1 00:00:00,000 --> 00:00:02,880 Lara : her blood pressure shot up and we gave her something to bring it down, and 2 00:00:02,880 --> 00:00:06,599 then it barreled and then bottomed out, and then we'd give her something to bring 3 00:00:06,599 --> 00:00:11,190 her back up and we're like, at some point, what could we And there was talk about 4 00:00:11,190 --> 00:00:14,600 moving her to ecmo, and her grandfather reached under the blanket and grabbed her 5 00:00:14,600 --> 00:00:16,595 hand and her blood pressure stabilized. 6 00:00:19,287 --> 00:00:22,047 Sam: Hi everyone, and welcome to another episode of EMPlify 7 00:00:22,047 --> 00:00:23,557 I'm your host, Sam Ashoo. 8 00:00:23,837 --> 00:00:27,787 Before we dive into this month's episode, I want to say thank you for joining us. 9 00:00:27,837 --> 00:00:31,377 I sincerely hope that you find it to be helpful and informative for your 10 00:00:31,377 --> 00:00:35,807 clinical practice, and I want to remind you that you can go to ebmedicine.net 11 00:00:35,877 --> 00:00:40,027 where you will find our three journals, Emergency Medicine Practice, Pediatric 12 00:00:40,037 --> 00:00:45,187 Emergency Medicine Practice, and Evidence Based Urgent Care, and a multitude of 13 00:00:45,207 --> 00:00:49,557 other resources, like the EKG course, the laceration course, interactive 14 00:00:49,557 --> 00:00:53,997 clinical pathways, just tons of information to support your practice 15 00:00:54,137 --> 00:00:55,747 and help you in your patient care. 16 00:00:56,017 --> 00:00:58,207 And now, let's jump into this month's episode. 17 00:00:58,817 --> 00:00:59,537 Lara: Hello. 18 00:00:59,767 --> 00:01:00,767 I'm Lara Zibners. 19 00:01:00,877 --> 00:01:06,137 I am a pediatric emergency medicine doctor, clinically now retired officially. 20 00:01:06,277 --> 00:01:07,837 I trained at Ohio State. 21 00:01:07,837 --> 00:01:09,757 I did medical school, residency, and fellowship 22 00:01:09,757 --> 00:01:11,457 there, and I had great training. 23 00:01:11,457 --> 00:01:14,907 I loved pediatric emergency medicine, and then I went to New York City 24 00:01:14,907 --> 00:01:16,887 and was an attending at Mount Sinai. 25 00:01:17,457 --> 00:01:23,277 And then in 2006 I moved to the UK because I was a trailing spouse. 26 00:01:23,637 --> 00:01:26,637 Ended up getting my UK license and had an honorary consultant 27 00:01:26,637 --> 00:01:30,567 post at St. Mary's and I also got a master's in medical education. 28 00:01:30,567 --> 00:01:33,267 I was quite involved with Advanced Trauma Life Support, and I became the 29 00:01:33,267 --> 00:01:37,217 emergency medicine rep to the steering group in the UK and then after I did 30 00:01:37,217 --> 00:01:42,707 my master's, I've been the national educator for the UK program since 2018, 31 00:01:42,707 --> 00:01:47,161 and I did a three year stint as educator to the board for Africa and Europe, so 32 00:01:47,161 --> 00:01:48,661 I've seen it kind of at a global level. 33 00:01:49,111 --> 00:01:54,131 And I also have an MBA from the University of North Carolina, and I now have a 34 00:01:54,131 --> 00:01:56,051 UK based women's healthcare startup. 35 00:01:56,051 --> 00:02:01,106 So I have really done everything and had about eight careers, but yes. 36 00:02:01,606 --> 00:02:03,501 Sam: And you have a relationship with EB Medicine. 37 00:02:04,201 --> 00:02:07,514 Lara: And I have been involved with EB Medicine since I think 2013. 38 00:02:08,214 --> 00:02:13,104 I came on as international editor of the Pediatric EM Practice. 39 00:02:13,454 --> 00:02:16,214 And I have done some peer reviewing for years. 40 00:02:16,214 --> 00:02:20,404 I was editor in chief of the trauma supplement for, I don't 41 00:02:20,404 --> 00:02:21,564 know, four or five years. 42 00:02:21,584 --> 00:02:24,849 I just passed that over to a dear friend of mine. 43 00:02:25,209 --> 00:02:31,081 And I, like a sucker, agreed to write a big article back in 2017 on 44 00:02:31,081 --> 00:02:34,521 something close to my heart, which is I've done a lot of vaccine advocacy. 45 00:02:34,521 --> 00:02:38,587 I was a regular contributor to Every Child By Two's website for a number of years. 46 00:02:39,007 --> 00:02:42,067 And so when they asked for an author for diphtheria, pertussis, 47 00:02:42,067 --> 00:02:44,077 and tetanus, raised my hand. 48 00:02:44,555 --> 00:02:45,095 Sam: Awesome. 49 00:02:45,245 --> 00:02:49,175 And we are happy that you raised your hand because it became the August 50 00:02:49,175 --> 00:02:53,025 2025 issue of Pediatric Emergency Medicine Practice and the reason 51 00:02:53,025 --> 00:02:54,315 why you're on the podcast today. 52 00:02:54,375 --> 00:02:57,552 So thank you for doing all of that, and then agreeing to be on the podcast. 53 00:02:58,203 --> 00:02:58,473 Lara: Yeah. 54 00:02:58,473 --> 00:03:00,933 EB Medicine and not, you know, Women's Health in the UK. 55 00:03:00,963 --> 00:03:02,206 No, I get why we're here. 56 00:03:02,206 --> 00:03:03,346 Thank you for having me. 57 00:03:03,870 --> 00:03:04,230 Sam: Yeah. 58 00:03:04,930 --> 00:03:09,520 So now we know why diphtheria, pertussis, and tetanus as a topic. 59 00:03:09,520 --> 00:03:12,565 You said a topic near and dear to your heart and for quite some 60 00:03:12,565 --> 00:03:18,115 time, I will say out of these three diseases, I've only seen pertussis 61 00:03:18,185 --> 00:03:20,405 in 20 years of clinical practice. 62 00:03:20,555 --> 00:03:24,335 I don't think I've ever come across a case of diphtheria or tetanus, knock on wood. 63 00:03:24,705 --> 00:03:26,932 Lara: You don't know for sure do you? 64 00:03:27,632 --> 00:03:28,396 Sam: That's a great point. 65 00:03:28,396 --> 00:03:29,446 That's a great point. 66 00:03:29,536 --> 00:03:30,676 I don't know for sure. 67 00:03:31,376 --> 00:03:34,226 Lara: You could have just totally missed it 'cause you didn't have this article. 68 00:03:34,710 --> 00:03:38,940 I've seen tetanus, I've seen lots of pertussis, lots of little blue babies, 69 00:03:39,000 --> 00:03:41,070 and lots of hacking, coughing kids. 70 00:03:41,360 --> 00:03:47,566 I have seen tetanus in a child when I was a fellow and it was, you know, 71 00:03:47,566 --> 00:03:51,796 we all learn from all of our patients and what I thought tetanus was before 72 00:03:51,796 --> 00:03:55,667 I learned what tetanus actually is and that little girl survived. 73 00:03:56,037 --> 00:03:57,337 But it was really heartbreaking. 74 00:03:57,747 --> 00:04:02,747 Because her family, she was from an Amish community that wasn't anti-vaccine. 75 00:04:02,927 --> 00:04:07,217 They just didn't know, they weren't connected with those community 76 00:04:07,217 --> 00:04:12,197 health sources, and her father was so upset when she was diagnosed and 77 00:04:12,197 --> 00:04:16,681 transferred to our that he brought in community health workers and had 78 00:04:16,681 --> 00:04:18,151 their entire community vaccinated. 79 00:04:18,780 --> 00:04:19,350 Sam: Wow. 80 00:04:20,050 --> 00:04:21,130 That's wonderful. 81 00:04:21,830 --> 00:04:22,800 What a cool outcome. 82 00:04:22,960 --> 00:04:23,110 And 83 00:04:23,110 --> 00:04:23,700 she survived. 84 00:04:23,700 --> 00:04:23,790 And 85 00:04:24,380 --> 00:04:24,890 Lara: she survived. 86 00:04:24,890 --> 00:04:27,230 She had a long road, but she survived. 87 00:04:27,350 --> 00:04:30,320 But that case stuck with me 'cause the whole family was there and you could 88 00:04:30,320 --> 00:04:33,612 just see how riddled they were with, you know, not just concern, but they 89 00:04:34,052 --> 00:04:35,128 didn't know what they didn't know. 90 00:04:35,828 --> 00:04:36,048 Sam: Wow. 91 00:04:36,503 --> 00:04:39,153 And probably saved her whole community just from that illness. 92 00:04:39,153 --> 00:04:39,273 Lara: That's 93 00:04:39,523 --> 00:04:39,993 Sam: pretty amazing. 94 00:04:40,016 --> 00:04:40,539 Lara: Hope so. 95 00:04:41,089 --> 00:04:42,009 Sam: What an amazing story. 96 00:04:42,228 --> 00:04:42,588 Okay. 97 00:04:42,648 --> 00:04:44,418 Well let's start with the diphtheria. 98 00:04:44,628 --> 00:04:50,158 So, of the three diseases here in the article, I think this is probably the 99 00:04:50,158 --> 00:04:55,438 one I know the least about because it's always been vaccine preventable and most 100 00:04:55,438 --> 00:05:00,188 of our community has been vaccinated here in Florida where I live, until recently. 101 00:05:00,468 --> 00:05:04,208 So it's going to be something that my partners and I are going to 102 00:05:04,208 --> 00:05:06,818 have to become adept at diagnosing. 103 00:05:07,068 --> 00:05:11,778 Tell me a little bit about what we know about diphtheria as far as 104 00:05:11,778 --> 00:05:15,133 what causes it and maybe some of the mortality associated with it. 105 00:05:15,163 --> 00:05:18,763 Lara: You're gonna make me go back to the thing here and look up what I said. 106 00:05:18,928 --> 00:05:19,603 'cause I'll tell you. 107 00:05:19,603 --> 00:05:24,943 So this article I originally wrote in 2017, it took me several months. 108 00:05:24,943 --> 00:05:28,078 I went through every resource because there's so much written, 109 00:05:28,078 --> 00:05:29,168 but so much of it's historical. 110 00:05:29,538 --> 00:05:35,812 So, not a lot new has happened other than vaccine changes and modifications. 111 00:05:36,178 --> 00:05:37,888 But diphtheria never left us. 112 00:05:38,158 --> 00:05:40,318 And so I did this article in 2017. 113 00:05:40,318 --> 00:05:44,278 In 2021, I think, I updated it again. 114 00:05:44,278 --> 00:05:45,418 Nothing had really changed. 115 00:05:45,848 --> 00:05:49,488 It had changed when I went to update it for this 2025 article, 116 00:05:49,788 --> 00:05:51,408 in the reporting conditions. 117 00:05:51,408 --> 00:05:54,188 Because all we used to see in the United States was cutaneous, 118 00:05:54,188 --> 00:05:56,088 which is generally localized. 119 00:05:56,088 --> 00:05:57,678 This is a corynebacterium.. Right. 120 00:05:57,918 --> 00:06:03,298 And localized disease was considered usually non toxigenic and local, and 121 00:06:03,298 --> 00:06:04,588 you could treat it with antibiotics. 122 00:06:04,588 --> 00:06:07,198 And there's a difference between toxigenic and non toxigenic, right? 123 00:06:07,228 --> 00:06:13,548 So the bacteria has to be infected with this toxigenic strain for it to form 124 00:06:13,548 --> 00:06:18,708 the diphtheria toxin, which causes all these systemic side effects, right? 125 00:06:18,708 --> 00:06:22,818 So, people think of diphtheria as just being a kid with a swollen neck 'cause 126 00:06:22,818 --> 00:06:25,848 that's the picture we all saw in our Zitelli when we were in training. 127 00:06:26,238 --> 00:06:31,348 But really, most people who get toxigenic diphtheria will have 128 00:06:31,348 --> 00:06:32,998 cardiac and neurologic complications. 129 00:06:33,852 --> 00:06:36,642 And other than with laryngeal, so you can have it in different 130 00:06:36,642 --> 00:06:39,822 locations, nasal, local, laryngeal. 131 00:06:40,385 --> 00:06:44,565 You get infected, the toxin starts to get produced, and then 132 00:06:44,765 --> 00:06:46,488 this causes the pseudo membrane. 133 00:06:47,188 --> 00:06:52,325 And in the pharynx, that pseudo membrane can obstruct the airway. 134 00:06:52,905 --> 00:06:54,375 So that's one of the causes of death. 135 00:06:54,375 --> 00:06:58,575 But the systemic effects of the toxin are largely cardiogenic, heart 136 00:06:58,575 --> 00:07:03,355 failure, arrhythmias all the associated bits and bobs, pulmonary edema. 137 00:07:03,565 --> 00:07:05,755 And then there are neurogenic complications. 138 00:07:05,975 --> 00:07:08,270 It used to be that local diphtheria, was not reportable. 139 00:07:08,790 --> 00:07:11,010 Because it wasn't considered a problem. 140 00:07:11,010 --> 00:07:14,620 And as of, I think last year, that guidance has been changed. 141 00:07:15,003 --> 00:07:20,143 So all cases of diphtheria, cutaneous or generalized, are reportable. 142 00:07:20,843 --> 00:07:25,493 And there have been actually cases of significant disease in 143 00:07:25,493 --> 00:07:27,443 people with non toxigenic strains. 144 00:07:27,593 --> 00:07:30,893 So this idea that we had in medical school of, okay, well it's either the 145 00:07:30,893 --> 00:07:33,743 good diphtheria or, as if there's good diphtheria, but you know what I mean? 146 00:07:33,923 --> 00:07:35,223 Good diphtheria, bad diphtheria. 147 00:07:35,243 --> 00:07:40,193 There have been cases of people getting severely ill with non toxigenic strains 148 00:07:40,523 --> 00:07:43,281 and there's enough existing there. 149 00:07:43,281 --> 00:07:48,081 I think the most recent big outbreak that I had read about was in parts of Russia. 150 00:07:48,081 --> 00:07:49,371 So this has never gone away. 151 00:07:49,371 --> 00:07:52,341 Just because we haven't seen it in the US does not mean that we haven't 152 00:07:52,346 --> 00:07:55,230 had disease presence around the world. 153 00:07:55,620 --> 00:08:00,580 And I think we had a death a year or so ago, not too long ago in the UK in an un 154 00:08:00,670 --> 00:08:04,720 immunized child, might have been in the last few years, but it's still out there. 155 00:08:04,720 --> 00:08:07,520 And I'm fearful as you just said, that we're gonna start seeing more of it. 156 00:08:07,780 --> 00:08:09,970 The one we worry about the most is laryngeal. 157 00:08:09,970 --> 00:08:14,666 That's the classic upper respiratory symptoms and then sore throat, 158 00:08:14,666 --> 00:08:16,166 and then you see this membrane. 159 00:08:16,546 --> 00:08:20,266 You do not want to pull the membrane off because it is really 160 00:08:20,266 --> 00:08:23,446 stuck in there and is gonna cause bleeding, if you try to yank it out. 161 00:08:23,866 --> 00:08:26,746 The bigger the membrane, probably the bigger the disease burden, 162 00:08:26,746 --> 00:08:31,006 because as the bacteria starts to produce toxin, the longer you're 163 00:08:31,006 --> 00:08:32,761 sick, the more toxin you produce. 164 00:08:32,761 --> 00:08:34,071 What's the treatment? 165 00:08:34,611 --> 00:08:35,335 Antitoxin. 166 00:08:36,085 --> 00:08:40,558 It only is going to bind the circulating toxin that has 167 00:08:40,558 --> 00:08:43,108 not yet clung to the tissues. 168 00:08:43,458 --> 00:08:47,478 So the longer you've been sick, the less effective your antitoxin's going to be. 169 00:08:47,523 --> 00:08:49,353 And then we can go into how you get antitoxin. 170 00:08:49,450 --> 00:08:51,790 I'll tell you, diphtheria is the one I'm the least familiar with. 171 00:08:51,790 --> 00:08:54,460 So I wrote this because I wanted people to have something you can go 172 00:08:54,460 --> 00:08:57,279 flip to the page and look for some great pictures in there about it. 173 00:08:57,279 --> 00:09:01,808 But I think the biggest take home for diphtheria is, it's not just 174 00:09:01,808 --> 00:09:02,938 about a membrane in your throat. 175 00:09:03,310 --> 00:09:06,580 Gotta make sure that you address the cardiac signs right away, getting 176 00:09:06,580 --> 00:09:11,760 the EKG, get this kid on intensive levels of monitoring cardiac enzymes, 177 00:09:11,760 --> 00:09:16,370 troponin, all your electrolytes, and be aware of the neurologic 178 00:09:16,370 --> 00:09:18,614 complications, and then go to battle. 179 00:09:19,314 --> 00:09:21,954 Sam: And those neurologic complications are treatable? 180 00:09:22,344 --> 00:09:26,824 Lara: Yes, the neurologic symptoms can be localized neuropathies and neuritis 181 00:09:26,884 --> 00:09:31,197 and in cases laryngeal can start sort of with some swallowing issues, 182 00:09:31,527 --> 00:09:34,997 paralysis of the soft palate, and then you can actually get peripheral 183 00:09:34,997 --> 00:09:40,377 neuritis that exists for weeks to months after the illness has run its course. 184 00:09:41,077 --> 00:09:46,077 Sam: And then in the article you mentioned that the fatality rate is 5 185 00:09:46,097 --> 00:09:50,405 to 10%, even in our modern medicine era. 186 00:09:51,080 --> 00:09:54,686 Lara: If you are treated in a high resource environment. 187 00:09:55,416 --> 00:09:56,196 Sam: Wow, that's crazy high. 188 00:09:56,713 --> 00:10:00,033 Lara: Yeah, I mean, when you think about that in numbers, if everyone's 189 00:10:00,033 --> 00:10:03,363 vaccinated and you only see one case in so many, but we're gonna 190 00:10:03,363 --> 00:10:04,283 start to see more and more of this. 191 00:10:04,983 --> 00:10:05,343 Sam: Yeah. 192 00:10:05,733 --> 00:10:10,823 And also the children under the age of five and adults over the age of 40 are 193 00:10:10,823 --> 00:10:14,283 at even higher risk for death, up to 20%. 194 00:10:14,533 --> 00:10:19,082 Lara: I think that stands for most of the diseases we see, right? 195 00:10:19,682 --> 00:10:24,242 It's gonna be the very young and the people my age and older that are gonna 196 00:10:24,942 --> 00:10:29,282 the vulnerable populations, which is why you vaccinate everybody for these 197 00:10:29,282 --> 00:10:32,845 things, because we're trying to protect the the vulnerable population, right? 198 00:10:32,845 --> 00:10:34,985 A baby under six months won't have seen a DPT. 199 00:10:35,469 --> 00:10:35,759 Sam: Okay. 200 00:10:36,219 --> 00:10:36,519 All right. 201 00:10:36,519 --> 00:10:43,009 And then, our next disease, pertussis, something we have seen here in the US 202 00:10:43,009 --> 00:10:45,979 recently, but may be seeing more cases of. 203 00:10:46,189 --> 00:10:47,016 Let's talk about that. 204 00:10:47,016 --> 00:10:49,386 So that's caused by bordetella pertussis. 205 00:10:49,626 --> 00:10:52,626 Supposedly gives you the classic whooping cough. 206 00:10:52,876 --> 00:10:56,241 But then there are some cases where that's not actually the case. 207 00:10:56,582 --> 00:11:00,949 Lara: So pertussis used to be called the a hundred day cough because it would give 208 00:11:00,949 --> 00:11:04,399 you that classic so that you know, you have a little bit of a cold, and then you 209 00:11:04,399 --> 00:11:06,379 start with this hacky, hacky, hacky cough. 210 00:11:06,752 --> 00:11:10,592 That cough can be so severe that people have broken ribs. 211 00:11:11,267 --> 00:11:14,607 There have been ruptured eardrums reported in literature. 212 00:11:14,907 --> 00:11:18,540 Post test of emesis is very, very common. 213 00:11:18,943 --> 00:11:22,760 It's just a horrible, horrible cough that disrupts people's lives. 214 00:11:22,760 --> 00:11:26,410 And actually there have been intracranial brain bleeds in one series that I read. 215 00:11:26,410 --> 00:11:27,850 I mean, it's not a joke, right? 216 00:11:27,850 --> 00:11:28,810 This a hundred day cough. 217 00:11:29,230 --> 00:11:34,634 The thing is, is the cough it is that whoop, that classic whooping cough sound 218 00:11:34,904 --> 00:11:38,385 comes from deep inspiratory intake. 219 00:11:39,075 --> 00:11:40,395 After your coughing, coughing, coughing. 220 00:11:40,395 --> 00:11:41,415 Cough, cough, cough, cough, cough. 221 00:11:42,222 --> 00:11:43,002 That's the whoop. 222 00:11:43,302 --> 00:11:46,122 Babies don't have the inspiratory strength to generate that. 223 00:11:46,587 --> 00:11:50,367 So they just go for the, you know, the lazy version, which 224 00:11:50,367 --> 00:11:51,747 is just to kind of go apnic. 225 00:11:52,027 --> 00:11:52,423 Sam: Awesome. 226 00:11:52,773 --> 00:11:56,569 Lara: So the risk of apnea is highest in those youngest babies. 227 00:11:56,569 --> 00:12:00,310 Again, our most vulnerable patients, so it used to be when I was a little 228 00:12:00,310 --> 00:12:05,510 doctor, we just hospitalized any newborn with suspected pertussis 229 00:12:05,540 --> 00:12:06,590 'cause of the risk of apnea. 230 00:12:06,800 --> 00:12:08,313 Now it's young babies. 231 00:12:08,313 --> 00:12:11,683 The younger you are, the more likely to be hospitalized for observation. 232 00:12:12,296 --> 00:12:13,346 But yeah. 233 00:12:13,751 --> 00:12:14,561 They don't whoop. 234 00:12:15,250 --> 00:12:17,245 Sam: And that's like six months and under? 235 00:12:17,645 --> 00:12:21,098 Lara: Six months and under will generally not whoop, but I'm not gonna put a like 236 00:12:21,098 --> 00:12:24,218 a day on it like you whoop tomorrow 'cause you didn't whoop yesterday. 237 00:12:24,218 --> 00:12:26,888 But you know, the weaker the baby, the sicker you are, just to remember 238 00:12:26,888 --> 00:12:27,938 that's where the whoop comes from. 239 00:12:27,938 --> 00:12:30,368 So if the kiddo's really knocked out, they're not gonna 240 00:12:30,368 --> 00:12:31,328 be able to make that sound. 241 00:12:32,023 --> 00:12:34,393 But you are gonna have some other family member in the 242 00:12:34,393 --> 00:12:35,743 room who is making that sound, 243 00:12:37,165 --> 00:12:37,325 Sam: Right. 244 00:12:37,393 --> 00:12:37,573 Lara: Right? 245 00:12:38,083 --> 00:12:41,443 So this is where when you see a baby with apnea, you need to ask who else in 246 00:12:41,443 --> 00:12:43,453 the family has had a cold or a cough. 247 00:12:43,973 --> 00:12:47,733 And the big challenge with pertussis is the immunity from 248 00:12:47,733 --> 00:12:50,133 the vaccine wanes over time. 249 00:12:50,133 --> 00:12:54,813 And with the new acellular formulations, it seems to wane quicker. 250 00:12:55,513 --> 00:12:58,873 So it used to be the pertussis vaccine used to cause really 251 00:12:58,873 --> 00:13:00,103 bad side effects, right? 252 00:13:00,103 --> 00:13:02,593 Everyone talks about their baby having this high fever, whatever, 253 00:13:02,593 --> 00:13:03,583 and it, here's what it was. 254 00:13:03,943 --> 00:13:09,967 There were so many little components to the pertussis that they didn't 255 00:13:09,967 --> 00:13:13,447 know which part was immunogenic, so they just basically whacked it in a 256 00:13:13,447 --> 00:13:18,637 blender, chopped it all up, and then gave you whole cell pertussis vaccine. 257 00:13:18,787 --> 00:13:21,097 Well, obviously if you've got stuff in there you don't need, you're 258 00:13:21,097 --> 00:13:22,207 gonna have more side effects. 259 00:13:22,537 --> 00:13:26,057 So then when they discovered that they could just isolate the immunogenic 260 00:13:26,057 --> 00:13:30,397 factors and get acellular, we don't have to whack in the whole cell. 261 00:13:30,877 --> 00:13:32,107 Acellular versions. 262 00:13:32,107 --> 00:13:32,617 Great. 263 00:13:32,647 --> 00:13:36,247 So many fewer side effects, but it seems that the immunity may wane a bit faster. 264 00:13:36,247 --> 00:13:42,977 So really, if you've got school age kids, 7, 8, 9, their immunity's probably waning. 265 00:13:43,375 --> 00:13:47,845 And that's why we've introduced this concept of boosting that 266 00:13:47,845 --> 00:13:51,617 pertussis component with one of your tetanus boosters. 267 00:13:51,947 --> 00:13:55,547 And also, one of the best things we can do to prevent this for our 268 00:13:55,547 --> 00:13:58,577 vulnerable population, 'cause the babies can't take it when they're under six 269 00:13:58,577 --> 00:14:03,487 months, is to immunize mom and then the babies get some passive immunity. 270 00:14:03,947 --> 00:14:07,979 But yeah, that a hundred day cough in adults, nobody wants it. 271 00:14:07,979 --> 00:14:09,899 And basically you cough, cough, cough, cough, cough. 272 00:14:10,199 --> 00:14:12,779 There's nothing you can really do about it except ride it out. 273 00:14:12,839 --> 00:14:16,519 But the earlier we can get in there and treat them, the less likely they 274 00:14:16,519 --> 00:14:18,149 are to spread it to everyone else. 275 00:14:18,519 --> 00:14:20,935 So that's why we treat pertussis antibiotics. 276 00:14:21,377 --> 00:14:26,327 Sam: And it comes with its own not insignificant mortality as well. 277 00:14:26,327 --> 00:14:30,467 It says here in the United States, in the US the case fatality rate is about 278 00:14:30,467 --> 00:14:33,347 1% for babies age less than two months. 279 00:14:33,667 --> 00:14:37,047 And 0.1% for the two to 11 month age group. 280 00:14:37,160 --> 00:14:37,496 Lara: Yeah. 281 00:14:37,496 --> 00:14:41,116 And it is funny, I had a conversation, my brother-in-law's also a peds EM doc. 282 00:14:41,116 --> 00:14:43,866 He actually trained with me, that's how he met my sister. 283 00:14:44,026 --> 00:14:46,106 But we were talking about this a few months ago and he goes, oh, I 284 00:14:46,106 --> 00:14:47,786 haven't seen pertussis in forever. 285 00:14:47,846 --> 00:14:51,866 And then I started looking at the numbers when I was reviewing this 286 00:14:51,866 --> 00:14:56,486 and there's outbreaks are rising, so we're gonna be seeing more of it. 287 00:14:56,756 --> 00:15:01,266 So I think my take home on this is to remember it's out there and so 288 00:15:01,266 --> 00:15:06,055 that upper respiratory infection in a young infant, consider pertussis. 289 00:15:06,335 --> 00:15:07,865 Consider swabbing them. 290 00:15:08,235 --> 00:15:12,465 If there's any concern about someone in the family having been exposed 291 00:15:12,525 --> 00:15:15,135 or having been recently ill with something that sounds like it could 292 00:15:15,135 --> 00:15:20,915 be pertussis, consider treating them because a little macrolide might do a 293 00:15:20,915 --> 00:15:22,905 lot to prevent what you just described. 294 00:15:23,305 --> 00:15:23,385 Sam: Hmm. 295 00:15:24,085 --> 00:15:28,165 And actually I think the last I looked, the cases are not just climbing here 296 00:15:28,165 --> 00:15:32,885 in the US, but there was a recent outbreak in the UK, in Europe, recently. 297 00:15:33,185 --> 00:15:34,835 I think it was three months ago. 298 00:15:34,985 --> 00:15:37,235 They were reporting an increase in cases there as well. 299 00:15:37,235 --> 00:15:39,845 So even if you're an international traveler, you're 300 00:15:39,845 --> 00:15:41,105 at a higher risk for exposure. 301 00:15:41,197 --> 00:15:47,017 Lara: This is the problem with pertussis, is it is so contagious that it really, 302 00:15:47,017 --> 00:15:49,987 really, really requires herd immunity. 303 00:15:50,337 --> 00:15:56,097 It is one of the most vulnerable to dropping vaccination rates, because 304 00:15:56,187 --> 00:15:59,857 as soon as you get below that threshold, which is pretty high, 305 00:16:00,307 --> 00:16:02,692 all of a sudden it starts running rampant through the community. 306 00:16:03,392 --> 00:16:03,722 Sam: Alright. 307 00:16:03,722 --> 00:16:05,792 And then lastly, let's talk about tetanus. 308 00:16:05,792 --> 00:16:08,882 So, you know, it seems like everybody who comes in with a scratch in the 309 00:16:08,882 --> 00:16:14,002 emergency department is getting a tetanus booster and yet in the US 310 00:16:14,002 --> 00:16:18,562 we seem to have controlled the total number of tetanus cases annually. 311 00:16:18,792 --> 00:16:23,292 At least the last I looked, I haven't seen any major tetanus outbreaks for now. 312 00:16:23,562 --> 00:16:25,017 But this is a disease that isn't gone. 313 00:16:25,717 --> 00:16:26,257 Lara: Well, no. 314 00:16:26,257 --> 00:16:27,877 So, and you know why you haven't seen outbreaks? 315 00:16:27,892 --> 00:16:31,912 It's because people don't get tetanus from each other, unlike the other 316 00:16:31,912 --> 00:16:35,872 two we've just talked about, if you have a drop in vaccination rates, 317 00:16:35,872 --> 00:16:38,462 then all of a sudden there's more circulating disease, and you're going 318 00:16:38,462 --> 00:16:41,472 to see more diphtheria, and you're gonna see a whole lot more pertussis. 319 00:16:42,172 --> 00:16:43,852 Tetanus is ubiquitous. 320 00:16:43,942 --> 00:16:45,142 Tetanus is everywhere. 321 00:16:45,592 --> 00:16:48,432 Clostridium tetani, it's everywhere. 322 00:16:48,462 --> 00:16:55,665 It's like the Darwinian master survivor of all infectious agents because it 323 00:16:55,665 --> 00:16:58,175 goes into a spore and just stays there. 324 00:16:58,215 --> 00:17:00,192 It's in dirt, it, it's everywhere. 325 00:17:00,192 --> 00:17:03,012 There have been people who have had tetanus from clean surgical wounds. 326 00:17:03,012 --> 00:17:05,835 You don't even have to have a wound to have tetanus, okay? 327 00:17:05,835 --> 00:17:11,795 It is in the mouth of the wasp that stings you because he was chewing up mud, right? 328 00:17:11,895 --> 00:17:13,050 It is everywhere. 329 00:17:13,725 --> 00:17:18,275 So, because of that, I wouldn't say we've contained the outbreak because there's 330 00:17:18,275 --> 00:17:19,925 never gonna be an outbreak of tetanus. 331 00:17:19,955 --> 00:17:22,985 But if we don't have high vaccination rates, we are gonna see more of it. 332 00:17:23,359 --> 00:17:28,819 In the US, there's always been a few cases that were an unimmunized person, 333 00:17:28,819 --> 00:17:33,559 but the majority have been in older adults because the immunity does wane. 334 00:17:34,259 --> 00:17:38,552 There's never been any study that anyone could ever do to say, what is 335 00:17:38,552 --> 00:17:41,822 a protective level of antibody, right? 336 00:17:42,032 --> 00:17:45,602 Because it is so unbelievably fatal. 337 00:17:45,602 --> 00:17:47,932 It's considered the most fatal toxin. 338 00:17:48,382 --> 00:17:52,342 If the amount you need to kill you is so small that we can barely even measure 339 00:17:52,342 --> 00:17:55,852 it, then you have to base your protective antibody levels on sort of an assumption. 340 00:17:56,552 --> 00:18:00,452 So it doesn't help you if somebody comes in with a scrape to do an antibody 341 00:18:00,452 --> 00:18:02,912 level and say, no, you don't need a jab. 342 00:18:03,392 --> 00:18:07,898 What's really interesting, I did a talk years ago because the tetanus vaccine 343 00:18:07,898 --> 00:18:09,438 schedules around the world differ. 344 00:18:09,438 --> 00:18:14,148 And they differ for, as always whenever something differs, 345 00:18:14,148 --> 00:18:15,588 follow the money, right? 346 00:18:15,918 --> 00:18:19,818 So in the UK, when I first moved to the UK, they would say, oh, if you've 347 00:18:19,818 --> 00:18:22,668 had your initial five injection series, you're covered for life. 348 00:18:22,728 --> 00:18:28,218 And I'm like, who said that, because we know that for clean wounds, we 349 00:18:28,458 --> 00:18:31,968 booster if they haven't had one in 10 years and for dirty wounds, five years. 350 00:18:32,538 --> 00:18:38,068 And I went and I actually read the Green Book, the UK vaccine book, 351 00:18:38,068 --> 00:18:41,128 and it said, you are covered for life unless you are going to a 352 00:18:41,128 --> 00:18:46,908 place where you cannot get antitoxin because you're not covered for life. 353 00:18:47,312 --> 00:18:47,972 Sam: I see. 354 00:18:48,603 --> 00:18:52,683 Lara: So I don't have a problem with you giving everybody with a scratch 355 00:18:52,683 --> 00:18:54,633 on their foot, a jab of tetanus. 356 00:18:55,148 --> 00:18:57,938 Sam: So does that mean they're just giving out antitoxin all the 357 00:18:57,938 --> 00:19:00,003 time in the UK for all wounds. 358 00:19:00,631 --> 00:19:05,059 Lara: No, actually what I found was even though they were saying that, most of 359 00:19:05,059 --> 00:19:09,534 the ER docs I knew, were giving it for every trauma, just like we do in the US. 360 00:19:09,861 --> 00:19:13,311 So that was the message to the community, but if you actually went into a hospital, 361 00:19:13,311 --> 00:19:14,881 somebody was like, look over there, jab. 362 00:19:15,304 --> 00:19:18,984 and another one, in the UK in particular, another group that there were outbreaks 363 00:19:18,984 --> 00:19:22,598 in for a while were intravenous drug users because the quinine that was 364 00:19:22,598 --> 00:19:28,733 used to cut the heroine would somehow promote the bacterial growth of tetanus. 365 00:19:29,108 --> 00:19:31,418 So, yeah, those are the groups you've seen. 366 00:19:31,938 --> 00:19:37,778 I am worried that we are gonna see more younger, healthy people with 367 00:19:38,128 --> 00:19:39,631 tetanus, and you have to suspect it. 368 00:19:39,631 --> 00:19:44,084 I mean, this is what the WHO has done dealing with maternal 369 00:19:44,124 --> 00:19:45,179 neonatal tetanus deaths. 370 00:19:45,649 --> 00:19:50,269 They have dropped it close to like 99% with these very, very active 371 00:19:50,659 --> 00:19:52,619 global outreaches for immunization. 372 00:19:53,009 --> 00:19:57,179 This used to be the leading cause of neonatal death in most of the world. 373 00:19:57,669 --> 00:20:00,079 And we're not seeing that anymore because people are immune. 374 00:20:00,489 --> 00:20:03,909 Sam: So here in the US for the time being, the current vaccine 375 00:20:03,909 --> 00:20:11,799 schedule is still 2, 4, 6, 15, and 18 months of age with another booster, 376 00:20:11,799 --> 00:20:13,989 somewhere between ages four and six. 377 00:20:14,299 --> 00:20:20,590 And then usually one of these doses is the big T, little Dap and the rest are the 378 00:20:20,590 --> 00:20:23,680 big D, big T and the acellular pertussis. 379 00:20:24,000 --> 00:20:28,020 And we're still giving these in the ED, like you mentioned, for wounds. 380 00:20:28,270 --> 00:20:30,820 If it's been more than five years and it's a dirty wound or if it's 381 00:20:30,820 --> 00:20:33,620 been more than 10 years and it's a clean wound, we give these out to 382 00:20:33,620 --> 00:20:35,000 our trauma patients all the time. 383 00:20:35,000 --> 00:20:40,030 And for the time being that's still not changing but also recommended in 384 00:20:40,030 --> 00:20:44,045 pregnancy between 27 and 36 weeks, and like you just mentioned, that's kind 385 00:20:44,045 --> 00:20:45,685 of reduced the mortality worldwide. 386 00:20:45,914 --> 00:20:46,274 Lara : Right. 387 00:20:46,274 --> 00:20:51,014 So going back, the Big D little D difference is the amount of the diptheria. 388 00:20:51,014 --> 00:20:52,424 Little kids handle it better. 389 00:20:52,484 --> 00:20:56,514 So by the time we get to after that kindergarten shot, then you're gonna 390 00:20:56,514 --> 00:21:00,154 start giving the little d , and then that little DT is what we booster 391 00:21:00,154 --> 00:21:06,964 the adults with, but we add back the pertussis for one of those for all adults. 392 00:21:06,964 --> 00:21:10,094 And then it's also recommended for women during pregnancy and 393 00:21:10,094 --> 00:21:12,404 ideally a family, the cocoon. 394 00:21:12,404 --> 00:21:16,431 So grandparents and partner would also booster during that time just so 395 00:21:16,431 --> 00:21:19,221 that everybody's got that extra layer of protection when baby comes home. 396 00:21:19,858 --> 00:21:22,768 Sam: And that booster in adulthood is just one time in adulthood, 397 00:21:22,768 --> 00:21:25,828 or is it like a every 10 years kind of thing, or do we know? 398 00:21:26,214 --> 00:21:27,579 Lara : They say one time. 399 00:21:28,075 --> 00:21:31,915 If I was in charge of the world, I mean, but I'm not so, I can't say anything. 400 00:21:32,125 --> 00:21:36,205 Right now it's officially at least one of your adult boosters, which 401 00:21:36,205 --> 00:21:37,885 you should be doing every 10 years. 402 00:21:38,305 --> 00:21:39,415 Should be one of those. 403 00:21:40,096 --> 00:21:43,996 Sam: All right, so let's talk about when they present to the ED, what 404 00:21:43,996 --> 00:21:46,156 their clinical exam is gonna look like. 405 00:21:46,216 --> 00:21:47,776 And let's start with diptheria. 406 00:21:47,776 --> 00:21:52,346 You already mentioned that if they have the pharyngitis component, they're gonna 407 00:21:52,346 --> 00:21:58,446 have this gray pseudo membrane from the posterior pharynx all the way down. 408 00:21:58,676 --> 00:22:02,366 And then you already also mentioned the bull neck appearance. 409 00:22:02,366 --> 00:22:04,016 Tell me more about the bull neck appearance. 410 00:22:04,016 --> 00:22:06,126 So this is just lymphadenopathy in the neck? 411 00:22:06,226 --> 00:22:08,173 Lara : It's enormous cervical lymphadenopathy. 412 00:22:08,780 --> 00:22:12,260 So they get really, really big tender lymph nodes that are 413 00:22:12,260 --> 00:22:13,850 like nothing you've seen before. 414 00:22:14,156 --> 00:22:20,956 But then they get this membrane and it will grow, unless you get the antitoxin in 415 00:22:20,956 --> 00:22:23,330 to kind of stop the disease progression. 416 00:22:23,346 --> 00:22:26,543 if it's laryngeal that membrane can actually cause airway obstruction. 417 00:22:26,783 --> 00:22:30,323 There is a nasal form that's much more mild, that has a little bit of 418 00:22:30,323 --> 00:22:33,226 a membranous appearance in the nares. 419 00:22:33,516 --> 00:22:35,760 But the one you really wanna be worried about is laryngeal. 420 00:22:35,790 --> 00:22:38,546 I mean, that membrane is producing the toxin, right? 421 00:22:38,546 --> 00:22:43,226 So the bigger it is, the longer it's been going, the more toxin you're 422 00:22:43,226 --> 00:22:46,176 gonna see circulating, the less effective your antitoxins gonna be 423 00:22:46,246 --> 00:22:46,786 Sam: Gotcha. 424 00:22:46,986 --> 00:22:49,626 Lara : because it needs to get in there before that toxin binds to 425 00:22:49,626 --> 00:22:52,206 the end tissues like your heart. 426 00:22:52,766 --> 00:22:53,096 Sam: Okay. 427 00:22:53,096 --> 00:22:56,816 And speaking of the heart, so if they were going to have some cardiac 428 00:22:56,816 --> 00:23:00,616 manifestations, how does that present when we're seeing them in the ED? 429 00:23:00,706 --> 00:23:03,406 We're gonna pick this up on exam, or everybody just gets a screening, 430 00:23:03,406 --> 00:23:05,386 EKG, and gets telemetry or. 431 00:23:05,904 --> 00:23:09,534 Lara : Screen everybody, get them on telemetry and get your labs, get 432 00:23:09,564 --> 00:23:13,554 your enzymes, your electrolytes, because I think it's kind of an 433 00:23:13,554 --> 00:23:16,734 all players welcome presentation. 434 00:23:16,734 --> 00:23:19,429 You can see anything from arrhythmias to heart failure. 435 00:23:20,254 --> 00:23:23,434 So I would whack them on monitor pretty quickly. 436 00:23:23,574 --> 00:23:26,474 Sam: And the mechanism is myocarditis in diptheria, 437 00:23:27,081 --> 00:23:30,081 Lara : It's the toxin effects on the myocardium. 438 00:23:30,086 --> 00:23:30,136 Yeah. 439 00:23:31,436 --> 00:23:35,166 Sam: Alright, so, in addition to their clinical exam, a screening, EKG, 440 00:23:35,196 --> 00:23:40,152 putting 'em on telemetry and pneumonia, other respiratory complications, 441 00:23:40,692 --> 00:23:42,252 hypoxia, or not necessarily. 442 00:23:42,294 --> 00:23:45,691 Lara : Well, yes, and partly that's going to be because these 443 00:23:45,691 --> 00:23:48,661 kids are often gonna be so sick that they're gonna be intubated. 444 00:23:49,141 --> 00:23:49,621 Right. 445 00:23:49,811 --> 00:23:52,841 So anything that you are gonna see in an ICU setting, you're 446 00:23:52,841 --> 00:23:54,161 gonna see in one of these kids. 447 00:23:54,371 --> 00:23:57,011 Plus, if you've got heart failure, that's gonna set you 448 00:23:57,011 --> 00:23:59,668 up for, infection, et cetera. 449 00:24:00,358 --> 00:24:00,598 Yeah. 450 00:24:00,941 --> 00:24:02,351 These are ICU children. 451 00:24:02,411 --> 00:24:03,496 These children go to the PICU. 452 00:24:04,961 --> 00:24:10,091 Sam: On the intubation side of things, if you are in the unfortunate circumstance of 453 00:24:10,091 --> 00:24:15,231 having to intubate one of these children does the pseudo membrane and the bull 454 00:24:15,231 --> 00:24:19,571 neck make it just all that much more difficult to intubate these children. 455 00:24:20,214 --> 00:24:23,724 Lara : So the pseudo membrane is really, really tightly attached. 456 00:24:23,724 --> 00:24:26,484 And even if you tried it, you're not likely to dislodge 457 00:24:26,484 --> 00:24:28,794 it easily with the tube. 458 00:24:28,824 --> 00:24:33,391 But when you're intubating anyone like this have a plan B and C. and the, bull 459 00:24:33,391 --> 00:24:34,994 neck, 'cause I've never seen this, right. 460 00:24:34,994 --> 00:24:36,164 I'm trying to work my head around it. 461 00:24:36,464 --> 00:24:39,764 It's not like a retropharyngeal abscess where you've got, you know, 462 00:24:39,764 --> 00:24:43,994 a big prominent airway distortion if you can get their neck back right. 463 00:24:43,994 --> 00:24:45,854 Unless there's just so much lymphadenopathy it's 464 00:24:45,854 --> 00:24:46,764 compressing the airway. 465 00:24:46,862 --> 00:24:50,132 Sam: In which case it's probably equally difficult to do it externally. 466 00:24:50,132 --> 00:24:53,272 I'm thinking about cricing a child who is in this scenario as well 467 00:24:53,288 --> 00:24:54,488 Lara : I would not wanna do that. 468 00:24:54,488 --> 00:24:58,024 I would probably want to go for the straight old tube in a tube approach. 469 00:24:58,074 --> 00:25:02,048 Because yeah, you're gonna have so much neck edema and surgical airways 470 00:25:02,048 --> 00:25:03,938 and little kids are hard enough. 471 00:25:04,234 --> 00:25:06,424 don't need to try to go through all that. 472 00:25:07,001 --> 00:25:07,301 Sam: All right. 473 00:25:07,301 --> 00:25:09,391 And then let's talk about pertussis. 474 00:25:09,391 --> 00:25:13,621 So obviously you mentioned the cough, you said clinically children under six 475 00:25:13,621 --> 00:25:17,611 months of age or so are not gonna have the whoop, so we might not recognize that. 476 00:25:17,731 --> 00:25:20,596 You know, parents might say that they've seen apnea. 477 00:25:20,596 --> 00:25:24,996 So we might see some of those episodes clinically or maybe just have elicited 478 00:25:25,086 --> 00:25:26,946 that there's a history of some apnea. 479 00:25:27,176 --> 00:25:32,766 And then looking at other members in the family for URI symptoms, congestion, 480 00:25:32,766 --> 00:25:36,786 cough, low grade fevers to see if they maybe were the infectious source. 481 00:25:37,074 --> 00:25:40,044 Lara : and don't forget that the number one complication with pertussis is gonna 482 00:25:40,044 --> 00:25:41,588 be a secondary bacterial pneumonia. 483 00:25:42,248 --> 00:25:45,368 So if you're seeing a baby who has a pneumonia, and the other thing is, 484 00:25:45,368 --> 00:25:51,798 is that little ones can develop an encephalopathy that was thought to 485 00:25:51,798 --> 00:25:54,198 be related to periods of hypoxia. 486 00:25:54,198 --> 00:25:58,108 So you can have seizures, as one of the presentations, but now it's thought that 487 00:25:58,108 --> 00:26:03,378 that could also possibly be a direct effect of the pertussis infection. 488 00:26:04,029 --> 00:26:04,539 Sam: Okay. 489 00:26:04,989 --> 00:26:08,619 So some neuro complications there, some pulmonary manifestations, maybe 490 00:26:08,619 --> 00:26:10,759 pneumonia, and then apnea. 491 00:26:11,701 --> 00:26:13,061 Lara : Pneumonia, seizing apnea. 492 00:26:13,601 --> 00:26:13,801 Yep. 493 00:26:14,629 --> 00:26:14,959 Sam: Okay. 494 00:26:15,409 --> 00:26:17,029 And then tetanus. 495 00:26:17,089 --> 00:26:21,969 So obviously if they're presenting with tetany that's something we can 496 00:26:22,584 --> 00:26:26,484 characteristically see, but now in the cases where they present to the 497 00:26:26,484 --> 00:26:31,014 ED and they're having tetany, we're talking about things like spasms of 498 00:26:31,014 --> 00:26:36,414 the musculature, neck stiffness, back stiffness, rigidity, abdominal rigidity. 499 00:26:36,674 --> 00:26:42,307 And then in the smaller children, they can also get some, facial tetany as well. 500 00:26:42,571 --> 00:26:43,651 Lara : Well, so it depends. 501 00:26:43,651 --> 00:26:44,941 There's different forms of tetanus. 502 00:26:44,941 --> 00:26:49,134 The one we always think of is generalized, but you can get, localized. 503 00:26:49,374 --> 00:26:54,234 So that's just persistent, painful, muscular contractions in one location. 504 00:26:54,744 --> 00:26:56,514 And then there's also cephalic. 505 00:26:56,874 --> 00:27:02,714 So you can just see, like ocular spasms and above head up, but the one we're 506 00:27:02,714 --> 00:27:04,634 always thinking of is generalized. 507 00:27:04,634 --> 00:27:09,191 And the WHO definition is this persistent, painful, muscular 508 00:27:09,191 --> 00:27:11,261 contraction with a history of a wound. 509 00:27:11,261 --> 00:27:14,751 But we know that you can get tetanus without a wound, so it's something 510 00:27:14,751 --> 00:27:16,994 you have to be quite, suspicious for. 511 00:27:17,154 --> 00:27:21,054 The biggest thing I think that I've taken away from just all the reading 512 00:27:21,054 --> 00:27:25,089 I've done on this is: Everyone thinks of tetanus as lockjaw, right? 513 00:27:25,119 --> 00:27:27,969 Oh, they must die because their jaw gets stuck. 514 00:27:27,969 --> 00:27:30,329 And that's the risus sardonicus, right? 515 00:27:30,329 --> 00:27:32,609 The classic picture of the grimacing face. 516 00:27:33,359 --> 00:27:36,869 In a developed country, that's not what kills tetanus patients. 517 00:27:36,929 --> 00:27:38,889 It's the autonomic instability, right? 518 00:27:38,939 --> 00:27:42,359 You are gonna have these painful spasms, but they will be triggered 519 00:27:42,359 --> 00:27:44,189 by loud noises, bright lights. 520 00:27:44,189 --> 00:27:47,639 So that's why the advice is put them in a dark, quiet room, immediately start 521 00:27:47,639 --> 00:27:54,238 sedating, which helps with the spasm, but also with the autonomic contribution and 522 00:27:54,238 --> 00:27:56,638 one of the best treatments is mag sulfate. 523 00:27:56,638 --> 00:27:59,674 And that's because it treats the muscle spasm, right? 524 00:27:59,854 --> 00:28:02,909 We know it's a good, muscle relaxant, but it also deals with some of 525 00:28:02,909 --> 00:28:06,276 that autonomic instability because it stabilizes magnesium levels. 526 00:28:06,606 --> 00:28:09,421 So, that's what actually will kill your patient. 527 00:28:09,918 --> 00:28:14,478 So you intubate them early, you move to early long-term access. 528 00:28:14,478 --> 00:28:17,658 You know, that's a kid who's also gonna, the ICU, they're one who's also gonna get 529 00:28:17,658 --> 00:28:20,814 a trach, 'cause they're gonna be tubed for a while because you're gonna have 530 00:28:20,814 --> 00:28:25,581 them on pretty significant, sedation, and muscle relaxants for a while. 531 00:28:25,666 --> 00:28:30,073 The patient that I took care of, it was, her blood pressure shot up and we gave 532 00:28:30,073 --> 00:28:33,913 her something to bring it down, and then it barreled and then bottomed out, and 533 00:28:33,913 --> 00:28:36,823 then we'd give her something to bring her back up and we're like, at some point, 534 00:28:37,663 --> 00:28:41,583 what could we And there was talk about moving her to ecmo, and her grandfather 535 00:28:41,583 --> 00:28:45,018 reached under the blanket and grabbed her hand and her blood pressure stabilized. 536 00:28:45,578 --> 00:28:50,543 And I'm not a terribly religious person, but I always cite that as like the one 537 00:28:50,543 --> 00:28:53,393 miracle I think I saw in my training. 538 00:28:53,828 --> 00:28:56,618 Whether you wanna call it whatever it was, but I remember that. 539 00:28:56,618 --> 00:28:58,838 I remember her, we were all talking about what do we do next? 540 00:28:58,838 --> 00:28:59,678 We're talking to the family. 541 00:28:59,678 --> 00:29:02,798 We don't have a lot of options left except ECMO and grandpa was there. 542 00:29:03,045 --> 00:29:03,705 Sam: That's amazing. 543 00:29:04,168 --> 00:29:07,108 Lara : So hopefully that story will remind people if you think you're seeing tetanus, 544 00:29:07,108 --> 00:29:11,208 to pay attention to the cardiovascular system, the autonomic system, the 545 00:29:11,208 --> 00:29:11,983 blood pressure, the heart rate. 546 00:29:12,800 --> 00:29:16,010 Sam: Okay, so let's go to treatment then. 547 00:29:16,130 --> 00:29:21,860 You had mentioned already that there is an antitoxin for diptheria if you're seeing 548 00:29:21,860 --> 00:29:26,900 a case of this, but this is not something your local hospital is going to stock. 549 00:29:27,140 --> 00:29:27,380 Right. 550 00:29:28,258 --> 00:29:31,288 Lara : No, you don't Run over to Walgreens and get yourself 551 00:29:31,288 --> 00:29:33,778 some DAT Diphtheria Antitoxin. 552 00:29:34,078 --> 00:29:37,648 This is one that's nice because you don't have to do any decision making. 553 00:29:38,038 --> 00:29:41,488 All you have to do for diptheria is suspect diptheria. 554 00:29:41,878 --> 00:29:46,978 That's it, because then you call the CDC assuming they're answering 555 00:29:46,978 --> 00:29:53,254 their phones, and you are put through to the diptheria person. 556 00:29:53,989 --> 00:29:57,229 Who will listen to your story and say, I agree. 557 00:29:57,439 --> 00:30:01,879 And they will dispatch the diptheria, antitoxin and walk you through based 558 00:30:01,879 --> 00:30:06,139 on the disease progression and the age of the patient and their weight 559 00:30:06,139 --> 00:30:10,009 and their symptoms, they will tailor that dose and give you very, very 560 00:30:10,009 --> 00:30:12,679 specific instructions on how to give it. 561 00:30:12,713 --> 00:30:17,849 You're going to need to do, some, sensitivity testing because there's about 562 00:30:17,909 --> 00:30:21,789 a five to 20%, rate of allergic reactions. 563 00:30:22,029 --> 00:30:24,549 But they'll walk you through all this, assuming they're answering the phone. 564 00:30:25,117 --> 00:30:28,897 Sam: it's like the one person holding the DAT calculator and 565 00:30:28,897 --> 00:30:31,507 has the one remaining book on dAT. 566 00:30:32,069 --> 00:30:33,899 Lara : They don't even make that info like public. 567 00:30:33,899 --> 00:30:34,769 I can't find it anywhere. 568 00:30:34,769 --> 00:30:38,399 It's basically, here's the phone number, call us and we will walk you through it. 569 00:30:38,399 --> 00:30:41,099 Because I think it's based on a number of factors that they 570 00:30:41,099 --> 00:30:43,049 assume are too complicated for us 571 00:30:43,102 --> 00:30:46,192 Sam: Well, thank goodness for the number, but then you did mention that 572 00:30:46,192 --> 00:30:51,232 there is a time sensitivity component to this, so it has to be given sooner 573 00:30:51,262 --> 00:30:53,092 to bind more of the free toxin. 574 00:30:53,639 --> 00:30:53,969 Lara : right. 575 00:30:53,969 --> 00:30:58,066 So the longer that you've got toxin production, the less effective this is 576 00:30:58,066 --> 00:31:00,886 gonna be because the more you've got circulating toxin, the more it's bound 577 00:31:00,886 --> 00:31:05,716 to the end organs and the tissues, the less likely the antitoxins gonna be able 578 00:31:05,716 --> 00:31:07,456 to bind it and take it outta circulation. 579 00:31:07,666 --> 00:31:10,636 So that's why the minute you suspect it, you get on the phone. 580 00:31:11,176 --> 00:31:14,146 I think everyone would rather you did that. 581 00:31:14,476 --> 00:31:18,166 The other thing that's important is you wanna get antibiotics on board, and that's 582 00:31:18,166 --> 00:31:22,866 not going to change the progression of the disease, 'cause these patients need 583 00:31:22,866 --> 00:31:28,923 to go into isolation and you're gonna need to identify close contacts and test them 584 00:31:28,923 --> 00:31:31,633 and offer them, prophylactic antibiotics. 585 00:31:31,723 --> 00:31:35,143 So you need antibiotics to prevent transmission that will not 586 00:31:35,143 --> 00:31:36,643 abort the course of the disease. 587 00:31:36,643 --> 00:31:40,846 What will affect the outcome is getting that antitoxin. 588 00:31:40,959 --> 00:31:44,019 Sam: And that anti-toxin coming from the CDC has to be shipped to you. 589 00:31:44,019 --> 00:31:47,499 So really, even if you're Johnny on the spot and call immediately, 590 00:31:47,499 --> 00:31:51,564 it's going to be a minimum of hours, if not a day before they get it 591 00:31:51,564 --> 00:31:53,574 to you, wherever you are in the US 592 00:31:54,191 --> 00:31:59,051 Lara : So it's actually listed in the WHO's list of essential medicines. 593 00:31:59,779 --> 00:32:01,244 I think that that is the case, 594 00:32:01,782 --> 00:32:03,882 Sam: I was gonna say, there's probably very few manufacturers. 595 00:32:03,882 --> 00:32:06,732 It is probably like some horse serum antitoxin or something. 596 00:32:08,192 --> 00:32:08,552 Okay. 597 00:32:08,582 --> 00:32:12,242 So , you're giving the antibiotics to kill off the remaining bacteria. 598 00:32:12,272 --> 00:32:17,632 Reduce the continuing creation of toxin and then also make them less contagious. 599 00:32:17,637 --> 00:32:19,517 And then you gotta treat family members as well. 600 00:32:20,057 --> 00:32:24,487 And, when we talk about isolation, this is like respiratory isolation. 601 00:32:24,487 --> 00:32:28,457 So everybody who enters the room has to be masked and gowned 602 00:32:28,457 --> 00:32:30,767 and gloved and all of this. 603 00:32:31,449 --> 00:32:35,819 Lara : Yeah, so it's droplet isolation, and identification of close contacts. 604 00:32:35,819 --> 00:32:39,163 And regardless of whether it is, respiratory or 605 00:32:39,533 --> 00:32:41,483 cutaneous, you're going to be 606 00:32:41,483 --> 00:32:41,993 reporting it. 607 00:32:42,644 --> 00:32:46,574 Sam: And then antibiotics in this disease for diptheria, 608 00:32:46,724 --> 00:32:49,454 erythromycin, or a penicillin. 609 00:32:49,824 --> 00:32:52,554 Lara : You go erythromycin or penicillin. 610 00:32:53,252 --> 00:32:54,392 They're both indeterminate. 611 00:32:54,400 --> 00:32:54,480 Sam: Hmm. 612 00:32:55,170 --> 00:32:55,520 Great. 613 00:32:56,419 --> 00:32:59,719 Lara : I don't think it's ethical to have a large perspective randomized 614 00:32:59,719 --> 00:33:03,139 control study on infecting people with diptheria and seeing whether, 615 00:33:03,139 --> 00:33:06,185 you know, erythromycin or penicillin is really where the money's at. 616 00:33:06,229 --> 00:33:08,749 Sam: Yeah, it's interesting 'cause I always think of like, you know, 617 00:33:08,749 --> 00:33:13,579 your critically sick patient is just gonna get vancomycin and zosyn or 618 00:33:13,579 --> 00:33:17,179 something at every hospital or fortaz or, you're gonna give some big gun. 619 00:33:17,179 --> 00:33:20,239 But in this case you're like, well, we have erythromycin and we have penicillin. 620 00:33:20,269 --> 00:33:21,859 Like, that's kind of what we, know works. 621 00:33:21,859 --> 00:33:23,659 But we haven't really studied it for the rest. 622 00:33:23,700 --> 00:33:27,090 Lara : We, don't have antitoxin and the antibiotics aren't gonna do anything 623 00:33:27,090 --> 00:33:30,060 right now, but at least you know and start passing out to the family. 624 00:33:30,090 --> 00:33:30,510 That's right. 625 00:33:30,510 --> 00:33:33,360 These are old school illnesses with old school antibiotics. 626 00:33:34,071 --> 00:33:37,611 Sam: And then for pertussis, when it comes to treatment, if you have a 627 00:33:37,611 --> 00:33:41,961 critically ill child, is there a role for antibiotics in that scenario, 628 00:33:41,961 --> 00:33:43,101 specifically against pertussis? 629 00:33:43,101 --> 00:33:44,931 I mean, assuming they don't have pneumonia or something. 630 00:33:45,594 --> 00:33:49,688 Lara : Yeah, everybody with pertussis is gonna get, first line is azithromycin. 631 00:33:50,084 --> 00:33:52,664 and, that is even for the little babies. 632 00:33:52,664 --> 00:33:58,028 there was some concern for the macrolides and, development of pylori hypertrophy. 633 00:33:58,351 --> 00:34:00,914 But the benefit clearly outweighs the risk. 634 00:34:01,004 --> 00:34:03,141 And so for a while, I remember when I was a little doctor, there 635 00:34:03,141 --> 00:34:04,371 was some concern about that. 636 00:34:04,371 --> 00:34:07,191 And sometimes people go erythromycin, but it's recommended 637 00:34:07,191 --> 00:34:08,271 that everybody get azithromycin. 638 00:34:09,231 --> 00:34:11,267 Sam: And that's, so that's close contact again. 639 00:34:11,517 --> 00:34:16,977 And then the patient, and then I assume if there was exposure for EMS personnel 640 00:34:16,977 --> 00:34:19,017 who might have brought the child in, they're getting treated as well. 641 00:34:19,017 --> 00:34:21,237 And same with the diptheria. 642 00:34:21,865 --> 00:34:25,315 Lara : Well, so diptheria is gonna be with guidance from your department of 643 00:34:25,315 --> 00:34:31,005 public health, because it depends on how close the contacts are, and the, health 644 00:34:31,005 --> 00:34:32,955 status of the other people in the family. 645 00:34:32,955 --> 00:34:37,905 So there's some quite complicated rules about the diptheria prophylaxis that 646 00:34:37,905 --> 00:34:40,215 you can find well on the CDC website, 647 00:34:40,823 --> 00:34:43,488 but that's where you notify Department of Health will walk you through 648 00:34:44,208 --> 00:34:46,308 who's going to be treated there. 649 00:34:46,308 --> 00:34:49,008 It's probably going to be the people actually live in the home. 650 00:34:49,418 --> 00:34:52,388 And some other select cases, potentially some healthcare workers, 651 00:34:52,388 --> 00:34:53,655 depending on the circumstances. 652 00:34:53,655 --> 00:34:57,235 pertussis is a little more, you know, 653 00:34:57,625 --> 00:34:58,375 Sam: everybody gets it. 654 00:34:58,435 --> 00:34:58,915 Yes. 655 00:34:58,945 --> 00:35:01,675 Nurses, techs, EMS personnel. 656 00:35:01,735 --> 00:35:03,175 Everybody just put it in your water. 657 00:35:03,685 --> 00:35:04,015 Okay. 658 00:35:04,015 --> 00:35:05,695 And then treatment for tetanus. 659 00:35:05,695 --> 00:35:09,452 Now you mentioned mag sulfate already it helps with tetany and 660 00:35:09,452 --> 00:35:10,892 with the autonomic instability. 661 00:35:11,414 --> 00:35:15,464 Lara : So you have two goals with someone with tetanus, which is one, 662 00:35:15,464 --> 00:35:20,417 to control the tetany, the muscular spasms, and get control of that airway. 663 00:35:20,781 --> 00:35:24,394 So that's one goal and that is accomplished with getting 664 00:35:24,394 --> 00:35:26,704 benzodiazepines on very quickly. 665 00:35:26,914 --> 00:35:31,274 and then considering mag sulfate, the benzos will sedate and help 666 00:35:31,274 --> 00:35:32,474 relieve the muscular contractions. 667 00:35:32,474 --> 00:35:35,368 'cause again, startling a patient, having them stressed out, that's gonna 668 00:35:35,548 --> 00:35:37,438 create this vicious cycle of doom. 669 00:35:37,708 --> 00:35:38,788 So that will help. 670 00:35:38,788 --> 00:35:44,264 Mag sulfate is also useful for, stabilizing that autonomic response. 671 00:35:44,624 --> 00:35:47,894 So everything I've looked at that seems to be everybody's go-to favorite. 672 00:35:48,194 --> 00:35:49,544 A number of things have been tried. 673 00:35:49,544 --> 00:35:53,084 They've tried intrathecal Baclofen, they've tried, you know, all kinds of 674 00:35:53,084 --> 00:35:54,524 things have been tried in literature. 675 00:35:54,584 --> 00:35:57,044 It's interesting, there are parts of the world where they have enough tetanus 676 00:35:57,044 --> 00:35:59,088 patients to really do some robust studies. 677 00:35:59,491 --> 00:36:01,387 but That, seems to be the number one go-to, 678 00:36:01,901 --> 00:36:02,261 Sam: Gotcha. 679 00:36:02,801 --> 00:36:03,191 Okay. 680 00:36:03,527 --> 00:36:05,417 Lara : And then you're also gonna want antibiotics. 681 00:36:05,512 --> 00:36:08,632 . And antibiotics are just going to hopefully eliminate 682 00:36:08,732 --> 00:36:10,442 any more of the Clostridium. 683 00:36:10,825 --> 00:36:13,265 antibiotics, whack 'em on all three across the board. 684 00:36:13,265 --> 00:36:14,555 Old school antibiotics, 685 00:36:14,669 --> 00:36:18,479 Sam: Yeah, so for tetanus it says metronidazole or penicillin again. 686 00:36:18,509 --> 00:36:21,649 So, kind of, , something you should have at your hospital. 687 00:36:22,293 --> 00:36:25,623 But again, not necessarily going to affect the course of 688 00:36:25,623 --> 00:36:27,393 the disease in this scenario. 689 00:36:27,633 --> 00:36:29,463 Just stop ongoing toxin creation. 690 00:36:29,913 --> 00:36:34,253 Lara : Right, Because that nano toxin is so toxic. 691 00:36:34,643 --> 00:36:37,163 I don't know how many times I use toxic to describe how toxic it is 692 00:36:37,184 --> 00:36:38,684 Sam: Virulent potent. 693 00:36:39,293 --> 00:36:39,953 Lara : Potent. 694 00:36:40,004 --> 00:36:41,194 Sam: Pull out the thesaurus. 695 00:36:41,213 --> 00:36:41,783 Lara : That's right. 696 00:36:41,783 --> 00:36:44,063 It's considered a nano toxin, like you need less than the 697 00:36:44,063 --> 00:36:45,863 pin of a head to cause disease. 698 00:36:45,863 --> 00:36:49,398 And so if you've got any bacteria around that's producing it like you're kinda. 699 00:36:50,468 --> 00:36:53,648 You're not doing well, but get rid of any more bacteria. 700 00:36:54,938 --> 00:36:55,238 Sam: All right. 701 00:36:55,238 --> 00:36:56,808 And then the clinical course. 702 00:36:56,808 --> 00:36:59,688 Now, all of these children, if they're children, are going to go to the ICU, 703 00:36:59,688 --> 00:37:03,108 if they're adults with these diseases, probably equally going to go to the ICU. 704 00:37:03,241 --> 00:37:04,535 Lara : I would send them to the, ICU. 705 00:37:04,535 --> 00:37:05,105 Yes. 706 00:37:05,151 --> 00:37:09,598 Sam: then the course, if they survive the expected course. 707 00:37:09,598 --> 00:37:13,353 So with tetanus, we're looking at a very long, protracted illness 708 00:37:13,613 --> 00:37:17,586 in the ICU, it's similarly long with pertussis and diptheria. 709 00:37:18,233 --> 00:37:22,457 Lara : No pertussis is really an illness that most people who have it probably 710 00:37:22,457 --> 00:37:23,987 don't even realize they've had it. 711 00:37:24,587 --> 00:37:28,307 So most adults who get it are just gonna be like, God, I had a terrible cough. 712 00:37:28,832 --> 00:37:29,642 For so long. 713 00:37:29,912 --> 00:37:34,232 If you are on either end of the spectrum where you're a more vulnerable person, 714 00:37:34,292 --> 00:37:35,462 then you're gonna be more prone. 715 00:37:35,462 --> 00:37:38,312 If you're an elderly person with pertussis, you're gonna be cracking 716 00:37:38,312 --> 00:37:40,872 your ribs and then that's where we see in the case reports of the 717 00:37:40,872 --> 00:37:43,797 intracranial bleeds and the pneumo mediastinum and the pneumothorax, 718 00:37:43,797 --> 00:37:45,942 and the ruptured, you know, eardrum. 719 00:37:46,302 --> 00:37:50,592 On the other end are the babies who are vulnerable, and that's the apnea, 720 00:37:50,652 --> 00:37:53,642 the seizures, the bacterial pneumonias. 721 00:37:53,852 --> 00:37:58,298 So if you were just, let's say in your twenties, cruising 722 00:37:58,298 --> 00:37:59,978 around and you got pertussis. 723 00:38:00,338 --> 00:38:02,048 You might not even realize you had it. 724 00:38:02,528 --> 00:38:03,248 I promise you. 725 00:38:03,248 --> 00:38:05,498 If you've got tetanus, you're gonna know it. 726 00:38:05,498 --> 00:38:07,808 And same thing with diptheria, right? 727 00:38:07,808 --> 00:38:13,638 So, both those cases with diptheria, how quickly you get that antitoxin on board, 728 00:38:13,728 --> 00:38:17,868 you know, the earlier it's recognized, before it's really progressed to a genuine 729 00:38:17,868 --> 00:38:23,543 pseudo membrane that's pumping out toxin with tetanus that's going to be a long 730 00:38:23,543 --> 00:38:27,113 course, and with that, prolonged ICU stay. 731 00:38:27,113 --> 00:38:32,053 Every other complication we see in every prolonged ICU stay is going to come 732 00:38:32,189 --> 00:38:32,609 Sam: Hmm. 733 00:38:33,154 --> 00:38:36,304 Well, if you're listening and you have access to the article, there 734 00:38:36,304 --> 00:38:40,564 is an excellent appendix number one on page 17, which summarizes 735 00:38:40,684 --> 00:38:43,894 everything we've talked about from the clinical features to the diagnostic 736 00:38:43,894 --> 00:38:47,734 studies, to the initial treatment for all three of these conditions. 737 00:38:48,114 --> 00:38:51,534 And there is a clinical pathway in this issue, which will 738 00:38:51,534 --> 00:38:53,364 walk you through step by step. 739 00:38:53,629 --> 00:38:59,119 From suspicion through diagnosis and treatment, which I also highly recommend. 740 00:38:59,179 --> 00:39:02,779 And if you're working here in the US and you're not familiar with 741 00:39:02,779 --> 00:39:07,519 these diseases, now is an excellent time to brush up on them and their 742 00:39:07,519 --> 00:39:11,676 clinical presentation, because it's coming to a hospital near you. 743 00:39:12,814 --> 00:39:13,186 So. 744 00:39:13,451 --> 00:39:15,761 Thank you for agreeing to be on the podcast. 745 00:39:15,761 --> 00:39:19,571 I found this article, I mean, exceedingly helpful, not just because of what we're 746 00:39:19,571 --> 00:39:23,238 going through in the US but just in general, for two diseases that, you 747 00:39:23,238 --> 00:39:26,808 know, we don't see in the hospital all that often, tetanus and diptheria. 748 00:39:26,998 --> 00:39:30,418 If you haven't seen these cases, there's some good pictures, some great 749 00:39:30,598 --> 00:39:33,901 clinical descriptors, and I think it's going to be even more valuable 750 00:39:33,901 --> 00:39:37,171 now than it has been in the last 10 years that you've been writing it. 751 00:39:37,852 --> 00:39:38,422 Lara : Well, thank you. 752 00:39:38,422 --> 00:39:42,652 I mean, I will say it's obvious if I've written this article three times now 753 00:39:42,652 --> 00:39:45,922 and I still have to go flip back and see what something says, that tells 754 00:39:45,922 --> 00:39:47,662 you how rare these illnesses are. 755 00:39:47,662 --> 00:39:52,312 So I really hope this article can be stuck on a wall somewhere in a department so 756 00:39:52,312 --> 00:39:53,512 that you don't have to think too hard. 757 00:39:53,512 --> 00:39:57,082 If you just suspect and you remember one thing from reading it or our 758 00:39:57,082 --> 00:40:00,442 chat today, then you can go find it and walk yourself through it 759 00:40:00,513 --> 00:40:01,563 Sam: Yeah, for sure. 760 00:40:02,073 --> 00:40:03,813 Well, thank you so much for being on the podcast. 761 00:40:03,873 --> 00:40:04,563 I appreciate it. 762 00:40:04,563 --> 00:40:08,523 Before you leave, you have your own podcast and I want you to 763 00:40:08,523 --> 00:40:09,963 share with our audience about it. 764 00:40:09,963 --> 00:40:10,623 Tell me more about that. 765 00:40:10,997 --> 00:40:11,357 Lara : I do. 766 00:40:12,283 --> 00:40:14,443 Totally different than yours. 767 00:40:14,503 --> 00:40:16,093 Mine is a little sillier. 768 00:40:16,319 --> 00:40:20,036 One of my business school professors, actually, Adam Brown, he's an ER doc. 769 00:40:20,136 --> 00:40:22,656 And we find ourselves rather amusing. 770 00:40:22,656 --> 00:40:25,319 We're both doctors who became entrepreneurs. 771 00:40:25,589 --> 00:40:30,469 And so we try to look at the business of healthcare in America and compare 772 00:40:30,469 --> 00:40:33,649 it to other systems and try to look at it from all different angles. 773 00:40:33,883 --> 00:40:37,563 We've had episodes on physician suicide, physician burnout, STEM 774 00:40:37,563 --> 00:40:40,203 education for kids, women's health. 775 00:40:40,433 --> 00:40:42,193 And , we like to think we're amusing. 776 00:40:42,193 --> 00:40:43,693 So it's called unstable vitals. 777 00:40:43,693 --> 00:40:46,693 You can find it wherever you find your podcast, and I hope 778 00:40:46,693 --> 00:40:47,683 it brings you a little giggle. 779 00:40:47,683 --> 00:40:51,538 It's not nearly as consequential as what you're doing here, Sam, 780 00:40:51,642 --> 00:40:53,718 but I hope it gives people a little laugh. 781 00:40:53,722 --> 00:40:54,142 Sam: Awesome. 782 00:40:54,262 --> 00:40:56,952 And we will put a link to that podcast in the show notes. 783 00:40:56,952 --> 00:40:59,742 Thank you so much for agreeing to be on the podcast. 784 00:40:59,742 --> 00:41:00,432 It's been a pleasure. 785 00:41:01,058 --> 00:41:01,872 Lara : Well, thank you. 786 00:41:02,708 --> 00:41:04,528 . Sam: And that's a wrap for this month's episode. 787 00:41:04,568 --> 00:41:07,148 I hope you found it educational and informative. 788 00:41:07,348 --> 00:41:12,208 Don't forget to go to ebmedicine.net to read the article and claim your CME. 789 00:41:12,378 --> 00:41:15,568 And of course, check out all three of the journals and the multitude of 790 00:41:15,568 --> 00:41:19,928 resources available to you, both for emergency medicine, pediatric emergency 791 00:41:19,928 --> 00:41:22,198 medicine, and evidence based urgent care. 792 00:41:22,508 --> 00:41:24,478 Until next time, everyone be safe.