Volume 32 Number 8 August 2018 Tourist Trap The ease and speed of travel facilitate exposure to conditions not endemic to the area where patients seek treatment. With international travel on the rise, particularly during summer months, emergency physicians must be prepared to evaluate and manage patients who become ill abroad. It is critically important to build a framework for assessing returned travelers who present with fever, as such cases can pose serious threats to patients and public health. Feeling No Pain Emergency physicians manage a spectrum of acute medical and traumatic conditions that often require painful treatments. In such cases, aptly administered procedural sedation and analgesia can improve the experience for both the provider and the patient. Because the appropriate regimen varies based on the particulars of each case, clinicians should thoroughly understand the advantages and potential risks of sedatives, dissociative agents, and analgesics. THE OFFICIAL CME PUBLICATION OF THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS IN THIS ISSUE Lesson 15 n Fever in the Returned Traveler . 3 Critical Procedure .............................................. 13 Critical Decisions in Emergency Medicine is the official CME publication of the American College of Emergency LLSA Literature Review ......................................... 14 Physicians. Additional volumes are available. Critical Image .................................................. 16 EDITOR-IN-CHIEF Critical ECG .................................................... 18 Michael S. Beeson, MD, MBA, FACEP Northeastern Ohio Universities, Lesson 16 n Procedural Sedation .............................. 19 Rootstown, OH CME Questions ................................................ 30 SECTION EDITORS Drug Box/Tox Box .............................................. 32 Joshua S. Broder, MD, FACEP Duke University, Durham, NC Andrew J. Eyre, MD, MHPEd Brigham & Women’s Hospital/Harvard Medical School, Contributor Disclosures. In accordance with the ACCME Standards for Commercial Boston, MA Support and policy of the American College of Emergency Physicians, all individuals with control over CME content (including but not limited to staff, planners, reviewers, and Frank LoVecchio, DO, MPH, FACEP authors) must disclose whether or not they have any relevant financial relationship(s) to Maricopa Medical Center/Banner Phoenix Poison learners prior to the start of the activity. These individuals have indicated that they have and Drug Information Center, Phoenix, AZ a relationship which, in the context of their involvement in the CME activity, could be Amal Mattu, MD, FACEP perceived by some as a real or apparent conflict of interest (eg, ownership of stock, grants, University of Maryland, Baltimore, MD honoraria, or consulting fees), but these individuals do not consider that it will influence the CME activity. Joshua S. Broder, MD, FACEP; GlaxoSmithKline; his wife is employed by Lynn P. Roppolo, MD, FACEP GlaxoSmithKline as a research organic chemist. All remaining individuals with control over UT Southwestern Medical Center, CME content have no significant financial interests or relationships to disclose. Dallas, TX This educational activity consists of two lessons, a post-test, and evaluation questions; Christian A. Tomaszewski, MD, MS, MBA, FACEP as designed, the activity should take approximately 5 hours to complete. The participant University of California Health Sciences, should, in order, review the learning objectives, read the lessons as published in the print San Diego, CA or online version, and complete the online post-test (a minimum score of 75% is required) Steven J. Warrington, MD, MEd and evaluation questions. Release date August 1, 2018. Expiration July 31, 2021. Orange Park Medical Center, Orange Park, FL Accreditation Statement. The American College of Emergency Physicians is accredited ASSOCIATE EDITORS by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Wan-Tsu W. Chang, MD University of Maryland, Baltimore, MD The American College of Emergency Physicians designates this enduring material for a Walter L. Green, MD, FACEP maximum of 5 AMA PRA Category 1 Credits™. Physicians should claim only the credit UT Southwestern Medical Center, commensurate with the extent of their participation in the activity. Dallas, TX Each issue of Critical Decisions in Emergency Medicine is approved by ACEP for 5 ACEP John C. Greenwood, MD Category I credits. Approved by the AOA for 5 Category 2-B credits. University of Pennsylvania, Philadelphia, PA Commercial Support. There was no commercial support for this CME activity. Danya Khoujah, MD University of Maryland, Baltimore, MD Target Audience. This educational activity has been developed for emergency physicians. Sharon E. Mace, MD, FACEP Cleveland Clinic Lerner College of Medicine/ Critical Decisions in Emergency Medicine is a trademark owned and published monthly by the American Case Western Reserve University, Cleveland, OH College of Emergency Physicians, PO Box 619911, Dallas, TX 75261-9911. Send address changes and Nathaniel Mann, MD comments to Critical Decisions in Emergency Medicine, PO Box 619911, Dallas, TX 75261-9911, or to Massachusetts General Hospital, Boston, MA [email protected]; call toll-free 800-798-1822, or 972-550-0911. Jennifer L. Martindale, MD, MSc Copyright 2018 © by the American College of Emergency Physicians. All rights reserved. No part of this Mount Sinai St. Luke’s/Mount Sinai West, publication may be reproduced, stored, or transmitted in any form or by any means, electronic or mechanical, New York, NY including storage and retrieval systems, without permission in writing from the Publisher. Printed in the USA. David J. Pillow, Jr., MD, FACEP The American College of Emergency Physicians (ACEP) makes every effort to ensure that contributors to its UT Southwestern Medical Center, Dallas, TX publications are knowledgeable subject matter experts. Readers are nevertheless advised that the statements and opinions expressed in this publication are provided as the contributors’ recommendations at the time George Sternbach, MD, FACEP of publication and should not be construed as official College policy. ACEP recognizes the complexity of Stanford University Medical Center, Stanford, CA emergency medicine and makes no representation that this publication serves as an authoritative resource Joseph F. Waeckerle, MD, FACEP for the prevention, diagnosis, treatment, or intervention for any medical condition, nor should it be the basis for the definition of or standard of care that should be practiced by all health care providers at any particular University of Missouri-Kansas City School of Medicine, time or place. 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Marta Foster, Director, Educational Products ISSN2325-0186(Print) ISSN2325-8365(Online) Tourist Trap Fever in the Returned Traveler LESSON 15 By Lauren Page Black, MD, MPH; Andrew Martin, MD; and Elizabeth DeVos, MD, MPH Dr. Black is an emergency medicine fellow at the University of Florida, College of Medicine — Jacksonville. Dr. Martin is an attending physician in the Department of Emergency Medicine at Emergency Resources Group in Jacksonville, Florida. Dr. DeVos is an associate professor of emergency medicine and the medical director of International Emergency Medicine Education at the University of Florida, College of Medicine — Jacksonville. Reviewed by David J. Pillow, Jr, MD, FACEP OBJECTIVES On completion of this lesson, you should be able to: CRITICAL DECISIONS 1. List the elements of a complete travel history. n What specific details should be obtained when 2. Identify and manage cases of suspected malaria and inquiring about a patient’s travel history? viral hemorrhagic fever. 3. Synthesize an assessment based on involved organ n How should suspected malaria be approached, systems and travel history to identify high-risk and what other diseases should be considered? conditions in febrile returned travelers. n What are the potential causes of hemorrhagic 4. Recognize reportable causes of fever in the returned fever, and how should they be managed? traveler. n What diseases should be considered in a febrile FROM THE EM MODEL returned traveler with abdominal pain, respiratory 1.0 Signs, Symptoms, and Presentations complaints, or neurological symptoms? 1.1 Abnormal Vital Signs n Which diseases must be reported to the CDC? 1.1.2 Fever The ease and speed of travel facilitate exposure to conditions not endemic to the area where patients seek treatment. With international travel on the rise, especially during summer months, emergency physicians must be prepared to evaluate and manage those who become ill abroad. An estimated 64% of travelers become ill abroad.1 Fortunately, most of these diseases are mild and