A Previously Healthy Infant with Lemierre Syndrome in the Emergency Department: Case Report.

INTRODUCTION: Lemierre syndrome (LS) is a rare condition with a high mortality risk. It is well described in older children and young adults involving bacteremia, thrombophlebitis, and metastatic abscess commonly due to Fusobacterium infections. Young, pre-verbal children are also susceptible to LS; thus, careful attention must be given to their pattern of symptoms and history to identify this condition in the emergency department (ED). CASE REPORT: A 12-month-old previously healthy boy with a recent diagnosis of acute otitis media and viral illness presented to the ED with a complaint of fever. Additional symptoms developed at the head and neck and were noted on subsequent ED visits. Advanced imaging revealed significant lymphadenopathy and deep space inflammation extending to the mediastinum. Subsequent imaging confirmed extensive sinus and deep vein thromboses, consistent with LS. Methicillin-resistant Staphylococcus aureus (MRSA) was the only organism identified. After surgical debridement, appropriate intravenous antibiotics, and heparin anticoagulation therapy, the patient experienced full recovery after prolonged hospitalization. CONCLUSION: A febrile infant with multiple acute care visits and development of lymphadenopathy, decreased oral intake, decreased cervical range of motion, and sepsis should raise suspicion for Lemierre syndrome. The medical evaluation of deep neck spaces and deep veins should be similar to that of older children and adults with LS, including advanced imaging of the head and neck. However, medical management should particularly target MRSA due to its emerging prevalence among infantile LS cases. Further research is necessary to determine the optimal management strategies of LS for this age group.

Pediatric Simulation-Based Prehospital Training Course in Botswana.

Audience: This simulation-based training focuses on the most common and high risk pediatric prehospital scenarios in low- and middle-income countries (LMIC). The curriculum was developed based on a needs assessment to train Ministry of Health and Wellness (MOHW) prehospital providers in Botswana specifically for pediatric resuscitation and could be used for emergency medical services (EMS) providers in other LMIC. After participating in this curriculum, providers should enhance their assessment and interventions in acutely ill pediatric prehospital patients. Length of Curriculum: The entire course was designed to be presented over two days with 6-8 hours of instruction each day. Introduction: In recent years, prehospital medicine has shown continued growth in LMICs, specifically in Sub-Saharan Africa. As these programs develop focused training for the pediatric population, equipping the workforce with pediatric resuscitation skills is essential. A few years after its inception, the Botswana MOHW identified deficiencies in their current training program and sought external expertise and educational training. We partnered with the MOHW to create and implement a novel, prehospital simulation curriculum to teach pediatric resuscitation to prehospital providers. Our aim was to create a curriculum based on the needs of the community that could also be implemented in other similar resource-limited settings. This course included didactic sessions, five simulation scenarios using low fidelity mannequins and three pediatric-focused skill sessions. This program was found to be effective based on statistically significant improvement in written and simulation post-test scores. Educational Goals: The objective of this educational project was to design, implement, and evaluate a curriculum relevant to an EMS system based in a LMIC, so that it could be a basis for curricula for use in similar contexts. The educational goal is to improve prehospital providers performance in common pediatric resuscitations. Educational Methods: The educational methods used in this curriculum included simulation using rapid cycle deliberate practice (RCDP), didactic lectures, and hands on skills training for common pediatric scenarios. Outcomes were measured by comparing performance on written and simulation-based pre-and post-tests. Research Methods: Participants completed written and simulation-based pre- and post-tests covering the concepts taught in the curriculum. Continuous variables (written and simulation test scores) were compared between two dependent groups (pre- and post-trainings) using paired t-tests. Results: Mean written test scores increased by 11%, from 75% to 86% (p<0.0001), while mean simulated test scores increased by 22% (from 56% to 78 % (p<0.0001). Discussion: The curriculum we developed focused on high-yield pediatric skills based on the needs of the Botswana MOHW EMS program. We believe simulation training was an excellent and effective method for this type of training. We specifically designed RCDP scenarios for the training, due to the limited experience of the prehospital providers at that time. RCDP offers ample opportunities for feedback with immediate practice and improvement. Trainees demonstrated retention of knowledge and improved performance in simulation-based testing. The overall satisfaction level of the trainees was high and suggests additional training would be beneficial and desired. Additionally, as the results of our needs assessment mirrored common chief complaints in other LMIC countries in Sub-Saharan Africa1,2 we feel that this curriculum can be utilized and adopted with minor modifications in other LMIC settings, particularly where EMS programs are developing and in circumstances where few EMS providers have had extensive field experience. Topics: Respiratory distress, asthma, dehydration, hypovolemic shock, hypoglycemia, seizure, toxic ingestion, newborn resuscitation, precipitous delivery, traumatic injury, EMS, Botswana, global health, collaboration, rapid cycle deliberate practice (RCDP), medical simulation.

Posterior Reversible Encephalopathy Syndrome (PRES).

Audience: Emergency medicine residents of all levels. Introduction: Posterior reversible encephalopathy syndrome (PRES) is a clinically significant cause of seizures, headache, neurologic deficit, and hypertensive emergency that is not uncommon in the emergency department. Posterior reversible encephalopathy syndrome was initially described as a clinical syndrome in 1996.1 It is an important cause of hypertensive emergency that is not often covered in depth in the emergency medicine curriculum since the true incidence and disease process continues to be researched.Populations who are at most risk for PRES include those with chronic hypertension, chronic renal disease, autoimmune disease, and immune suppression.2 Patients with PRES will often present with varied forms of encephalopathy and sometimes even focal neurologic symptoms that would suggest a cerebral vascular accident. These neurologic symptoms can include visual complaints and headache. Seizures are also frequently reported in association with PRES.3Early identification and appropriate management of PRES decreases morbidity and mortality without chronic neurologic sequelae. The pillars of diagnosis and management can be initiated in the emergency department. This includes a diagnosis made by a thorough history and physical exam and cerebral imaging.4 The mainstay of management is parenteral anti-hypertensives with proper blood pressure monitoring.5. Educational Objectives: By the end of the simulation, the learner will be able to: 1) manage an acute seizure 2) discuss imaging modalities to diagnose PRES 3) discuss medical management of PRES. Educational Methods: This simulation exercise is meant to be presented as a traditional medium-to-high-fidelity medical simulation case. With minor adjustments, it could be utilized as a low-fidelity case or an oral exam case. Research Methods: The educational content and general usefulness of this simulation was evaluated by open verbal (qualitative) feedback from a convenience sample of random participants following a completion of the case and debriefing by a participant group (n=30) of emergency medicine residents at a large 3-year residency training program. Results: The overall feedback was positive. Participants felt that it was a good opportunity to practice identifying PRES and managing it in a safe learning environment. They especially appreciated learning more about the pathophysiology of PRES, the high-risk factors for PRES, and management of the condition. Discussion: Posterior reversible encephalopathy syndrome, an uncommon condition, presents similar to many other benign and common complaints. It is crucial to be able to differentiate PRES from other causes of headache, visual disturbance, and seizures. It is important to keep PRES in mind when considering hypertensive emergencies. Many PGY-1 residents struggled to diagnose and treat PRES because it was often not on their differential, and this case helped broaden their differential. PGY-2 and PGY-3 were more frequently able to appropriately diagnose and treat PRES in this patient but found the case to be helpful in their decision-making and learning more about PRES pathophysiology. This case and associated high-yield debriefing session were effective for learners of all levels. Topics: Posterior reversible encephalopathy syndrome (PRES), altered mental status, seizure, headache, hypertensive emergency.

Auricular Perichondritis after a "High Ear Piercing:" A Case Report.

Body piercings in sites other than the ear lobe are becoming increasingly popular. It is not uncommon for patients to present to the emergency department with complications resulting from body piercings. We present a 29-year-old female who underwent a "high ear piercing" which resulted in auricular perichondritis. Left untreated, this infection can progress and potentially result in permanent deformity of the external ear or invasive infection of the surrounding structures. It is important to properly diagnose auricular perichondritis, because unlike many more common soft tissue infections, which are usually due to common skin flora and are simply treated with anti-streptococcal or anti-staphylococcal antibiotics, auricular perichondritis is most commonly due to Pseudomonas aeruginosa. The treatment of acute auricular perichondritis specifically requires anti-pseudomonal antibiotic therapy, usually a fluoroquinolone, to avoid inflammatory and cosmetic complications. This case report focuses on the clinical diagnosis of auricular perichondritis, which can be easily misdiagnosed or mistreated on initial assessment in an emergency setting. Topics: Auricular perichondritis, ear piercing, cartilaginous piercing, otalgia.

A Pediatric Emergency Medicine Refresher Course for Generalist Healthcare Providers in Belize: Respiratory Emergencies.

Audience and type of curriculum: This is a refresher curriculum utilizing multiple methods of education to augment the skills of generalist healthcare providers in low- and middle-income countries (LMICs) in the identification and stabilization of pediatric respiratory emergencies. Our audience of implementation was Belizean generalist providers. Length of curriculum: Nine hours. Introduction: In the pediatric population, early recognition and stabilization can improve patient outcomes. Compared with many Western systems that rely on specialists and even subspecialists, in many lower-resource settings, generalists provide most emergency medical care. The purpose of this module is to present a curriculum focused on the identification and stabilization of common pediatric respiratory emergencies for general practitioners (physicians and nurses) working in the acute care setting. Our aim is to provide a care framework and refresher training for the management of pediatric respiratory emergencies for providers who may regularly see the acutely ill pediatric patient but who may not have had recent or any extensive teaching in the management of acute pediatric airway management, bronchiolitis, pneumonia, and asthma. Educational Goals: This curriculum presents a refresher course in recognizing and stabilizing pediatric acute respiratory complaints for generalist healthcare providers practicing in LMICs. Our goal is to implement this curriculum in the small LMIC of Belize. This module focuses on common respiratory complaints, including asthma, bronchiolitis, pneumonia and acute airway management. Educational Methods: The educational strategies used in this curriculum include didactic lectures, medical simulation, small-group sessions, and a skills lab. Research Methods: We scored written pretests before and posttests after intervention and retested participants to evaluate for knowledge retention. Participants provided qualitative feedback on the module. Results: We taught 26 providers. Twenty-one providers completed the posttest and eight completed the retest. The mean test scores improved from 8.3 ± 2.8 in the pretest to 9.7 ± 1.3 to the posttest (mean difference = 1.4; P = 0.027). The mean test score at pretest was 8.0 ± 4.0, which increased to 9.9 ± 2.5 at retest four months later (mean difference = 1.9, P = 0.049). Fifteen (71.4%) participants found the course "extremely useful," and 28 (28.5%) participants "very useful." Discussion: This curriculum is an effective and well-received training tool for Belizean generalist providers. Although limited by sample size and 20% attrition for the retest, there was a statistically significant improvement in test performance. We believe that our pilot in Belize shows that this type of refresher course could be useful for teaching generalist providers in LMICs to optimize care of the acutely ill pediatric patient with respiratory ailment. Evaluation of other modules in this curriculum, application of the curriculum in other locations, and measuring clinical patient outcomes will be included in future investigations. Topics: Medical simulation, rapid cycle deliberate practice (RCDP), Belize, bronchiolitis, pneumonia, asthma, airway, respiratory distress, low- and middle-income country (LMIC), collaboration, global health.