25 year old F with no pmh present with 3 days of fever, chills, body aches, sore throat. She is a school teacher and has had many of her kids out sick this week. Her vitals are stable, and she is in no acute distress. She is triaged to the B side at Sinai.
What are the 2 most important things for you to do for this patient during her ED stay?
- Pregnancy Test
- Pt a mask on this patient (droplet precautions- prevent spread to other patients)
This patient likely has influenza, the rates are on the rise in NYC (See below). If this patient looks well, has the ability to tolerate PO, and does not have any factors that would require treatment (ie pregnancy) then patient can be discharge with symptomatic control and PMD follow up.
Influenza Fast Facts:
In the US 5-20% of population affected by the Flu up to 200,000 hospital admissions for flu related complications
Incubation period:
-People usually begin to have sx 1-4 days after exposure, with an average of 2 days
How long is the patient contagious?
-Patient is contagious starting 1 day before onset of symptoms to about 5-7 days after becoming sick (probably the most asked question from my family)
Whats in the vaccines this year:
Every vaccine includes H1N1, H2N3, and Influenza B strains
U.S. influenza vaccines for 2012–13 will contain A/California/7/2009 (H1N1)-like, A/Victoria/361/2011 (H3N2)-like, and B/Wisconsin/1/2010-like (Yamagata lineage) antigens
High Risk for complications from the Flu:
- Pregnant women
- Women who have given birth, or had a miscarriage or abortion in the past 2 weeks
- People younger than 2 or 65 and over
- Asthma or any other chronic respiratory diseases
- Heart, kidney or liver disease
- Hematologic diseases, such as sickle cell anemia
- Metabolic disorders, such as diabetes
- Weakened immune system, from illness or medication
- Neuromuscular disorders that interfere with breathing or the discharge of mucus
- Long-term aspirin therapy in people under 19
- Morbid obesity
Influenza testing:
-not recommended in average/mild cases
-POC or commercially available rapid test kits (EIA) have poor sensitivity for detecting influenza. A positive result is indicative of infection but a negative result should not be used to rule out influenza.
-Other, more sensitive, assays including RT-PCR for subtyping of influenza A are available commercially but are not available at the point of care. Results of these tests may not be back within 48 hours of illness onset (i.e., in time for treatment decisions).
-The NYC Public Health Laboratory is not accepting individual specimens for influenza diagnostic testing except as part of ongoing surveillance programs.
*our policy is to PCR test those patients being admitted with respiratory symptoms, for CDC surveillance
Who should you empirically treat? Ideally within 48hrs but can be helpful at any point in:
– patients with severe symptoms
-patients being hospitalized for severe influenza
-Any of the patients in the high risk group
CDC algorithm http://www.cdc.gov/h1n1flu/clinicians/pdf/adultalgorithm.pdf
Treatment:
-Oseltamivir- 75mg BID x 5 days
-Zanamivir- 10mg (2 inhalations) BID x 5 days (use if oseltamivir resistance- look at surveillance data)
What to tell your patients about prevention of spread:
-GET FLU SHOT YEARLY IF ABOVE 6MO OF AGE
-Stay home
-cover cough (with tissue, sleeve, or inside of elbow, NOT hands)
-wash hands with soap and water, or alcohol based hand sanitizer
-stay 3 feet away from those that are sick
Good references:
http://www.nyc.gov/html/doh/flu/html/home/home.shtml
http://www.cdc.gov/flu/about/season/index.htm
