained Events
By Andrew Loomis MD, LCDR; and Daphne Morrison Ponce MD, LCDR
Naval Medical Center, Portsmouth, Virginia
Reviewed by Andrew Eyre, MD, MHPEd
Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief resolved unexplained events (formerly apparent life-threatening
events) and evaluation of lower-risk infants: executive summary. Pediatrics. 2016 May;137(5).

Infants frequently present to the emergency department for episodes that trigger parental
concern, even after the initial event has resolved. Before 1986, many of these cases were
attributed to near-miss sudden infant death syndrome (SIDS); in 1986, SIDS was replaced by a
new term: apparent life-threatening event (ALTE). This updated clinical practice guideline by
the American Academy of Pediatrics has two primary objectives. First, it recommends replacing
the term ALTE with a new one: brief resolved unexplained event (BRUE). Second, it provides
guidance for the systematic, risk-based evaluation and management of these cases.

This summary outlines a three-step process
for the evaluation of a possible BRUE.
1. Is this a BRUE?
• Is the patient younger than 1 year?
• Is the patient well appearing?
• Did the child present following
a sudden, brief, resolved event
that included one or more of the
following: cyanosis or pallor;
absent, decreased, or irregular
breathing; a marked change in tone
(hyper- or hypotonia); or altered
responsiveness?
• Is the event unexplained (eg, no
history or symptoms of gastro­
esophageal reflux disease [GERD],
feeding difficulties, or airway
abnormalities)?
If the answer to any question is NO,
BRUE should be ruled out, and
the patient should undergo further
evaluation. If the answer to all four
questions is YES, BRUE should be
KEY POINTS
n Children who meet the criteria for BRUE without high-risk features can be
safely discharged without undergoing invasive testing, diagnostic imaging,
or inpatient admission.
n There are no formal guidelines regarding the evaluation or disposition of
high-risk BRUE cases.
n The patient’s parents should be involved in clinical decision making.
diagnosed, and risk stratification
should proceed.
2. Is the patient low risk?
• Is the child older than 60 days?
• Was the child born at or after
32 weeks of gestation, and is the
corrected gestational age 45 weeks
or more?
• Did the event last less than
1 minute?
• Is this the first such event?
• Are the patient’s history and
examination normal (eg, no family
history of sudden cardiac death;
no nondiagnostic social, feeding,
or respiratory problems)?
If the answer to any question is NO
and the child required CPR by a
trained medical provider, the case
should be considered HIGH RISK.
Although these patients require further
evaluation, there is no evidence to
guide their management. If the answer
to the above questions is YES and no
CPR was required, the patient should
be considered LOW RISK; treatment
should proceed according to the following
guidelines.
3. When managing low-risk BRUE,
clinicians:
• SHOULD educate caregivers, provide
resources for CPR training, and use
a shared decision-making approach
regarding the child’s evaluation,
disposition, and follow-up care.
• MAY offer or consider pertussis
testing, obtain an ECG, and provide
brief monitoring (eg, pulse oximetry,
serial examinations).
• SHOULD NOT reflexively initiate
laboratory testing, diagnostic
imaging, GERD studies,
electroencephalography, or home
cardiac or respiratory monitoring.
In addition, there is no need
to prescribe GERD or seizure
medications or admit a low-risk
patient solely for cardiovascular or
respiratory monitoring.
DISCLOSURES
The views expressed in this article are those of the authors and do
not necessarily reflect the official policy or position of the Dept. of
the Navy, Dept. of Defense, or the US Government.
We are military service members. This work was prepared as
part of our official duties. Title 17 U.S.C. 105 provides that
“Copyright protection under this title is not available for any
work of the US Government.” Title 17 U.S.C. 101 defines a
US Government work as a work prepared by a military service
member or employee of the US Government as part of that
person’s official duties.

Critical Decisions in Emergency Medicine’s series of LLSA reviews features articles from ABEM’s 2019 Lifelong Learning and
Self-Assessment Reading List. Available online at acep.org/moc/llsa and on the ABEM website.

July 2019 n Volume 33 Number 7 25

 CME
Reviewed by Lynn Roppolo, MD, FACEP

Qualified, paid subscribers to Critical Decisions in Emergency Medicine may receive

CME certificates for up to 5 ACEP Category I credits, 5 AMA PRA Category 1
Credits™, and 5 AOA Category 2-B credits for completing this activity in its

QUESTIONS entirety. Submit your answers online at acep.org/cdem; a score of 75% or better
is required. You may receive credit for completing the CME activity any time within
3 years of its publication date. Answers to this month’s questions will be published
in next month’s issue.

1 In what pattern does a measles rash typically

spread?
A. Extremities to trunk and head
B. Head to trunk and extremities
C. Trunk to extremities only
D. Trunk to head and extremities
6 Which patient population is at greatest risk for
pertussis-related complications?
A. Children aged 2 to 5 years
B. Children aged 5 to 12 years
C. Infants aged 4 months to 1 year
D. Infants younger than 4 months

2 Which measles-related complication can arise

7 to 10 years after the acute illness? 7 The American Academy of Pediatrics recommends
oral antiviral varicella treatment for which group?
A. Myocarditis A. Unvaccinated children older than 12 years
B. Otitis media B. Unvaccinated children younger than 12 years
C. Pneumonia C. Vaccinated children older than 12 years
D. SSPE D. Vaccinated children younger than 12 years

3 A 17-year-old boy presents after his boarding

school roommate is diagnosed with mumps. He
explains that six of his classmates have been
8 A 13-year-old girl presents with a right-sided facial
droop for 1 day. She reports sustaining a minor
laceration to her right cheek 1 week ago, which was
diagnosed with the illness this week. The patient contaminated by horse manure. The patient is noted
previously received one dose of the MMR vaccine. to have right-sided facial weakness, weak closure of
Which post-exposure prophylaxis should be the right eye, and an absence of forehead wrinkling
administered? on the right side. She has no other symptoms, and
A. Immunoglobulin the rest of her physical examination is normal. Which
B. MMR vaccine diagnosis is probable?
C. MMR vaccine and IVIG A. Cephalic tetanus
D. Ribavirin B. Generalized tetanus
C. Localized tetanus

4 A fully vaccinated 17-year-old girl presents after

being exposed to her unvaccinated 14-year-old
D. Splanchnic tetanus

brother, who returned home from a school trip

2 days prior with a varicella rash. She reports that
she is 28 weeks pregnant. Which treatment should
9 Which treatment is an ineffective tetanus
prophylaxis?
A. Antibiotics
be administered as a post-exposure prophylaxis? B. DTaP
A. Acyclovir C. Tdap
B. IVIG D. TIG
C. Varicella vaccine
D. VariZIG
10
What second-line treatment should be administered
to a 4-month-old infant diagnosed with pertussis who

5 While culture is the gold standard, what is the

clinical study of choice for diagnosing pertussis?
is allergic to macrolide antibiotics?
A. Amoxicillin
A. Chest x-rays B. Cefdinir
B. Direct fluorescent antibody testing C. Ciprofloxacin
C. PCR testing D. Trimethoprim-sulfamethoxazole
D. Serology

26 Critical Decisions in Emergency Medicine

11 Which observation model is most efficient?
A. Unit based; closed 17 Which of the following patients is appropriate
for observation care?
B. Unit based; open A. 20-year-old asthmatic with complete symptom
C. Virtual; closed resolution after treatment
D. Virtual; open B. 60-year-old with a brief facial droop and
slurred speech that is now fully resolved

12 What is the approximate length of stay for most

patients who require observation?
pending a neurology consultation, telemetry
monitoring, MRI, and neurological checks
A. 2-4 hours C. 80-year-old with an acute hip fracture pending
B. 6-8 hours surgical repair
C. 12-18 hours D. An admitted patient who has been boarding
D. 24-48 hours in the emergency department due to inpatient
capacity overload

13 What percentage of observation patients can

be managed and discharged without inpatient
admission? 18
What resource should be referenced when
determining if a case warrants inpatient
A. 15% admission?
B. 50% A. CENTOR score
C. 80% B. Medical textbooks
D. 90% C. Milliman Care Guidelines or InterQual Criteria
D. The opinions of the nursing staff

14 Which Medicare program covers observation

services?
A. Part A outpatient services
19
B. Part B inpatient services
C. Part B outpatient services
D. Part D outpatient services
Which approach is most helpful when
developing observation protocols?
A. Create the protocol autonomously, without
input from consulting services or hospital
leadership
B. Include guidelines regarding inclusion/

15 Which of the following is considered a key metric

for tracking observation care?
A. The average emergency department length of stay
B. The final disposition of observation patients
C. The number of 72-hour emergency department
returns
D. The percentage of negative cardiac
catheterizations
20
exclusion criteria, ideal testing and treatment,
and disposition planning information
C. List all possible testing and treatment options
regardless of evidence
D. Write loosely defined guidelines to allow for
clinician discretion
Which of the following most accurately
describes the role of virtual observation?

16 For whom are observation services most

appropriate?
A. Patients who do not warrant inpatient admission
but require treatment beyond the scope of the
emergency department
B. Patients who require more than 2 midnights of
hospital care
C. Patients whose care is completed but whose ride
home may be delayed or prolonged
D. Stroke patients who require skilled nursing or
placement in a rehabilitation facility
A. Any policy that allows a clinician to place
patients under observation
B. Documentation that outlines a patient’s need
for observation after an insurance denial
C. The process of interspersing observation
patients among those on general admission
floors
D. Using telemedicine to provide services to
observation patients

ANSWER KEY FOR JUNE 2019, VOLUME 33, NUMBER 6

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
A C C B A D C A D B D C A A C D D B D D

July 2019 n Volume 33 Number 7 27

 zz
Drug Box
METHOHEXITAL
By Frank LoVecchio, DO, MPH, FACEP
Maricopa Medical Center, Phoenix, Arizona
Methohexital is a rapid anesthetic that can be used
in the acute setting for procedural sedation. As a
short-acting barbiturate, the drug produces cortical
and cerebellar sedation and hypnosis.
Dose
Adults and children: 1 mg/kg IV, then 0.5 mg/kg
every 2-5 minutes as needed
Induction: 50-120 mg (70 mg average) IV push at
10 mg (1 mL of 1% solution) over 5 seconds,
depending on the patient’s response
Pharmacokinetics
Half-life: 3-6 hours
Onset: Immediate (IV); 2-10 min (IM); 5-15 min (PR)
Duration: 10-20 min (IV); 45 min (PR)
Metabolism: Hepatically conjugated to inactive
metabolites; slow
Excretion: Urine; trace amounts of drug and/or
metabolites also excreted in feces and sweat
Precautions
Rare cases of laryngospasm have been reported.
In such cases, experts recommend administering
an additional dose.
Contraindications include porphyria (almost never
a concern in the emergency department) and a
known hypersensitivity to barbiturates.
Relative contraindications include cardiovascular
disease, hypotension, respiratory disease,
respiratory depression, and hypotension.
Methohexital should be used only when
continuous monitoring of respiratory (eg, pulse
oximetry) and cardiac function can be provided.
Resuscitative drugs and age- and size-appropriate
equipment for bag-valve-mask ventilation and
intubation should be readily available as well
as personnel skilled in airway management.
Deeply sedated patients should be continuously
monitored by a designated clinician (other than
the practitioner performing the procedure).
Pregnancy Category B
Tox Box
METHANOL POISONING
By Christian A. Tomaszewski, MD, MS, MBA, FACEP
University of California, San Diego
In 2018, more than 150 deaths in India were attributed to the consumption
of counterfeit liquor that had been laced with methanol. In recent months,
a number of American tourists have died mysteriously in the Dominican
Republic after drinking from their hotel minibars. Methanol, a substance
often used to extend the life of bootleg liquor, is widely suspected to be
the culprit. Also known as wood alcohol, methanol is found in carburetor
cleaner, windshield washer fluid, paint removers, and fracking fluid. The
toxin accounts for approximately 5,000 poisonings in the US every year.
Pharmacokinetics
• Potentially toxic dose: 0.1 mL/kg; potentially lethal dose: 1 mL/kg
• Peaks quickly (<1 hour) post ingestion
Mechanism of Action
• Methanol is hepatically metabolized to toxic acids.
• The metabolites formaldehyde and formic acid are toxic.
Clinical Manifestations (can be delayed by hours)
• Central nervous system: inebriation (less than with ethanol), headache
• Vision: blindness (ie, “snowstorm”)
• Gastrointestinal: vomiting, abdominal pain, pancreatitis
• Metabolic: anion gap acidosis (formate and lactate)
• Kidney: acute kidney injury (AKI)
Diagnostic Tests (if the patient is symptomatic or the ingestion is
intentional)
• Basic metabolic panel to screen for acidosis and AKI
• Osmol gap (insensitive)
• Serum methanol level (>10 mg/dL)
Treatment and Disposition
• Decontamination is ineffective.
• Folinic (or folic) acid: 1 mg/kg (up to 50 mg)
• Fomepizole (15 mg/kg IV) for suspected ingestions in patients with:
— Methanol level >20 mg/dL
— Osmol gap >10 mOsm/L
— Serum bicarbonate <20 mmol/L
• Hemodialysis in patients with:
— Severe refractory acidosis (pH <7.25)
— Methanol >50 mg/dL
— Visual complications
Disposition
• Discharge 4-6 hours after ingestion if bicarbonate and osmol gap levels
are normal. Admit if antidotal therapy or hemodialysis is required.