1. September 2012
ENVIRONMENTAL EMERGENCIES
From the Editors:
From the Site Administrator:
Do you remember the difference between a crotaline
and an elapid snake? Neither do we. That’s why the focus
of the fall edition of the PEMNetwork newsletter is
environmental emergencies. Hot and cold, bites and
stings, disasters and preparedness, you’ll find it all here.
"Welcome to the exciting new face of the
PEMNetwork. With new topic search-ability,
active group forums, and more collaborative
members than ever before, we continue to
innovate and educate. We are looking
forward to seeing you at the 2012 NCE where
the PEMNetwork will hold an open meeting
and present at the SOEM conferences.”
Contents:
Bath Salts..........................2
Lyme Disease........................3
BASE Camp...........................4
Hurricane Preparedness............5-6
EKG Feature: Hypothermia............7
Heat Illness........................8
Board Review: Bites and Stings...9-10
Altitude Illness...................11
Image Feature: Worms!.............12
Notes from the Sub-site Editors....13
[1]
- Angela Lumba, MD, FAAP
Washington University School of Medicine
PEMNetwork.org, Head Site Administrator

2. BATH SALTS
Sing-Yi Feng, MD FAAP
Assistant Professor of Pediatrics/Medical Toxicologist
UT Southwestern Medical Center at Dallas
“Bath salts” were first reported as drug of abuse to
the North Texas Poison Center in 2010. Since then, Poison
Centers across the United States have reported increasing
numbers of calls involving “bath salts”. These “bath salts”
usually contain mephedrone and
methylenedioxypyrovalerone (MDPV) and are insufflated or
“snorted” much like cocaine.
Mephedrone is a synthetic stimulant of the
amphetamine and cathionine class.
Methylenedioxypyrovalerone is also a synthetic stimulant
with effects similar to amphetamines. Both drugs have
been reported to cause agitation, euphoria, hypertension
and tachycardia. These effects resemble
methamphetamine and cocaine toxicity. Patients can also
develop hyperthermia and ultimately rhabdomyolysis, end
organ failure and possibly death from the use of “bath
salts.” So far, one
death in Florida in
2011 has been
attributed to the
use of bath salts.
Bath salts
are easily
purchased on the
Internet and at
“head shops.” It
is considered a
designer drug
because although
mephedrone and
MDPV have never
been used for
bath salts, they
are labeled as
such with the
phrase “Not for
Human
Consumption” in
order to bypass
the Federal
Analog Act. The
Federal Analog
Act of the United
States Controlled
Substance Act states that any chemical "substantially
similar" to a controlled substance listed in Schedule I or II
is to be treated as if it were also listed in those schedules,
but only if intended for human consumption. Many states
such as Florida have now made the substances contained
in bath salts illegal to own and sell. Also, as of September
7, 2011, The United States Drug Enforcement
Administration (DEA) used its emergency scheduling
authority to temporarily control mephedrone. This was
deemed necessary to protect the public from the
supposed hazard posed by the drug. Except as authorized
by law, this action will make possessing and selling
mephedrone or the products that contain it illegal in the
U.S. for at least one year while the DEA and the United
States Department of Health and Human Services conduct
further study.
[2]

3. LYME DISEASE
lymphatics to bone, synovial tissue, CNS,
heart, or skin. 25% of patients will have
Matthew Thornton, MD
common. Meningitis, cranial
neuropathies, and carditis are more
Yale University School of Medicine
Lyme Disease is the most common
vector-borne illness in the U.S. “Lyme
arthritis” was first described in 1976, with
multiple EM. Fever and myalgia are also
LYME DISEASE
serious complications. Heart block
responsive to antibiotics is the most
common manifestation of carditis.
the discovery of the causative spirochete,
Borrelia burgdorferi in 1981. Borrelia is
Late disseminated disease causes
“Lyme arthritis”, typically in the knee.
transmitted by the Ixodid tick and occurs
Arthritis resolves in 1-2 weeks, but even
untreated cases will eventually resolve.
primarily in New England, New York, the
mid-Atlantic Coast, Wisconsin, and
Recurrences are not uncommon.
Minnesota.
Animal studies have shown that
Serologic testing is an adjunct to
clinical diagnosis in disseminated disease.
infected ticks must feed for 36-72 hours in
ELISA for IgM and IgG may be sent, and if
positive, followed by confirmatory Western
order for transmission to occur, such that
the risk of transmission from a known tick
Blot. False-positive ELISA is extremely
bite is only 1-2%.
Lyme Disease is divided into 3
common.
Treatment of Lyme disease is a bit
chronological stages, all with different
tricky, with regimens differing based on
disease stage and manifestations. Tick
presentations and distinct pathology,
though there may be some degree of
bite prophylaxis is not recommended,
overlap. These stages are 1) Early
localized, 2) Early disseminated, and 3)
even in Lyme endemic regions, unless the
tick has been attached for >36 hours and
Late disseminated.
the patient is able to take doxycycline.
Early localized disease is treated with oral
Early localized disease occurs 1-55
days after a bite, involving the classic
doxycycline, amoxicillin, or cefuroxime for
erythema chronicum migrans (EM) rash at
the site of the bite, and may also include
14-21 days. Doxycycline has the
advantage of being active against possible
flu-like symptoms. A characteristic rash
coexisting ehrlichiosis. Disseminated
disease causing multiple EM or an isolated
and possible tick exposure are all that is
required for diagnosis and treatment.
nerve palsy requires a longer treatment of
Early disseminated disease occurs
3-10 weeks after a bite when the
21-28 days. Meningitis/encephalitis and
symptomatic carditis with heart block
spirochetes spread via blood or
require IV therapy with ceftriaxone, as
does persistent or recurrent arthritis.
1. Steere AC. Lyme disease. N Engl J Med 2001; 345:115.
2. Shapiro ED, Gerber MA. Lyme disease. Clin Infect Dis
2000; 31:533.
3. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical
assessment, treatment, and prevention of lyme disease,
human granulocytic anaplasmosis, and babesiosis: clinical
practice guidelines by the Infectious Diseases Society of
Incidence of
Lyme (per
100,000 pop.)
America. Clin Infect Dis 2006; 43:1089.
4. Centers for Disease Control and Prevention: Lyme
Disease. Accessed 7/3/12. http://www.cdc.gov/lyme/
[3]
Manifestations
Erythema migrans
rash (top)is caused
by local spread of
spirochetes. It is
nonpruritic and
nonpainful and lasts
1-2 weeks. Bells
palsy (middle) in
early disseminated
disease. Lyme
arthritis (above) is
a late
manifestation.

4. BASE CAMP
BASE Camp: A Multi-Institutional Teamwork and
Procedural Skills Simulation Training Conference for
Pediatric Emergency Medicine Fellows
Kevin Ching, MD
For more information, see:
PEMBasecamp.com
In order to provide similar experiences
for PEM fellows, BASE Camp assembled a
Weill-Cornell Medical Center
collaborative group of expert PEM faculty
In the fast-paced practice of emergency from 10 universities to develop an
intensive two-day multidisciplinary training
medicine, fellows must develop critical
skills and behaviors swiftly. From day one, program. Using state-of-the-art simulation
technology, BASE Camp provides new
PEM fellows are expected to develop an
fellows with an opportunity to begin
ability to lead a team under crisis
conditions, while possessing the technical developing hands-on experience and
proficiency to perform a staggering number proficiency in crucial teamwork and
of complex procedural skills. Yet, with only procedural domains.
Before arriving at BASE Camp, fellows
a 4-month pediatric residency requirement
are provided online an interactive prefor acute care, there is no guarantee that
conference introduction and overview of
graduating residents have been
teamwork concepts, emergency trauma
adequately prepared for this challenge.
procedural skills, the approach to a difficult
The probability is high that a new fellow
pediatric airway, and advanced airway
has never had the opportunity to insert a
techniques to establish a cognitive
chest tube or manage an infant in
framework for the 2-day course. In the
cardiopulmonary arrest. In addition to
course, fellows are challenged to
technical competency, fellows must
collaborate in teams, often as leaders, in
develop team leadership and crisis
varied resuscitations. Fellows are given
management skills, neither of which are
ample opportunities to learn, practice, and
likely to fully develop in residency.
apply advanced airway maneuvers, like
The ACGME requires that fellows
“learn the skills necessary to prioritize and the use of an intubating-LMA in a child with
a retropharyngeal abscess, or the video
simultaneously manage the emergency
laryngoscope in an adolescent with
care of multiple patients,” and that “they
laryngeal edema in anaphylaxis.
must have supervised experiences using
their technical/procedural and resuscitation Emergency trauma procedural skills like
cricothyroidotomy, chest tube
competency skills.” Such skills have
traditionally been acquired through “trial by thoracostomy, and pericardiocentesis are
fire” in the emergency department—with all practiced first on advanced trauma
simulators, then human cadavers and
the risks related to such practice.
animal tracheas, before applying these
skills together as teams during a largeBASE Camp: Basic Training for
scale multi-casualty trauma simulation.
Pediatric Emergency Medicine
Last year, BASE Camp hosted its 2nd
Fellows was developed to offer a highannual conference, training 24 first-year
impact, immersive, and standardized
PEM fellows from 13 fellowships across 8
learning solution that would level the
Northeastern states. Preliminary data has
playing field for incoming fellows and
shown that even among this population of
prepare them for the challenges of an EM
highly motivated learners, the opportunities
fellowship. BASE camp brings together
to acquire experience as team leaders in a
new first-year PEM fellows to collectively
resuscitation or inserting a chest tube are
introduce, review, and provide
limited. As BASE Camp looks forward to
opportunities to practice teamwork
introducing new educational strategies for
behaviors and critical emergency
its 3rd year this Fall, the hope is not only to
procedural skills. The first PEM “boot
provide experiences that foster complex
camp” of its kind in the Northeast, the
thought and decision making within a
inspiration for BASE Camp grew out of a
teamwork domain, but to provide practice
pediatric critical care program inspired by
in rare but critical emergency procedural
Nishizaki at the Childrenʼs Hospital of
skills.
Philadelphia.
[4]

5. HURRICANE PREPAREDNESS
Daniel Park, MD
Medical University of South Carolina
The 2012 hurricane season runs
from June 1 through November 30. This
• Learn about your community’s
emergency plans, warning signals,
year’s season is marked by the 20th
evacuation routes, and locations of
anniversary of Hurricane Andrew, the
catastrophic category 5 hurricane that
emergency shelters
• Inform local authorities about any
barreled through South Florida on
August 24, 1992. Andrew caused an
special needs. For children with
special health care needs it is
estimated 20-40 million dollars in
important to complete a health care
damage and killed at least 60 people.
For those living in hurricane prone areas,
summary, including names/contact
information for the child’s medical care
knowledge of hurricane readiness and
evacuation procedures is not only
providers. A two-week supply of
medications, equipment, supplies, and
prudent but essential. The Centers for
foods for special diets is also
Disease Control and the American
Academy of Pediatrics have outlined
recommended.
• Locate and secure important
specific steps for hurricane readiness
that will arm the prescient citizen with
documents
• Stock your home with emergency
the knowledge to protect one’s family
supplies. At minimum, this should
and vulnerable members of the
community.
include a 3-5 day supply of water (5
gallons/person) and non-perishable
Emergency care places the ABCs
paramount during an initial evaluation of
food, first aid kit, battery-powered
radio, flashlights, batteries, sleeping
any patient. Similarly, hurricane
bags/blankets, water-purifying
preparedness carries its own critical
reflexive moves: 1) Taking the first steps,
supplies (chlorine, iodine tablets, etc.),
baby food/supplies, toiletries, and an
2) Preparing to evacuate, and 3)
Completing your family disaster plan.
emergency kit for the car with food,
flares, booster cables, maps, tools, a
Taking the first steps
first aid kit, fire extinguisher, etc.
If you are under a hurricane watch or Preparing to evacuate
warning, the CDC advises the following:
If the forecast calls for a hurricane,
expect the need to evacuate and
[5]
Mass flooding prompts
helicopter rescues after Hurricane
Katrina (top, center); Hurricane
Victim holds a meal package
administered by U.S. Army (above).
Specific steps to ensure food and
water safety during hurricanes,
power outages, and floods can be
found at www.fda.gov.

6. prepare for it. When a hurricane watch is issued you
should:
• Living and learning spaces (including homes,
schools, and day-care facilities) are free from physical
• Never ignore an evacuation order
• Fill up your car’s gas tank/arrange for transport
• Fill up clean water containers
and environmental hazards to children
• Spaces where children play should be clear of
debris and free from environmental hazards to children
• Prepare an emergency kit for your car
• Cover windows and doors with plywood or boards
to reduce risk of flying glass
Completing your family disaster plan
It is important to meet with your family before a
disaster occurs to discuss the importance of preparation.
• Place pets and livestock in safe areas. Often,
animals are prohibited from emergency shelters.
If developmentally appropriate, discuss with children what
to do if the family is separated. Practicing the disaster
• Fill sinks and bathtubs with water for washing
plan is both a practical and essential exercise not only for
hurricanes, but for any emergency.
If ordered to evacuate:
Sources:
• Take only essential items with you
• Make sure the car’s emergency kit is ready
• Follow designated evacuation routes
• Stay indoors until authorities declare the storm over;
1. AAP Children and Disasters: Disaster preparedness to meet
children’s needs. Retrieved June 30, 2012, from http://www2.aap.org/
disasters/hurricanes-storms.cfm
2. AAP: Clinician Recommendations Regarding Return of Children
to Areas Impacted by Flooding and/or Hurricanes. Retrieved June 30,
if possible take shelter in a windowless, interior room or
2012, from http://www2.aap.org/disasters/pdf/Hurricanes-
closet. Stay away from all windows and exterior doors.
ReturnofChildren.pdf
3. CDC Emergency Preparedness and Response. Retrieved June
After the storm has passed, the American Academy of
Pediatrics recommends the following before children are
30, 2012, from http://www.bt.cdc.gov/
4. Food Facts from the U.S. Food and Drug Administration: What
returned to areas impacted by flooding and/or hurricanes:
Consumers Need to Know About Food and Water Safety During
• Basic utilities and public services should be reliably
re-established
Hurricanes, Power Outages, and Floods. Retrieved June 30, 2012, from
http://www.fda.gov/Food/ResourcesForYou/Consumers/ucm076881.htm
[6]

7. BABY, IT’S COLD
OUTSIDE!
J-waves
J-waves were noted on the
EKG (above), with
resolution on the repeat
EKG (right) after
rewarming.
EKG FEATURE:
Rahul Kaila, MD
University of Minnesota Amplatz Children's Hospital
This is a case of 14 y/o male who had altered mental status and was found to be hypothermic with a
temperature of 91 F on the street. His EKG showed Osborne or J wave ( marked in the EKG ) which is the
upward deflection at the junction of QRS and ST representing distortion in the earliest phase of repolarization.
J waves are usually observed in people suffering from hypothermia with a temperature of less than 32 C
though they may also occur in people with high blood levels of calcium, brain injury, vasoplastic angina.
[7]

8. The major outcome
determinant in heat
stroke is duration of
hyperpyrexia.
HEAT-RELATED ILLNESS
Amanda Greuter, MD
Childrens Medical Center of Dallas
Heat illness is defined as “the
inability to maintain normal body
temperature because of excess heat
hyperthermia (38-40*C),
and incoordination.
Heat stroke is a life-
production or decreased heat transfer
to the environment.” Heat stroke
threatening emergency, defined
as severe hyperthermia (>40*C),
occurs when the excess body
temperature results in cellular injury,
with severe CNS dysfunction.
Patients with heat stroke present
and is a common cause of morbidity
with hot, dry, ashen skin and can have
and mortality among athletes, with
mortality rates of nearly 10%.
significant end-organ involvement.
Profound peripheral vasodilation and
Acclimatization, or lack thereof,
thermal damage to the myocardium
can play a significant role in the risk for leads to decreased cardiac output and
heat illness. With prolonged exposure, shock. Acute tubular necrosis leading
cardiac output due to massive
peripheral vasodilation and a stressed,
dysfunctional myocardium (resulting
from thermal damage). Patients do
not often require aggressive volume
resuscitation as they are not typically
severely dehydrated. Inotropic
sweating rates increase, promoting
effective cooling as well as triggering
to renal failure, rhabdomyolysis,
hepatic failure, and DIC are common
increased aldosterone secretion (and
thus decreased sodium losses). Un-
manifestations. The major outcome
determinant in heat stroke victims is
acclimatized people are prone to
the duration of hyperpyrexia.
significantly greater salt losses and
less effective sweating.
Management of heat cramps and
heat exhaustion involve simple,
Heat illness can progress from
mild to severe depending on a variety
practical measures of removal from
heat, rest, and oral or IV fluid and salt
of factors, including acclimatization
replacement. Management of heat
and conditioning. Heat cramps are a
relatively minor condition occurring in
stroke involves immediate, active
cooling to a temperature of 38.5*C.
References:
Council on Sports Medicine and Fitness
well-acclimatized and conditioned
patients. Severe muscle cramps
This may be achieved by ice packs to
the neck, groin, and axilla, submersion
Stress and Exercising Children and Adolescents.
occur upon relaxation, contact with
in ice water, cooling blankets,
cold, or passive extension of a flexed
convection cooling with fans and mist,
limb. This occurs after inadequate salt cooled IV fluids, and lavage (gastric,
replacement causes electrolyte
depletion.
Heat exhaustion occurs primarily
bladder, peritoneal, thoracic) if
necessary. Ice water submersion is
support (specifically dobutamine,
which increases contractility while
maintaining peripheral vasodilation
and thus cooling) should be
considered early, with a goal to
maintain UOP>1mL/kg/hr.
Chemistries, creatine kinase, coags,
and urine should be used to assess for
end-organ involvement.
and Council on School Health. Climatic Heat
Pediatrics. 2011;128(3):e741-7.
Ewald MB, Baum CR. Environmental
Emergencies. In Fleisher GR and Ludwig S 6th
Edition Textbook of Pediatric Emergency
Medicine (783-6, 791-4). 2010. Philadelphia:
Lippincott Williams and Wilkins.
McLaren C, Null J, Quinn J. Heat Stress
most effective, but may be impractical,
From Enclosed Vehicles: Moderate Ambient
in un-acclimatized patients who have
either inadequate fluid or salt
with evaporative cooling the most
effective next choice. Sedation and
Temperatures Cause Significant Temperature
replacement. It is characterized by
profuse sweating, fatigue, weakness,
paralysis may be used to decrease
metabolic heat production. Heat
thirst, headache, vomiting, mild
stroke patients often have insufficient
[8]
Rise in Enclosed Vehicles. Pediatrics. 2005;
116:e109-112.
Smith JE. Cooling Methods Used in the
Treatment of Exertional Heat Illness. British J. of
Sports Med. 2005;39:503-7.

9. Snakes, Spiders, and
Scorpions
BOARD REVIEW:
BITES AND STINGS
Questions used with
permission by Jennifer
Pai, MD, editor of
Pediatric Emergency
Medicine Practice.
For full text and more
review topics, visit
EBMedicine.net.
1. Which of the following crotaline snakes causes
significant neurological toxicity with or with- out local
b. Crotaline snake: triangular head, elliptical pupils
c. Brown recluse spider: red hourglass -shaped mark
tissue damage and hemotoxicity?
on ventral abdomen
a.Cottonmouth snake
b.Eastern Diamondback Rattlesnake
d.Black widow spider: violin-shaped mark on dorsal
thorax
c. Mojave Rattlesnake
d.Copperhead snake
6. Which of the following statements regarding
Centruroides exilicauda scorpion stings is correct?
2. Which of the following is a common finding following
a. Local pain and paresthesias are decreased by
black widow spider envenomation?
percussion over the affected area
a. Severe local tissue damage at the site of the bite
b.Muscle pain and cramping
b.Young children are least severely affected
c. Severe cases include fasciculations, uncontrolled
c. Respiratory failure
muscle movements, and cranial nerve dysfunction
d.Thrombocytopenia
7. Which of the following is the best treatment modality
3. What is one of the most common toxicities following
brown recluse spider envenomation?
for dermatonecrosis caused by brown recluse spider
envenomations?
a.Dermatonecrosis
b.Neuromuscular weakness
c.Respiratory failure
a. Good local wound care, analgesia, and tetanus
prophylaxis
b.Hyperbaric oxygen therapy
c.Electric shock therapy
d. Dapsone or colchicine
4. What is the most appropriate treatment for rapidly
progressing local tissue swelling and hemotoxicity
following crotaline envenomation?
a. Fasciotomy
b.Corticosteroids
c.Constrictive tourniquet of affected extremity
8. Which of the following are important aspects for
treatment for coral snake envenomation?
a. Careful monitoring and support of respiratory
function
d.CroFab® antivenom administration
b. Repeated monitoring of coagulation profiles
c. Careful monitoring of the site of envenomation for
severe tissue damage
5. Which toxic species and matching distinguishing
physical characteristic is correct?
a. Eastern coral snake: red on black on yellow bands
see p. 9 for
answers and
discussion
[9]

10. Bites and Stings Answers
1. c. While local tissue damage is
venomous snake bites in the U.S.
They are identified by their triangular
head, elliptical pupils, and fangs.
the most common complication of
most crotaline bites, the venom of
Eastern Coral Snake has red on
yellow on black bands but is easily
the Mojave Rattlesnake contains a
potent neurotoxin, with clinical
confused with the nonvenomous
King Snake, leading to the saying,
presentation similar to coral snake
“red on yellow, kill a fellow; red on
(elapid) envenomation.
black, venom lack”. The black
widow spider is characterized by a
2. b. Black widow spider venom
lacks cytotoxic agents, so there is
red hourglass-shaped mark on its
abdomen, while the brown recluse
little to no local tissue injury.
has a violin-shaped mark on its
Instead, the venom decreases
acetylcholine reuptake, resulting in
BITES & STINGS
thorax.
severe muscle cramps, abdominal
pain and muscle spasm. Symptoms
can be managed with opioids and
6. c. The neurotoxins of C.
exilicauda scorpions cause
sympathetic and parasympathetic
benzodiazepines.
overstimulation, which may be
mistaken for seizure activity.
3. a. Brown recluse venom
contains many cytotoxic digestive
Catacholamine release may result in
enzymes, thus the hallmark of bites
is local tissue necrosis ranging from
mild to extensive.
myocardial damage and
dysrhythmias as well.
7. a. Tetanus status should be
addressed in all bites and stings.
reverse pathology at the site of
Rest and elevation to decrease
venom spread, analgesics, and
envenomation, does halt progression
of local toxicity, systemic
antihistimines for pruritis are typically
the only necessary care. Steroids,
dysfunction, and coagulopathy.
Repeat dosing may be needed in
antibiotics, dapsone, and hyperbaric
4. d. Antivenom, while not able to
severe cases. CroFab® is a
fragmented antibody which is less
antigenic than previous formulations,
with lower risk of serum sickness.
Fasciotomy, steroids, and
oxygen have been reported but not
shown to be effective.
8. b. Coral snake venom
produces systemic neurotoxicity,
tourniquettes are not recommended,
which may be delayed up to 18
hours after envenomation.
as these treatments may worsen
outcomes.
Envenomation can lead to loss of
muscle strength and paralysis, thus,
patients with a history of an elapid
5. b. Crotaline snakes, or pit
vipers, account for 99% of
bite should be observed in the
hospital for neurologic abnormalities.
[10]
Stay Away from these Bad
Boys!
Pictured above are a
water
moccasin (top),
scorpion, and
diamondback
rattlesnake.
Both snakes
EBMedicine.net
are of the
crotaline
CME Reviews >3
class.
years old are
downloadable
for free.

11. HIGH ALTITUDE ILLNESS
Bogota, Colombia (above) 8,661 ft (2640m) above sea level. As
a point of reference, the elevation of Denver, CO is 5280 ft
(1609m).
Lilia Reyes, MD
NYU Medical Center
Altitude illness is defined as the cerebral and
pulmonary syndromes resulting from an ascent to high
Treatment of AMS consists of halting further ascent
until symptoms resolve, or descent to lower altitude if
altitude, and represents a broad spectrum of pathology,
symptoms are not improving. Acetazolamide can also be
ranging from mild to life threatening. Hypobaric hypoxia
used as treatment or as a preventative medication, acting
results in a broad range of physiologic responses, including by causing a mild metabolic acidosis, increasing ventilatory
increased sympathetic activity (with increased cardiac
output), pulmonary vasoconstriction, and diuresis,
rate and thus the PaO2.
More serious altitude related illnesses include high
with eventual increase in hematocrit to increase
oxygen-carrying capacity. Three major
factors influence the incidence and severity
of altitude sickness; rate of ascent, altitude
achieved, and length of stay.
Acute Mountain Sickness (AMS) is the
most common form of altitude sickness,
occurring in approximately half of lowland-
altitude cerebral edema (HACE) and high
Children are at
greater risk of AMS
than adults due to
increased
susceptibility to
hypoxia.
altitude pulmonary edema (HAPE). HACE is
the most severe form of altitude sickness in
which hypoxia increases cerebral blood
flow, resulting in edema and decreased
integrity of the blood-brain barrier. It occurs
in 1-2% of individuals who ascend without
acclimatization and progresses from confusion
living individuals who ascend to >14,000 ft. It
presents (in order of prevalence) with headache, fatigue,
and truncal ataxia to coma, with a 60% mortality
rate among patients with coma. HAPE also occurs after
shortness of breath, dizziness, anorexia, and nausea/
excessive hypoxia, with edema resulting from alveolar
vomiting. AMS typically occurs 8-36 hours after arrival at
altitudes above 8200 ft (2500m). Of note, children are at
capillary membrane leak, increased ADH and resultant
overload, and inflammatory cytokine release. Treatment of
greater risk of AMS due to increased susceptibility to
hypoxia and V/Q mismatch. Age less than 1 year,
both consists of descent from altitude, oxygen, bed rest,
and dexamethasone. Dexamethasone’s mechanism of
prematurity, systemic disease, and respiratory infections
action is unknown, but has been proven somewhat
are all risk factors.
effective in management of altitude illness.
[11]

12. FEATURE PHOTO: NAME THAT PARASITE
Santi Mintegi
Pediatric Emergency Department. Cruces University Hospital. Bilbao
Professor of Pediatrics. University of the Basque Country
“A fellow came one night
some months ago to my
office showing me what I
send to you. She told me
that boy's parents found it in
the stools. Grandpa is a
hunter.”
Ascaris
lumbricoides
Ascariasis is a nematode (roundworm) and one of the most common human parasitic infections worldwide.
Transmssion occurs via ingestion of contaminated water or food, or less commonly, contaminated soil. Its prevalence
is greatest in tropical climates, with the majority of infections in Asia, Africa, and South America. Often, there are no
symptoms with an A. lumbricoides infection. However, in the case of a particularly bad infection, symptoms may
include bloody sputum, cough, fever, abdominal discomfort, or passing worms. Most diagnoses are made by
identifying the appearance of the worm or eggs in feces. Due to the large quantity of eggs laid, physicians can
diagnose using only one or two fecal smears.
Infections can be treated with drugs called ascaricides. The treatment of choice is mebendazole. The drug
functions by binding to tubulin in the worms' intestinal cells and body-wall muscles.
[12]

13. NOTES FROM OUR SUB-SITE EDITORS
From the Fellowship Corner:
Hello everyone,
Over these past few weeks, we
recommendation, and suggestions on
what to include in your personal
have been hard at work updating the
statement. We have also included a
fellowship subsection of
PEMNetwork.org so that it contains
list of suggested questions to ask on
your interview days along with some
even more helpful information for the helpful tips on how to schedule
upcoming PEM fellowship application interviews and even arrange your
season.
travel plans.
The Applicant's Corner has been
updated to include the application
We look forward to hearing your
suggestions on how we can continue
timeline for the 2012 season. We have to improve the Applicant's Corner.
also included a variety of topics to
help you through this application
- Saranya Srinivasan, MD
season. We have included general
application tips, advice on how and
Boston Combined Residency
Program in Pediatrics
From the Ultrasound
Subsite:
The PEM Fellows ultrasound
subsite includes a list of ultrasound
fellowships, cases and teaching
points. We welcome submissions
for interesting cases and hope to
see the subsite continue to grow.
- Catherine Chung, MD
Inova Fairfax Hospital for Children
when to ask for letters of
Editors:
Purva Grover
Michelle Alletag
Angela Lumba
Send Us Your Cases!
We are currently accepting case reports, interesting photos, radiographic
images, and EKGs for our winter newsletter.
[13]