ACEP News - June 2008 - (Page 18)

18 ACEP NEWS • J U N E 2 0 0 8 CONTINUING Continued from previous page as hematocrit increase greater than 20%) are evident, the intravascular volume deficit must be corrected using isotonic fluids. Normal saline solution (20 mL/kg boluses) can be administered every 15 minutes as needed. If improvement does not result despite aggressive hydration, or if hemoconcentration is present, consider internal bleeding that may require a blood transfusion. If the patient is coagulopathic, treat with fresh frozen plasma. Intravenous fluids can be stopped once the patient is hemodynamically stable, intravascular volume is restored, and hematocrit reaches 40%, to avoid fluid overload. The patient can be discharged from the hospital once he or she is afebrile, tolerating oral ingestion, and experiencing no respiratory difficulty, and has a platelet count above 50,000 per microliter, hematocrit returned to baseline, and normal renal function. Dengue Hemorrhagic Fever/ Shock Syndrome Dengue hemorrhagic fever was first recognized and described in the Philippines in 1953. The incidence of DHF has increased in Latin America and the Caribbean and throughout the Western Hemisphere during the past 2 decades.10 DHF is the most severe manifestation of dengue fever. The WHO states that the incidence of DHF is around 500,000 cases, with 22,000 deaths every year, especially children. Prior to 1970, only nine countries had reported cases of DHF. Today, that number has multiplied four times and is expected to continue to rise. The WHO has specific clinical criteria for the diagnosis of DHF (see sidebar). Dengue hemorrhagic fever is caused by the same virus as dengue. It should be suspected in patients with hemorrhagic signs, such as mucosal or gastrointestinal bleeding, petechiae, ecchymoses, or purpura, and thrombocytopenia. Dengue shock syndrome is characterized by the presence of dengue hemorrhagic criteria, as well as hypotension, tachycardia, cold clammy skin, and altered mental status. Currently, mortality is less than 1%. Summary Dengue fever is a global epidemic that is currently increasing its presence in the United States. The disease is characterized by high fever, 2- to 7day evolution, rash, retro-orbital headache, joint pain, and back pain. Emergency physicians should recognize key clinical findings that may predict hemorrhagic complications and shock. Hemoconcentration, a positive tourniquet test, and signs of hemodynamic instability are some findings that may portend an adverse MEDICAL EDUCATION mannitya S., et al. Early clinical and laboratory indicators of acute dengue illness. J. Infect. Dis. 1997;176:313-21. 10. Gubler D.J. Dengue and dengue hemorrhagic fever. In: Guerrant R., Walker D., Weller P., eds. Tropical infectious diseases. 2nd ed. Philadelphia: Elsevier;2006:813-22. 11. Centers for Disease Control and Prevention. Underdiagnosis of dengue—Laredo, Texas, 1999. MMWR 2001;50:57-9. 12. Price D., Dengue Fever. Emedicine Web MD. Emergency Medicine/ Infectious Diseases. January 2008. www.emedicine.com/emerg/ topic124.htm. Contributors Dr. Cabañas is academic chief resident in the Emergency Medicine Program at the Universi- outcome such as DHF and/or dengue shock syndrome. ■ References 1. Centers for Disease Control and Prevention. Dengue Fact Sheet, 2005, p. 1-3. 2. World Health Organization. Dengue hemorrhagic fever: diagnosis, treatment, prevention and control. 2nd ed. Geneva, Switzerland: World Health Organization, 1997. Available at www.who.int/csr/resources/publications/dengue/Denguepublication/en/. 3. Morens D.M., Sather G.E., Gubler D.J., Rammohan M., Woodall J.P. Dengue shock syndrome in an American traveler. Am. J. Trop. Med. Hyg. 1987;36:424-6. 4. Benedict M.Q., Levine R.S., Hawley W.A., Lounibos L.P. Spread of the tiger: global risk of invasion by the mosquito Aedes albopictus. Vector Borne Zoonotic Dis. 2007;7:76-85. 5. Effler P., Pang L., Kitsutani P., et al. Dengue fever, Hawaii, 2001–2002. Emerg. Infect. Dis. [serial on the Internet]. 2005 May. Available at www.cdc.gov/ncidod/EID/vol11no05/ 04-1063.htm. 6. Centers for Disease Control and Prevention. Dengue Hemorrhagic Fever— U.S.-Mexico Border, 2005. MMWR 2007;56:785-9. 7. Rigau-Perez J.G., Laufer M.K. Dengue-related deaths in Puerto Rico, 1992-1996: diagnosis and clinical alarm signals. Clin. Infect. Dis. 2006;42:1241-6. 8. Centers for Disease Control and Prevention. Dengue outbreak associated with multiple serotypes—Puerto Rico, MMWR 1998;47:952-6. 9. Kalayanarooj S., Vaughn D.W., Nim- Focus On: Dengue Fever This educational activity should take approximately 1 hour to complete. The participant should, in order, review the learning objectives, read the article, and complete and return the CME post-test/evaluation form to ACEP to receive 1 ACEP Category 1 credit and 1 AMA/PRA Category 1 credit. Please return the entire form. Mail the completed post-test/evaluation form with your check for $10 payable to the American College of Emergency Physicians, ACEP News CME, P.O. Box 619911, Dallas, TX 75261-9911. Or fax the test and evaluation to 972-580-2816. You MUST complete both the test and the evaluation form to receive credit. You will receive your CME certificate in 2-3 weeks. Or take the quiz online at www.ACEP.org/focuson. The credit for this CME activity is available through May 31, 2011. 1. All of the following are WHO criteria of DHF except: A. Platelets <100,000/mm3. B. Positive tourniquet test. C. Hyponatremia. D. Hemoconcentration. 2. Which of the following are symptoms of dengue? A. Fever of 2-7 day duration. B. Rash. C. Retro-orbital headache. D. All of the above. 3. Which of the following statements about dengue fever is correct? A. The traditional mosquito vector is known as Aedes albopictus. B. The disease is exclusive to tropical regions. C. It is a common arboviral illness also known as “break bone fever.” D. None of the above. 4. Which of the following treatment strategies should be avoided in dengue fever and DHF? A. Acetaminophen. B. Aspirin. C. Normal saline infusions. D. Fresh frozen plasma. Evaluation 1. The learner objectives (stated at the beginning of the educational activity) are met. A. Strongly agree B. Agree C. Disagree D. Strongly disagree 2. The content of the educational activity is of high quality and relevant to my practice. A. Strongly agree B. Agree C. Disagree D. Strongly disagree 3. The content of the educational activity is presented in an objective, unbiased manner. A. Strongly agree B. Agree C. Disagree D. Strongly disagree 4. What I learned will result in a change in my practice or treatment of patients. A. Strongly agree B. Agree C. Disagree D. Strongly disagree Please Print Date Name ACEP Member ID # Address City / State / Zip Telephone ( ) Fax ( ) E-mail My check for $10 is enclosed VISA MasterCard American Express Card # Exp. Name on Card Signature 6/08 http://www.cdc.gov/ncidod/EID/vol11no05/04-1063.htm http://www.cdc.gov/ncidod/EID/vol11no05/04-1063.htm http://www.who.int/csr/resources/publications/dengue/Denguepublication/en/ http://www.who.int/csr/resources/publications/dengue/Denguepublication/en/ http://www.emedicine.com/emerg/topic124.htm http://www.emedicine.com/emerg/topic124.htm http://www.ACEP.org/focuson

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ACEP News - June 2008 Contents News - Time to Move Tricks of the Trade - Revealing Tips Focus On - Dengue Fever Practice Trends - EMTALA Results

ACEP News - June 2008

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